Case report: Percutaneous adrenal arterial embolization cures resistant hypertension

Bilateral adrenal artery embolization for the treatment of idiopathic hyperaldosteronism: A proof-of-principle single center study

Unilateral adrenal artery embolization (AAE) has emerged as an alternative treatment for patients with primary aldosteronism due to aldosterone-producing adenomas or idiopathic hyperaldosteronism with bilateral adrenal hyperplasia. This study aimed to investigate the effectiveness and safety of bilateral AAE in idiopathic hyperaldosteronism. We enrolled a total of 58 patients with idiopathic hyperaldosteronism who underwent successful bilateral AAE, and 55 of them completed 6-month follow-up. Bilateral AAE significantly lowered blood pressure of patients with IHA at 1, 3, and 6 months (all P < 0.01). Six months after the procedure, office, home, and 24-hour ambulatory blood pressure decreased by 20.3/13.5, 18.4/12.6, and 13.7/9.9 mmHg, respectively. Among them, 92.7%, 90.9%, and 89.1% had significant or moderate improvement in blood pressure control at 1, 3, and 6 months after the procedure. Bilateral AAE substantially decreased plasma aldosterone levels, reversed plasma renin suppression, decreased aldosterone-to-renin ratio, and corrected hypokalemia. Importantly, the procedure did not significantly change serum cortisol and plasma adrenocorticotropic hormone (ACTH) levels, and the cortisol and ACTH circadian rhythms remained intact three months after the procedure. Additionally, 16 patients underwent ACTH stimulation tests three months post-procedure and all of them had normal results except for one with a decreased response due to exogenous steroid therapy. Flank pain was the most common side effect which happened in 96.4% of the patients and resolved within 48 h. There were no long-term side effects in the 6 months. The present study provides evidence that bilateral AAE is an effective and safe alternative treatment for patients with IHA. Changes in office and 24h ambulatory blood pressure at 1, 3, and 6 months after bilateral adrenal artery embolization in patients with idiopathic hyperaldosteronism.

Comparative Assessment of the Influence of Embolizing Agents on the Adrenal Parenchyma

A comparative analysis of morphological and functional changes in the adrenal glands after embolization of supplying arteries with Lifepearl microspheres (100±25 μm; Terumo) and with a solution of polidocanol (Aethoxysklerol, Kreussler Pharma) was performed in male Vietnamese Lop-Bellied pigs (n=20). The introduction of the microspheres into the arterial bed did not affect the adrenal parenchyma. However, the injection of the liquid sclerosing agent caused foci of productive inflammation leading to the formation of sclerotic tissue and reduction of the volume of glandular tissue. Administration of the sclerosant was accompanied by arterial hypotension, an indirect indication of a decrease in vasoactive hormone production by the adrenal cortex. These findings suggest that polidocanol can be used as an embolization agent for hyperplastic diseases of the adrenal cortex.

The impact of superselective adrenal artery embolization on renal function in patients with primary aldosteronism: a prospective cohort study

Superselective adrenal artery embolization (SAAE) is an effective treatment for patients with primary aldosteronism (PA). However, the impact of SAAE on renal function in the PA population remains uncertain. We investigated the estimated glomerular filtration rate (eGFR) and age, sex, body mass index, and diabetes-specific percentiles of eGFR residuals in 182 PA patients treated with SAAE in a prospective cohort from Nanchang SAAE in treating PA registry study. Data suggest that SAAE caused a significant decrease in eGFR from 91.9 ± 26.1 to 88.7 ± 24.1 ml/min/1.73 m2 (p < 0.05) after a median follow-up of 8 months in PA patients. Patients experienced a significant decrease in eGFR from 110.6 ± 18.9 to 103.8 ± 18.2 ml/min/1.73 m2 (p < 0.001) and a very slight increase from 71.1 ± 14.8 to 71.8 ± 17.8 ml/min/1.73 m2 (p = 0.770) with baseline eGFR ≥90 and <90 ml/min/1.73 m2, respectively. Patients with high eGFR residuals (glomerular hyperfiltration) experienced a significant decrease in their eGFR levels from 123.1 ± 22.6 to 105.0 ± 18.6 ml/min/1.73 m2 (p < 0.001). In contrast, there was no significant impact of SAAE on the eGFR of patients with normal or low eGFR residuals. The very early eGFR changes (24 h after SAAE) best predicted the effect of SAAE on eGFR changes after median of eight months in PA patients. On the whole, SAAE seems to have a beneficial impact on renal function in patients with PA, the results of which vary depending on the patient's baseline eGFR and glomerular hyperfiltration status.

