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Adrenal Vein Sampling: How to Make It Quick, Easy, and Successful¹

¹ From the X-Ray Department, Greenslopes Private Hospital, Newdegate Street, Greenslopes, Queensland 4120, Australia. Recipient of a Cum Laude award for an education exhibit at the 2004 RSNA Annual Meeting. Received March 14, 2005; revision requested April 15 and received June 13; accepted June 17. The author has no financial relationships to disclose.

View larger version (158K): [in a new window]   Figure 1.  CT scan shows a 13-mm-diameter nonhyperfunctioning adenoma in the lateral limb of the left adrenal gland (arrow). At adrenal vein sampling, the patient’s disease was lateralized to the right adrenal gland. (The adrenal vein sampling was repeated to confirm the unexpected finding.) The patient’s hypertension was cured with right adrenalectomy.

 

View larger version (155K): [in a new window]   Figure 2.  CT scan clearly shows the right adrenal vein (arrow).

 

View larger version (53K): [in a new window]   Figure 3.  Diagram shows the anatomy of the adrenal veins.

 

View larger version (129K): [in a new window]   Figure 4.  Fluoroscopic image obtained with injection into the right adrenal vein shows opacification of small peripheral hepatic vessels (arrow).

 

View larger version (127K): [in a new window]   Figure 5.  Fluoroscopic image shows a Mikaelsson catheter passed distally in the right adrenal vein to superselect a medial limb branch; with this catheter position, drainage from a lateral limb adenoma could be missed. The wedged position of the catheter tip (open arrow) has resulted in some extravasation or staining around small branches inferiorly (arrowheads). More cephalad, there is possible filling of a hepatic branch (solid arrow).

 

View larger version (112K): [in a new window]   Figure 6.  Fluoroscopic image obtained with a C2 catheter in the central right adrenal vein shows superficial communications superolaterally and inferolaterally (arrows) and to the right renal vein (arrowhead).

 

View larger version (110K): [in a new window]   Figure 7.  Fluoroscopic image obtained with injection into the left adrenal vein shows two separate left adrenal veins and extensive communicating veins draining into the left renal vein (1) and IVC (2).

 

View larger version (142K): [in a new window]   Figure 8.  Fluoroscopic image obtained with injection into the left adrenal vein shows numerous adrenal branches. Also noted is a renal vein ring, with a normal preaortic vein (top arrow) and a retroaortic vein inferiorly (bottom arrow).

 

View larger version (124K): [in a new window]   Figure 9.  Fluoroscopic image shows a C2 catheter passed via a retroaortic renal vein into the left adrenal vein, with injected contrast material draining into the normal preaortic renal vein.

 

View larger version (119K): [in a new window]   Figure 10.  Fluoroscopic image shows the classic glandlike pattern of injection into the right adrenal vein.

 

View larger version (119K): [in a new window]   Figure 11.  Fluoroscopic image shows the classic glandlike pattern of injection into the right adrenal vein with prominent lateral communicating veins.

 

View larger version (119K): [in a new window]   Figure 12.  Fluoroscopic image shows what appears to be a right adrenal vein injection but is actually injection into a hepatic radicle. The subtle upsloping vessel (arrow) arising from the superficial lateral border of the adrenal gland is the giveaway.

 

View larger version (101K): [in a new window]   Figure 13.  Fluoroscopic image shows the delta pattern of injection into the central adrenal vein. There are two or three major branches with acute angles between them.

 

View larger version (130K): [in a new window]   Figure 14.  Fluoroscopic image shows injection into the right adrenal vein with a reverse catheter. There is a basic delta pattern with extensive communications from superficial veins into the retroperitoneum and an intercostal vein (arrow).

 

View larger version (87K): [in a new window]   Figure 15.  Fluoroscopic image obtained with injection into the right adrenal vein shows mainly the central vein. The early branches of a delta configuration are also seen (arrows), thus confirming good catheter position; no more contrast material needs to be injected.

 

View larger version (115K): [in a new window]   Figure 16.  Fluoroscopic image obtained with adrenal vein injection shows a triangular pattern of veins (arrows) and minor blush with communicating superficial veins inferiorly.

 

View larger version (111K): [in a new window]   Figure 17.  Fluoroscopic image obtained with adrenal vein injection shows vessels in a triangular configuration with subtle background blush and an extremely large communicating superficial vein.

 

View larger version (89K): [in a new window]   Figure 18.  Fluoroscopic image obtained with injection into the right adrenal vein. It is difficult to make out any background adrenal structure; however, positive cortisol ratios were found at sampling.

 

View larger version (112K): [in a new window]   Figure 19.  Fluoroscopic image shows a right adrenal gland with an irregular intraglandular structure. Although no normal adrenal structure is discernible, there are large communicating vessels laterally.

 

View larger version (121K): [in a new window]   Figure 20.  Fluoroscopic image obtained with injection into the right adrenal vein. It is difficult to make out a normal background adrenal structure; however, the extensive inferolateral communicating veins support the premise of good catheter position.

