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Renal and Adrenal Veins: Sampling and Intervention
Keith B. Quencer, MD
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KEY FACTS

  • Preprocedure

    • Procedure

      TERMINOLOGY

      • Synonyms

        • Adrenal vein sampling (AVS)
          • Primary (hyper) aldosteronism (PA), aldosterone-producing adenoma (APA), bilateral adrenal hyperplasia (BAH)
        • Renal vein renin sampling (RVRS)
          • Renal artery stenosis (RAS), renal vascular hypertension (RVH), plasma renin activity (PRA)
        • Nutcracker syndrome (NCS), nutcracker phenomena (NCP)
      • Definitions

        • Primary aldosteronism (PA): Renin-independent hypersecretion of aldosterone by adrenal glands
          • Suspected if patient has refractory HTN ± hypokalemia
            • Autonomous aldosterone secretion leads to elevated serum aldosterone:renin ratio
          • Cause of 5-20% of all cases of HTN
            • PA more difficult to treat and has higher rate of morbidity and mortality consistent with essential HTN
        • NCP
          • Left renal vein (LRV) compression between superior mesenteric artery (SMA)/abdominal aorta
          • NCS if symptomatic
            • Left flank pain, pelvic pain, and microscopic hematuria
            • May also result in varicocele or pelvic congestion syndrome
          • Has been treated with LRV stent with varying degrees of success
            • Surgical alternatives include LRV transposition, renal autotransplant, gonadal vein transposition
      • Adrenal Vein Anatomy

        • Right: Drains directly into inferior vena cava (IVC)
          • Typically located T12-L1, enters posterolateral
          • 4-5 cm above right renal vein
          • Rare communication with accessory hepatic veins
        • Left: Joins inferior phrenic vein to form common trunk
          • Drains into superior aspect of LRV
          • Typically located 3-5 cm from LRV orifice
      • Renal Vein Anatomy

        • LRV courses between aorta and SMA to join IVC
          • Anterior NCP: Compression between aorta and SMA
          • Posterior NCP: Compression of retroaortic LRV between aorta and vertebral column
        • Right renal vein is shorter, drains into IVC at ~ L2 vertebral level

      PREPROCEDURE

      • Indications

        • Contraindications

          • Preprocedure Imaging

            • Special Considerations

              • Getting Started

                PROCEDURE

                • Patient Position/Location

                  • Procedure Steps

                    • Findings and Reporting

                      • Alternative Procedures/Therapies

                        POST PROCEDURE

                        • Expected Outcome

                          • Things to Do

                            • Things to Avoid

                              • Interpreting Results

                                OUTCOMES

                                • Problems

                                  • Complications

                                    • Expected Outcomes

                                      Selected References

                                      1. Loberg C et al: Update: selective adrenal venous sampling (AVS) - indication, technique, and significance. Rofo. 193(6):658-66, 2021
                                      2. Quencer KB: Adrenal vein sampling: technique and protocol, a systematic review. CVIR Endovasc. 4(1):38, 2021
                                      3. Rossi GP: Primary aldosteronism: JACC state-of-the-art review. J Am Coll Cardiol. 74(22):2799-811, 2019
                                      4. Ota H et al: Dynamic multidetector CT and non-contrast-enhanced MR for right adrenal vein imaging: comparison with catheter venography in adrenal venous sampling. Eur Radiol. 26(3):622-30, 2016
                                      5. Rossi GP et al: An expert consensus statement on use of adrenal vein sampling for the subtyping of primary aldosteronism. Hypertension. 63(1):151-60, 2014
                                      6. Wolley M et al: Reninoma: the importance of renal vein renin ratios for lateralisation and diagnosis. Am J Nephrol. 39(1):16-9, 2014
                                      7. Kahn SL et al: Adrenal vein sampling. Tech Vasc Interv Radiol. 13(2):110-25, 2010
                                      8. Kurklinsky AK et al: Nutcracker phenomenon and nutcracker syndrome. Mayo Clin Proc. 85(6):552-9, 2010
                                      Related Anatomy
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                                      Related Differential Diagnoses
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                                      References
                                      Tables

