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102
a
b
H. Yu and C. W. Commander
c
d
e
Fig. 6.3 Digital subtraction venographic (DSV) ndings of the right adrenal vein (RAV). (a) DSV
shows a typical gland-like pattern of the RAV with the central vein (long arrow), small branches
(small arrows), and a faint gland-like blush. (b) DSV demonstrates a delta pattern of the RAV with
multiple prominent veins without small branches or glandular structures. (c) DSV demonstrates a
triangular pattern of the RAV with multiple crowded branches, showing a triangular “blush-like”
appearance. (d) DSV demonstrates a spiderweb pattern of the RAV. (e) DSV demonstrates the
RAV with no discernible pattern. There are multiple irregular branches without a pattern or glandlike blush
ab
6 Adrenal Vein Sampling
Fig. 6.4 Digital subtraction venographic (DSV) ndings of the accessory hepatic vein (AHV). (a)
DSV of the AHV (short arrow) shows a hepatic parenchymal blush (double arrow) and multiple
intraparenchymal collateral veins draining into the right hepatic vein (long arrow) with a superomedial course. (b) DSV of the AHV shows a hepatic parenchymal blush with irregular outer margins
103
the angiography suite. As a result, the success rates were signicantly improved
(93–94%) compared to AVS without quick cortisol assay (60–63%).
Sequential vs. Simultaneous AVS
Sequential AVS involves a single puncture of the femoral vein with sequential catheterization of the adrenal veins and samplings. The AVS usually starts from the
RAV, followed by LAV, and completed with infrarenal IVC.This technique requires
a continuous infusion of cosyntropin (50μg/h) during the procedure to minimize the
stress-induced uctuation in hormone secretion [79, 80]. Simultaneous AVS, on the
other hand, involves two separate accesses in the femoral vein, two different types
of catheters for bilateral adrenal veins, and a collection of all three sets of blood
samples at the same time for eliminating bias from stress-induced hormone uctuation [36, 80–83]. Therefore, simultaneous AVS can potentially obviate the need for
cosyntropin stimulation. Also, it allows multiple samplings for comparing values
between before and after a bolus of cosyntropin (250μg) without reentering the
veins. However, simultaneous AVS is relatively more invasive, technically demanding, and time-consuming and has an increased risk of adrenal vein thrombosis due
to prolonged catheterization [58, 80]. According to the 2012 AVIS, sequential AVS
has been the primary technique adopted by most centers, with simultaneous AVS
performed only in 35% of the centers worldwide [36]. Several studies have advocated using simultaneous AVS over sequential AVS, without comparing two methods [81, 84, 85]. To date, only two studies compared two methods and concluded
104
H. Yu and C. W. Commander
that the results from both techniques were concordant without compromising the
reliability of time-sensitive AVS [80, 86]. In a most recent study evaluating simultaneous and simulated sequential AVS, Rossitto etal. recommended primarily simultaneous AVS if the time delay between the RAV and LAV is longer than 15min [84].
We use sequential AVS at our institution approximately 30min after initiating continuous infusion of cosyntropin, with an average time delay between two adrenal
veins of less than 10min.
C-Arm Cone-Beam CT
Cone-beam CT (CBCT) generates a volumetric data set in a single gantry rotation
using a two-dimensional, digital at-panel detector system [87, 88]. The CBCT
mounted on a C-arm (C-arm CBCT) produces projection radiography, uoroscopy,
digital subtraction angiography, and three-dimensional CT images in a single patient
setup in the angiography suite. C-arm CBCT has been used to improve AVS’s diagnostic outcomes by conrming an appropriate catheter position before collecting
blood samples, especially in the RAV [89–91]. In a retrospective study of 156
patients with PA, the rate of adequate bilateral AVS increased from 40.6% to 88.7%
when C-arm CBCT was used [90]. Also, the rate of catheterization failure from the
RAV decreased signicantly. In a similar study of 91 AVS, Meyrignac etal. demonstrated an improved overall success rate of AVS from 44% to 80% with C-arm
CBCT [91]. However, the patient’s radiation dose can be signicant in C-arm CBCT
due to the automatic exposure control system [88]. When it is performed repeatedly
to conrm the catheter position, the patient’s radiation exposure further increases.
Therefore, C-arm CBCT is usually recommended when the institutional overall
AVS success rate is below 50% or for an inexperienced interventional radiologist [92].
Interpretation ofAVS
Successful AVS is dened by the correct catheterization of the adrenal vein measured by the selectivity index (SI). The SI is the ratio of plasma cortisol concentration (PCC) in the adrenal vein and IVC (right SI=PCC
PCC
) [65]. Although different SI values are used during AVS in most centers,
IVC
studies have shown that higher SI is more reliable, and the obtained results are more
accurate and reproducible [93, 94]. The Endocrine Society Guidelines recommend
SI≥ 2 without ACTH stimulation and SI≥ 5 with ACTH stimulation as benchmarks for correct adrenal vein catheterization [28, 67].