A controlled trial of percutaneous adrenal arterial embolization for hypertension in patients with idiopathic hyperaldosteronism

Our prior study has suggested that percutaneous superselective adrenal arterial embolization (SAAE) with ethanol reduces blood pressure in patients with primary aldosteronism. This study aimed to compare the efficacy of SAAE with mineralocorticoid receptor antagonists (MRA) in treating patients with idiopathic hyperaldosteronism. In this prospective, randomized, controlled trial, we randomly assigned patients with idiopathic hyperaldosteronism in a 1:1 ratio to undergo SAAE (n = 29) or receive MRA (n = 30) treatment. The primary endpoint was the change in mean 24-hour ambulatory systolic blood pressure at 6 months. The secondary endpoints included changes in office blood pressure, home blood pressure, correction of aldosterone-to-renin ratio, and adverse events at 6 months. The mean change in 24-h ambulatory systolic blood pressure from baseline to 6-month follow-up was significantly different between the two groups (-8.4 mmHg; 95% confidence interval, -15.2 to -2.1 mmHg; P < 0.01). Office, home, and ambulatory blood pressure reduction at 6 months was more pronounced in the SAAE group than the MRA group (all P < 0.05). Aldosterone-to-renin ratio was lower in the SAAE group than the MRA group at 1 and 3 months (both P < 0.01), while it had no difference between the two groups at 6 months. None of the patients experienced serious adverse events in the perioperative and 6-month follow-up periods. SAAE, as a hormonal debulking procedure, is superior to MRA in blood pressure control and correction of biochemical abnormalities in patients with idiopathic hyperaldosteronism.

Treating Primary Aldosteronism-Induced Hypertension: Novel Approaches and Future Outlooks

Primary aldosteronism (PA) is the most common cause of secondary hypertension and is associated with increased morbidity and mortality when compared with blood pressure-matched cases of primary hypertension. Current limitations in patient care stem from delayed recognition of the condition, limited access to key diagnostic procedures, and lack of a definitive therapy option for nonsurgical candidates. However, several recent advances have the potential to address these barriers to optimal care. From a diagnostic perspective, machine-learning algorithms have shown promise in the prediction of PA subtypes, while the development of noninvasive alternatives to adrenal vein sampling (including molecular positron emission tomography imaging) has made accurate localization of functioning adrenal nodules possible. In parallel, more selective approaches to targeting the causative aldosterone-producing adrenal adenoma/nodule (APA/APN) have emerged with the advent of partial adrenalectomy or precision ablation. Additionally, the development of novel pharmacological agents may help to mitigate off-target effects of aldosterone and improve clinical efficacy and outcomes. Here, we consider how each of these innovations might change our approach to the patient with PA, to allow more tailored investigation and treatment plans, with corresponding improvement in clinical outcomes and resource utilization, for this highly prevalent disorder.

Unilateral chemical ablation of the adrenal gland lowers blood pressure and alleviates target organ damage in spontaneously hypertensive rats

Adrenal gland hormones play a critical role in the development and maintenance of hypertension. Adrenal ablation has been used to treat primary aldosteronism but not essential hypertension. The present study aimed to investigate the effectiveness and safety of unilateral adrenal gland ablation in treating spontaneously hypertensive rats (SHR). SHR and Wistar-Kyoto rats (WKY) were subjected to unilateral adrenal ablation with injection of anhydrous ethanol or a sham procedure. Blood pressure was monitored by both tail-cuff plethysmography and telemetry until 6 months after the procedure. Adrenal ablation significantly lowered systolic and diastolic blood pressure of the SHR (P < 0.05 or P < 0.01) but not WKY from 4 to 24 weeks after the procedure. Adrenal ablation substantially damaged adrenal cortex and medulla with fibrosis in SHR and WKY rats. The ablation procedure remarkably reduced the levels of renin, angiotensin II, aldosterone, cortisol, noradrenaline, and epinephrine in SHR (all P < 0.05) but not in WKY. Hypokalemia in SHR was significantly improved by adrenal ablation (P < 0.05), while the serum sodium levels were not affected by adrenal ablation in either SHR or WKY rats. Additionally, adrenal ablation improved cardiac, renal, and vascular remodeling and function measured 3 months after the procedure in SHR. In conclusion, the present study shows that ethanol ablation of adrenal gland can effectively lower blood pressure and prevent target organ damage in SHR. These findings suggest that unilateral debulking of the adrenal gland using ethanol ablation is a promising therapeutic strategy for treating hypertension.

METHODS

Spontaneously hypertensive rats (SHR) and Wistar-Kyoto rats (WKY) were subjected to unilateral adrenal ablation with injection of ethanol or a sham procedure. Blood pressure was monitored for 24 weeks.

RESULTS

Adrenal ablation significantly lowered systolic and diastolic blood pressure of SHR but not WKY from 4 to 24 weeks after the procedure.

CONCLUSION

Unilateral debulking of the adrenal gland using ethanol ablation is a promising therapeutic strategy for treating hypertension.