TECHNICAL NOTE

Coaxial Guide Wire Placement in the Right Adrenal Veinfor Repeated Adrenal Venous Samplings

Youri Kaitoukov • Gilles Soulez • Vincent L. Oliva •

Marie-France Giroux • Isabelle Bourdeau •

Andre Lacroix • Patrick Gilbert • Eric Therasse

Received: 21 July 2013 / Accepted: 27 October 2013

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

Abstract

Purpose Many adrenal venous sampling (AVS) protocols

require repeated samplings before and after adrenocorti-

cotrophic hormone (ACTH) stimulation. Maintaining

catheter selectivity in the adrenal vein over time is essential

but can be challenging, especially in the short right adrenal

vein, where the catheter is often in an unstable position.

The aim of our study was to evaluate guide wire insertion

into the right adrenal vein catheter to sustain AVS selec-

tivity (adrenal/peripheral cortisol ratio [Ca/Cp]) over time.

Methods This retrospective investigation was approved by

our institutional review board, and informed consent was

obtained. A 0.014-inch guide wire was inserted in the right

adrenal vein 5F catheter to secure its positioning and to

facilitate blood sampling. Plasma cortisol levels from the left

and right adrenal veins and left iliac vein were assessed in

117 consecutive patients undergoing bilateral, simultaneous

sets of AVS at -5 and 0 min (baseline) and 5, 10, and 15 min

after intravenous bolus of 250 lg ACTH (stimulated). Ca/Cp

ratios of C2 for baseline and[10 for stimulated AVS were

considered selective.

Results The first sampling, at time -5 min, was nonselec-

tive in 41 of 116 (35.3 %) right and 30 of 116 (25.9 %) left

AVSs retained for analysis. In patients with a selective first

sampling, 74 of 75 (98.7 %) right and 85 of 86 (98.8 %) left

AVSs were selective in all post-ACTH samplings. Right and

left selectivity rates were not statistically different (p [ 0.87).

No complications arose from guide wire insertion.

Conclusion Guide wire insertion into the right adrenal

vein catheter is safe and effective to maintain AVS selec-

tivity over time.

Keywords Adrenal venous sampling � Primary

hyperaldosteronism � Protocol � Technique

Introduction

Primary aldosteronism (PA), currently estimated to occur in

more than 10 % of the hypertensive population, is the most

frequent cause of nonessential hypertension [1]. Although

bilateral PA is treated medically, 43 % of PA cases have a

surgically curable unilateral form [2, 3]. Identifying lateralized

forms of PA is important for selecting patients who could benefit

from surgery (unilateral adrenalectomy). This management

Y. Kaitoukov � G. Soulez � V. L. Oliva � M.-F. Giroux �P. Gilbert � E. Therasse (&)

Division of Interventional Radiology, Department of Radiology,

Centre Hospitalier de l’Universite de Montreal (CHUM), 3840

Saint-Urbain St, Montreal, QC H2W 1T8, Canada

e-mail: eric.therasse.chum@ssss.gouv.qc.ca

Y. Kaitoukov

e-mail: youri13@gmail.com; youri.kaitoukov@umontreal.ca

G. Soulez

e-mail: gilles.soulez.chum@ssss.gouv.qc.ca

V. L. Oliva

e-mail: voliva@sympatico.ca;

vincent.oliva.chum@ssss.gouv.qc.ca

M.-F. Giroux

e-mail: m_fgiroux@videotron.ca

P. Gilbert

e-mail: gilbert_patrick@hotmail.com

I. Bourdeau � A. Lacroix

Division of Endocrinology, Department of Medicine, Centre

Hospitalier de l’Universite de Montreal (CHUM), 3840 Saint-

Urbain St, Montreal, QC H2W 1T8, Canada

e-mail: isabelle.bourdeau@umontreal.ca

A. Lacroix

e-mail: andre.lacroix@umontreal.ca

123

Cardiovasc Intervent Radiol

DOI 10.1007/s00270-013-0794-9

approach is imperative to minimize the multiorgan and vascular

toxicities from long-term hyperaldosteronism [4, 5].

