Should adrenal venous sampling be performed before adrenalectomy in primary aldosteronism? Con
There is no doubt that AVS plays a central role in differentiating PA subtypes and that adrenalectomy is only indicated in patients with unilateral aldosterone hypersecretion.
However, AVS is not widely available. It is invasive and not devoid of morbidity (pain, adrenal hematoma). Cannulating the two adrenal veins is technically demanding and may fail in up to one patient in four. The procedure is not standardized (sequential or simultaneous bilateral AVS? with or without cosyntropin stimulation?). There is no consensus regarding the threshold for the cortisol-corrected aldosterone ratio that indicates a lateralized AVS. Even the use of cortisol-corrected aldosterone ratios can be questioned as it relies on the unproven assumption that cortisol secretion in symmetrical in all cases of surgically-curable PA.
The presence of a unilateral adenoma at computed tomography is a surrogate marker of unilateral aldosterone hypersecretion. Whether a lateralized AVS improves the prediction of surgery outcome in younger patients (e.g. aged 40 or less) with a unilateral adenoma is not documented. The prevalence of non-functioning adrenal masses increases with age. Therefore younger patients have a very low probability for the combination of idiopathic PA with a non-functioning adrenal adenoma.
Consequently, AVS cannot be considered a sine qua non condition for adrenalectomy in PA, specifically in younger patients, i.e. in patients who are the best candidates for surgery.
Should AVS be performed in a many patients with PA before surgery? YES
Should all young patients with PA and a typical adenoma at computed tomography undergo AVS before surgery? NO.