Disclosure: P. Vibhatavata: None. J. Shields: None. J. Rege: None. A. Udager: None. W.E. Rainey: None. A. Turcu: None. Background: In patients with primary aldosteronism (PA), adrenal vein sampling (AVS) is commonly used to direct surgical vs. medical therapy. Cosyntropin [ACTH N-terminal 24 amino acids (1–24)] stimulation boosts the confidence of successful adrenal vein (AV) catheterization, by amplifying the AV-peripheral cortisol gradient. In addition, both normal zona glomerulosa cells and autonomous aldosterone sources respond acutely to cosyntropin stimulation, due to variable expression of ACTH receptors (MC2R). We hypothesized that cosyntropin exposes the reserve of aldosterone-producing cells in the non-dominant adrenal gland. Objective: To assess the association between contralateral aldosterone response to cosyntropin during AVS and post-operative outcomes. Methods: Patients with PA who underwent successful AVS both before and after cosyntropin stimulation between January 2015 and December 2024 in a tertiary-referral center were included. The aldosterone reserve in the non-dominant adrenal gland was assessed with: 1. Contralateral Aldosterone Reserve Ratio (CARR), defined by a ratio of aldosterone in the non-dominant AV post-cosyntropin/baseline; and 2. Lateralization Index Ratio (LIR= LIpost-cosyntropin : LIbaseline). CYP11B2-guided aldosterone-driver mutations and postoperative outcomes were assessed in available cases. Results: In total, 434 patients (57% men), with mean age of 53 + 12 years, 66% White, and 25% Black were included. AVS lateralization (LI ≥4) occurred only at baseline in 52 (12%) of patients (Unilateral/Bilateral; UB), only after cosyntropin in 46 (11%, BU), and in both protocols in 166 (38%, UU); 170 (39%) patients had bilateral PA (BB). Aldosterone reserve in the non-dominant adrenal was similarly high in UB and BB cases (high CARR, low LIR), while BU and UU patients had lower CARR and higher LIR. Of 169 patients treated with adrenalectomy, 78% had persistent hypertension, and 15% had residual PA. Median CARR increased gradually from patients with PA cure (4.9; IQR 2.5-9.4), to those without cure (11.2; IQR 5.0-23.5), and to bilateral PA (17.9; IQR 9.1-32.0, p<0.01). Conversely, LIR decreased progressively across these groups. CARR was higher in Black vs. White individuals, in those older than 45 years vs. younger individuals, and in those with CACNA1D vs. other aldosterone-driver mutations. ROC curves analysis showed that CARR and post-cosyntropin LI were predictive of residual PA (AUC=0.73, p<0.001 for both), while baseline LI and LIR were not useful predictors of postoperative outcomes. Conclusion: Cosyntropin stimulation during AVS unveils the aldosterone reserve in the non-dominant adrenal gland, exposing the risk of residual disease after adrenalectomy. Presentation: Monday, July 14, 2025

Almost a third of patients with primary aldosteronism had intraprotocol inconsistencies in subtyping during simultaneous adrenal vein sampling; thus, obtaining multiple sample sets may reduce erroneous surgical recommendations.

Background. Correct subtyping of primary aldosteronism (PA) is critical for guiding clinical management. Adrenal imaging is less accurate than adrenal vein sampling (AVS); nonetheless, AVS is invasive, technically challenging, and scarcely available. Objective. To identify predictors of concordance between cross-sectional imaging and lateralized AVS in patients with PA that could help circumvent AVS in a subset of patients. Methods. We retrospectively studied all patients with PA who underwent AVS in a tertiary referral center from 2009 to 2019. AVS was performed before and after cosyntropin stimulation. Patients with lateralized AVS in at least one condition were included. Aldosterone synthase-guided next-generation sequencing was performed on available adrenal tissue. Logistic regression was implemented to identify predictors of imaging-AVS lateralization concordance. Results. A total of 234 patients (62% men), age 20 to 79 years, 73% white, 23% black, and 2% Asian were included. AVS lateralization was found: 1) both pre- and post-cosyntropin (Uni/Uni) in 138 patients; 2) only at baseline (Uni/Bi) in 39 patients; 3) only after cosyntropin stimulation (Bi/Uni) in 29 patients. Catheterization partially failed in 28 patients. AVS-imaging agreement was higher in patients with KCNJ5 versus other aldosterone-driver somatic mutations (90.3% versus 64.6%; P < 0.001); in Asian and white versus black Americans (75%, 70%, and 36%, respectively); in younger patients; and those with left adrenal nodules and contralateral suppression. Conversely, AVS-imaging agreement was lowest in Uni/Bi patients (38% vs. 69% in Uni/Uni, and 62% in Bi/Uni; P = 0.007). Conclusions. While AVS-imaging agreement is higher in young white and Asian patients, who have KCNJ5-mutated aldosterone producing adenomas, no predictor confers absolute imaging accuracy.

