Venous sampling technique in Endocrinology: a renewed

technique

Poster No.: C-0682

Congress: ECR 2014
Type: Educational Exhibit
Authors: 1 2
M. E. Rodriguez Cabillas , J. Garcia Villanego , I. Olea Comas , A.
3

3 3 1
Collantes Gonzalez , J. A. Fernandez Roche ; San Fernando/ES,
2 3
11007 Cadiz/ES, Cádiz/ES
Keywords: Abdomen, Pancreas, Catheter venography, Fluoroscopy,
Catheters, Diagnostic procedure, Endocrine disorders, Neoplasia
DOI: 10.1594/ecr2014/C-0682

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Learning objectives

- To describe the technique and experience of our Hospital with adrenal venous sampling,
in cases of primary aldosteronism, overactive pancreas tumor localization and inferior
petrosal sinus sampling in pituitary microadenomas.

- To analyze results of the technique and meaning in each of the processes.

Background

Peripheral venous sampling for the diagnosis and localization of functioning tumors or
autonomous hormonal hypersecretion, is used when imaging has not been able to locate
the secreting tumor. This could be due to the following reasons: either because of its
small size, or because of the presence of a hyperplasia gland or the coexistence of other
lesions (nonfunctioning adenomas), which do not allow to identify the laterality of the
overactive gland.

Findings and procedure details

I) ADRENAL VENOUS SAMPLING:

INDICATIONS:

- Primary hyperaldosteronism is the most frequent endocrine cause of hypertension.

- The aldosterone-producing adenomas (aldosteronomas) and bilateral hyperplasia are

the most common causes of hyperaldosteronism. Other more rare causes include
hyperplasia unilateral, adrenal carcinoma and familial hyperaldosteronism.

- The CT and MRI are very sensitive in the detection of adrenal adenomas
(90% sensitivity), but its performance is very poor in order to locate and lateralize
hyperfunctioning tumors.

- This technique seeks to determine whether the overproduction of aldosterone is

unilateral or bilateral, since if the hyperfunction is unilateral, adrenalectomy can be
healed, but if the hyperfunction is bilateral, surgery is contraindicated.

PROCEDURE:

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- To perform venous phase angio-CT in order to identify the existence of anatomical
variants in inferior cava vein; to get to know the venous anatomy at each adrenal; and to
have the vertebral bodies as a reference so as to locate the right adrenal vein (by placing
the catheter 1 cm higher than the TAC of reference, since this is carried out in deep
breathing). If the vein is not found, we use the midpoint of the gland as the theoretical
position.

- The right adrenal vein drains directly into the back wall of the inferior cava vein, whereas
the left adrenal vein drains by forming a common trunk with the lower left phrenic vein
on the upper side of the left renal vein (Figure 1)

- Vascular sheaths are placed in both common femoral veins for simultaneous extraction
of each adrenal gland, one of 5F and another one of 6F that will help us to take samples
of peripheral blood.

- To use cobra catheter 2 with 5F lateral hole, channeling the right adrenal vein and the
left one from the right introducer. In the cases where it is not possible to catheterize the
vessels, we should use Simmons 1 catheter.

- It is necessary to extract samples of both sides and of peripheral blood simultaneously,

because the existence of a gradient of 3 between cortisol from the adrenal and peripheral
samples ensures that the adrenal catheterization is correct. Gradients below 2, indicate
that the sample is not valid, gradients between 2 and 3 should be analyzed individually
(Figure 2).

* Samples are taken:

- In a basal way

- After ACTH stimulation in a peripheral drip. The aspiration of blood must be smoothly
and contrast injections for venography are not allowed to be given, since it can produce
infarction or hemorrhage of the gland.

* INTERPRETATION OF RESULTS:

- Correct catheterization: Ratio adrenal cortisol in adrenal vein / cortisol VCI vein: 5/1.

- Aldosterone ratio corrected with cortisol (dividing aldosterone from each side by the
cortisol of each side, to avoid the dilutional effect of phrenic vein in the right adrenal vein):

#Major aldosterone corrected / minor aldosterone corrected: 4/1:Unilateral lesion.

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#If <3: bilateral hypersecretion

- Besides, the unilateral lesion is confirmed if the minor corrected aldosterone is less than
the aldosterone corrected in VCI value.

- This technique has a 95% sensitivity and a 100% specificity

II) SUPRAHEPATIC VENOUS SAMPLING IN INSULINOMAS

INDICATION:

- The insulinomas are small tumors (90% <2 cm) with difficult location by using
conventional techniques (CT, MRI) and EUS.

- The pancreas is supplied by the gastroduodenal splenic and superior mesenteric

arteries, each of which has a preferred irrigation area within the pancreas.

- Insulinomas increase the insulin secretion in response to the infusion of calcium,

whereas the normal beta cells do not respond to this stimulus.

- The calcium infusion into the hepatic artery allows us to detect hyperinsulinism areas
(metastasis) in the liver, which, sometimes, can not be detected by morphological tests.

- By measuring the insulin response in the right hepatic vein after the infusion of calcium
in each of the three arteries,we can detect the sensitive area of surgical resection.

