Experience in Identifying the Venous Drainage of the Adrenal Gland During Laparoscopic Adrenalectomy
ABSTRACT Laparoscopic adrenalectomy (LA) is the procedure of choice for most adrenal tumors. An important part of LA is the early identification and ligation of the adrenal veins. The venous drainage from each adrenal gland is usually via a single vein: the right vein draining into the inferior vena cava (IVC) and the left vein into the left renal vein. Although infrequent, variable venous drainage has been documented. The aim of the study was to clarify if LA identified venous drainage and its variants. Between January 1999 and January 2008, 142 consecutive patients underwent LA. Adrenal vein anatomy was documented on a prospective database. In total, 142 patients underwent 162 LA (right = 62, left = 66, bilateral = 17). All adrenal veins were identified at the time of laparoscopy. For 157 LA, the adrenal venous drainage was constant: right vein drained into the IVC and left vein drained into left renal vein. Five patients had adrenal vein variants: two right veins draining separately into IVC (n = 1), two right veins draining into the IVC and right renal vein (n = 1), and two left veins draining separately into the left renal vein (n = 3). Adrenal vein variants were present in patients with phaeochromocytomas (n = 4) or adrenocortical carcinoma (n = 1). The laparoscopic approach allowed an excellent view of the main adrenal venous anatomy. This has helped confirm the constant nature of the venous drainage and successfully identify variant adrenal veins.
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ABSTRACT: The adrenal veins may present with a multitude of anatomical variants, which surgeons must be aware of when performing adrenalectomies. The adrenal veins originate during the formation of the prerenal inferior vena cava (IVC) and are remnants of the caudal portion of the subcardinal veins, cranial to the subcardinal sinus in the embryo. The many communications between the posterior cardinal, supracardinal, and subcardinal veins of the primordial venous system provide an explanation for the variable anatomy. Most commonly, one central vein drains each adrenal gland. The long left adrenal vein joins the inferior phrenic vein and drains into the left renal vein, while the short right adrenal vein drains immediately into the IVC. Multiple variations exist bilaterally and may pose the risk of surgical complications. Due to the potential for collaterals and accessory adrenal vessels, great caution must be taken during an adrenalectomy. Adrenal venous sampling, the gold standard in diagnosing primary hyperaldosteronism, also requires the clinician to have a thorough knowledge of the adrenal vein anatomy to avoid iatrogenic injury. The adrenal vein acts as an important conduit in portosystemic shunts, thus the nature of the anatomy and hypercoagulable states pose the risk of thrombosis. Clin. Anat., 2014. © 2014 Wiley Periodicals, Inc.Clinical Anatomy 11/2014; 27(8):1253-1263. DOI:10.1002/ca.22374 · 1.16 Impact Factor
Article: Adrenal vein sampling.[Show abstract] [Hide abstract]
ABSTRACT: Adrenal vein sampling is the gold standard for localizing aldosterone-secreting adenomas and for distinguishing adenomas from bilateral adrenal hyperplasia in patients with primary hyperaldosteronism. The importance of this distinction cannot be overstated because the former is curable surgically, whereas the latter is managed medically. Primary hyperaldosteronism has historically been underdiagnosed as a cause of hypertension, but recent reports highlight its ubiquitous nature with a prevalence of 5%-10% in screened hypertensive patients. Of such patients, up to 62.5% have a potentially curable adenoma as the underlying etiology. Adrenal vein sampling is a safe, highly effective procedure that is shown to alter the clinical management in 35.7% of primary hyperaldosteronism patients who would have otherwise been treated improperly based on the results of CT or other modalities. Although adrenal vein sampling is hindered by the inherent difficulty of catheterizing the right adrenal vein, technical success is reported as high as 97% in experienced hands. In this article, we review aldosterone physiology and the clinical workup of primary aldosteronism as well as the anatomic, technical, and analytical factors to be considered with adrenal vein sampling.Techniques in vascular and interventional radiology 06/2010; 13(2):110-25. DOI:10.1053/j.tvir.2010.02.006
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ABSTRACT: In primary aldosteronism, adrenal vein sampling (AVS) suggests unilateral aldosterone-producing adenoma (APA) when the aldosterone/cortisol (A/F) ratio is less than or equal to peripheral on one side and at least two times peripheral on the other. When A/F ratios are lower bilaterally than peripheral despite adequate samples (adrenal venous cortisol ≥3 times peripheral), we recommend repeat AVS. This study aimed to determine the frequency of this occurrence and outcomes in such cases. We performed a retrospective observational study of all cases of primary aldosteronism undergoing initial AVS over a 34-year period. Initial AVS in 1397 patients returned satisfactory and discriminatory results in 1066 (76.3%) but 37 patients (2.6%) had adequate samples but bilateral A/F ratios no higher than peripheral. Of the 22 of these 37 who agreed to repeat AVS, 10 demonstrated unilateral aldosterone production, and eight of these had unilateral adrenalectomy disclosing APAs and resulting in cure (3) or improvement (5) in hypertension. Eight had bilateral aldosterone production. Four studies were inconclusive. Patients with initial unsatisfactory AVS because of bilaterally low A/F ratios had significantly (P = 0.023) more unilateral disease [10 of 18 satisfactory repeat studies (55.6%) vs. 326 of 1066 satisfactory initial studies (30.6%)] and a significantly higher (67.6 vs. 49.9%, P = 0.034) percentage of males. As the incidence of APAs was high in a subgroup with low A/F bilaterally on initial AVS, these patients should be offered repeat AVS. This might reflect both a greater dependence of aldosterone production on adrenocorticotrophic hormone (ACTH) in APAs and the pulsatile nature of ACTH secretion.Journal of Hypertension 10/2013; 31(10):2005-2009. DOI:10.1097/HJH.0b013e328362add3 · 4.22 Impact Factor