Adrenal vein sampling (AVS) is required to distinguish unilateral from bilateral aldosterone sources in primary aldosteronism (PA), and cortisol is used for AVS data interpretation, but cortisol has several pitfalls. In this study, we present the utility of several other steroids in PA subtyping, both during AVS, as well as in peripheral serum. We included patients with PA who underwent AVS at University of Michigan between 2012 and 2018. We used mass spectrometry to simultaneously quantify 17 steroids in adrenal veins (AV) and periphery, both at baseline and after cosyntropin administration. PA was classified as unilateral or bilateral based on a lateralization index ≥ or <4, respectively, separately for baseline and post-cosyntropin administration. Of 131 participants, AV catheterizations was deemed failed in 28 (21 %) patients (36 AVs) at baseline. Eight steroids demonstrated higher AV/periphery ratios than cortisol ( P <0.01 for all); 11β-hydroxyandrostenedione, 11-deoxycortisol, and corticosterone rescued most failed baseline catheterizations. Lateralization was generally consistent when using these alternative steroids. Based on pre- and post-cosyntropin data, the remaining 103 patients were classified as: U/U, 37; B/B, 32; U/B, 20; B/U, 14. Discriminant analysis of multi-steroid panels from peripheral serum showed distinct profiles across the 4 groups, with highest aldosterone, 18-oxocortisol and 11-deoxycorticosterone in U/U patients. In conclusion, 11β-hydroxyandrostenedione and 11-deoxycortisol are superior to cortisol for AVS data interpretation. Single assay multi-steroid panels measured in peripheral serum are helpful in stratified PA subtyping and have the potential to circumvent AVS in a subset of patients with PA.

Context: Cosyntropin [ACTH (1-24)] stimulation during adrenal vein (AV) sampling (AVS) enhances the confidence in the success of AV cannulation and circumvents intraprocedure hormonal fluctuations. Cosyntropin's effect on primary aldosteronism (PA) lateralization, however, is controversial. Objectives: To define the major patterns of time-dependent lateralization, and their determinants, after cosyntropin stimulation during AVS. Methods: We retrospectively studied patients with PA who underwent AVS before, 10, and 20 minutes after cosyntropin stimulation between 2009 and 2018. Unilateral (U) or bilateral (B) PA was determined on the basis of a lateralization index (LI) value >= 4 or < 4, respectively. Available adrenal tissue underwent aldosterone synthase-guided next-generation sequencing. Results: PA lateralization was concordant between basal and cosyntropin-stimulated AVS in 169 of 222 patients (76%; U/U, n = 110; B/B, n = 59) and discordant in 53 patients (24%; U/B, n = 32; B/U, n = 21). Peripheral and dominant AV aldosterone concentrations and LI were highest in U/U patients and progressively lower across intermediate and B/B groups. LI response to cosyntropin increased in 27% of patients, decreased in 33%, and remained stable in 40%. Baseline aldosterone concentrations predicted the LI pattern across time (P < 0.001). Mutation status was defined in 61 patients. Most patients with KCNJ5 mutations had descending LI, whereas those with ATP1A1 and ATP2B3 mutations had ascending LI after cosyntropin stimulation. Conclusion: Patients with severe PA lateralized robustly regardless of cosyntropin use. Cosyntropin stimulation reveals intermediate PA subtypes; its impact on LI varies with baseline aldosterone concentrations and aldosterone-driver mutations.

Nasoenteric, gastrojejunostomy, and jejunostomy tubes are methods of enteral nutrition in patients with functioning gastrointestinal tracts who cannot maintain adequate oral intake. Current placements; however, may be complicated by redundant wire and catheter loops within the stomach preventing operators from optimal feeding tube placement and predisposing patients to feeding tube prolapse. This report describes the occlusion balloon reduction technique for salvage of malpositioned tubes and placement of new enteric tubes in the setting of redundant loops. Five patients underwent the occlusion balloon reduction technique for jejunostomy (n = 3), gastrojejunostomy (n = 1), or nasojejunal tube placement (n = 1). All patients (n = 5) had redundant wires coiled within the stomach. In all patients (n = 5), a 9-French × 32 mm × 120 cm Coda balloon was inserted over the wire and passed into the small bowel. The balloon was inflated after which reduction of redundancy in the upper gastrointestinal tract was performed. Feeding tubes were then placed with tips in the distal jejunum. Technical success of the occlusion balloon reduction technique, successful placement of enteric tube, complications, and follow-up were recorded. The occlusion balloon reduction was technically successful in all patients (n = 5). Feeding tube placement was successful in all patients (n = 5). No minor or major complication occurred. Mean follow-up was 56 days. The occlusion balloon reduction technique provides a method for reduction of redundant wire and catheter loops within the stomach during enteric tube placement or repositioning.

