Browsing by Author "Amaral, S"
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- Adrenal Vein Sampling in the Management of Primary Aldosteronism: The Added Value of Intraprocedural Cortisol AssessmentPublication . Manique, I; Amaral, S; Matias, A; Bouça, B; Serranito, S; Torres, J; Gutu, O; Bilhim, T; Coimbra, E; Rodrigues, I; Godinho, C; Cortez, L; Silva-Nunes, JIntroduction: Primary aldosteronism is the most common cause of secondary hypertension. Adrenal vein sampling is the gold standard for subtyping primary aldosteronism. However, this procedure is technically challenging and often has a low success rate. Our center is one of the very few performing this technique in our country with an increasing experience. Objective: The aim of this study was to evaluate the role of the cortisol intraprocedural assay in improving the performance of adrenal vein sampling. Design: We enrolled all of the patients with primary aldosteronism that underwent adrenal vein sampling from February 2016 to April 2023. The cortisol intraprocedural assay was introduced in October 2021. Methods: We enrolled a total of 50 adrenal vein samplings performed on 43 patients with the diagnosis of primary aldosteronism. In this sample, 19 patients and 24 patients underwent adrenal vein sampling before and after intraprocedural cortisol measurement, respectively. The procedure was repeated in seven patients (one before and six after intraprocedural cortisol measurement), given the unsuccess of the first exam. Selectivity of the adrenal vein sampling was assumed if the serum cortisol concentration from the adrenal vein was at least five times higher than that of the inferior vena cava. Lateralization was assumed if the aldosterone to cortisol ratio of one adrenal vein was at least four times the aldosterone to cortisol ratio of the contralateral side. Results: The mean age of the patients that underwent adrenal vein sampling (N = 43) was 55.2 ± 8.9 years, and 53.5% (n = 23) were female. The mean interval between the diagnosis of hypertension and the diagnosis of primary aldosteronism was 9.8 years (±9.9). At diagnosis, 62.8% of the patients (n = 27) had hypokalemia (mean value of 3 mmol/L (±0.34)), 88.4% (n = 38) had adrenal abnormalities on preprocedural CT scan, and 67.4% (n = 29) described as unilateral nodules. There were no statistically significant differences in the patients' baseline characteristics between the two groups (before and after intraprocedural cortisol measurement). Before intraprocedural cortisol measurement, adrenal vein sampling selectivity was achieved in 35% (n = 7) patients. Selectivity increased to 100% (30/30) after intraprocedural cortisol measurement (p < 0.001). With the exception of one patient who refused it, all patients with lateralized disease underwent unilateral adrenalectomy with normalization of the aldosterone to renin ratio postoperatively. Conclusions: The lack of effective alternatives in subtyping primary aldosteronism highlights the need to improve the success rate of adrenal vein sampling. In this study, intraprocedural cortisol measurement allowed a selectivity of 100%. Its addition to this procedure protocol should be considered, especially in centers with a low success rate.
- Adrenal Vein Sampling: How We Do ItPublication . Resende Neves, T; Proença Caetano, A; Manique, I; Amaral, S; Godinho, C; Bilhim, T; Coimbra, EPrimary aldosteronism is the most common cause of secondary hypertension. When unilateral disease is present, patients can be treated curatively by adrenalectomy. Adrenal vein sampling (AVS) is considered essential for discrimination between unilateral versus bilateral disease. Knowledge of normal and variant anatomy of the adrenal veins is important to avoid misleading results and increase technical success. The main reason for technical failure of AVS is the inability to catheterize the right adrenal vein. Pre-procedural CT imaging can help identify the venous anatomy of the adrenals. To validate the technical success of AVS, the catheterization index is calculated comparing the cortisol levels in each adrenal gland with those of the inferior vena cava. To assess the laterality index, the aldosterone levels are compared between both adrenals. We generally use a femoral access and a 4Fr Berenstein catheter for the left adrenal vein and a 5Fr Cobra, Simmons or Micahelson for the right adrenal vein. Some centers adopt an intravenous perfusion of a synthetic peptide of the adrenocorticotropic hormone immediately prior to the procedure to stimulate the adrenal glands. AVS is a safe and feasible procedure, with low risk of failure. Due to the technical difficulties of execution, especially right adrenal vein cannulation, AVS has low usage among hospital centers. The learning curve is estimated to be around 20 to 30 procedures, with a maintenance of about 15 annual procedures to achieve satisfactory results.
- Preoperative Location of Parathyroid Adenomas in Primary Hyperparathyroidism: the Role of Cervical Doppler UltrasoundPublication . Amaral, S; Rego, T; Palha, A; Carrilho, N; Coutinho, JM; Tavares, P; Silva-Nunes, JIntroduction: Parathyroid adenoma is the most frequent cause of primary hyperparathyroidism. In recent years, the preoperative location of parathyroid adenomas allowed minimally invasive surgical techniques that have become preferred over the traditional bilateral neck exploration. The more recent guidelines on this subject highlight the role of nuclear medicine imaging tests. The aim of this study was to review the current role of Doppler ultrasound (US) in assessing the preoperative location of parathyroid adenomas in patients with primary hyperparathyroidism. Material and methods: Retrospective study based on data from patients with primary hyperparathyroidism that underwent parathyroidectomy between January 2013 and January 2022 at the Centro Hospitalar Universitário Lisboa Central. Statistical analysis was performed with IBM SPSS Statistics, version 26.0.0.0®. Results: Parathyroidectomy was performed in 171 patients (77.8% females) with primary hyperparathyroidism. Cervical Doppler ultrasound was the most performed test (64.3%, n = 110) for preoperative location and detected a suspicious lesion in 98 patients (89.1%). The preoperative location of the parathyroid adenomas was assessed through the Doppler ultrasound and was compared with the surgical reports and histological findings; a correct identification was made in 76 patients (77.6%). Doppler ultrasound slightly underestimated the mean adenoma size (18.1 ± 7.7 mm preoperative versus 22 ± 8.4 mm postoperative). Calcium, parathyroid hormone levels, adenoma size and concomitant presence of thyroid nodules did not affect the accuracy of Doppler ultrasound. Conclusion: Doppler ultrasound showed high diagnostic accuracy even in patients with nodular thyroid disease regardless of calcium and parathyroid hormone levels and adenoma size. Furthermore, its safety, affordability and availability should favor its use as first line test in primary hyperparathyroidism to assess the preoperative location of parathyroid adenomas.