 

View larger version (101K): [in a new window]   Figure 21.  Fluoroscopic image shows a barely discernible adrenal structure. However, there is a background spidery pattern with thin vessels and some communicating veins, which are also of small caliber.

 

View larger version (137K): [in a new window]   Figure 22.  Fluoroscopic image shows the spidery pattern of adrenal vein injection. There is a central adrenal vein with straight branches at multiple angles and with lateral communicating veins.

 

View larger version (90K): [in a new window]   Figure 23.  Fluoroscopic image obtained with injection into the right adrenal vein shows a poorly defined stellate or spidery pattern with inferior communicating veins.

 

View larger version (110K): [in a new window]   Figure 24.  Fluoroscopic image obtained with right adrenal vein injection through a reverse Simmons 1 catheter shows no discernible adrenal structure. However, the large communicating veins extending into intercostal veins make it highly likely that the sample will be positive. At sample analysis, good cortisol gradients were obtained.

 

View larger version (104K): [in a new window]   Figure 25.  Fluoroscopic image obtained with right-sided venous injection shows what appears to be the delta pattern of an adrenal gland. However, the veins coursing upward and to the right are suggestive of hepatic vessels. Samples obtained at this point showed low cortisol values, findings typical of hepatic drainage.

 

View larger version (459K): [in a new window]   Figure 26.  Three sequential thin CT sections show the caudal alignment of the right adrenal vein (arrow), which drains into the mid posterior wall of the IVC.

 

View larger version (72K): [in a new window]   Figure 27.  Fluoroscopic image obtained with injection into the central adrenal vein shows virtually no intraglandular structure (same patient as in Fig 12). This injection technique reduces the risk of extravasation to the minimum.

 

View larger version (116K): [in a new window]   Figure 28.  Fluoroscopic image obtained with right adrenal vein injection through a C2 catheter shows extensive distortion of the adrenal venous structure due to a large adenoma (arrows). At surgery, a 2.3-cm-diameter adenoma was removed.

 

View larger version (138K): [in a new window]   Figure 29.  Fluoroscopic image obtained with left adrenal vein injection shows the rounded configuration of an adenoma (arrow) in the lateral limb of the gland (same patient as in Fig 1).

 

View larger version (112K): [in a new window]   Figure 30.  Fluoroscopic image obtained with a C1 catheter in the central adrenal vein shows spindly intraglandular adrenal veins with superficial communications laterally.

 

View larger version (121K): [in a new window]   Figure 31.  Fluoroscopic image shows a reverse catheter (MK1B) deeply engaged within the central right adrenal vein.

 

View larger version (94K): [in a new window]   Figure 32.  Fluoroscopic image shows a reverse catheter (Mikaelsson) placed too selectively in the adrenal vein, with the catheter tip in the main medial limb branch (arrow).

 

View larger version (103K): [in a new window]   Figure 33.  Fluoroscopic image shows an MK1B catheter in the left adrenal vein (common trunk). Although the catheter points slightly toward the inferior phrenic vein (arrow), there is excellent filling of only the adrenal venous structure with contrast material injection.

 

View larger version (100K): [in a new window]   Figure 34.  Fluoroscopic image shows an unusually large common trunk and central left adrenal vein with good demonstration of the entire intraglandular venous system.

 

View larger version (133K): [in a new window]   Figure 35.  Fluoroscopic image shows an MK1B catheter in the common trunk just beyond the confluence and pointing laterally toward the adrenal veins. An unusual aberrant vein joins the central vein at the confluence (arrow).

 

View larger version (120K): [in a new window]   Figure 36.  Fluoroscopic image obtained with an MK1B catheter deep in the central left adrenal vein shows extensive communicating veins laterally, medially, and inferiorly. The catheter position is too deep (arrow); as a result, venous supply from some parts of the left adrenal gland could be missed.

 

View larger version (115K): [in a new window]   Figure 37.  Fluoroscopic image shows a catheter deep in the central adrenal vein, past some of the early branches. In addition, the inferior phrenic vein is filled by an unusual communicating superficial vein superiorly (arrow).

 

View larger version (114K): [in a new window]   Figure 38.  Fluoroscopic image obtained with left adrenal vein injection shows the tip of the catheter just past the confluence and in the central adrenal vein. An unusual, extensive varicose branch arises from the common trunk and passes inferiorly.

 

View larger version (115K): [in a new window]   Figure 39.  Fluoroscopic image shows injection into the common trunk with no inferior phrenic vein seen. Extensive corkscrew communicating veins extend from the gland inferiorly and laterally.

 

View larger version (122K): [in a new window]   Figure 40.  Fluoroscopic image obtained with injection into the common trunk shows filling of left adrenal venous structures and communicating veins, with extension into an aberrant branch draining retroperitoneal structures (arrow).

 

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