Persistent Primary Aldosteronism Despite Iatrogenic Adrenal Hemorrhage After Adrenal Vein Sampling

Hemorrhage from Adrenal Vein Rupture during Adrenal Vein Sampling

We describe a case of right adrenal hemorrhage from adrenal vein sampling treated conservatively with overnight admission and pain control. We review the existing literature on rates of this complication, typical clinical outcomes, and practical tips to avoid its occurrence.

Imaging CXCR4 expression in patients with suspected primary hyperaldosteronism

PURPOSE

It is challenging to differentiate unilateral aldosterone-producing adenoma (APA) from bilateral idiopathic adrenal hyperplasia (IAH) and nonfunctional adrenal adenoma (NFA) in primary aldosteronism (PA). In a first primarily ex vivo study detection, CXC chemokine receptor type 4 (CXCR4) expression has been shown to be a valuable tool for the detection of APA. In this study, we aimed to clinically evaluate CXCR4 imaging with ⁶⁸Ga-pentixafor PET/CT for detecting APA.

METHODS

We prospectively recruited 36 patients with clinical suspicion of PA. All patients underwent ⁶⁸Ga-pentixafor PET/CT. Positive lesions were defined based on higher tracer uptake in adrenal nodular(s) shown on CT than the normal adrenal. These lesions were referred for adrenalectomy subsequently. All patients received clinical follow-up. Semi-quantitative analysis using maximum standardized uptake value (SUV_max), lesion-to-liver ratio (LLR), and lesion-to-contralateral ratio (LCR) has also been performed. PET/CT results were correlated with clinical presentation and follow-up.

RESULTS

Thirty-nine adrenal lesions in 36 patients were found; 25 APA, 4 IAH, and 10 NFA according to histopathology and clinical assessment. Sensitivity, specificity, and accuracy of ⁶⁸Ga-pentixafor PET/CT in distinguishing APA by visualization were 100%, 78.6%, and 92.3% respectively. The SUV_max of APA (21.34 ± 9.41, n = 25) was significantly higher than that of non-APA lesions (6.29 ± 2.10, n = 14, P < 0.0001). An optimal threshold of SUV_max = 11.18 was determined for predicting APA with a sensitivity of 88.0%, specificity of 100%, and an accuracy of 92.3%. A cutoff value for LCR of 2.12 yielded a sensitivity of 100% and a specificity of 92.9%, whereas a cutoff value for LLR of 2.36 reached at both 100% of sensitivity and specificity. All patients with (removed) positive lesions benefited from surgery.

CONCLUSION

⁶⁸Ga-Pentixafor PET/CT may be used to non-invasively detect APA in PA patients.

A Patient with Bilateral Primary Aldosteronism Refractory to Oral Eplerenone Who Responded to Esaxerenone with Increased Renin Activity

Patient: Male, 45-year-old

Final Diagnosis: Bilateral primary aldosteronism

Symptoms: Hypertension

Medication: Mineralocorticoid receptor blocker

Clinical Procedure: Segmental adrenal venous sampling and medication

Specialty: Cardiology

A Case of Primary Aldosteronism Due to A Primary Adrenal Adenoma Diagnosed by Segmental Adrenal Venous Sampling (S-AVS) Using a Modified Catheter System and Lateral Cine Angiography

BACKGROUND Before partial adrenalectomy for primary aldosteronism due to a primary adrenal adenoma, the aldosterone-producing tumor can be localized by segmental adrenal vein sampling (S-AVS). Cardiologists, who regularly perform percutaneous coronary intervention (PCI), or coronary angioplasty with stent, may not be familiar with the technique of S-AVS. A case of the use of S-AVS is reported in a patient who presented with primary aldosteronism and a right adrenal adenoma. CASE REPORT A 44-year-old man with a history of hypertension presented with a man in the posterior part of the right adrenal gland. He had hypokalemia, and a high plasma aldosterone concentration/plasma renin activity ratio. A captopril stress test confirmed the diagnosis of primary aldosteronism. Pre-operative S-AVS was performed using a microwire and microcatheter, which were advanced into the segmental adrenal vein using a 6.5 French guiding catheter and a Y-shaped connector, under biplane cine angiography guidance. S-AVS showed a high plasma aldosterone concentration in the right superior tributary adrenal vein draining the adrenal mass. Right partial adrenalectomy was performed. Postoperatively, the patient's blood pressure and plasma aldosterone levels normalized. CONCLUSIONS S-AVS can be performed relatively easily before partial adrenalectomy using a catheter system with biplane cine angiography, which is a technique that is familiar to cardiologists.