venous sampling in endocrine dx

8/22/2019 Venous Sampling in Endocrine Dx

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VENOUS SAMPLING IN

ENDOCRINE DISEASE

Dr. A. O. AdeyinkaConsultant Radiologist UCH Ibadan

Radiology-Endocrine Update Course

18th September 2012

LUTH Lagos


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What is Venous Sampling

Sensitive physiological investigation for

functional localization of hormonal

hyper-secretion

Direct assessment of hormonal

secretions in blood samples taken from

relevant Venous circulations (IVC,

Hepatic Veins, Adrenal Veins)


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Objectives of Venous Sampling

To evaluate hormonal secretionabnormalities in endocrine disorders

Aids Differential diagnosis or Sub-type ofabnormal hormonal secretions

Applied to address individual clinicalproblems in coordination with other imagingmodalities

May achieve regional localization orlateralization of the endocrine tumors

Guides therapeutic Management


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Types ofEndocrine Venous

Sampling Inferior petrosal sinus sampling

Selective parathyroid venous sampling

Hepatic venous sampling with arterial

stimulation

Adrenal venous sampling

Ovarian venous sampling.

Pancreatic Venous Sampling with Arterial

stimulation

(mmnemonic: HIPOPA)


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Technique

Seldinger Technique via the Femoral Veinfollowed by selective catheterization of the

relevant veins

Selective Arterial Catheterization in Arterialstimulation combined with Venous sampling

Blood Samples collected and Hormonal levels

are biochemically analyzed in each of the veins

selectively catheterized.


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PRIMARY ALDOSTERONISM Xterized by the overproduction of the

mineralocorticoidhormonealdosterone by the

adrenal glands.

Aldosterone causes increase in sodium and

water retention and potassium excretion in the

kidneys, leading to arterial hypertension &

usually hypokalemia

Symptoms: Muscle cramps, Headache and

Muscle weakness.
http://en.wikipedia.org/wiki/Mineralocorticoidhttp://en.wikipedia.org/wiki/Hormonehttp://en.wikipedia.org/wiki/Aldosteronehttp://en.wikipedia.org/wiki/Adrenal_glandhttp://en.wikipedia.org/wiki/Sodiumhttp://en.wikipedia.org/wiki/Potassiumhttp://en.wikipedia.org/wiki/Kidneyhttp://en.wikipedia.org/wiki/Arterial_hypertensionhttp://en.wikipedia.org/wiki/Arterial_hypertensionhttp://en.wikipedia.org/wiki/Kidneyhttp://en.wikipedia.org/wiki/Potassiumhttp://en.wikipedia.org/wiki/Sodiumhttp://en.wikipedia.org/wiki/Adrenal_glandhttp://en.wikipedia.org/wiki/Aldosteronehttp://en.wikipedia.org/wiki/Hormonehttp://en.wikipedia.org/wiki/Mineralocorticoid


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Types

Adrenal Adenoma (Conn's Syndrome) (66%)

Bilateral idiopathic adrenal hyperplasia (30%)

Primary (unilateral) adrenal hyperplasia2% ofcases

Aldosterone-producing adrenocortical carcinoma


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Diagnostic Screening

First Test

Simple blood tests that measure the levels ofpotassium, aldosterone, and renin (HighA ldos terone, Low Renin & Low Potassiumis Diagno st ic)

Second Test

Plasma aldosterone concentration (PAC) to

Plasma renin activity (PRA) ratio (PAC:PRA) -A high rat io is Diagnos t ic

Confirmatory Test

Captopril Suppression Test High

A ldos terone and Low Renin is Diagnos t ic .
http://endocrinediseases.org/adrenal/hyperaldosteronism_diagnosis.shtmlhttp://endocrinediseases.org/adrenal/hyperaldosteronism_diagnosis.shtml


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Diganosis and Treatment Algorithm for Primary Hyperaldosteronism

Screening test:


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Etiological Diagnosis

Determination of the etiology of primary

aldosteronism remains a diagnostic challenge.

MRI or CT imaging is not a reliable method to

differentiate primary aldosteronism

AVS is more specific than anatomical imaging

modalities.

AVS was considered the gold standard in

determining the specific subtype of primary

aldosteronism


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ADRENAL VENOUS SAMPLING[AVS]

IndicationsAVS is a direct assessment of hormonal

secretion

Detection of excessive aldosterone excretion

(Conn's syndrome)

Differentiation ofBilateral hyperplasia,

Aldosterone-secreting adenoma, and

Primary adrenal hyperplasiaUsed as Guide to Therapeutic Management


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AVS - TECHNIQUE

EQUIPMENT

Angiography tray

5-Fr access sheath

5-Fr cobra-2 Catheter 5-Fr Hilal HS1 spinal, RDC or

sidewinder catheter

Small hole punch Nonionic contrast medium (25-50

mL)


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AVS - TECHNIQUE

AVS - via the femoral vein

approach

Blood samples obtained

from IVC, Right and Left

adrenal vein. Samples for

Aldosterone, Cortisol,

and Epinephrine

concentrations wereobtained from all three

sites.

