Obtaining multiple sample sets during adrenal vein sampling (AVS) in patients with primary aldosteronism could more accurately guide treatment, according to a study published April 15 in Radiology.
The finding is from an analysis that found AVS data inconsistencies in a third of patients with primary aldosteronism who underwent the procedure, noted first author Livia Mermejo, MD, of the University of Michigan in Ann Arbor, and colleagues.
“Almost a third of included patients (129 of 402; 32.1%) had intraprotocol AVS data discrepancies, underscoring the importance of obtaining multiple sample sets during the procedure to accurately guide primary aldosteronism treatment,” the group wrote.
Primary aldosteronism is characterized by the overproduction of the hormone aldosterone. The disorder affects up to 10% of individuals with hypertension and up to 25% of those with treatment-resistant hypertension. The disorder is associated with a risk of cardiovascular and renal complications, the authors explained.
Adrenal vein sampling (AVS) is the standard of care test for identifying patients with unilateral (lateralized) primary aldosteronism who would benefit from surgery versus bilateral primary aldosteronism involving both glands, which typically requires life-long targeted medical therapy, the group noted.
Images show adrenal vein sampling. (A) Schematic representation shows anatomy of the adrenal veins (created with BioRender.com). (B, C) Venograms obtained during the procedure show (B) right adrenal vein and (C) left adrenal vein. Two separate catheters were used to cannulate the right and left adrenal veins. The vein locations were visually confirmed using adrenal venography and occasional adjunctive cone-beam CT. Image and caption courtesy of RSNA.
Although AVS has been performed for decades, the procedure protocols and data interpretation remain highly variable across centers and data concerning intraprotocol variability are lacking, the researchers added. Thus, the group aimed to assess the rates of intraprotocol inconsistency during AVS.
The researchers analyzed sets of left and right adrenal vein serum samples obtained simultaneously from 402 patients during AVS procedures: three baseline samples obtained five minutes apart and three samples obtained between five and 30 minutes after cosyntropin injections. Cosyntropin is a synthetic hormone that stimulates the adrenal glands, which allows an assessment of their function.
The researchers analyzed inconsistencies between the three baseline results, between the three post-cosyntropin stimulation results, and between the pre- and post-cosyntropin samples. They defined inconsistency as the proportion of tests in which one of three sample results from the same location was discordant with the other two.
According to the results, of the 402 patients (median age, 53 years years old) 129 patients (32.1%) had at least one “lateralization index” inconsistency, meaning mismatcheed results in the AVS tests: 89 patients (22.1%) had lateralization inconsistencies within the baseline sets, 53 patients (13.2%) within cosyntropin-stimulated sets, and 13 patients (3.2%) in both baseline and cosyntropin-stimulated sets.
Ultimately, many centers obtain only a single set of samples during AVS, and while numerous other factors might contribute to inconsistent AVS results, such as the time of day, sedatives, cosyntropin administration protocols, and assay inaccuracies, the study results emphasize the value of obtaining multiple datasets to best inform treatment decision, the researchers suggested.
“Obtaining multiple sample sets may reduce erroneous surgical recommendations,” the group concluded.
In an accompanying editorial, Christos Georgiades, MD, PhD, of Johns Hopkins University in Baltimore, MD, wrote that the study results are a call to arms for the Society of Interventional Radiology (SIR), the Endocrine Society, and the American Association of Endocrine Surgeons (AAES) to develop a commonly accepted AVS protocol.
“Considering the amassing cautionary literature regarding the pitfalls in the variability of patient selection, preparation, AVS protocol, technique, and interpretation of results, the burden of addressing this challenge rests squarely on the shoulders of the relevant scientific societies,” he wrote.
The findings of the study represent “just another proverbial tree in the forest that our scientific societies must at long last see,” Georgiades concluded.
The full study can be found here.
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