Consequences of Adrenal Venous Sampling in Primary Hyperaldosteronism and Predictors of Unilateral Adrenal Disease

Mathur, Aarti; Kemp, Clinton D.; Dutta, Utpal; Baid, Smita; Ayala, Alejandro; Chang, Richard E.; Steinberg, Seth M.; Papademetriou, Vasilios; Lange, Eileen; Libutti, Steven K.; Pingpank, James F.; Alexander, H. Richard; Phan, Giao Q.; Hughes, Marybeth; Linehan, W. Marston; Pinto, Peter A.; Stratakis, Constantine A.; Kebebew, Electron

doi:10.1016/j.jamcollsurg.2010.05.006

« Previous Next »Journal of the American College of Surgeons
Volume 211, Issue 3 , Pages 384-390, September 2010

Consequences of Adrenal Venous Sampling in Primary Hyperaldosteronism and Predictors of Unilateral Adrenal Disease

Aarti Mathur, MD
- Endocrine Oncology Section, Surgery Branch, National Cancer Institute
Clinton D. Kemp, MD
- Endocrine Oncology Section, Surgery Branch, National Cancer Institute
Utpal Dutta, MD
- Program on Developmental Endocrinology and Genetics, Eunice Kennedy Shriver National Institutes of Child Health and Human Development (NICHD)
Smita Baid, MD
- Program on Developmental Endocrinology and Genetics, Eunice Kennedy Shriver National Institutes of Child Health and Human Development (NICHD)
Alejandro Ayala, MD
- Program on Developmental Endocrinology and Genetics, Eunice Kennedy Shriver National Institutes of Child Health and Human Development (NICHD)
Richard E. Chang, MD
- Department of Diagnostic Radiology, Warren F Magnuson Clinical Center
Seth M. Steinberg, PhD
- Biostatistics and Data Management Section, Office of the Clinical Director, Center for Cancer Research, National Cancer Institute
Vasilios Papademetriou, MD
- Veterans Administration and Georgetown University, Washington DC
Eileen Lange, RN, CCRP
- Program on Developmental Endocrinology and Genetics, Eunice Kennedy Shriver National Institutes of Child Health and Human Development (NICHD)
Steven K. Libutti, MD, FACS
- Department of Surgery, Montefiore Medical Center and the Albert Einstein College of Medicine, Bronx, NY
James F. Pingpank, MD, FACS
- Division of Surgical Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, PA
H. Richard Alexander, MD, FACS
- Department of Surgery, Greenebaum Cancer Center, University of Maryland School of Medicine, Baltimore, MD
Giao Q. Phan, MD
- Endocrine Oncology Section, Surgery Branch, National Cancer Institute
Marybeth Hughes, MD, FACS
- Endocrine Oncology Section, Surgery Branch, National Cancer Institute
W. Marston Linehan, MD
- Urologic Oncology Branch, National Cancer Institute
Peter A. Pinto, MD
- Urologic Oncology Branch, National Cancer Institute
Constantine A. Stratakis, MD, D(Med)Sci
- Program on Developmental Endocrinology and Genetics, Eunice Kennedy Shriver National Institutes of Child Health and Human Development (NICHD)
Electron Kebebew, MD, FACS
- Endocrine Oncology Section, Surgery Branch, National Cancer Institute
- Correspondence address: Electron Kebebew, MD, FACS, National Cancer Institute Surgery Branch CRC, Room 4-5952, 10 Center Dr, MSC 1201, Bethesda, MD 20892-1201

Received 5 March 2010; received in revised form 4 May 2010; accepted 11 May 2010. published online 14 July 2010.

Background

In patients with primary hyperaldosteronism, distinguishing between unilateral and bilateral adrenal hypersecretion is critical in assessing treatment options. Adrenal venous sampling (AVS) has been advocated by some to be the gold standard for localization of the responsible lesion, but there remains a lack of consensus for the criteria and the standardization of technique.

Study Design

We performed a retrospective study of 114 patients with a biochemical diagnosis of primary hyperaldosteronism who all underwent CT scan and AVS before and after corticotropin (ACTH) stimulation. Univariate and multivariate analyses were performed to determine what factors were associated with AVS lateralization, and which AVS values were the most accurate criteria for lateralization.

Results

Eighty-five patients underwent surgery at our institution for unilateral hyperaldosteronism. Of the 57 patients who demonstrated unilateral abnormalities on CT, AVS localized to the contralateral side in 5 patients and revealed bilateral hyperplasia in 6 patients. Of the 52 patients who showed bilateral disease on CT scan, 43 lateralized with AVS. The most accurate criterion on AVS for lateralization was the post-ACTH stimulation value. Factors associated with AVS lateralization included a low renin value, high plasma aldosterone-to plasma-renin ratio, and adrenal mass ≥ 3 cm on CT scan.

Conclusions

Because 50% of patients would have been inappropriately managed based on CT scan findings, patients with biochemical evidence of primary hyperaldosteronism and considering adrenalectomy should have AVS. The most accurate measurement for AVS lateralization was the post-ACTH stimulation value. Although several factors predict successful AVS lateralization, none are accurate enough to perform AVS selectively.

Abbreviations and Acronyms: AC, aldosterone-to-cortisol ratio, ACTH, corticotropin, AVS, adrenal venous sampling, PAC, plasma aldosterone concentration, PRA, plasma renin activity