TECHNICAL NOTE

Abdominal Pressing Maneuver During Adrenal Venous Samplingfor Stabilization of Catheter Position

Takuji Araki • Hiroki Okada • Tsutomu Araki

Received: 26 March 2013 / Accepted: 14 August 2013

� Springer Science+Business Media New York and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) 2013

Abstract

Purpose The abdominal pressing maneuver (APM) is to

control respiration movement of the right adrenal vein

(RAV) during adrenal venous sampling (AVS). Instability

of a catheter inserted into the RAV due to respiration

movement can be a factor contributing to the unfeasibility

of AVS.

Materials and Methods Sixty-five consecutive patients

who underwent AVS for primary aldosteronism were

enrolled. We measured distances (D) of respiration move-

ment of the RAV both without and with APM in patients

who were resting breathing (n = 30) or deep breathing

(n = 35). This method was clinically applied on 37

patients in whom the catheter became disconnected from

the RAV either during venography or when collecting

blood caused by respiration movement.

Results The average values for D-resting without APM

and D-resting with APM were 7.6 (SD 2.5) and 3.6 (SD

1.7) mm, respectively, which was significantly different.

The average values for D-deep without APM and D-deep

with APM were 16.3 (SD 5.2) and 8.6 (SD 3.8) mm, which

was also significantly different. The average control rates

under conditions of deep or resting breathing were 45 %

[SD 17 % (median 43 %)] and 50 % [SD 19 % (median

49 %)], respectively. The catheter was stable in 33 (88 %)

of 37 patients while using the APM.

Conclusion The APM is considered convenient and fea-

sible for successfully controlling respiration movement in

patients undergoing AVS.

Keywords Adrenal venous sampling � Respiration

movement � Abdominal press maneuver

Introduction

Catheterization of the right adrenal vein (RAV) to obtain

blood samples can sometimes be difficult and may con-

tribute to the unfeasibility of adrenal venous sampling

(AVS) [1–3]. One of the reasons for this difficulty is

instability of the catheter due to respiration movement. The

RAV, which is a direct branch from the inferior vena cava

and has a shorter length than the left adrenal vein, can be

affected by respiration movement owing to its anatomical

position just below the liver.

Methods for restricting respiration movement have been

developed for radiation therapy or imaging diagnoses [4, 5].

Performing shallow respiration with inhalation of supple-

mental oxygen or thoracic respiration can restrain movement

of the diaphragm. A combination of thoracic breathing and

oxygen can be clinically useful for restricting respiration

movement; however, this may be insufficient for controlling

respiration movement in some cases because most patients

cannot immediately change abdominal breathing into thoracic

breathing. Therefore, we controlled respiration movement of

the RAV by pressing on the lower abdomen with the hand,

which is called the ‘‘abdominal pressing maneuver’’ (APM).

The purpose of this study was to assess the effectiveness

of controlling the respiration movement of the RAV by the

APM and to evaluate the usefulness of this method during

the AVS.

T. Araki (&) � H. Okada � T. Araki

Department of Radiology, University Hospital, University of

Yamanashi, 1110 Shimokato, Chuo 409-3898, Yamanashi, Japan

e-mail: taraki@yamanashi.ac.jp

H. Okada

e-mail: hokada@yamanashi.ac.jp

T. Araki

e-mail: arakit@yamanashi.ac.jp

123

Cardiovasc Intervent Radiol

DOI 10.1007/s00270-013-0749-1

Materials and Methods

Study Design

This study was approved by the Institutional Review Board

at our hospital. Written informed consent was obtained

from all patients.

Patients

The effectiveness of controlling breathing movement by

the APM was evaluated in 65 consecutive patients who

underwent AVS for primary aldosteronism from October

2010 to October 2012. The patients included 29 men and

36 women with an average age of 56.8 years [range 38–79

(median 57)].

Methods

A sampling 5F double-angled catheter (Serecon safe-tip

catheter for the RAV; Terumo, Tokyo, Japan) was used.

The press position of the hand during the APM was the

lower abdomen, which was out of the field of view on

fluoroscopy; this position was used while we instructed the

patient on how to perform thoracic breathing (Fig. 1).

