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Workup of Cushing’s syndrome. Suspected endogenous Cushing’s syndrome is evaluated in a stepwise manner. BIPSS is indicated when noninvasive testing is inconclusive for diagnosing Cushing’s disease which involves a pituitary source of ACTH. CS: Cushing’s syndrome; ACTH: adrenocorticotropic hormone; CRH: corticotropin-releasing hormone; IPS: inferior petrosal sinus; P: peripheral; BIPSS: bilateral inferior petrosal sinus sampling.
Source publication
Venous sampling is the gold standard for localizing abnormal hormone secretion in several endocrine disorders. The most common indication for venous sampling is in the workup of primary aldosteronism, adrenocorticotropic hormone-dependent Cushing's syndrome, and hyperparathyroidism. In experienced hands, venous sampling is safe and accurate. This r...
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BACKGROUND
Anatomical variations, such as high jugular bulbs and air cell development in the petrosal bone, should be evaluated before surgery. Most bone defects in the internal auditory canal (IAC) posterior wall are observed in the perilabyrinthine cells. An aberrant vascular structure passing through the petrous bone is rare.
OBSERVATIONS
A 48-...
Citations
... Adrenal computed tomography (CT) imaging can show adrenal adenoma, but cannot distinguish nonfunctioning incidentalomas [9,10]. Currently, adrenal venous sampling (AVS) is the only procedure to identify UAH; however, it is available only in few referral centers worldwide because its technique is challenging [11][12][13]. ...
... The discordance between CT imaging and AVS is higher in PA patients with normal adrenal imaging and UAH or PA patients with unilateral nodules and isolated contralateral aldosterone hypersecretion [9,[14][15][16]. Obviously, it is impossible to identify these adrenal hypersecretions without AVS. ...
Background
Primary aldosteronism (PA) is highly prevalent in hypertensive population. Adrenal vein sampling (AVS) is the only procedure to assess adrenal aldosterone hypersecretion in PA. PA patients without aldosterone-producing adenomas (APA) frequently have unilateral aldosterone hypersecretion (UAH). These patients could bear inappropriate adrenalectomy without AVS. This study aims to identify which clinical characteristics should be recommended to perform AVS in these PA patients.
Methods
This study was performed from January 2018 to July 2019 at a center for hypertension and metabolic diseases. Adrenal computed tomography (CT) scan, biochemical evaluation, and AVS were performed.
Results
Total 141 patients were included in this study. Aldosterone to renin ratio (ARR) after confirmatory test is highly associated with adrenal laterality. The specificity of ARR > 10 (ng/dL)/(mU/L) after confirmatory test is 100%. After confirmatory test, patients with ARR > 10 (ng/dL)/(mU/L) had higher plasma aldosterone concentration and incidences of ischemic heart diseases and renal damage( p < 0.05).
Conclusions
After confirmatory tests, ARR > 10 (ng/dL)/(mU/L) indicates adrenal laterality, with increasingly cardiorenal damage in PA patients without APA. Thus, AVS should be recommended in these patients before surgery.
Trial registration
NCT03398785 , Date of Registration: December 24, 2017.
... Selective arterial stimulation and hepatic venous sampling-Occasionally, pNETs can be occult on noninvasive imaging (i.e., CT, MRI, and PET); in these instances, interventional radiologists can perform arterial stimulation with hepatic venous sampling whereby pancreatic segmental arterial injections of neuroendocrine stimulatory medications are infused and simultaneous hepatic venous sampling is performed [73][74][75][76]. Using fluoroscopic guidance, an interventional radiologist places a percutaneous transvenous catheter within a hepatic vein and places selective transarterial catheters in the gastroduodenal artery, which supplies the pancreatic upper pancreatic head and neck; superior mesenteric artery, which supplies the lower pancreatic head and uncinate process; and finally the proximal splenic artery, which supplies the pancreatic body and tail [73]. ...
... Then, at various time intervals ranging from 30 seconds to 5 minutes after arterial injection, hepatic venous samples are obtained and assessed by enzymatic assays to measure changes in insulin or gastrin levels and are compared with baseline (i.e., nonstimulated) levels. A twofold or greater increase in hormonal levels is typically considered a positive result and as likely representing the seg-mental pancreatic location of neuroendocrine tumor [73,75,76]. On the basis of the results, a potentially more directed surgical approach could be considered and, in some instances, transarterial embolization may be performed after selective arterial stimulation to identify gastrinomas and metastases [76]. ...