R AV
/PCC
, left SI=PCC
IVC
L AV
/
6 Adrenal Vein Sampling
105
The lateralization index (LI) is used to identify the source of excess secretion of
aldosterone. It is calculated by dividing the aldosterone-to-cortisol (A/C) ratio from
the adrenal vein by the A/C ratio from the IVC (right LI=[A
left LI= [A
L AV/CL AV
]/[A
IVC/CIVC
]) [95, 96]. To date, there is no consensus on the
R AV/CR AV
]/[A
IVC/CIVC
],
ideal cutoff values of the LI to select the patients for surgery [28]. Based on the
retrospective studies and the Endocrine Society Guidelines, LI of 4 is recommended
to lateralize the source of aldosterone, regardless of the ACTH stimulation [28, 58,
83]. Although ACTH stimulation could potentially reduce the LI by increasing aldo-
sterone secretion from the suppressed adrenal gland, the systematic review showed
that the number of incorrect lateralization was similar between the groups with and
without ACTH stimulation [28, 67].
Complications
Complications associated with AVS include adrenal hemorrhage resulted from
adrenal vein rupture or dissection, infarction of the adrenal gland, and adrenal vein
thrombosis. The reported overall complication rate was 0.61% in the AVIS [36].
When an extreme outlier was excluded, the corrected complication rate was only
0.51%. In this international study, the number of AVS performed by each interventional radiologist and the number of AVS performed per center were the major predictors for adrenal vein rupture. Also, the higher number of attempts necessary to
select the adrenal vein contributes to the higher rate of adrenal hemorrhage, especially in the RAV due to anatomical complexity [97]. Abdominal pain is the most
common symptom associated with adrenal hemorrhage, requiring conservative
management with opioids in most cases. If the symptom persists, follow-up CT is
recommended to rule out major retroperitoneal hemorrhage. Major complications,
such as adrenal insufciency or hypertensive crisis, requiring long-term treatment,
are extremely rare [97].
Conclusion
Despite the advanced imaging technologies, AVS is still the only reliable method for
differentiating unilateral versus bilateral subtypes of PA before surgery. AVS is a
safe procedure with a low complication rate, but technically challenging. Therefore,
successful AVS requires experience, skills, and knowledge of adrenal venous anatomy, variations, and venographic ndings. A combination of cosyntropin stimulation and rapid or on-site quick cortisol assay should be considered to improve the
success rate. C-arm CBCT can also be considered for interventional radiologists
with limited experience or a center with a small number of AVS procedures.
106
H. Yu and C. W. Commander
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H. Yu and C. W. Commander
Chapter 7
Selective Venous Sampling
forHyperparathyroidism
TakayukiYamada andAkiyukiKotoku
Introduction
Surgical dissection of the responsible parathyroid gland is the curative treatment for
primary hyperparathyroidism (pHPT). The conventional approach requires bilateral
neck exploration (BNE), but recently minimally invasive parathyroidectomy (MIP)
has become the preferred option. Both BNE and MIP are effective in terms of cure
rate; however, the safety prole of MIP is superior to BNE with lower rates of hypocalcemia and recurrent laryngeal nerve injury [1]. MIP does require precise preoperative localization of the abnormal parathyroid gland [2]. This preoperative localization
can be performed with a variety of noninvasive and invasive imaging studies. The
noninvasive studies include ultrasound, computed tomography (CT), magnetic resonance imaging (MRI), and
inadequate, venous sampling is a minimally invasive study that can be used.
Selective venous sampling (SVS) was initially reported in 1970 [3]. Taking
advantage of the fact that venous drainage of the four parathyroid glands is into the
adjacent thyroid veins [4], SVS identies the area of venous drainage of a hyperactive gland rather than its exact anatomical location [5]. Despite potential anatomic
variations, both radiology and surgical studies conrm the utility of SVS. Nevertheless,
improvements in noninvasive imaging techniques have reduced the utilization of
SVS over time. Yet, there continue to be situations in which SVS continues to have
a role in the localization of abnormal glands for pHPT.For these situations, a thorough understanding of the complex anatomy and potential variants, as well as the
ability to selectively catheterize small veins draining the thyroid gland, is paramount to accurately localize the abnormal parathyroid gland.
99m
Tc-sestamibi (MIBI). When noninvasive studies are
T. Yamada (*) · A. Kotoku
Department of Radiology, St. Marianna University School of Medicine, Yokohama City Seibu
Hospital, Yokohama, Kanagawa, Japan
e-mail: yamataka@marianna-u.ac.jp
Switzerland AG 2022
H. Yu et al. (eds.), Diagnosis and Management of Endocrine Disorders in
Interventional Radiology, https://doi.org/10.1007/978-3-030-87189-5_7
111© The Author(s), under exclusive license to Springer Nature