3 minute lightning oral presentation (and poster) ESA-SRB-APEG-NZSE 2022

Utility of Adrenal Vein Sampling (AVS) with and without ultra-low dose ACTH infusion (#126)

Christopher A Preston 1 , Eric Yong 2 , Ben Marginson 2 , Stephen Farrell 3 , Matthew P Sawyer 1 , Hikaru Hashimura 1 , Maresa Derbyshire 1 , Richard J MacIsaac 1 4 , Nirupa Sachithanandan 1
  1. Department of Endocrinology & Diabetes, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
  2. Department of Radiology, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
  3. Department of Surgery, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
  4. Department of Medicine, The University of Melbourne, Fitzroy, Victoria, Australia

Background
Adrenal vein sampling (AVS) is integral to identifying cases of surgically remediable unilateral primary aldosteronism (PA), however, is technically challenging, limiting its overall success. The administration of intra-procedural synthetic adrenocorticotrophic hormone (ACTH), conventionally as a 250mcg bolus or 50mcg per hour infusion, increases cortisol and aldosterone secretion and can improve successful adrenal vein sampling, however, may mask lateralisation.

Aim
The primary aim of this study was to assess if AVS performed with ultra-low dose ACTH infusion masks lateralisation.

Methods
Retrospective review of results of consecutive AVS procedures (n=21) performed both with and without ultra-low dose ACTH infusion at 1.25mcg per hour (1). Successful adrenal vein (AV) cannulation (the selectivity index) was defined by an AV to peripheral vein cortisol ratio >2.0 pre-ACTH and >4.0 post-ACTH. Lateralisation was defined by an aldosterone-to-cortisol ratio of the dominant to non-dominant adrenal vein >3.0 pre-ACTH and >4.0 post-ACTH (the lateralisation index). ACTH was measured at baseline and immediately following unstimulated AVS and again following stimulated AVS. Histological confirmation of pathology following unilateral adrenalectomy was sought where available.

Results
Bilateral AV cannulation was successful in 86% of procedures pre-ACTH and 90% post-ACTH. The number of studies that lateralised improved from 57% pre-ACTH and 43% post-ACTH to 71% in the combined AVS. Lateralisation results were discordant in 43% of cases, including 29% in which lateralisation was masked by ACTH, and 14% in which lateralisation was identified only with ACTH stimulation. Of these, 22% were confirmed histologically as adenomas and 22% as adrenal hyperplasia, with the remainder awaiting surgery. ACTH levels were highest at baseline and lowest following ACTH-stimulated AVS.

Conclusion
AVS performed with ultra-low dose ACTH masked lateralisation and did not obviate the need for non-ACTH AVS; however, combined AVS both with and without ultra-low dose ACTH improved the overall diagnostic yield, facilitating the identification of additional cases of surgically curable unilateral PA.

  1. 1. Espiner EA, Ross DG, Yandle TG, Richards AM, Hunt PJ. Predicting surgically remedial primary aldosteronism: role of adrenal scanning, posture testing, and adrenal vein sampling. J Clin Endocrinol Metab. 2003; 88: 3637-44