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Venous Sampling and Venography: Endocrine, Nonadrenal
Keith B. Quencer, MD; T. Gregory Walker, MD, FSIR; Brandt C. Wible, MD
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KEY FACTS

  • Terminology

    • Preprocedure

      • Procedure

        TERMINOLOGY

        • Definitions

          • Cushing syndrome
            • Clinical complex caused by prolonged inappropriate glucocorticoid exposure
            • Endogenous Cushing
              • Adrenocorticotrophic hormone (ACTH) sources
                • Pituitary tumor
                • Adrenal neoplasm
                • Ectopic ACTH (e.g., lung cancer)
            • MR not sensitive or specific for adenoma ACTH production
              • 40-50% of pituitary Cushing patients have no lesion
              • 10% of population aged 30-40 years harbor incidental pituitary abnormality
                • Lesion presence does not imply functionality
            • Inferior petrosal sinus sampling (IPSS)
              • Venous blood sampling from both inferior petrosal sinuses
              • Evaluates for ACTH-secreting pituitary adenoma as etiology for endogenous Cushing syndrome
              • Considered gold standard for confirming origin of ACTH secretion in Cushing syndrome
          • Functioning pancreatic endocrine tumors
            • Insulinoma (most common)
              • Symptoms: Hypoglycemia, palpitations, diplopia; elevated serum insulin and C-peptide levels
              • 75% solitary and benign; 10% malignant
            • Gastrinoma (2nd most common)
              • Leads to Zollinger-Ellison syndrome
                • Severe peptic ulcer disease, gastric hypersecretion, elevated serum gastrin, diarrhea, and non-B islet cell tumor
                • Gastrinomas can be intrapancreatic or extrapancreatic, solitary or multiple
            • Most often localized via cross-sectional imaging
              • Lesions < 1 cm may be difficult to visualize
            • Selective arterial calcium stimulation with hepatic venous sampling (SACST)
              • Used for preoperative localization of pancreatic endocrine tumors
          • hyperparathyroidism
            • Estimated prevalence of 1:1,000
              • Hypercalcemia with high or inappropriately normal parathyroid hormone (PTH) level
            • 85% of cases secondary to parathyroid adenoma
              • 10% of parathyroid adenomas may be in ectopic location; 5-10% of parathyroid glands ectopic
                • Ectopic locations: Anterior mediastinum (10%), posterior mediastinum (3-5%), within thyroid gland (1-3%), and retroesophageal (1%)
            • Selective venous sampling (SVS)
              • Sampling from veins draining parathyroid gland for PTH assay
              • Localization imaging includes ultrasound, scintigraphy (Tc-99m sestamibi), CT, MR
              • Invasive procedure of SVS also used for localization

