Use of partial data from failed adrenal venous sampling to guide surgical management in primary aldosteronism; a case report and review of literature

Primary aldosteronism is associated with increased morbidity, mortality, and poor quality of life. Attempts should be made to diagnose, establish subtype classification, and offer the most appropriate diagnosis depending on the subtype. Adrenal venous sampling is the gold standard method in subtype classification. However, failure to cannulate the right adrenal vein is commonly encountered. A 55-year-old male with hypertension for 21 years, presented with generalized body aches, paraesthesia, and cramps for three months. His blood pressure was controlled on telmisartan and amlodipine. Serum potassium was 2.9 mmol/L. Serum aldosterone was elevated with suppressed plasma renin concentration. Magnetic resonance imaging of the abdomen showed a well-defined round 1.4 cm×1.3 cm isointense lesion in the right suprarenal gland and multiple bilateral renal cysts. During bilateral adrenal vein sampling, the right adrenal vein was not cannulated. Aldosterone: cortisol ratio of the left adrenal vein and inferior vena cava were 0.0264 and 0.0699, respectively. Left adrenal vein/ inferior vena cava index was 0.377, suggesting contralateral aldosterone excess. He underwent laparoscopic right adrenalectomy, which resulted in the resolution of hypertension and hypokalaemia. Careful analysis of partial data from ‘failed’ adrenal vein sampling can support management decisions avoiding unnecessary repetition of invasive procedures.