VENOUS SAMPLING IN ENDOCRINE DISEASE

Dr. A. O. Adeyinka Consultant Radiologist UCH Ibadan

Radiology-Endocrine Update Course 18th September 2012 LUTH Lagos

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)

Objectives of Venous Sampling

To evaluate hormonal secretion abnormalities in endocrine disorders Aids Differential diagnosis or Sub-type of abnormal hormonal secretions Applied to address individual clinical problems in coordination with other imaging modalities May achieve regional localization or lateralization of the endocrine tumors Guides therapeutic Management

Types of Endocrine 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)

Technique
Seldinger Technique via the Femoral Vein followed by selective catheterization of the relevant veins Selective Arterial Catheterization in Arterial stimulation combined with Venous sampling Blood Samples collected and Hormonal levels are biochemically analyzed in each of the veins selectively catheterized.

PRIMARY ALDOSTERONISM
Xterized by the overproduction of the mineralocorticoid hormone aldosterone 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.

Types
Adrenal Adenoma (Conn's Syndrome) (66%) Bilateral idiopathic adrenal hyperplasia (30%) Primary (unilateral) adrenal hyperplasia2% of cases Aldosterone-producing adrenocortical carcinoma <1% of cases Familial Hyperaldosteronism (FH) Glucocorticoid-remediable aldosteronism (FH type I)<1% of cases FH type II (APA or IHA)<2% of cases Ectopic aldosterone-producing adenoma or carcinoma< 0.1% of cases

Diagnostic Screening
First Test Simple blood tests that measure the levels of potassium, aldosterone, and renin (High Aldosterone, Low Renin & Low Potassium is Diagnostic) Second Test Plasma aldosterone concentration (PAC) to Plasma renin activity (PRA) ratio (PAC:PRA) A high ratio is Diagnostic Confirmatory Test Captopril Suppression Test High Aldosterone and Low Renin is Diagnostic.

Diganosis and Treatment Algorithm for Primary Hyperaldosteronism Screening test:

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

ADRENAL VENOUS SAMPLING[AVS]

Indications AVS is a direct assessment of hormonal secretion Detection of excessive aldosterone excretion (Conn's syndrome) Differentiation of Bilateral hyperplasia, Aldosterone-secreting adenoma, and Primary adrenal hyperplasia Used as Guide to Therapeutic Management

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)

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 were obtained from all three sites. Cortrosyn given during AVS. Successful AVS was determined by at least a 3-fold elevation in adrenal vein Epinephrine and Cortisol levels compared with the IVC.

AVS - TECHNIQUE
Normalized Aldosterone Each Aldosterone concentration 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 rupture of the vein. Infarction of the gland and loss of function

AVS - INTERPRETATION
APA and PAH Diagnosis Ratio of Dominant to Non-dominant normalized aldosterone would be 4 or greater Non-dominant normalized aldosterone would be less than or equal to the Normalized aldosterone in the IVC. BAH - Diagnosis Aldosterone in each adrenal vein was equal to or greater than the normalized aldosterone from the IVC.

Arteriography and Arterial Stimulation with Venous Sampling (ASVS) for Localizing Pancreatic Endocrine Tumors Pancreatic endocrine tumors are uncommon tumors that belong to the family of APUD neoplasm. 1. Functional hormone -Associated with clinical syndrome Gastrinomas (20%) Ulcerative (Zollinger) Insulinomas (50%) - hypoglycemia 2. Nonfunctional - if not associated with clinical symptoms. Pancreatic polypeptide secreting tumors

Role of ASVS in Insulinoma

Insulinomas are usually solitary Distributed evenly throughout the pancreas 5 -15% of insulinomas are malignant. Preoperative workup with ASVS helps establishing the diagnosis of insulinoma Sensitivity of angiography in localizing insulinomas 35% to 94%. Sensitivity of calcium ASVS in localizing insulinomas ranges from 78% to 100%.[ Insulinomas found at surgery are small: 90% less than 2 cm, 66% less than 1.5 cm, and 40% less than 1 cm.[2]

ASVS - INSULINOMA
Arterial stimulation and venous sampling (ASVS) is an important technique for localizing insulinoma. The principle behind ASVS is that insulin secretion is promoted from insulinoma cells by the injection of calcium into the insulinomafeeding artery

ASVS - TECHNIQUE
Indications for Calcium ASVS -Failure of non-invasive imaging to localize an insulinoma. -Regionalization of the insulinoma tumor when multiple tumors are present. Contraindications Similar to diagnostic arteriography. Relative contraindications include uncontrolled hypertension, uncorrectable coagulopathy , severe allergy to iodinated contrast, severe renal insufficiency, and congestive heart failure. For calcium ASVS, cardiac glycosides are a relative contraindication.

ASVS - TECHNIQUE
EQUIPMENT 4- or 5-Fr Simmons-1 catheter for Hepatic Veins catheterization. 4-Fr cobra-2, SOS Omni, Simmons-1, and/or Simmons-2 catheters for visceral arteriography 0.027-inch inner diameter microcatheters such as the Renegade Hi-Flo allow a tighter bolus of secretagogue. Nonionic iodinated agent such as iopamidol SELDINGER APPROACH Bilateral femoral venous approach, catheters are placed into the right and left hepatic veins. Femoral arterial approach, standard visceral arteriography is performed Selective injections of contrast agent into mid and proximal splenic artery in an attempt to localize a tumor to the pancreatic tail or body, respectively

Sampling Technique
If a tumor blush is Then 5-mL samples from visualized, the artery the hepatic veins are supplying the blush is obtained before and 20, injected with the 40, and 60 seconds after secretagogue last & 10% calcium injection for calcium gluconate. baseline Insulin levels

Conclusion
Visceral arteriography together with arterial stimulation with venous sampling (ASVS) has a high sensitivity in localizing gastrinomas and insulinomas independent of their size.