Adrenal gland imaging by computed tomography (CT)

scan or magnetic resonance imaging (MRI) cannot reliably

differentiate bilateral from unilateral PA subtypes because

hormone secretion cannot be assessed [6–8]. A systematic

CT and MRI review of 950 patients from 38 studies con-

cluded that adrenal imaging alone, without adrenal venous

sampling (AVS), may lead to 14.6 % inappropriate

adrenalectomies, 19.1 % missed unilateral functional

tumors, and 3.9 % resections on the wrong side [9].

AVS is the gold standard for identifying lateralized forms

of PA (defined as an adrenal aldosterone/cortisol ratio of[4

times the opposite side) [1]. It is a challenging procedure that

requires cannulation of both adrenal veins for blood sam-

pling either at baseline and/or after stimulation with adre-

nocorticotrophic hormone (ACTH). Right adrenal vein

cannulation is difficult because the vein is small and short,

and it drains directly into the inferior vena cava, where its

ostium presents significant anatomical variability [10, 11].

Respiratory movement may also reduce the catheter stabil-

ity. The left adrenal vein has less anatomic variation; it nearly

always drains to the left renal vein. Catheterization is often

much more stable than on the right side.

Although subject to debate in the literature, many centers

have adopted repeated sampling AVS protocols before and

after ACTH stimulation [12]. In our experience, determining

catheter selectivity with biochemical markers (using adre-

nal/peripheral cortisol ratio [Ca/Cp]) has a higher sensitivity

after ACTH stimulation, while the side of aldosterone

hypersecretion is better determined on basal samplings

(before ACTH stimulation). Repeated sampling protocols

require the catheter tip to remain in the adrenal veins over

time. Maintenance of stable catheter position is desired to

avoid unnecessary catheter manipulations between sam-

plings. Repeated catheter cannulation or wedging in the

adrenal veins increases procedure time, labor intensity and

may be traumatic or result in inability to draw blood.

For many years, we have inserted micro–guide wires

coaxially into the right adrenal vein to stabilize the catheter

and maintain its selectivity over time. The aim of this study

was to evaluate whether guide wire insertion in the right

adrenal vein catheter could safely stabilize it to sustain

AVS selectivity over time to similar high levels as those

generally seen on the left side.

Materials and Methods

Study Population

Our retrospective investigation was approved by our insti-

tutional review board and complied with Health Insurance

Portability and Accountability Act regulations. We

reviewed the medical and imaging files of all 117 patients

who had clinically and biochemically confirmed PA and

were referred to our institution for AVS between 1989 and

2011. All patients were medically admissible and consented

to adrenalectomy if the unilateral source of hyperaldoste-

ronism was found. At least 2 months before AVS, sodium

intake was normalized and medications were adjusted to

prevent interference with patients’ native aldosterone pro-

duction [7, 13]. Hypokalemia, if present, was corrected with

oral or intravenous potassium supplements.

AVS Technique

AVSs were undertaken by bilateral femoral venous

approach. The left adrenal vein was catheterized with a

Simmons 5F medium or large curve catheter (Cordis, Miami,

FL) and the right adrenal vein, with either a Chuang 2.5 5F

catheter (Cook, Bloomington, IN), Simmons 5F small curve

catheter, or Cobra 5F medium curve catheter (Cook). In all

patients, the left adrenal vein catheter was inserted through a

6F sheath, allowing simultaneous blood sampling of both

adrenal veins and left common iliac vein. Two side holes

were manually created a few millimeters from the catheter

tip to ease blood withdrawal. The distal tip of a 0.014-inch

hydrophilic guide wire (Transend, Boston Scientific, Fre-

mont, CA) was positioned in the 5F catheter through a Y

rotating hemostatic valve and advanced about 1–2 cm into

the right adrenal vein to stabilize it and ease blood sampling

during AVS by preventing adrenal vein collapse during

blood aspiration (Fig. 1). Proper catheter positioning was

verified by gentle injection of contrast media into both

adrenal veins (Fig. 2) before the first venous sampling, and

3,000 units of heparin were then administered intravenously.

