Olivier Steichen1, Laurence Amar. 1. aInternal Medicine Department, AP-HP, Tenon HospitalbFaculty of Medicine, Sorbonne Universités, UPMC University Paris 06cINSERM, Sorbonne Universités, UPMC Univ Paris 06, UMR_S1142dFaculty of Medicine, Université Paris-DescarteseHypertension Unit, AP-HP, Georges Pompidou European HospitalfINSERM, UMR_S970, équipe 14, Paris, France.
Abstract
PURPOSE OF REVIEW: Primary aldosteronism accounts for 3 to 5% of all hypertension cases. Unilateral aldosterone hypersecretion can be treated with adrenalectomy. Guidelines for primary aldosteronism management recommend adrenal vein sampling (AVS) to ascertain unilateral primary aldosteronism before surgery. Many different protocols are used to perform AVS and for the interpretation of its results, but without hard evidence of why one should be given preference. Experts have proposed recommendations to guide clinical practice and the grounds for future research to address this situation. RECENT FINDINGS: Proper patient preparation is a prerequisite for interpretable results. New trends are emerging to improve adequate cannulation of adrenal veins including: training of a limited number of dedicated radiologists, contrast computed tomography of adrenal veins before or during AVS, and rapid assays to measure cortisol concentrations during AVS. Cosyntropin stimulation is performed in several centers to avoid the variability of cortisol secretion during AVS, but whether this improves diagnostic performance is unknown. SUMMARY: Better markers of adequate catheter placement are currently under investigation, including other adrenal steroids and metanephrines. Innovative strategies for interpreting partially failed AVS are also being developed. Other approaches to ascertain primary aldosteronism subtype will be necessary because of limited patient access to AVS.
PURPOSE OF REVIEW: Primary aldosteronism accounts for 3 to 5% of all hypertension cases. Unilateral aldosterone hypersecretion can be treated with adrenalectomy. Guidelines for primary aldosteronism management recommend adrenal vein sampling (AVS) to ascertain unilateral primary aldosteronism before surgery. Many different protocols are used to perform AVS and for the interpretation of its results, but without hard evidence of why one should be given preference. Experts have proposed recommendations to guide clinical practice and the grounds for future research to address this situation. RECENT FINDINGS: Proper patient preparation is a prerequisite for interpretable results. New trends are emerging to improve adequate cannulation of adrenal veins including: training of a limited number of dedicated radiologists, contrast computed tomography of adrenal veins before or during AVS, and rapid assays to measure cortisol concentrations during AVS. Cosyntropin stimulation is performed in several centers to avoid the variability of cortisol secretion during AVS, but whether this improves diagnostic performance is unknown. SUMMARY: Better markers of adequate catheter placement are currently under investigation, including other adrenal steroids and metanephrines. Innovative strategies for interpreting partially failed AVS are also being developed. Other approaches to ascertain primary aldosteronism subtype will be necessary because of limited patient access to AVS.