Venous sampling technique in Endocrinology: a renewed technique

Transcription

1 Venous sampling technique in Endocrinology: a renewed technique Poster No.: C-0682 Congress: ECR 2014 Type: Educational Exhibit Authors: M. E. Rodriguez Cabillas 1, J. Garcia Villanego 2, I. Olea Comas 3, A. Collantes Gonzalez 3, J. A. Fernandez Roche 3 ; 1 San Fernando/ES, Cadiz/ES, 3 Cádiz/ES Keywords: DOI: Abdomen, Pancreas, Catheter venography, Fluoroscopy, Catheters, Diagnostic procedure, Endocrine disorders, Neoplasia /ecr2014/C-0682 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 10

2 Learning objectives - To describe the technique and experience of our Hospital with adrenal venous sampling, in cases of primary aldosteronism, overactive pancreas tumor localization and inferior petrosal sinus sampling in pituitary microadenomas. - To analyze results of the technique and meaning in each of the processes. Background Peripheral venous sampling for the diagnosis and localization of functioning tumors or autonomous hormonal hypersecretion, is used when imaging has not been able to locate the secreting tumor. This could be due to the following reasons: either because of its small size, or because of the presence of a hyperplasia gland or the coexistence of other lesions (nonfunctioning adenomas), which do not allow to identify the laterality of the overactive gland. Findings and procedure details I) ADRENAL VENOUS SAMPLING: INDICATIONS: - Primary hyperaldosteronism is the most frequent endocrine cause of hypertension. - The aldosterone-producing adenomas (aldosteronomas) and bilateral hyperplasia are the most common causes of hyperaldosteronism. Other more rare causes include hyperplasia unilateral, adrenal carcinoma and familial hyperaldosteronism. - The CT and MRI are very sensitive in the detection of adrenal adenomas (90% sensitivity), but its performance is very poor in order to locate and lateralize hyperfunctioning tumors. - This technique seeks to determine whether the overproduction of aldosterone is unilateral or bilateral, since if the hyperfunction is unilateral, adrenalectomy can be healed, but if the hyperfunction is bilateral, surgery is contraindicated. PROCEDURE: Page 2 of 10

3 - To perform venous phase angio-ct in order to identify the existence of anatomical variants in inferior cava vein; to get to know the venous anatomy at each adrenal; and to have the vertebral bodies as a reference so as to locate the right adrenal vein (by placing the catheter 1 cm higher than the TAC of reference, since this is carried out in deep breathing). If the vein is not found, we use the midpoint of the gland as the theoretical position. - The right adrenal vein drains directly into the back wall of the inferior cava vein, whereas the left adrenal vein drains by forming a common trunk with the lower left phrenic vein on the upper side of the left renal vein (Figure 1) - Vascular sheaths are placed in both common femoral veins for simultaneous extraction of each adrenal gland, one of 5F and another one of 6F that will help us to take samples of peripheral blood. - To use cobra catheter 2 with 5F lateral hole, channeling the right adrenal vein and the left one from the right introducer. In the cases where it is not possible to catheterize the vessels, we should use Simmons 1 catheter. - It is necessary to extract samples of both sides and of peripheral blood simultaneously, because the existence of a gradient of 3 between cortisol from the adrenal and peripheral samples ensures that the adrenal catheterization is correct. Gradients below 2, indicate that the sample is not valid, gradients between 2 and 3 should be analyzed individually (Figure 2). * Samples are taken: - In a basal way - After ACTH stimulation in a peripheral drip. The aspiration of blood must be smoothly and contrast injections for venography are not allowed to be given, since it can produce infarction or hemorrhage of the gland. * INTERPRETATION OF RESULTS: - Correct catheterization: Ratio adrenal cortisol in adrenal vein / cortisol VCI vein: 5/1. - Aldosterone ratio corrected with cortisol (dividing aldosterone from each side by the cortisol of each side, to avoid the dilutional effect of phrenic vein in the right adrenal vein): #Major aldosterone corrected / minor aldosterone corrected: 4/1:Unilateral lesion. Page 3 of 10

4 #If <3: bilateral hypersecretion - Besides, the unilateral lesion is confirmed if the minor corrected aldosterone is less than the aldosterone corrected in VCI value. - This technique has a 95% sensitivity and a 100% specificity II) SUPRAHEPATIC VENOUS SAMPLING IN INSULINOMAS INDICATION: - The insulinomas are small tumors (90% <2 cm) with difficult location by using conventional techniques (CT, MRI) and EUS. - The pancreas is supplied by the gastroduodenal splenic and superior mesenteric arteries, each of which has a preferred irrigation area within the pancreas. - Insulinomas increase the insulin secretion in response to the infusion of calcium, whereas the normal beta cells do not respond to this stimulus. - The calcium infusion into the hepatic artery allows us to detect hyperinsulinism areas (metastasis) in the liver, which, sometimes, can not be detected by morphological tests. - By measuring the insulin response in the right hepatic vein after the infusion of calcium in each of the three arteries,we can detect the sensitive area of surgical resection. - The angiography of the gastroduodenal, splenic and superior mesenteric arteries, which can detect hypervascularization areas ("blush"), suggestive of tumor pathology up to 75% of cases. PROCEDURE: Vascular sheaths were placed: - In left common femoral vein from which the right hepatic vein is catheterised with 2 5F catheter with hole on the side to extract the venous samples. - In right common femoral artery from which we catheterize selectively and sequentially superior mesenteric artery, splenic artery, hepatic artery and gastroduodenal artery. Selective arteriography is performed in each vessel, and subsequently, calcium Page 4 of 10

