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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)
- Adrenal vein sampling (AVS)
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
- Suspected if patient has refractory HTN ± hypokalemia
- 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
- Primary aldosteronism (PA): Renin-independent hypersecretion of aldosterone by adrenal glands
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
- Right: Drains directly into inferior vena cava (IVC)
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
- LRV courses between aorta and SMA to join IVC
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
- Loberg C et al: Update: selective adrenal venous sampling (AVS) - indication, technique, and significance. Rofo. 193(6):658-66, 2021
- Quencer KB: Adrenal vein sampling: technique and protocol, a systematic review. CVIR Endovasc. 4(1):38, 2021
- Rossi GP: Primary aldosteronism: JACC state-of-the-art review. J Am Coll Cardiol. 74(22):2799-811, 2019
- 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
- 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
- Wolley M et al: Reninoma: the importance of renal vein renin ratios for lateralisation and diagnosis. Am J Nephrol. 39(1):16-9, 2014
- Kahn SL et al: Adrenal vein sampling. Tech Vasc Interv Radiol. 13(2):110-25, 2010
- Kurklinsky AK et al: Nutcracker phenomenon and nutcracker syndrome. Mayo Clin Proc. 85(6):552-9, 2010
Related Anatomy
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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)
- Adrenal vein sampling (AVS)
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
- Suspected if patient has refractory HTN ± hypokalemia
- 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
- Primary aldosteronism (PA): Renin-independent hypersecretion of aldosterone by adrenal glands
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
- Right: Drains directly into inferior vena cava (IVC)
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
- LRV courses between aorta and SMA to join IVC
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
- Loberg C et al: Update: selective adrenal venous sampling (AVS) - indication, technique, and significance. Rofo. 193(6):658-66, 2021
- Quencer KB: Adrenal vein sampling: technique and protocol, a systematic review. CVIR Endovasc. 4(1):38, 2021
- Rossi GP: Primary aldosteronism: JACC state-of-the-art review. J Am Coll Cardiol. 74(22):2799-811, 2019
- 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
- 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
- Wolley M et al: Reninoma: the importance of renal vein renin ratios for lateralisation and diagnosis. Am J Nephrol. 39(1):16-9, 2014
- Kahn SL et al: Adrenal vein sampling. Tech Vasc Interv Radiol. 13(2):110-25, 2010
- Kurklinsky AK et al: Nutcracker phenomenon and nutcracker syndrome. Mayo Clin Proc. 85(6):552-9, 2010
