title: Reversing the established order: Should adrenal venous sampling precede cross-sectional imaging in the evaluation of primary aldosteronism?
abstract: BACKGROUND
  Adrenal venous sampling (AVS) is the definitive evaluation for primary aldosteronism (PA). Pre-AVS cross-sectional imaging does not reduce the need for AVS. The goal of this study was to examine whether performing AVS prior to imaging could decrease the use of imaging in the evaluation of PA at a high volume, experienced center.
  
  
  METHODS
  We performed a retrospective analysis of all AVS procedures (n = 337) done for PA from 2001-2013. Patients whose cross-sectional imaging reports were unavailable (n = 90) or AVS was non-diagnostic (n = 12) were excluded. AVS was performed using modified Mayo technique. Univariate analysis utilized the χ² test and fisher's exact test.
  
  
  RESULTS
  Of the 235 patients analyzed, 63% (n = 148) were male. The mean age was 55 ± 11 years. AVS was non-lateralizing in 43% (n = 101); these patients might have avoided imaging with an AVS-first approach. Imaging and AVS were concordant in 52% (n = 123). In patients ≤40yo (n = 23), 35% (n = 8) had no lateralization on AVS, and might have avoided imaging in an AVS-first approach. Imaging and AVS were concordant in 52% (n = 12) of patients ≤ 40yo, versus 52% (n = 111) of patients > 40 yo (P = 0.987).
  
  
  CONCLUSIONS
  An AVS-first, imaging-second approach could have avoided CT/MRI in 43% of patients. At a high volume, experienced center, performing AVS first on patients with PA may reduce unnecessary cross-sectional imaging studies.
authors.affiliation: Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Melissa
authors.initials: M
authors.lastname: Asmar
authors.affiliation: Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Heather
authors.initials: H
authors.lastname: Wachtel
authors.affiliation: Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Yan
authors.initials: Y
authors.lastname: Yan
authors.affiliation: Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Douglas L
authors.initials: DL
authors.lastname: Fraker
authors.affiliation: Department of Medicine, Renal, Electrolyte and Hypertension Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Debbie
authors.initials: D
authors.lastname: Cohen
authors.affiliation: Department of Radiology, Division of Vascular and Interventional Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Scott O
authors.initials: SO
authors.lastname: Trerotola
mesh_terms: D000310:Adrenal Gland Neoplasms / Q000097:blood / Q000098:blood supply / Q000175:diagnosis* / Q000601:surgery; D000311:Adrenal Glands / Q000098:blood supply* / Q000601:surgery; D000315:Adrenalectomy; D000328:Adult; D000368:Aged; D000450:Aldosterone / Q000097:blood*; D000465:Algorithms; D015415:Biomarkers / Q000097:blood; D001800:Blood Specimen Collection / Q000379:methods / Q000592:standards / Q000639:trends; D005260:Female; D006801:Humans; D006929:Hyperaldosteronism / Q000097:blood / Q000175:diagnosis* / Q000473:pathology / Q000601:surgery; D008279:Magnetic Resonance Imaging / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D014057:Tomography, X-Ray Computed / Q000706:statistics & numerical data*; D014680:Veins
chemical_list: D015415:Biomarkers; D000450:Aldosterone
keywords: adrenal vein sampling; aldosteronoma; imaging; primary aldosteronism; primary hyperaldosteronism