Procedure: Bilateral adrenal vein sampling
Indication:Â Hypertension refractory to medication.
Date: 01/01/2022
Operators: John Doe, MD (Attending)/Jane Doe, MD (Fellow)
Medications: 3 mg IV Versed, 150 mcg IV fentanylÂ
Contrast:Â 60 mLÂ non-ionic
Fluoro time:Â 17 minutes
Access site: Right common femoral vein with ultrasound
Complications:Â None immediate.
Technique:
The risks, benefits, and alternatives to the procedure and sedation were explained to the patient. The specific risks of bleeding, infection, and vascular injury were detailed and accepted. Written informed consent was obtained. A time out/call to order was performed prior to procedure initiation.
The patient was assessed for conscious sedation and found to be an adequate candidate. A dedicated nurse monitored heart rate, blood pressure, and oxygen saturation throughout the procedure. A time out was performed prior to procedure initiation.
The right groin was prepped and draped in sterile fashion.Â
The vascular structures were ultrasonographically evaluated.  Images were stored and transferred to PACS. Under ultrasound guidance, the right common femoral vein was accessed with a micropuncture needle. Vein patency and needle entry were documented. A 0.018″ wire was placed and the needle exchanged for a 5 French dilator.
An Amplatz wire was advanced into the inferior vena cava, and the dilator exchanged for a 5 French sheath. A 5 French pigtail catheter was advanced over the wire into the right external iliac artery and a peripheral venous blood sample was obtained. The pigtail catheter was then advanced into the IVC and venous blood samples were obtained at the suprarenal and infrarenal IVC.
Wire was then directed into the left common iliac artery and the 5 French pigtail catheter was exchanged for a Simmons 2 which was reformed over the bifurcation. Simmons 2 catheter was advanced up the IVC and the left adrenal vein was selectively catheterized. Contrast injection confirmed location. 2 separate venous blood samples were obtained from the left adrenal vein. Â
Attention was then turned to the right adrenal vein. The ostium of the right adrenal vein was selected with a C2 catheter and transcend wire was advanced distally. 3 separate adrenal vein samples were obtained. Positioning of the catheter in the right adrenal vein was confirmed by contrast injection during 3-D spin imaging.  3-D images were reformatted and reviewed on a separate workstation during the case.Â
The catheter and sheath were removed, and hemostasis achieved with compression.
No immediate complication occurred, and the patient was discharged from the angiography suite in satisfactory condition.
Venous samples from the right external iliac vein, infrahepatic IVC, suprahepatic IVC, left adrenal vein, and right adrenal vein were delivered to the laboratory for quantitative analysis of aldosterone and cortisol.
Findings:
- The left adrenal vein is patent with normal anatomic appearance.
- The right adrenal vein is patent with normal anatomic appearance.
- The right common femoral vein is ultrasonographically patent and compresses. Needle entry was documented. Images were stored to PACS.
Impression:
Successful adrenal vein sampling for refractory hypertension. Venous blood samples were obtained from the left and right adrenal veins, suprahepatic and intrahepatic IVC, and right external iliac vein, as described above.
Recommendation:
Follow-up quantitative analysis of aldosterone and cortisol.
The attending radiologist, John Doe MDÂ Â , was present for the procedure and interpreted the images.