5 stimulation is performed from the arterial catheter in each collecting vessel and venous samples in suprahepatic catheter at baseline, at 30 ', 60' and 120 '. INTERPRETATION: Insulinemia VHD is compared before and after infusion of calcium in each of the four arteries. A positive finding is a insulinemia VHD ratio after calcium / VHD Insulinemia calcium previous to calcium, more than 2.0 sometimes (30, 60 or 120 seconds after the calcium infusion): -Ratio> 2.0 after infusion in gastroduodenal or superior mesenteric artery: indicates the location in pancreatic head or uncinado process. -Ratio> 2.0 after splenic artery infusion: insulinoma in corporo caudal location. -Ratio> 2.0 after common hepatic artery infusion: insulinoma with metastatic spread to the liver. * Angiography results provide the following: - Confirmation of localization in cases of borderline ratios. - Defining more specific location in the sections marked by the irrigation of an entire principal artery (Figure 3 and 4). III) INFERIOR PETROSAL SINUS: INDICATION: - Cushing syndrome (CS) is more frequently caused by exogenous administration of corticosteroids. The CS causes differ in endogenous levels of ACTH: #Low: SC ACTH-independent: adrenal adenomas, more rare adrenal carcinoma. It is studied by abdomen imaging. #High: SC ACTH-dependent: the origin of ACTH can be pituitary (pituitary adenoma) or ectopic. Page 5 of 10

6 - The sampling of petrosal sinus is indicated in all cases which could not be determined by other imaging techniques the origin of Cushing disease PROCEDURE: - Channeling both common femoral veins with introducer 6F and 5F on the right and left side respectively. The one with the highest calibre is used for extracting peripheral samples. - If the channeling of petrosal sinus is not posible, due to its small diameter, microcatheters are used. Contrast injection is performed to check the correct placement. - The taking of blood in basal petrosal sinus and peripheral blood are carried out, subsequent stimulation with CRH, and samples are obtained at 3, 5, 10 and 15 minutes in petrosal sinuses and peripheral. INTERPRETATION: - Calculate the proportion of ACTH in petrosal / peripheral sinus: Basal # 2 or # 3 after stimulation confirming the diagnosis of Cushing disease of pituitary origin. - 1% -10% false negatives, in such cases the IPS ratio / prolactin can be carried out. - The venous drainage of the pituitary is predominantly ipsilateral. Theoretically, the test could provide data on the laterality of the lesion. A ratio between the sinus # 1.4 is considered evidence on the laterality of the adenoma with a % accuracy, although in surgery the entire gland should be checked (Figure 5). Images for this section: Page 6 of 10

7 Fig. 1: Drawing illustrate the normal anatomy of artery and venous anatomy of adrenal glands Page 7 of 10

8 Fig. 2: Figure 2.- Right and left suprarrenal gland Page 8 of 10

9 Fig. 3: Figure 3.- Nodule uptake in pancreatic head not described in TAC or RM corresponding to insulinoma Fig. 4: Figure 4.- Nodule uptake in pancreatic head not described in TAC or RM corresponding to insulinoma Fig. 5: Figure 5.- Right and left inferior petrosal sinus Page 9 of 10

10 Conclusion - Venous sampling is a useful technique, and sometimes of our choice to locate hidden neuroendocrine tumors. - It requires a meticulous technique and knowledge of the anatomy of the investigated vascular areas and normal variants, with a high percentage of success. - Most failures are due to the impossibility of catheterization of one of the areas because of obtaining glow flows in some areas with low volume outlets. - In some areas, it is difficult to interpret results by variations in venous drainage. - It has minimal effects and few contraindications (venous thrombosis, extravasation medium contrast, myocardial gland studied), together with the characteristic of arterial and / or venous catheterization complications. Personal information References 1.- Qureshi AI, Georgiadis AL. Textbook of Interventional Neurology. Cambridge University Press. (2011) 2.- Miller DL, Doppman JL. Petrosal sinus sampling: technique and rationale. Radiology. 1991;178 (1): Walker TG. Interventional Procedures. Lippincott Williams & Wilkins. (2012) 4.- Patel SM, Lingam RK, Beaconsfield TI et-al. Role of radiology in the management of primary aldosteronism. Radiographics. 27 (4): Demos TC, Posniak HV, Harmath C et-al. Cystic lesions of the pancreas. AJR Am J Roentgenol. 2002;179 (6): Page 10 of 10