A New Spin on Adrenal Vein Sampling

Adrenal vein sampling (AVS) is experiencing a renaissance of sorts for a variety of reasons. While this procedure is well over 50 years old, for the first several decades of its existence it was hampered by published reports of poor outcomes, with diagnostic failure usually due to unsuccessful sampling of the right adrenal vein. There is rising demand for AVS due to increasing recognition of primary aldosteronism as an important and potentially surgically treatable cause of hypertension coupled with improved outcomes from the procedure. The latter has been the result of multiple valuable technical refinements to the procedure published over the past 20 years. These include description of the inferior emissary vein sign [1], preoperative CT [2] and the use of intra-procedure cone beam computed tomography (CBCT) [3] to help less experienced operators localize and successfully sample the right adrenal vein in particular. In this issue of CVIR, Hafezi-Nejad et al. have provided a systematic review based on publications describing the use of CBCT [4] and demonstrated that there is improved operator success using CBCT compared to not using it. The authors also found that certain demographic characteristics made the use of CBCT more valuable, including higher BMI and younger age. The authors temper their conclusions appropriately by stating that intra-procedural CT should not be used all the time, but rather selectively. Indeed, since there is significant radiation associated with CBCT, judicious application of this technology should be the rule. The authors suggest that less experienced operators or difficult cases would be criteria for the use of CBCT. …