OBJECTIVE. The purpose of this study was to describe the results of an ongoing program implemented in an academic radiology department to support the execution of small- to medium-size improvement projects led by frontline staff and leaders. MATERIALS AND METHODS. Staff members were assigned a coach, were instructed in improvement methods, were given time to work on the project, and presented progress to department leaders in weekly 30-minute reports. Estimated costs and outcomes were calculated for each project and aggregated. An anonymous survey was administered to participants at the end of the first year. RESULTS. A total of 73 participants completed 102 projects in the first 2 years of the program. The project type mix included 25 quality improvement projects, 22 patient satisfaction projects, 14 staff engagement projects, 27 efficiency improvement projects, and 14 regulatory compliance and readiness projects. Estimated annualized outcomes included approximately 4500 labor hours saved, $315K in supply cost savings, $42.2M in potential increased revenues, 8- and 2-point increase in top-box patient experience scores at two clinics, and a 60-incident reduction in near-miss safety events. Participant time equated to approximately 0.35 full-time equivalent positions per year. Approximately 0.4 full-time equivalent was required to support the program. Survey results indicated that the participants generally viewed the program favorably. CONCLUSION. The program was successful in providing a platform for simultaneously solving a large number of organizational problems while also providing a positive experience to frontline personnel.
... In addition, the diagnosis of ACTH-independent hypercortisolism (adrenal Cushing syndrome) is another indication for AVS [21]. ...
Background Primary aldosteronism (PA) is the most common detectable cause of secondary hypertension. The majority of patients have either an adrenal aldosterone-producing adenoma (APA) or bilateral adrenal hyperplasia (BAH) demanding different therapeutic approaches. Screening tests and imaging cannot reliably distinguish between a unilateral or bilateral PA.
Methods This review article gives an overview concerning etiology, diagnostics, and therapeutic options of PA, and reviews the indication, the technique, and relevance of selective adrenal venous sampling (AVS) in the context of the current literature and the authors’ experience.
Results AVS can verify or exclude a unilaterally dominated secretion with a high success rate. Patients with PA and a unilateral APA can be treated curatively by adrenalectomy.
Conclusions AVS is an established diagnostic examination for differentiation of unilateral from bilateral adrenal disease in patients with PA.
Key Points:
Citation Format
... Noninvasive tests examining blood cortisol, salivary cortisol, and urinary cortisol have variable sensitivity and specificity. 2,6 When CD is suspected, bilateral inferior petrosal sinus sampling (IPSS) is currently the gold standard confirmatory and localizing test. 3 IPSS involves catheterizing both inferior petrosal sinuses (IPSs) in order to sample blood from each side of the cavernous sinus, the venous drainage of the pituitary gland. ...
The authors report the case of a 30-year-old female patient with suspected Cushing's disease with an anatomical variation of hypoplastic inferior petrosal sinuses and nearly exclusive anterior drainage from the cavernous sinus, who underwent external jugular venous blood sampling with successful disease confirmation and microadenoma localization. The patient presented with signs and symptoms consistent with Cushing's syndrome, but with discordant preliminary diagnostic testing. She underwent attempted bilateral inferior petrosal sinus sampling; however, she had hypoplastic inferior petrosal sinuses bilaterally and predominantly anterior drainage from the cavernous sinus into the external jugular circulation. Given this finding, the decision was made to proceed with external jugular venous access and sampling in addition to internal jugular venous sampling. A positive adrenocorticotropic hormone (ACTH) response to corticotropin-releasing factor was obtained in the right external jugular vein alone, suggesting a right-sided pituitary microadenoma as the cause of her Cushing's disease. The patient subsequently underwent a transsphenoidal hypophysectomy that confirmed the presence of a right-sided ACTH-secreting microadenoma, which was successfully resected. She was hypocortisolemic on discharge and has had no signs of recurrence or relapse at 6 months postoperation.
... 7,8 With diagnostic challenges, it might be necessary for patients to undergo percutaneous transfemoral adrenal vein catheterisation and adrenal vein sampling which gives a unilateral 2-3 fold increase in aldosterone in adenoma unlike in bilateral disease. 13 Autonomous secretion is diagnosed by none aldosterone suppression with volume expansion. Ectopic Adrenocorticotropic hormone (ACTH) production, hypermineralocorticoid states and Bartter and Gitelman syndromes are differentials that can be ruled out by the presence or not, of oedema, hypertension, hypomagnesaemia, hyperreninaemia and elevated aldosterone level. ...
... The principle relies on selective catheterisation of the parathyroid gland draining veins and comparison of intravenous parathormone levels obtained from these vessels (2-3 millilitres blood sample required per site) against a reference i.e. parathormone level from the subclavian vessels. Whilst this has been proven to be the most sensitive test for ectopic or missed lesions, its invasive nature, average procedure time of 90 min [12] and inherent risks render it less desirable as a tool for initial investigations [13]. ...
