title: Failure mode analysis in adrenal vein sampling: a single-center experience.
abstract: OBJECTIVE
  To analyze failure modes in a high-volume adrenal vein sampling (AVS) practice in an effort to identify preventable causes of nondiagnostic sampling.
  
  
  METHODS
  A retrospective database was constructed containing 343 AVS procedures performed over a 10-year period. Each nondiagnostic AVS procedure was reviewed for failure mode and correlated with results of any repeat AVS. Data collected included selectivity index, lateralization index, adrenalectomy outcomes if performed, and details of AVS procedure. All AVS procedures were performed after cosyntropin stimulation, using sequential technique.
  
  
  RESULTS
  AVS was nondiagnostic in 12 of 343 (3.5%) primary procedures and 2 secondary procedures. Failure was right-sided in 8 (57%) procedures, left-sided in 4 (29%) procedures, bilateral in 1 procedure, and neither in 1 procedure (laboratory error). Failure modes included diluted sample from correctly identified vein (n = 7 [50%]; 3 right and 4 left), vessel misidentified as adrenal vein (n = 3 [21%]; all right), failure to locate an adrenal vein (n = 2 [14%]; both right), cosyntropin stimulation failure (n = 1 [7%]; diagnostic by nonstimulated criteria), and laboratory error (n = 1 [7%]; specimen loss). A second AVS procedure was diagnostic in three of five cases (60%), and a third AVS procedure was diagnostic in one of one case (100%). Among the eight patients in whom AVS ultimately was not diagnostic, four underwent adrenalectomy based on diluted AVS samples, and one underwent adrenalectomy based on imaging; all five experienced improvement in aldosteronism.
  
  
  CONCLUSIONS
  A substantial percentage of AVS failures occur on the left, all related to dilution. Even when technically nondiagnostic per strict criteria, some "failed" AVS procedures may be sufficient to guide therapy. Repeat AVS has a good yield.
authors.affiliation: Department of Radiology, Division of Interventional Radiology, University of Pennsylvania Medical Center, 1 Silverstein, 3400 Spruce Street, Philadelphia, PA 19104. Electronic address: streroto@uphs.upenn.edu.
authors.forename: Scott O
authors.initials: SO
authors.lastname: Trerotola
authors.affiliation: Department of Radiology, Division of Interventional Radiology, University of Pennsylvania Medical Center, 1 Silverstein, 3400 Spruce Street, Philadelphia, PA 19104.
authors.forename: Melissa
authors.initials: M
authors.lastname: Asmar
authors.affiliation: Department of Radiology, Division of Interventional Radiology, University of Pennsylvania Medical Center, 1 Silverstein, 3400 Spruce Street, Philadelphia, PA 19104.
authors.forename: Yan
authors.initials: Y
authors.lastname: Yan
authors.affiliation: Department of Surgery, Division of Surgical Oncology, University of Pennsylvania Medical Center, 1 Silverstein, 3400 Spruce Street, Philadelphia, PA 19104.
authors.forename: Douglas L
authors.initials: DL
authors.lastname: Fraker
authors.affiliation: Department of Medicine, Division of Nephrology, University of Pennsylvania Medical Center, 1 Silverstein, 3400 Spruce Street, Philadelphia, PA 19104.
authors.forename: Debbie L
authors.initials: DL
authors.lastname: Cohen
mesh_terms: D000311:Adrenal Glands / Q000098:blood supply* / Q000601:surgery; D000315:Adrenalectomy; D000328:Adult; D000368:Aged; D000450:Aldosterone / Q000097:blood*; D015415:Biomarkers / Q000097:blood; D001800:Blood Specimen Collection / Q000009:adverse effects* / Q000379:methods; D002406:Catheterization, Peripheral / Q000009:adverse effects*; D003366:Cosyntropin; D016208:Databases, Factual; D005260:Female; D061847:Hospitals, High-Volume; D006801:Humans; D006854:Hydrocortisone / Q000097:blood*; D006929:Hyperaldosteronism / Q000097:blood / Q000175:diagnosis* / Q000601:surgery; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D015143:Philadelphia; D010690:Phlebography; D011237:Predictive Value of Tests; D015203:Reproducibility of Results; D012189:Retrospective Studies; D016896:Treatment Outcome; D014680:Veins
chemical_list: D015415:Biomarkers; D003366:Cosyntropin; D000450:Aldosterone; D006854:Hydrocortisone