Blood samples were drawn simultaneously, with minimal

negative pressure, from both adrenal veins and left iliac vein

5 min before, immediately before, and 5, 10, and 15 min

after intravenous bolus injection of 250 lg of cosyntropin

(Cortrosyn, Organon Pharmaceuticals, West Orange, NJ).

Heparinized normal saline drip was perfused into the cath-

eters between sequential blood samplings.

Before each sampling, removal of dead space volume

from the catheter was achieved by aspirating the saline

until blood was seen. AVS was considered selective when

the Ca/Cp ratio was C2 without (t = -5 min) and [10

with ACTH stimulation (t = ?15 min) [14].

Analysis

The inclusion criterion were all initial and repeated AVS

attempts. Exclusion criteria were technically impossible

catheterization of either adrenal vein and AVSs that were

not biochemically selective (Ca/Cp ratio of C2) in the

Y. Kaitoukov et al.: Coaxial Guide Wire Placement

123

initial (-5 min) sampling. Among patients with biochem-

ically selective first sampling, the Chi square test compared

the percentage of AVSs between the right and left sides

that remained selective until the last sampling (20 min after

the first sampling).

Results

In total, 117 patients (83 men and 34 women), aged

29–75 years, underwent AVS in our institution from 1989

to 2011 (Fig. 3). The procedure was repeated in 10 patients

because of biochemically nonselective sampling on one or

both sides (9 cases) or inconclusive results of lateralization

despite adequate selectivity (1 case).

Technical AVS failure attributed to inability to catheter-

ize the right adrenal vein (3 AVSs) or to withdraw blood from

it (2 AVSs) was encountered in 5 cases. Six additional cases

were excluded because no or partial information regarding

their biochemical tests was available in our hospital com-

puter system, presumably as a result of misidentified or lost

sample tubes. Technical failure to position the micro–guide

wire in the right adrenal vein catheter occurred in 1 (0.9 %)

patient. In general, once the catheter was inside the right

adrenal vein, micro–guide wire insertion took\5 min.

Out of 116 AVS eligible for analysis, 41 (35.3 %) right

and 30 (25.9 %) left AVSs were considered nonselective in

the first sampling at time -5 min, according to the basal

Ca/Cp ratio of \2 threshold and were excluded from ana-

lysis. However, 21 of the 41 (51 %) right and 26 of the 30

(87 %) left AVSs considered to be nonselective on baseline

threshold (Ca/Cp ratio of C2) were, in fact, selective

according to the Ca/Cp ratio of [10 criterion after ACTH

stimulation. Therefore, selectivity of the first baseline AVS

was, in fact, at least 83 % (96 of 116) for the right and at

least 97 % (112 of 116) for the left adrenal vein. However,

we kept the Ca/Cp ratio of C2 basal sampling selectivity

criteria to prevent any verification bias.

From 75 right and 86 left sets of AVSs that were

selective on first baseline sampling (Ca/Cp ratio of C2), 74

right and 85 left samplings remained selective until the last

blood withdrawal, 15 min after ACTH stimulation (i.e.,

20 min after the first sampling at t = -5 min), represent-

ing similar selectivity rates of 98.7 % on the right and

98.8 % on the left (p \ 0.87). There were no instances

where access was lost and needed to be regained. In our

review, no contrast extravasations were noted with the

micro–guide wire–assisted technique. No adverse events,

retroperitoneal hemorrhage or signs of dissection were

apparent in relation to micro–guide wire insertion.

Discussion

AVS is a highly sensitive and specific method of dis-

criminating between unilateral aldosterone-secreting ade-

nomas and bilateral idiopathic hyperplasia [3]. However,

AVS sampling can be challenging with technical difficul-

ties in catheterizing and maintaining catheter position in

the right adrenal vein [11, 15]. The technical success rates

of catheter positioning and maintaining access during AVS

are reported to be close to 60–70 % on the right and over

90 % on the left [16, 17].

