Implement measures to improve adrenal venous sampling success rate
STEP 1 — Gather Information
Confirm referral to an experienced specialized center and obtain preoperative multidetector CT (MDCT) to map adrenal vein anatomy; document patient age, serum potassium, plasma aldosterone concentration, and presence of adrenal tumor on CT.
STEP 2 — Rule In / Rule Out
Is AVS being performed at an experienced center with preoperative MDCT completed? If yes, proceed to STEP 3; if no, arrange transfer to an experienced center and perform MDCT before AVS.
STEP 3 — Classify or Stratify
Determine whether ACTH stimulation, contrast radiography during catheterization, and rapid intraoperative cortisol measurement are available; if any are unavailable, implement them per protocol to maximize success.
STEP 4 — Decide
Execute AVS using a standardized protocol at the specialized center, incorporating MDCT‑guided anatomy, ACTH stimulation, contrast radiography to confirm catheter position, and rapid cortisol measurement to verify successful sampling.
Clinical Guardrails / Mimics / Pitfalls
Do not skip preoperative MDCT, omit ACTH stimulation, fail to confirm catheter position with contrast, delay cortisol measurement, or perform AVS at low‑volume centers lacking expertise, as these reduce success rates and increase non‑selective sampling.
Concrete Clinical Example
A 48‑year‑old woman with resistant hypertension, hypokalemia (K⁺ 3.2 mmol/L), and a 1.2 cm left adrenal nodule undergoes AVS after MDCT shows a short left adrenal vein; ACTH (250 µg IV bolus) is given, catheter position is confirmed by contrast venography, and cortisol is measured within 2 min, yielding successful lateralization (LI > 4) and guiding left adrenalectomy.
Source: Japan Endocrine Society clinical practice guideline for the diagnosis and management of primary aldosteronism 2021, Japan Endocrine Society, 2022.