        PREPROCEDURE

        • Indications

          • Getting Started

            PROCEDURE

            • Patient Position/Location

              • Procedure Steps

                • Findings and Reporting

                  • Alternative Procedures/Therapies

                    POST PROCEDURE

                    • Interpreting Results

                      • Things to Do

                        • Things to Avoid

                          OUTCOMES

                          • Complications

                            • Expected Outcomes

                              Selected References

                              1. Perlman JE et al: Pitfalls in performing and interpreting inferior petrosal sinus sampling: personal experience and literature review. J Clin Endocrinol Metab. 106(5):e1953-67, 2021
                              2. Vassiliadi DA et al: Inferior petrosal sinus sampling in Cushing's syndrome: usefulness and pitfalls. Endocrine. 73(3):530-9, 2021
                              3. Zolin SJ et al: Selective parathyroid venous sampling in reoperative parathyroid surgery: a key localization tool when noninvasive tests are unrevealing. Surgery. 169(1):126-32, 2021
                              4. Hatoko T et al: Low-dose selective arterial calcium stimulation test for localizing insulinoma: a single-center experience of five consecutive cases. Intern Med. 59(19):2397-403, 2020
                              5. Zampetti B et al: Bilateral inferior petrosal sinus sampling. Endocr Connect. 5(4):R12-25, 2016
                              6. Kunstman JW et al: Clinical review: parathyroid localization and implications for clinical management. J Clin Endocrinol Metab. 98(3):902-12, 2013
                              7. Okabayashi T et al: Diagnosis and management of insulinoma. World J Gastroenterol. 19(6):829-37, 2013
                              8. Ito F et al: The utility of intraoperative bilateral internal jugular venous sampling with rapid parathyroid hormone testing. Ann Surg. 245(6):959-63, 2007
                              9. Lad SP et al: The role of inferior petrosal sinus sampling in the diagnostic localization of Cushing's disease. Neurosurg Focus. 23(3):E2, 2007
                              10. Lau JH et al: The current role of venous sampling in the localization of endocrine disease. Cardiovasc Intervent Radiol. 30(4):555-70, 2007
                              11. Moriyama T et al: Diagnosis of a case of ectopic parathyroid adenoma on the early image of 99mTc-MIBI scintigram. Endocr J. 54(3):437-40, 2007
                              12. Tseng LM et al: The role of intra-arterial calcium stimulation test with hepatic venous sampling (IACS) in the management of occult insulinomas. Ann Surg Oncol. 14(7):2121-7, 2007
                              13. Eloy JA et al: Preoperative selective venous sampling for nonlocalizing parathyroid adenomas. Thyroid. 16(8):787-90, 2006
                              14. Ogilvie CM et al: Selective parathyroid venous sampling in patients with complicated hyperparathyroidism. Eur J Endocrinol. 155(6):813-21, 2006
                              15. Reidel MA et al: Localization of hyperfunctioning parathyroid glands by selective venous sampling in reoperation for primary or secondary hyperparathyroidism. Surgery. 140(6):907-13; discussion 913, 2006
                              16. Jackson JE: Angiography and arterial stimulation venous sampling in the localization of pancreatic neuroendocrine tumours. Best Pract Res Clin Endocrinol Metab. 19(2):229-39, 2005
                              17. Sung YM et al: Selective intra-arterial calcium stimulation with hepatic venous sampling for preoperative localization of insulinomas. Korean J Radiol. 4(2):101-8, 2003
                              Related Anatomy
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                              Related Differential Diagnoses
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                              References
                              Tables

                              Tables

                              KEY FACTS

                              • Terminology

                                • Preprocedure

                                  • Procedure

                                    TERMINOLOGY

                                    • Definitions

                                      • Cushing syndrome
                                        • Clinical complex caused by prolonged inappropriate glucocorticoid exposure
                                        • Endogenous Cushing
                                          • Adrenocorticotrophic hormone (ACTH) sources
                                            • Pituitary tumor
                                            • Adrenal neoplasm
                                            • Ectopic ACTH (e.g., lung cancer)
                                        • MR not sensitive or specific for adenoma ACTH production
                                          • 40-50% of pituitary Cushing patients have no lesion
                                          • 10% of population aged 30-40 years harbor incidental pituitary abnormality
                                            • Lesion presence does not imply functionality
                                        • Inferior petrosal sinus sampling (IPSS)
                                          • Venous blood sampling from both inferior petrosal sinuses
                                          • Evaluates for ACTH-secreting pituitary adenoma as etiology for endogenous Cushing syndrome
                                          • Considered gold standard for confirming origin of ACTH secretion in Cushing syndrome
                                      • Functioning pancreatic endocrine tumors
                                        • Insulinoma (most common)
                                          • Symptoms: Hypoglycemia, palpitations, diplopia; elevated serum insulin and C-peptide levels
                                          • 75% solitary and benign; 10% malignant
                                        • Gastrinoma (2nd most common)
                                          • Leads to Zollinger-Ellison syndrome
                                            • Severe peptic ulcer disease, gastric hypersecretion, elevated serum gastrin, diarrhea, and non-B islet cell tumor
                                            • Gastrinomas can be intrapancreatic or extrapancreatic, solitary or multiple
                                        • Most often localized via cross-sectional imaging
                                          • Lesions < 1 cm may be difficult to visualize
                                        • Selective arterial calcium stimulation with hepatic venous sampling (SACST)
                                          • Used for preoperative localization of pancreatic endocrine tumors
                                      • hyperparathyroidism
                                        • Estimated prevalence of 1:1,000
                                          • Hypercalcemia with high or inappropriately normal parathyroid hormone (PTH) level
                                        • 85% of cases secondary to parathyroid adenoma
                                          • 10% of parathyroid adenomas may be in ectopic location; 5-10% of parathyroid glands ectopic
                                            • Ectopic locations: Anterior mediastinum (10%), posterior mediastinum (3-5%), within thyroid gland (1-3%), and retroesophageal (1%)
                                        • Selective venous sampling (SVS)
                                          • Sampling from veins draining parathyroid gland for PTH assay
                                          • Localization imaging includes ultrasound, scintigraphy (Tc-99m sestamibi), CT, MR
                                          • Invasive procedure of SVS also used for localization

