Best Practices: Indications and Procedural Controversies of Adrenal Vein Sampling for Primary Aldosteronism

Primary hyperaldosteronism (PA) is the most common secondary form of hypertension in middle-aged adults. Its harmful effects exceed those of essential hypertension. Once PA is diagnosed, treatment hinges on whether aldosterone secretion is unilateral or bilateral, as the former can be effectively treated with adrenalectomy but the latter is treated medically with mineralocorticoid receptor antagonists such as spironolactone or eplerenone. Adrenal vein sampling (AVS) is critical in this determination. There is wide variation in how AVS is performed, including whether to use synthetic adrenocorticotropic hormone stimulation and where the catheter tip should be placed during left adrenal gland sampling. In addition, some institutions and guidelines omit AVS in young patients (i.e., those younger than an age threshold ranging from 35 to 40 years old) who have unilateral adrenal findings on cross-sectional imaging. In this article, we provide background on PA and performance of AVS and then summarize the evidence supporting best practices for these three areas of controversy regarding how and when to perform AVS.

Automated summary

Primary hyperaldosteronism (PA) is the most common secondary form of hypertension in middle-aged adults. Treatment options depend on the extent of aldosterone secretion, with unilateral cases treated surgically and bilateral cases treated medically. Adrenal vein sampling (AVS) is crucial in determining the appropriate treatment approach, but there is variability in AVS techniques and guidelines regarding its use in young patients with unilateral adrenal findings on imaging.