Modification of the protocol for selective adrenal venous sampling results in both a significant increase in the accuracy and necessity of the procedure in the management of patients with primary hyperaldosteronism

Surgery. 2012 Oct;152(4):643-9; discussion 649-51. doi: 10.1016/j.surg.2012.07.007. Epub 2012 Aug 26.


Background: Adrenal venous sampling (AVS) is used in the work-up of primary hyperaldosteronism (PA) to distinguish unilateral PA from bilateral adrenal hyperplasia. In 2006, we reported that only 44% of AVS had biochemical evidence of bilateral adrenal vein cannulation (BAVC). Critical appraisal of our practice resulted in a protocol change. This study examined the impact of this new protocol on both the technical success rate and its influence on management of PA.

Methods: Since 2006, all patients with biochemically documented PA referred to either a single endocrine surgeon or endocrine specialist underwent AVS. Successful BAVC was defined as an adrenal vein to inferior vena cava/cortisol ratio of >3:1. Lateralization was defined as an aldosterone:cortisol ratio >3 times the unaffected side.

Results: Of the 86 AVS performed on 84 patients with PA, 82 had BAVC (95%). AVS altered the management in 26 of 84 (31%) patients. Despite clear unilateral findings on imaging in 45 patients, AVS demonstrated bilateral adrenal hyperplasia. in 10 and contralateral disease in 3. AVS confirmed unilateral PA in 5 patients with equivocal <1 cm nodules. In 4 of 25 patients with normal adrenal glands, AVS demonstrated lateralization. AVS demonstrated unilateral PA in 4 of 9 patients in whom imaging suggested bilateral adrenal hyperplasia.

Conclusion: Our new AVS protocol resulted in a marked improvement in BAVC. AVS influenced management in a third of patients with PA. Surgical decision-making cannot be made solely on the basis of cross-sectional imaging.

MeSH terms

  • Adenoma / blood
  • Adenoma / diagnosis
  • Adenoma / surgery
  • Adrenal Gland Neoplasms / blood
  • Adrenal Gland Neoplasms / diagnosis
  • Adrenal Gland Neoplasms / surgery
  • Adrenal Glands / blood supply*
  • Adrenal Hyperplasia, Congenital / blood
  • Adrenal Hyperplasia, Congenital / diagnosis
  • Adrenal Hyperplasia, Congenital / surgery
  • Adrenalectomy
  • Aldosterone / blood
  • Catheterization / methods
  • Clinical Protocols
  • Diagnosis, Differential
  • Female
  • Humans
  • Hydrocortisone / blood
  • Hyperaldosteronism / blood*
  • Hyperaldosteronism / diagnosis*
  • Hyperaldosteronism / surgery
  • Magnetic Resonance Imaging
  • Male
  • Middle Aged
  • Tomography, X-Ray Computed
  • Vena Cava, Inferior


  • Aldosterone
  • Hydrocortisone