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technique
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.
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.
INDICATIONS:
- 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.
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.
- 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):
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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.
INDICATION:
- The insulinomas are small tumors (90% <2 cm) with difficult location by using
conventional techniques (CT, MRI) and EUS.
- 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:
- 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 common hepatic artery infusion: insulinoma with metastatic spread to
the liver.
- Defining more specific location in the sections marked by the irrigation of an entire
principal artery (Figure 3 and 4).
INDICATION:
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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:
- 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).
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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
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Conclusion
- Venous sampling is a useful technique, and sometimes of our choice to locate hidden
neuroendocrine tumors.
- 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.
Personal information
References
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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