- The angiography of the gastroduodenal, splenic and superior mesenteric arteries, which
can detect hypervascularization areas ("blush"), suggestive of tumor pathology up to 75%
of cases.

PROCEDURE:

Vascular sheaths were placed:

- In left common femoral vein from which the right hepatic vein is catheterised with 2 5F
catheter with hole on the side to extract the venous samples.

- In right common femoral artery from which we catheterize selectively and sequentially
superior mesenteric artery, splenic artery, hepatic artery and gastroduodenal artery.
Selective arteriography is performed in each vessel, and subsequently, calcium

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stimulation is performed from the arterial catheter in each collecting vessel and venous
samples in suprahepatic catheter at baseline, at 30 ', 60' and 120 '.

INTERPRETATION:

Insulinemia VHD is compared before and after infusion of calcium in each of the four
arteries. A positive finding is a insulinemia VHD ratio after calcium / VHD Insulinemia
calcium previous to calcium, more than 2.0 sometimes (30, 60 or 120 seconds after the
calcium infusion):

-Ratio> 2.0 after infusion in gastroduodenal or superior mesenteric artery: indicates the
location in pancreatic head or uncinado process.

-Ratio> 2.0 after splenic artery infusion: insulinoma in

corporo caudal location.

-Ratio> 2.0 after common hepatic artery infusion: insulinoma with metastatic spread to
the liver.

* Angiography results provide the following:

- Confirmation of localization in cases of borderline ratios.

- Defining more specific location in the sections marked by the irrigation of an entire
principal artery (Figure 3 and 4).

III) INFERIOR PETROSAL SINUS:

INDICATION:

- Cushing syndrome (CS) is more frequently caused by exogenous administration of

corticosteroids. The CS causes differ in endogenous levels of ACTH:

#Low: SC ACTH-independent: adrenal adenomas, more rare adrenal carcinoma. It is

studied by abdomen imaging.

#High: SC ACTH-dependent: the origin of ACTH can be pituitary (pituitary adenoma) or

ectopic.

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- The sampling of petrosal sinus is indicated in all cases which could not be determined
by other imaging techniques the origin of Cushing disease

PROCEDURE:

- Channeling both common femoral veins with introducer 6F and 5F on the right and
left side respectively. The one with the highest calibre is used for extracting peripheral
samples.

- If the channeling of petrosal sinus is not posible, due to its small diameter,
microcatheters are used. Contrast injection is performed to check the correct placement.

- The taking of blood in basal petrosal sinus and peripheral blood are carried out,
subsequent stimulation with CRH, and samples are obtained at 3, 5, 10 and 15 minutes
in petrosal sinuses and peripheral.

INTERPRETATION:

- Calculate the proportion of ACTH in petrosal / peripheral sinus: Basal # 2 or # 3 after

stimulation confirming the diagnosis of Cushing disease of pituitary origin.

- 1% -10% false negatives, in such cases the IPS ratio / prolactin can be carried out.

- The venous drainage of the pituitary is predominantly ipsilateral. Theoretically, the test
could provide data on the laterality of the lesion. A ratio between the sinus # 1.4 is
considered evidence on the laterality of the adenoma with a 50-100% accuracy, although
in surgery the entire gland should be checked (Figure 5).

Images for this section:

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Fig. 1: Drawing illustrate the normal anatomy of artery and venous anatomy of adrenal
glands

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Fig. 2: Figure 2.- Right and left suprarrenal gland

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Fig. 3: Figure 3.- Nodule uptake in pancreatic head not described in TAC or RM
corresponding to insulinoma

Fig. 4: Figure 4.- Nodule uptake in pancreatic head not described in TAC or RM
corresponding to insulinoma

Fig. 5: Figure 5.- Right and left inferior petrosal sinus

Page 9 of 10
Conclusion

- Venous sampling is a useful technique, and sometimes of our choice to locate hidden
neuroendocrine tumors.

- It requires a meticulous technique and knowledge of the anatomy of the investigated

vascular areas and normal variants, with a high percentage of success.

- Most failures are due to the impossibility of catheterization of one of the areas because
of obtaining glow flows in some areas with low volume outlets.

- In some areas, it is difficult to interpret results by variations in venous drainage.

- It has minimal effects and few contraindications (venous thrombosis, extravasation

medium contrast, myocardial gland studied), together with the characteristic of arterial
and / or venous catheterization complications.

Personal information

References

1.- Qureshi AI, Georgiadis AL. Textbook of Interventional Neurology. Cambridge

University Press. (2011)

2.- Miller DL, Doppman JL. Petrosal sinus sampling: technique and rationale. Radiology.
1991;178 (1): 37-47

3.- Walker TG. Interventional Procedures. Lippincott Williams & Wilkins. (2012)

4.- Patel SM, Lingam RK, Beaconsfield TI et-al. Role of radiology in the management of
primary aldosteronism. Radiographics. 27 (4): 1145-57.

5.- Demos TC, Posniak HV, Harmath C et-al. Cystic lesions of the pancreas. AJR Am J
Roentgenol. 2002;179 (6): 1375-88

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