The Department of Cardiology at Shanghai General Hospital Carries Out An Innovative " Transmedian Cubital Combined with Transfemoral Vein Catheterization in Simultaneous Adrenal Vein Sampling (AVS) " to Target the "Culprit" of Hypertension

Link of the Original Article:

https://mp.weixin.qq.com/s/aPpv48vkmtuonfqdmPuDKA

If hypertension is "less effective" with the drug, then it may be wrong with the adrenal gland. Recently, the Department of Hypertension of Shanghai General Hospital Cardiovascular Center, along with the Department of Endocrinology, Department of Urology, and the Department of Laboratory Medicine, used an innovative "Transmedian cubital combined with transfemoral vein catheterization in simultaneous Adrenal Vein Sampling" to subtype a patient with "primary aldosteronism".After the sophisticated procedure was successfully performed, the patient was properly treated.

Mr. Chen has been suffering from hypertension for more than 20 years and his blood pressure was marginally controlled with drugs. Recently, he always felt fatigued and had a poor appetite, and his blood pressure reached 160-170/90-100 mmHg even though he was taking anti-hypertensive drugs as usual.

Zhi Zhang, the deputy director of the hypertension department (North Campus) examined Mr. Chen’s condition and did relevant tests such as serum potassium and other indexes of hypertension. The test results revealed that Mr. Chen's blood potassium was low and his aldosterone level was elevated. Additonlly, his aldosterone-to-renin ratio (ARR) was much higher than normal, reaching 171, which meant that Mr. Chen's high blood pressure might be secondary hypertension due to "primary aldosteronism". Subsequently, further Adrenal CT examination also leads to this impression. His left adrenal was hyperplasia with a vague small nodule, which was highly suspected as "adrenal adenoma".

Primary aldosteronism (PA) means that the adrenal cortex is "overexcited" and overproduces aldosterone, resulting in resistant hypertension and hypokalemia which was related to fatigue,  loss of appetite, nausea, and vomiting. An adrenal adenoma is the most common cause of primary aldosteronism, accounting for 60% to 70% of cases.

Since the diagnosis of PA is relatively clear, then the next difficult step is to categorize the  PA. Doctors need to lateralize Mr. Chen's adrenal lesion. Is it a unilateral or bilateral lesion? If it is unilateral, which side is the " dominant side"? Strategies are determined by lateralization. And correct strategy could relieve the patient's symptoms. For this reason, Prof. Zhi Zhang’s team performed bilateral adrenal vein sampling (AVS) for him.

AVS is currently recognized as the "gold standard" for subtyping Primary Aldosteronism. Because of the difficulty of this technique, it has not been widely performed in China. At the same time, because cortisol is secreted in a pulsatile manner if blood is taken from both adrenal glands non-simultaneously, there is a risk of false discrepancy in cortisol concentration between the two adrenal glands caused by time lag, which may lead to false lateralization.

To overcome this problem, the hypertension specialized team of Shanghai General Hospital, developed the "Transmedian cubital combined with transfemoral vein catheterization in simultaneous Adrenal Vein Sampling", together with the point-of-care cortisol test, which greatly improved the success rate and accuracy of AVS. The innovation was based on the findings that the median cubital vein approach makes it easy to catheterize the left adrenal vein, while the femoral vein approach greatly improves the success rate of right adrenal vein catheterization. On the day of the examination, the team used the technique to take blood from the bilateral adrenal veins for Mr. Chen, and the data were double-checked by an ACTH stimulation method. Finally, they successfully located the left adrenal adenoma and provided an adrenal venous sampling-guided left adrenalectomy. Shortly after the adrenalectomy, Mr. Chen's blood pressure returned to normal and his previous symptoms were all gone.

According to the literature, the proportion of patients with primary aldosteronism in resistant hypertension can reach as high as 30%. Therefore, patients with resistant hypertension in whom the drugs don’t work effectively should be fully alert to the possibility of " primary aldosteronism ". After the diagnosis of PA is confirmed, lateralization of the lesion should be judged by AVS. If unilateral predominance is confirmed, PA is possible to achieve complete relief through surgery. Percutaneous adrenal artery embolization (SAAE) may also be considered for patients who are intolerant to the surgery or those who are worried about the surgery.

This article originated from Wen Hui Journal on Aug.2, 2022

Correspondent: Yang Hu, Department of Publicity 

Editor: Shishi Cai, Department of Publicity