Primary hyperparathyroidism is associated with significant morbidity and mortality. It is in this day and age, an eminently treatable condition which relies heavily on preoperative imaging to localise enlarged parathyroid glands. The imaging appearances of parathyroid gland enlargement are varied; this paper seeks to address some of its more unusual manifestations with an emphasis on its atypical enhancement patterns, mimics and associations. An enlarged glands may also present as an 'incidentaloma' in head and neck imaging performed for entirely different indications, or as part of sporadic or familial syndrome. Radiologists are in a good position to expedite the relevant investigations and curative treatment, and knowledge of the spectrum of imaging appearances is crucial.
... AVS is used to localize and lateralize aldosterone hypersecretion. It is a highly specific procedure and requires high technical expertise albeit with varying success rates, thus rendering it not widely available [17]. Once lateralization is confirmed and consistent with the presence of an adenoma, surgery can proceed and patient can potentially be cured. ...
Primary aldosteronism (PA) causes a persistently elevated blood pressure (BP) due to excessive release of the hormone aldosterone from the adrenal glands. Classically, it is called Conn’s syndrome and is described as the triad of hypertension and hypokalemia with the presence of unilateral adrenal adenoma. It can be cured with surgical resection of the aldosterone-secreting adenoma leading to resolution of hypertension, hypokalemia and increased cardiovascular risk associated with hyperaldosteronism. We present a case of a man with previous ischemic heart disease (IHD) who presented with resistant hypertension. Investigations for secondary causes of hypertension revealed an elevated aldosterone level and saline suppression test confirmed the diagnosis of PA. Radiological examination revealed a left adrenal adenoma and a normal right adrenal gland. However, adrenal venous sampling showed lateralization of aldosterone secretion towards the right. He subsequently underwent a laparoscopic right adrenalectomy which improved his BP control promptly. This case highlights the importance of recognizing the need to investigate for secondary causes of hypertension. It also underscores the importance of dynamic tests, which may not be easily accessible to most clinicians but should pursue, to allow a definitive diagnosis and effective treatment.
Selective venous sampling (SVS), an invasive radiographic procedure that depends on contrast media, holds a unique role in diagnosing and guiding the treatment of certain types of secondary hypertension, particularly in patients who may be candidates for curative surgery. The adrenal venous sampling (AVS), in particular, is established as the gold standard for localizing and subtyping primary aldosteronism (PA). Throughout decades of clinical practice, AVS could be applied not only to PA but also to other endocrine diseases, such as adrenal Cushing syndrome (ACS) and Pheochromocytomas (PCCs). Notably, the application of AVS in ACS and PCCs remains less recognized compared to PA, with the low success rate of catheterization, the controversy of results interpretation, and the absence of a standardized protocol. Additionally, the AVS procedure necessitates enhancements to boost its success rate, with several helpful but imperfect methods emerging, yet continued exploration remains essential. We also observed renal venous sampling (RVS), an operation akin to AVS in principle, serves as an effective means of diagnosing renin-dependent hypertension, aiding in the identification of precise sources of renin excess and helping the selection of surgical candidates with renin angiotensin aldosterone system (RAAS) abnormal activation. Nonetheless, further basic and clinical research is needed. Selective venous sampling (SVS) can be used in identifying cases of secondary hypertension that are curable by surgical intervention. Adrenal venous sampling (AVS) and aldosterone measurement for classificatory diagnosis of primary aldosteronism (PA) are established worldwide. While its primary application is for PA, AVS also holds the potential for diagnosing other endocrine disorders, including adrenal Cushing's syndrome (ACS) and pheochromocytomas (PCCs) through the measurements of cortisol and catecholamine respectively. In addition, renal venous sampling and renin measurement can help to diagnose renovascular hypertension and reninoma.
The history and evolution of parathyroid hormone is a true testament to inter-disciplinary collaboration among anatomists, biochemists and surgeons. The parathyroid glands were the last endocrine glands to be discovered in the mid-1800s. Over the next century, progress in the evaluation of primary hyperparathyroidism, the identification of parathyroid hormone (PTH) and its application for use in the field of parathyroid surgery have led to a significant improvement in surgical cure rates, accompanied by a shift toward minimally invasive surgical options. This chapter provides a historical lens through which we can view these relatively recent advancements, as well as the current role of parathyroid hormone, both with regards to pre-operative localization and intra-operative detection of abnormal glands. Furthermore, we discuss the importance of parathyroid hormone in the management of complex multiglandular disease and reoperative cases, as well as the significance of persistently elevated PTH levels post-parathyroidectomy.