The movement distances of the RAV while the vein was

enhanced were measured under conditions with and without

APM and under resting breathing (n = 30) or deep breathing

(n = 35). To decrease X-ray exposure, image data from

fluoroscopy were used to measure the distance. While the

RAV was enhanced by injection of contrast material, fluo-

roscopic image data were recorded while the patient per-

formed resting or deep breathing with and without APM

several times on fluoroscopy. The differences between the

top and bottom positions were defined as the moving distance

(D), and the D under resting or deep breathing was described

as D-resting or D-deep. D with or without APM were

expressed as D with or without APM. In the first set of 30

patients with resting breathing, D-resting with and without

APM were measured (Fig. 2). In the latter 35 patients with

deep breathing, D-deep with and without APM were mea-

sured. When the moving distance was too long in a patient

who had breathing without APM, the catheter was moved in

unison with the breathing movement.

The control rate for moving distances was calculated as

follows: control rate = 100 9 (D without APM - D with

APM)/D without APM. The calculation was performed

under conditions of resting or deep breathing (Fig. 2).

Statistics

Paired Student’s t test for each patient in group D without

APM and group D with APM was performed using JMP 9

software (SAS, Cary, NC).

Application for Clinical AVS

To evaluate technical feasibility, we applied APM in 37

patients in whom the catheter became disconnected from

the RAV either during venography or when collecting

blood. Sampling success with the APM was defined as

successful blood collection in one trial of right AVS.

Fig. 1 The press position of the hand in the APM. The press position

of the hand is the lower abdomen, which is out of the field of view on

fluoroscopy (the dotted-line square)

Fig. 2 Measurement of the moving distance under resting breathing

(D-resting) in a 56-year-old man. A Measurement of D-resting

without APM. B Measurement of D-resting with APM. The moving

difference between the top and bottom of the catheter tip position

during several resting breaths both with and without APM were

measured. The moving distance was successfully controlled by APM.

The control rate was calculated as 70 % [=100 9 (10.4 - 3.1)/0.4]

T. Araki et al.: Abdominal Pressing Maneuver During AVS

123

Results

In all patients with either resting breathing or deep

breathing, the APM successfully controlled the moving

distances (Fig. 3A). The average values for D-resting

without and with APM were 7.6 (SD 2.5) mm and 3.6 (SD

1.7) mm, respectively, which was significantly different.

The average values for D-deep without and with APM

were 16.3 (SD 5.2) mm and 8.6 (SD 3.8) mm, which was

also significantly different (Fig. 3B). The average control

rates under resting or deep breathing were 45 % [SD 17 %

(median 43 %)] and 50 % [SD 19 % (median 49 %)],

respectively.

The catheter was stable while using the APM in 33 of 37

patients, thus making it possible to successfully collect

blood in 1 trial. The catheter became disconnected in 4

patients even when using the APM, and 2 or 3 trials were

necessary to successfully collect blood. The success rate of

1 trial of right AVS using the APM was 88 %.

Discussion

According to previous reports, organ movements by resting

breathing were an average of 12 (SD 8) mm (range 7–28)

for the diaphragm and an average of 10 (SD 7) mm (range

5–17) for the liver [4, 6]. These results support our findings

under resting breathing. Breathing movement can be larger

during abdominal than during thoracic breathing. However,

patients who usually use abdominal breathing cannot easily

convert to thoracic breathing. These patients will become

accustomed to thoracic breathing only by stimulation of

pressing the abdomen.

Controlling movement using the APM has two advan-

tages. The first is the physical restriction of diaphragmatic

movement by pressing the abdomen. The second is that the

patient becomes strongly aware of the need to perform

thoracic breathing. Before this method is used, it is

important to check for abdominal diseases in patients, such

as abdominal aortic aneurysm. We press the patient’s

abdomen gently at first during observation of a catheter tip

while we indicate the movement of thoracic respiration,

which requires less abdominal movement. When the

patient cannot do this, we gradually press more firmly until

the patient learns to perform thoracic respiration.

A restriction belt device can also be pressed on the

patient’s abdomen [4]. However, the strength or the posi-

tion of abdominal pressing can be controlled more easily

by the APM than by the belt device according to the

patient’s condition, such as physical discomfort.

Breathing movement of the RAV can be successfully

controlled using the APM. The APM is considered con-

venient and feasible for successfully controlling respiration

movement in patients undergoing AVS.

Acknowledgments We received generous support from the tech-

nologists in our hospital. We express our gratitude to Hajime

Sakamoto, Hiroshi Kobayashi, and Shinji Ohshima.

Conflict of interest There are no conflict of interests in Takuji

Araki, Hiroki Okada and Tsutomu Araki.

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