Cortrosyn given

during AVS.

Successful AVS

was determined by

at least a 3-foldelevation in

adrenal vein

Epinephrine and

Cortisol levelscompared with the

IVC.


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AVS - TECHNIQUENormalized Aldosterone

Each Aldosteroneconcentration sample

was divided by the

Cortisol concentration

Dominant Gland the

larger sized gland

Non-Dominant - the

smaller sized gland

COMPLICATIONS

Adrenal vein damage

Spasm - result in

failure of the

procedure or ruptureof the vein.

Infarction of the gland

and loss of function


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AVS - INTERPRETATION

APA and PAH Diagnosis

Ratio ofDom inant toNon-dominant

normal ized

aldosteronewould be4 or greater

Non-dominantnormal ized

aldosteronewould beless than or equal tothe Normal izedaldo sterone in the

IVC.

BAH - Diagnosis Aldosterone in each

adrenal vein wasequal to or greater

than the normalizedaldosterone from theIVC.


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Arteriography and Arterial Stimulation with

Venous Sampling (ASVS) for Localizing

Pancreatic Endocrine Tumors

Pancreatic endocrine tumors are uncommontumors that belong to the family of APUDneoplasm.

1. Functional hormone -Associated withclinical syndrome

Gastrinomas (20%) Ulcerative (Zollinger)

Insulinomas (50%) - hypoglycemia

2. Nonfunctional - if not associated with clinicalsymptoms.

Pancreatic polypeptide secreting tumors


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Role of ASVS in Insulinoma

Insulinomas are usually solitary

Distributed evenly throughout the pancreas5 -15% of insulinomas are malignant.

Preoperative workup with ASVS helps establishing

the diagnosis of insulinoma

Sensitivity of angiography in localizing insulinomas35% to 94%.

Sensitivity of calcium ASVS in localizing insulinomas

ranges from 78% to 100%.[

Insulinomas found at surgery are small: 90% lessthan 2 cm, 66% less than 1.5 cm, and 40% less than

1 cm.[2]
http://www.expertconsultbook.com/expertconsult/ob/linkTo?type=bookPage&isbn=978-1-4160-2964-9&eid=4-u1.0-B978-1-4160-2964-9..50117-4--bib21&appID=NGEhttp://www.expertconsultbook.com/expertconsult/ob/linkTo?type=bookPage&isbn=978-1-4160-2964-9&eid=4-u1.0-B978-1-4160-2964-9..50117-4--bib6&appID=NGEhttp://www.expertconsultbook.com/expertconsult/ob/linkTo?type=bookPage&isbn=978-1-4160-2964-9&eid=4-u1.0-B978-1-4160-2964-9..50117-4--bib6&appID=NGEhttp://www.expertconsultbook.com/expertconsult/ob/linkTo?type=bookPage&isbn=978-1-4160-2964-9&eid=4-u1.0-B978-1-4160-2964-9..50117-4--bib21&appID=NGE


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ASVS - INSULINOMA

Arterial stimulation and venous sampling(ASVS) is an important technique for localizing

insulinoma.

The principle behind ASVS is that insulinsecretion is promoted from insulinoma cells by

the injection of calcium into the insulinoma-

feeding artery


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ASVS - TECHNIQUEIndications forCalcium ASVS

-Failure of non-invasive imaging to localize aninsulinoma.

-Regionalization of the insulinoma tumor whenmultiple tumors are present.

Contraindications Similar to diagnostic arteriography.

Relative contraindications include uncontrolledhypertension, uncorrectable coagulopathy ,

severe allergy to iodinated contrast, severerenal insufficiency, and congestive heartfailure.

For calcium ASVS, cardiac glycosides are a

relative contraindication.


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ASVS - TECHNIQUEEQUIPMENT

4- or 5-Fr Simmons-1

catheter forHepaticVeins catheterization.

4-Fr cobra-2, SOS Omni,Simmons-1, and/or

Simmons-2 catheters forvisceral arteriography

0.027-inch inner diametermicrocatheters such asthe Renegade Hi-Flo allowa tighter bolus ofsecretagogue.

Nonionic iodinated agentsuch as iopamidol

SELDINGER APPROACH

B i lateral femo ral venous

approach, catheters areplaced into the right and lefthepatic veins.

Femoral arter ial approach,standard visceralarteriography is performed

Select ive inject ions of

con trast agent into m id

and prox imal splenic

artery in an attempt tolocalize a tumor to thepancreatic tail or body,respectively


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Sampling Technique If a tumor blush is

visualized, the artery

supplying the blush is

injected with the

secretagogue last & 10%calcium gluconate.

Then 5-mL samples from

the hepatic veins are

obtained before and 20,

40, and 60 seconds after

calcium injection forbaseline Insulin levels


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Conclusion

Visceral arteriography together with

arterial stimulation with venous sampling

(ASVS) has a high sensitivity in localizing

gastrinomas and insulinomas independentof their size.

venous sampling in endocrine dx

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