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Venous Sampling and Venography: Renal and Adrenal
Brandt C. Wible, MD; T. Gregory Walker, MD, FSIR
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KEY FACTS

  • Preprocedure

    • Procedure

      TERMINOLOGY

      • Synonyms

        • Adrenal vein sampling (AVS), renal vein sampling (RVS), renal vein renin sampling (RVRS), renin venous renin lateralization ratio (RVRR)
        • Nutcracker syndrome (NCS) = left renal vein (LRV) entrapment syndrome
      • Definitions

        • Primary aldosteronism: Hypersecretion of aldosterone by adrenal glands
          • 2/3 caused by unilateral aldosterone-producing adenoma (APA), i.e., Conn syndrome
            • Treated with unilateral adrenalectomy
            • 2% of cases have bilateral APA
          • 1/3 caused by bilateral idiopathic adrenal hyperplasia, i.e., idiopathic hyperaldosteronism
            • Treated with lifelong mineralocorticoid receptor blocker (spironolactone)
        • Cushing syndrome: Clinical complex resulting from prolonged inappropriate exposure to glucocorticoids
          • Most frequently caused by administration of exogenous glucocorticoids or adrenocorticotrophic hormone (ACTH)
          • Endogenous causes include ACTH-secreting pituitary tumor, adrenal neoplasm (benign or malignant), or ectopic ACTH secretion by tumor
        • NCS: Symptomatic extrinsic compression of LRV
          • Associated with pelvic congestion syndrome/varicocele
          • Nutcracker phenomenon: LRV compression in asymptomatic patient
      • Adrenal Vein Anatomy

        • In most individuals, each gland has single main vein
          • Multiple adrenal veins occasionally occur
          • Adrenal veins communicate with retroperitoneal and renal capsular veins
        • Right adrenal vein drains directly into posterolateral aspect of inferior vena cava (IVC)
          • Typically located 2-4 cm above right renal vein
          • Small accessory hepatic vein may rarely drain into right adrenal vein or vice versa (10% incidence)
        • Left adrenal vein drains into superior aspect of LRV
          • Typically located 3-5 cm from LRV orifice
          • May very rarely drain directly into IVC
      • Renal Vein Anatomy

        • Usually each kidney is drained by single renal vein
          • Renal veins rarely have valves
          • Communicate with other retroperitoneal veins (e.g., lumbar, azygos, gonadal veins)
        • LRV courses between the aorta and overlying superior mesenteric artery to join IVC
          • LRV drains somewhat anteriorly into IVC
        • Right renal vein is shorter, drains into IVC at ~ L2 vertebral level
        • Frequent variations in renal venous anatomy
          • Anterior NCS: Compression between aorta and superior mesenteric artery
          • Posterior NCS: Compression of retroaortic LRV between aorta and vertebral column

      PREPROCEDURE

      • Indications

        • Contraindications

          • Preprocedure Imaging

            • Special Considerations

              • Getting Started

                PROCEDURE

                • Patient Position/Location

                  • Procedure Steps

                    • Alternative Procedures/Therapies

                      POST PROCEDURE

                      • Things to Do

                        • Things to Avoid

                          • Interpreting Results

                            OUTCOMES

                            • Problems

                              • Complications

                                • Expected Outcomes

                                  Selected References

                                  1. Blondin D et al: Indication and technical aspects of adrenal blood sampling. Rofo. 187(1):19-28, 2015
                                  2. Goupil R et al: The utility of renal venous renin studies in selection of patients with renal artery stenosis for angioplasty: a retrospective study. J Hypertens. 33(9):1931-8; discussion 1938, 2015
                                  3. Powlson AS et al: Nuclear imaging in the diagnosis of primary aldosteronism. Curr Opin Endocrinol Diabetes Obes. 22(3):150-6, 2015
                                  4. He Y et al: Nutcracker syndrome--how well do we know it? Urology. 83(1):12-7, 2014
                                  5. Quevedo HC et al: Systematic review of endovascular therapy for nutcracker syndrome and case presentation. Cardiovasc Revasc Med. 15(5):305-7, 2014
                                  6. 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
                                  7. Wolley M et al: Reninoma: the importance of renal vein renin ratios for lateralisation and diagnosis. Am J Nephrol. 39(1):16-9, 2014
                                  8. Avgerinos ED et al: Surgical and endovascular interventions for nutcracker syndrome. Semin Vasc Surg. 26(4):170-7, 2013
                                  9. Kahn SL et al: Adrenal vein sampling. Tech Vasc Interv Radiol. 13(2):110-25, 2010
                                  10. Georgiades CS et al: Adjunctive use of C-arm CT may eliminate technical failure in adrenal vein sampling. J Vasc Interv Radiol. 18(9):1102-5, 2007
                                  11. Mengozzi G et al: Rapid cortisol assay during adrenal vein sampling in patients with primary aldosteronism. Clin Chem. 53(11):1968-71, 2007
                                  12. Rossi GP: New concepts in adrenal vein sampling for aldosterone in the diagnosis of primary aldosteronism. Curr Hypertens Rep. 9(2):90-7, 2007
                                  13. Nwariaku FE et al: Primary hyperaldosteronism: effect of adrenal vein sampling on surgical outcome. Arch Surg. 141(5):497-502; discussion 502-3, 2006
                                  14. Hasbak P et al: Hypertension and renovascular disease: follow-up on 100 renal vein renin samplings. J Hum Hypertens. 16(4):275-80, 2002
                                  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), renal vein sampling (RVS), renal vein renin sampling (RVRS), renin venous renin lateralization ratio (RVRR)
                                        • Nutcracker syndrome (NCS) = left renal vein (LRV) entrapment syndrome
                                      • Definitions