                                    PREPROCEDURE

                                    • Indications

                                      • Getting Started

                                        PROCEDURE

                                        • Patient Position/Location

                                          • Procedure Steps

                                            • Findings and Reporting

                                              • Alternative Procedures/Therapies

                                                POST PROCEDURE

                                                • Interpreting Results

                                                  • Things to Do

                                                    • Things to Avoid

                                                      OUTCOMES

                                                      • Complications

                                                        • Expected Outcomes

                                                          Selected References

                                                          1. Perlman JE et al: Pitfalls in performing and interpreting inferior petrosal sinus sampling: personal experience and literature review. J Clin Endocrinol Metab. 106(5):e1953-67, 2021
                                                          2. Vassiliadi DA et al: Inferior petrosal sinus sampling in Cushing's syndrome: usefulness and pitfalls. Endocrine. 73(3):530-9, 2021
                                                          3. Zolin SJ et al: Selective parathyroid venous sampling in reoperative parathyroid surgery: a key localization tool when noninvasive tests are unrevealing. Surgery. 169(1):126-32, 2021
                                                          4. Hatoko T et al: Low-dose selective arterial calcium stimulation test for localizing insulinoma: a single-center experience of five consecutive cases. Intern Med. 59(19):2397-403, 2020
                                                          5. Zampetti B et al: Bilateral inferior petrosal sinus sampling. Endocr Connect. 5(4):R12-25, 2016
                                                          6. Kunstman JW et al: Clinical review: parathyroid localization and implications for clinical management. J Clin Endocrinol Metab. 98(3):902-12, 2013
                                                          7. Okabayashi T et al: Diagnosis and management of insulinoma. World J Gastroenterol. 19(6):829-37, 2013
                                                          8. Ito F et al: The utility of intraoperative bilateral internal jugular venous sampling with rapid parathyroid hormone testing. Ann Surg. 245(6):959-63, 2007
                                                          9. Lad SP et al: The role of inferior petrosal sinus sampling in the diagnostic localization of Cushing's disease. Neurosurg Focus. 23(3):E2, 2007
                                                          10. Lau JH et al: The current role of venous sampling in the localization of endocrine disease. Cardiovasc Intervent Radiol. 30(4):555-70, 2007
                                                          11. Moriyama T et al: Diagnosis of a case of ectopic parathyroid adenoma on the early image of 99mTc-MIBI scintigram. Endocr J. 54(3):437-40, 2007
                                                          12. Tseng LM et al: The role of intra-arterial calcium stimulation test with hepatic venous sampling (IACS) in the management of occult insulinomas. Ann Surg Oncol. 14(7):2121-7, 2007
                                                          13. Eloy JA et al: Preoperative selective venous sampling for nonlocalizing parathyroid adenomas. Thyroid. 16(8):787-90, 2006
                                                          14. Ogilvie CM et al: Selective parathyroid venous sampling in patients with complicated hyperparathyroidism. Eur J Endocrinol. 155(6):813-21, 2006
                                                          15. Reidel MA et al: Localization of hyperfunctioning parathyroid glands by selective venous sampling in reoperation for primary or secondary hyperparathyroidism. Surgery. 140(6):907-13; discussion 913, 2006
                                                          16. Jackson JE: Angiography and arterial stimulation venous sampling in the localization of pancreatic neuroendocrine tumours. Best Pract Res Clin Endocrinol Metab. 19(2):229-39, 2005
                                                          17. Sung YM et al: Selective intra-arterial calcium stimulation with hepatic venous sampling for preoperative localization of insulinomas. Korean J Radiol. 4(2):101-8, 2003