Scintigraphy vs. AVS

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Scintigraphy vs. AVS:

The fact that a more favorable regression of left ventricular hypertrophy was seen in surgically compared with medically treated patients with APA [11, 12] further reinforces the need for an accurate diagnosis, leading to a specific treatment. Adrenal venous sampling (AVS) has been recently advocated as an essential tool in differentiating unilateral from bilateral aldosterone hypersecretion in HA [13–15]. However, AVS is an invasive procedure, its success rate is variable depending on the radiologist experience, and it is not without risks [14, 15].

In this study, we reviewed our experience to determine if non-invasive preoperative imaging studies are able to reliably differentiate patients with IHA and APA/PAH.....

.....On the other hand, despite the widespread successful use and proven diagnostic value of AVS, both the procedure and the methods used to analyze its results vary in literature. Moreover, it remains a challenging procedure that requires a skilled and experienced angiographer, especially on the right side were the adrenal vein enters the inferior vena cava at an acute angle. In fact, unsuccessfully or inappropriate right adrenal vein cannulation have been reported in up to 26% of the cases [9, 25].

Noteworthy, both adrenal veins must be sampled for significant comparison. Moreover, considering that AVS is an invasive procedure with a reported risk of symptomatic groin hematoma, adrenal hemorrhage, and adrenal vein’s rupture [15], we think that this procedure should be limited only to those cases in which CT scan and ACS cannot identify an anatomic or functional adrenal abnormality, inferred from the presence of an hormonal hypersecretion.

Careful attention to details, both in the biochemical evaluation and in the localization studies, will allow a correct identification of APA/PAH versus IHA, with a high degree of accuracy in patients with PA.

In case of equivocal or inconclusive CT scan findings, as minimal unilateral adrenal-limb thickening, unilateral adrenal micronodules, or bilateral macronodules, ACS could represent an essential tool in differentiating unilateral from bilateral hypersecretion in PA. As all the patients who underwent adrenalectomy were biochemically cured and we observed no false positive results, in our experience, the sensitivity of integrated imaging modalities (CT and ACS) in detecting histologically proven and biochemically cured APA and PAH was 100%. [Ref.]

ACS = adrenal cortical scintiscanAPA = aldosterone-producing adenomaIHA = bilateral idiopathic hyperaldosteronismPAH = unilateral primary adrenal hyperplasia