Primary aldosteronism (PA) represents a spectrum of conditions characterized by autonomous adrenal aldosterone secretion, and hypertension. Adrenalectomy is associated with excellent outcomes in patients with unilateral autonomous primary aldosteronism, whereas bilateral adrenal aldosteronism does not respond to unilateral adrenalectomy and such patients are better managed using medical therapy. Given the importance of lateralization on therapeutic decision-making and outcomes, the accuracy of lateralization tests is crucial.
Cross-sectional imaging techniques such as CT and MRI suffer from poor accuracy, particularly because of the prevalence of non-functional adrenal nodules in many patients. As such, much interest exists regarding adrenal vein sampling (AVS) for lateralization. Routine AVS is associated with excellent surgical outcomes, however AVS is invasive, technically demanding and requires expertise. In addition, AVS is not widely available.
In an attempt to better define which population of patients require AVS, we reviewed the literature to provide evidence of the use of routine versus selective AVS. We find that patients with young patients with very high serum aldosterone levels in the context of suppressed plasma renin activity, who have a defined unilateral adrenal nodule and a normal contralateral adrenal gland, can undergo adrenalectomy without AVS. We recommend AVS for lateralization for all other patients with PA.
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