As demonstrated in this study, the added selectivity

detection provided by ACTH stimulation supports the use

Fig. 1 Chuang 2.5 5F catheter (Cook, Bloomington, IN) (left) with

coaxially inserted 0.014-inch hydrophilic guide wire (Transend,

Boston Scientific, Fremont, CA) and 5F Simmons medium curve

catheter (Cordis, Miami, FL) (right) for right and left AVSs,

respectively

Fig. 2 Selective retrograde right adrenal phlebography with a

Chuang 2.5 5F catheter and coaxial positioning of a micro–guide

wire inside the adrenal vein

Y. Kaitoukov et al.: Coaxial Guide Wire Placement

123

of protocols with repeated AVSs before and after ACTH

bolus injection. Continuous ACTH infusion approach

requires a prolonged infusion period, starting before the

patient enters the angiography suite in order to achieve a

steady-state aldosterone secretion, allowing for successive

right and then left AVS with a single catheter. Contrary to

the bolus ACTH approach, this protocol does not allow for

basal and stimulated sampling to be performed in the same

session. However, post-ACTH-stimulated samplings need

to be drawn simultaneously rather than sequentially from

the right and left adrenal veins because aldosterone secre-

tion is not stable but rapidly increases over time.

This study demonstrates that coaxial placement of a

micro–guide wire in the right adrenal vein during simul-

taneous, repeated AVS is associated with high-level

maintenance of catheter selectivity, similar to that of much

more stable left adrenal vein catheters. Micro–guide wire

insertion not only helps to maintain catheter selectivity but

also assists in assessing catheter positioning during the

procedure by intermittently monitoring wire configuration

with fluoroscopy. In addition, we also found that there is

improved flow through the catheter after placement of a

wire, speeding up the sampling and reducing the chance of

having the sample coagulate.

Because the catheter tends to slip out of the right adrenal

vein with breathing movements, angiographers are tempted

to push it slightly further into this small and fragile vessel,

risking venous rupture or dissection, which may result in

adrenal infarction and technical AVS failure [15]. By

inserting a 0.014-inch guide wire through the right-sided

catheter and pushing it slightly further into the vein, the

catheter is prevented from slipping out between samplings.

The main limitations of this study are its retrospective

nature and that it does not provide a control group with no

guide wire. It rather evaluates selectivity between both sides.

However, maintaining similar selectivity levels on both sides

([98 %) is encouraging, especially considering the well-

known right adrenal vein catheterization difficulties reported

in the literature [18]. An additional limitation of this retro-

spective study is that it does not completely exclude the

possibility that access was lost and regained during the

procedures. The relatively high baseline Ca/Cp threshold

tested in our study also excluded a significant number of

AVSs (35.3 % of the right and 25.9 % of the left side) from

analysis. However, lateralization of aldosterone hyperse-

cretion with AVS can only be assessed if the catheters are

selectively inserted into the adrenal veins with a high level of

certainty. Ca/Cp ratio thresholds for catheter selectivity vary

significantly in the literature [14]. Some authors consider that

a Ca/Cp ratio of[1.1 is sufficient, but others believe that this

ratio should be above 2 or 3 [10]. Although a higher selec-

tivity threshold increased the number of falsely nonselective

samplings, it ensured that all adrenal vein catheters analyzed

were really inside the adrenal vein at AVS onset, which was

an essential requirement in our study.

This study demonstrates that coaxial placement of a

micro–guide wire in the right adrenal vein during simul-

taneous, repeated AVS is associated with high-level

maintenance of catheter selectivity similar to that of much

more stable left adrenal vein catheters.

Fig. 3 Outline of adrenal

venous samplings

Y. Kaitoukov et al.: Coaxial Guide Wire Placement

123

Conflict of interest The authors declare that they have no conflict

of interest.

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