                                      Tables

                                      KEY FACTS

                                      • Preprocedure

                                        • Procedure

                                          TERMINOLOGY

                                          • Synonyms

                                            • Adrenal vein sampling (AVS)
                                              • Primary (hyper) aldosteronism (PA), aldosterone-producing adenoma (APA), bilateral adrenal hyperplasia (BAH)
                                            • Renal vein renin sampling (RVRS)
                                              • Renal artery stenosis (RAS), renal vascular hypertension (RVH), plasma renin activity (PRA)
                                            • Nutcracker syndrome (NCS), nutcracker phenomena (NCP)
                                          • Definitions

                                            • Primary aldosteronism (PA): Renin-independent hypersecretion of aldosterone by adrenal glands
                                              • Suspected if patient has refractory HTN ± hypokalemia
                                                • Autonomous aldosterone secretion leads to elevated serum aldosterone:renin ratio
                                              • Cause of 5-20% of all cases of HTN
                                                • PA more difficult to treat and has higher rate of morbidity and mortality consistent with essential HTN
                                            • NCP
                                              • Left renal vein (LRV) compression between superior mesenteric artery (SMA)/abdominal aorta
                                              • NCS if symptomatic
                                                • Left flank pain, pelvic pain, and microscopic hematuria
                                                • May also result in varicocele or pelvic congestion syndrome
                                              • Has been treated with LRV stent with varying degrees of success
                                                • Surgical alternatives include LRV transposition, renal autotransplant, gonadal vein transposition
                                          • Adrenal Vein Anatomy

                                            • Right: Drains directly into inferior vena cava (IVC)
                                              • Typically located T12-L1, enters posterolateral
                                              • 4-5 cm above right renal vein
                                              • Rare communication with accessory hepatic veins
                                            • Left: Joins inferior phrenic vein to form common trunk
                                              • Drains into superior aspect of LRV
                                              • Typically located 3-5 cm from LRV orifice
                                          • Renal Vein Anatomy

                                            • LRV courses between aorta and SMA to join IVC
                                              • Anterior NCP: Compression between aorta and SMA
                                              • Posterior NCP: Compression of retroaortic LRV between aorta and vertebral column
                                            • Right renal vein is shorter, drains into IVC at ~ L2 vertebral level

                                          PREPROCEDURE

                                          • Indications

                                            • Contraindications

                                              • Preprocedure Imaging

                                                • Special Considerations

                                                  • Getting Started

                                                    PROCEDURE

                                                    • Patient Position/Location

                                                      • Procedure Steps

                                                        • Findings and Reporting

                                                          • Alternative Procedures/Therapies

                                                            POST PROCEDURE

                                                            • Expected Outcome

                                                              • Things to Do

                                                                • Things to Avoid

                                                                  • Interpreting Results

                                                                    OUTCOMES

                                                                    • Problems

                                                                      • Complications

                                                                        • Expected Outcomes

                                                                          Selected References

                                                                          1. Loberg C et al: Update: selective adrenal venous sampling (AVS) - indication, technique, and significance. Rofo. 193(6):658-66, 2021
                                                                          2. Quencer KB: Adrenal vein sampling: technique and protocol, a systematic review. CVIR Endovasc. 4(1):38, 2021
                                                                          3. Rossi GP: Primary aldosteronism: JACC state-of-the-art review. J Am Coll Cardiol. 74(22):2799-811, 2019
                                                                          4. Ota H et al: Dynamic multidetector CT and non-contrast-enhanced MR for right adrenal vein imaging: comparison with catheter venography in adrenal venous sampling. Eur Radiol. 26(3):622-30, 2016
                                                                          5. Rossi GP et al: An expert consensus statement on use of adrenal vein sampling for the subtyping of primary aldosteronism. Hypertension. 63(1):151-60, 2014
                                                                          6. Wolley M et al: Reninoma: the importance of renal vein renin ratios for lateralisation and diagnosis. Am J Nephrol. 39(1):16-9, 2014
                                                                          7. Kahn SL et al: Adrenal vein sampling. Tech Vasc Interv Radiol. 13(2):110-25, 2010
                                                                          8. Kurklinsky AK et al: Nutcracker phenomenon and nutcracker syndrome. Mayo Clin Proc. 85(6):552-9, 2010