Introduction. Primary aldosteronism is the most common cause of secondary hypertension. Adrenal vein sampling is the gold standard for subtyping primary aldosteronism. However, this procedure is technically challenging and often has a low success rate. Our center is one of the very few performing this technique in our country with an increasing experience. Objective. The aim of this study was to evaluate the role of the cortisol intraprocedural assay in improving the performance of adrenal vein sampling. Design. We enrolled all of the patients with primary aldosteronism that underwent adrenal vein sampling from February 2016 to April 2023. The cortisol intraprocedural assay was introduced in October 2021. Methods. We enrolled a total of 50 adrenal vein samplings performed on 43 patients with the diagnosis of primary aldosteronism. In this sample, 19 patients and 24 patients underwent adrenal vein sampling before and after intraprocedural cortisol measurement, respectively. The procedure was repeated in seven patients (one before and six after intraprocedural cortisol measurement), given the unsuccess of the first exam. Selectivity of the adrenal vein sampling was assumed if the serum cortisol concentration from the adrenal vein was at least five times higher than that of the inferior vena cava. Lateralization was assumed if the aldosterone to cortisol ratio of one adrenal vein was at least four times the aldosterone to cortisol ratio of the contralateral side. Results. The mean age of the patients that underwent adrenal vein sampling (N = 43) was 55.2 ± 8.9 years, and 53.5% (n = 23) were female. The mean interval between the diagnosis of hypertension and the diagnosis of primary aldosteronism was 9.8 years (±9.9). At diagnosis, 62.8% of the patients (n = 27) had hypokalemia (mean value of 3 mmol/L (±0.34)), 88.4% (n = 38) had adrenal abnormalities on preprocedural CT scan, and 67.4% (n = 29) described as unilateral nodules. There were no statistically significant differences in the patients’ baseline characteristics between the two groups (before and after intraprocedural cortisol measurement). Before intraprocedural cortisol measurement, adrenal vein sampling selectivity was achieved in 35% (n = 7) patients. Selectivity increased to 100% (30/30) after intraprocedural cortisol measurement (). With the exception of one patient who refused it, all patients with lateralized disease underwent unilateral adrenalectomy with normalization of the aldosterone to renin ratio postoperatively. Conclusions. The lack of effective alternatives in subtyping primary aldosteronism highlights the need to improve the success rate of adrenal vein sampling. In this study, intraprocedural cortisol measurement allowed a selectivity of 100%. Its addition to this procedure protocol should be considered, especially in centers with a low success rate.

中文翻译：

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肾上腺静脉采样在原发性醛固酮增多症治疗中的应用：术中皮质醇评估的附加价值

介绍。原发性醛固酮增多症是继发性高血压的最常见原因。肾上腺静脉取样是原发性醛固酮增多症分型的金标准。然而，这个过程在技术上具有挑战性，并且通常成功率较低。我们的中心是我国极少数开展这项技术且经验不断增加的中心之一。客观的。本研究的目的是评估皮质醇术中测定在改善肾上腺静脉采样性能中的作用。设计。我们纳入了 2016 年 2 月至 2023 年 4 月期间接受肾上腺静脉采样的所有原发性醛固酮增多症患者。皮质醇术中检测于 2021 年 10 月推出。我们总共对 43 名诊断为原发性醛固酮增多症的患者进行了 50 次肾上腺静脉采样。在该样本中，19 名患者和 24 名患者在术中皮质醇测量之前和之后分别接受了肾上腺静脉采样。鉴于第一次检查不成功，七名患者重复了该程序（一名在术中皮质醇测量之前，六名在术中皮质醇测量之后）。如果肾上腺静脉的血清皮质醇浓度至少比下腔静脉高五倍，则假定肾上腺静脉取样具有选择性。如果一条肾上腺静脉的醛固酮与皮质醇比率至少是对侧醛固酮与皮质醇比率的四倍，则假定侧化。结果。接受肾上腺静脉采样的患者（n  =43）的平均年龄为55.2±8.9岁，其中53.5%（n  =23）为女性。高血压诊断与原发性醛固酮增多症诊断之间的平均间隔为 9.8 年 (±9.9)。诊断时，62.8% 的患者 ( n  = 27) 患有低钾血症（平均值为 3 mmol/L (±0.34)），88.4% ( n  = 38) 的术前 CT 扫描显示肾上腺异常，67.4% ( n  = 29) 描述为单侧结节。两组患者的基线特征（术中皮质醇测量之前和之后）没有统计学上的显着差异。在术中皮质醇测量之前，35%（ n = 7）的患者实现了肾上腺静脉采样选择性 。术中皮质醇测量后选择性增加至 100% (30/30)（）。除一名患者拒绝外，所有患有单侧疾病的患者均接受单侧肾上腺切除术，术后醛固酮与肾素的比率正常化。结论。原发性醛固酮增多症分型缺乏有效的替代方法，凸显了提高肾上腺静脉采样成功率的必要性。在这项研究中，术中皮质醇测量的选择性为 100%。应考虑将其添加到该程序协议中，特别是在成功率较低的中心。