BLOOD SCIENCES
DEPARTMENT OF CLINICAL BIOCHEMISTRY
Title of Document: Adrenal Vein Sampling
Q Pulse Reference No: DS/CB/DCB/EN/22
Authoriser: Peter Beresford
Version NO: 1
Page 1 of 2
Adrenal Vein Sampling
Indications
If biochemistry points to hyperaldosteronism, sampling right and left adrenal veins can differentiate between
unilateral or bilateral disease.
Contraindications
Bleeding tendency, accelerated hypertension, significant ischaemic heart disease, allergy to contrast. If patient
on aspirin/clopidogrel discuss with radiology.
Side effects
Bleeding, adrenal infarction or haemorrhage, venous thrombosis
Preparation
1.
2.
3.
4.
5.
6.
7.
Discontinue drugs:
Spironolactone, oestrogens
6 weeks
Diuretics
4 weeks
ACE Inhibitors and NSAIDs
2 weeks
Calcium antagonists
1 week
Sympathomimetics
1 week
Beta-blockers
1 week
Avoid Liquorice
If anti-hypertensive therapy needs to be continued then prazosin, doxazosin or bethanidine may be
used. Consider home BP monitoring.
Patient should be on unrestricted sodium intake before admission.
The day before the procedure, check FBC, U + E, INR, G + S.
Consent (done by radiology)
Fast overnight.
Synacthen 250 micrograms requires prescribing and ordering
Arrangements for the transfer of samples to laboratory. A clinical biochemist will be required to assist.
Procedure
The adrenal veins are catheterised under X-ray control via femoral vein access.
Bolus of Synacthen may be given 20 minutes prior to sampling.
Take samples simultaneously for cortisol and aldosterone from left and right adrenal veins and inferior vena
cava.
Interpretation
Normal adrenal vein aldosterone is 100–400ng/dl.
In aldosterone producing adenoma the ipsilateral value is 1000–10000ng/dl. A ratio of >10:1 between sides is
considered diagnostic by the Hammersmith.
Cortisol corrected aldosterone ratios are used in order to correct for dilutional effects. Aldosterone is divided by
the corresponding cortisol. The highest ratio is compared to the contra-lateral side ratio. If >4.0x higher it is
diagnostic, but >2.0 is suggestive, of an adenoma (Young et al, Surgery, 2004)
Adrenal and peripheral cortisol values are used to confirm cannulation with the typical ratio being >3:1 when no
synacthen is used. Alternatively comparing cortisol and adrenal androgen levels on the two sides can confirm
successful catheterisation.
Sensitivity and specificity
The main problem with this procedure is difficulty in catheterising the right adrenal vein with success varying
from 40-70%. This is because the catheter enters the inferior vena cava at an acute angle and may be multiple.
In patients in whom both adrenal veins are successfully cannulated this procedure is 90-95% successful in
correctly distinguishing between idiopathic (bilateral) hyperaldosteronism and
aldosterone producing adenoma by demonstrating a unilateral increase in aldosterone secretion.
BLOOD SCIENCES
DEPARTMENT OF CLINICAL BIOCHEMISTRY
Title of Document: Adrenal Vein Sampling
Q Pulse Reference No: DS/CB/DCB/EN/22
Authoriser: Peter Beresford
Version NO: 1
Page 2 of 2
WORKSHEET
Please print off these guidelines and use the worksheet to keep a record of which site the samples have been
taken from.
Right Adrenal Vein
Left Adrenal Vein
Inferior Vena Cava
3x serum
Cortisol
Time:
3x Li Heparin
Aldosterone
Time:
Sample No:
Sample No:
Specimen No:
Specimen No:
Cortisol
Time:
Aldosterone
Time:
Sample No:
Sample No:
Specimen No:
Specimen No:
Cortisol
Time:
Aldosterone
Time:
Sample No:
Sample No:
Specimen No:
Specimen No:
Laboratory processing
1. The assisting clinical biochemist will need to bring the samples direct to the laboratory as soon as possible
after the procedure.
2. They must make sure the samples are clearly labelled with the patient I.D, the site the sample was taken from
and that the correct laboratory specimen labels are applied.
3. They must make sure that the cortisol is NOT measured by NBT laboratory but sent with the
Aldosterone specimens to Charing Cross hospital.
4. The samples will require sending frozen and this should be supervised to make sure samples are sent
correctly.
5. Duplicate aliquots for each sample should be made and stored in the send-away freezer for reference.
6. The biochemist should telephone the send-away laboratory to let them know the samples have been sent.
7. The worksheet should be scanned onto the request for future reference.
References
1. Hammersmith Endobible
2. Case Detection, Diagnosis and treatment of Patients with Primary Aldosteronism. The Endocrine Society’s
Clinical Guidelines. J Clin Endocrinol Metab 93: 3266-3281, 2008.