                                        • Primary aldosteronism: Hypersecretion of aldosterone by adrenal glands
                                          • 2/3 caused by unilateral aldosterone-producing adenoma (APA), i.e., Conn syndrome
                                            • Treated with unilateral adrenalectomy
                                            • 2% of cases have bilateral APA
                                          • 1/3 caused by bilateral idiopathic adrenal hyperplasia, i.e., idiopathic hyperaldosteronism
                                            • Treated with lifelong mineralocorticoid receptor blocker (spironolactone)
                                        • Cushing syndrome: Clinical complex resulting from prolonged inappropriate exposure to glucocorticoids
                                          • Most frequently caused by administration of exogenous glucocorticoids or adrenocorticotrophic hormone (ACTH)
                                          • Endogenous causes include ACTH-secreting pituitary tumor, adrenal neoplasm (benign or malignant), or ectopic ACTH secretion by tumor
                                        • NCS: Symptomatic extrinsic compression of LRV
                                          • Associated with pelvic congestion syndrome/varicocele
                                          • Nutcracker phenomenon: LRV compression in asymptomatic patient
                                      • Adrenal Vein Anatomy

                                        • In most individuals, each gland has single main vein
                                          • Multiple adrenal veins occasionally occur
                                          • Adrenal veins communicate with retroperitoneal and renal capsular veins
                                        • Right adrenal vein drains directly into posterolateral aspect of inferior vena cava (IVC)
                                          • Typically located 2-4 cm above right renal vein
                                          • Small accessory hepatic vein may rarely drain into right adrenal vein or vice versa (10% incidence)
                                        • Left adrenal vein drains into superior aspect of LRV
                                          • Typically located 3-5 cm from LRV orifice
                                          • May very rarely drain directly into IVC
                                      • Renal Vein Anatomy

                                        • Usually each kidney is drained by single renal vein
                                          • Renal veins rarely have valves
                                          • Communicate with other retroperitoneal veins (e.g., lumbar, azygos, gonadal veins)
                                        • LRV courses between the aorta and overlying superior mesenteric artery to join IVC
                                          • LRV drains somewhat anteriorly into IVC
                                        • Right renal vein is shorter, drains into IVC at ~ L2 vertebral level
                                        • Frequent variations in renal venous anatomy
                                          • Anterior NCS: Compression between aorta and superior mesenteric artery
                                          • Posterior NCS: Compression of retroaortic LRV between aorta and vertebral column

                                      PREPROCEDURE

                                      • Indications

                                        • Contraindications

                                          • Preprocedure Imaging

                                            • Special Considerations

                                              • Getting Started

                                                PROCEDURE

                                                • Patient Position/Location

                                                  • Procedure Steps

                                                    • Alternative Procedures/Therapies

                                                      POST PROCEDURE

                                                      • Things to Do

                                                        • Things to Avoid

                                                          • Interpreting Results

                                                            OUTCOMES

                                                            • Problems

                                                              • Complications

                                                                • Expected Outcomes

                                                                  Selected References

                                                                  1. Blondin D et al: Indication and technical aspects of adrenal blood sampling. Rofo. 187(1):19-28, 2015
                                                                  2. Goupil R et al: The utility of renal venous renin studies in selection of patients with renal artery stenosis for angioplasty: a retrospective study. J Hypertens. 33(9):1931-8; discussion 1938, 2015
                                                                  3. Powlson AS et al: Nuclear imaging in the diagnosis of primary aldosteronism. Curr Opin Endocrinol Diabetes Obes. 22(3):150-6, 2015
                                                                  4. He Y et al: Nutcracker syndrome--how well do we know it? Urology. 83(1):12-7, 2014
                                                                  5. Quevedo HC et al: Systematic review of endovascular therapy for nutcracker syndrome and case presentation. Cardiovasc Revasc Med. 15(5):305-7, 2014
                                                                  6. 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
                                                                  7. Wolley M et al: Reninoma: the importance of renal vein renin ratios for lateralisation and diagnosis. Am J Nephrol. 39(1):16-9, 2014
                                                                  8. Avgerinos ED et al: Surgical and endovascular interventions for nutcracker syndrome. Semin Vasc Surg. 26(4):170-7, 2013
                                                                  9. Kahn SL et al: Adrenal vein sampling. Tech Vasc Interv Radiol. 13(2):110-25, 2010
                                                                  10. Georgiades CS et al: Adjunctive use of C-arm CT may eliminate technical failure in adrenal vein sampling. J Vasc Interv Radiol. 18(9):1102-5, 2007
                                                                  11. Mengozzi G et al: Rapid cortisol assay during adrenal vein sampling in patients with primary aldosteronism. Clin Chem. 53(11):1968-71, 2007
                                                                  12. Rossi GP: New concepts in adrenal vein sampling for aldosterone in the diagnosis of primary aldosteronism. Curr Hypertens Rep. 9(2):90-7, 2007
                                                                  13. Nwariaku FE et al: Primary hyperaldosteronism: effect of adrenal vein sampling on surgical outcome. Arch Surg. 141(5):497-502; discussion 502-3, 2006
                                                                  14. Hasbak P et al: Hypertension and renovascular disease: follow-up on 100 renal vein renin samplings. J Hum Hypertens. 16(4):275-80, 2002