Context: Many antihypertensive medications modulate the renin-angiotensin-aldosterone system, possibly skewing the diagnosis and subtyping of primary aldosteronism (PA). Particularly, mineralocorticoid receptor antagonists (MRA) might raise renin and stimulate aldosterone synthesis from nonautonomous areas, potentially obscuring lateralization on adrenal vein sampling (AVS). Withdrawal of MRA in severe PA, however, can precipitate hypokalemia and/or hypertension and therefore is not always practical. Objective: To assess the effects of MRA on the interpretation of AVS data. Design and Participants: A cohort study of all PA patients who underwent AVS at University of Michigan between January 2009 and January 2018 was conducted. Demographics, diagnostic, AVS, surgical pathology, and follow-up data were collected retrospectively. Results: Of 191 patients who underwent AVS, 51 (27%) were exposed to MRA at the time of the procedure. Plasma aldosterone concentration and the daily defined dose of antihypertensives were higher in patients taking vs those not taking MRA. Unilateral PA was more frequent in the MRA group, both precosyntropin and postcosyntropin (P < 0.05). The MRA group included two patients with unsuppressed renin, who demonstrated unequivocal AVS lateralization. To date, 86 patients underwent unilateral adrenalectomy, including 30 patients taking MRA during AVS. The proportion of clinical and biochemical success was not statistically different between patients exposed to and those not exposed to MRA during AVS (P = 0.17 and 0.65, respectively). Conclusion: Our data suggest that conclusive AVS lateralization is often achieved in patients with severe PA despite MRA use.

To report technical success and clinical outcomes of the transnasal and transgastric snare techniques for placement of retrograde primary jejunostomy tubes. 6 female patients underwent the retrograde snare technique for the placement of a primary jejunostomy tube. Mean age was 54.5 years (range, 25-82 years). Patients presented with Roux-en-Y gastric bypass (n = 2), sleeve gastrectomy (n = 1), esophagectomy (n = 1), intra-thoracic stomach (n = 1), and gastroparesis (n = 1). Patients had targeting devices placed via either a transnasal (n = 5) or transgastric (n = 1) approach. Loop snare devices were used as a target in 5 patients and an uncovered stent in 1. Ultrasound and fluoroscopy were used to confirm the targeting device was within a superficial bowel loop in 4 patients, and cone-beam CT and fluoroscopy alone in 1 patient each. All snares and the stent were punctured with a styleted needle and used to capture a wire thereby obtaining through-and-through access for subsequent tract dilatation and placement of a primary retrograde jejunostomy. All (n = 6) transnasal and transgastric snare technique retrograde primary jejunostomy tube placements were technically successful. All tubes were 16 French MIC jejunostomy tubes (Halyard Health; Alpharetta, Georgia). 1 patient had abdominal pain on postoperative day 1 and couldn’t begin feeds until postoperative day 3. 1 patient’s tube was too long and extended above the gastroesophageal junction resulting in aspiration, requiring repositioning 4 days later. The remaining 4 patients were able to begin tube feeds on postoperative day 1. 1 patient’s tube hub cracked 6 weeks after placement and required exchange which was uneventful. The patient who underwent transgastric approach for placement of retrograde jejunostomy had no complications related to the removal of the transgastric catheter used for snare placement after the procedure. One patient died 2 weeks after tube placement secondary to aspiration pneumonitis. The remaining 5 patients had no issues with their tubes at average 41 days of follow-up. The transnasal and transgastric snare technique is a feasible and simple technique for the placement of retrograde primary jejunostomy.

© 2018. The Arab Journal of Interventional Radiology. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).

To report technical success and clinical outcome of cholecystostomy tube placement along with timing—and method—of tube removal.

To report a transnasal snare technique for retrograde primary jejunostomy placement after surgical gastrojejunostomy.

Correct subtyping of primary aldosteronism (PA) is essential for good surgical outcomes. Adrenal vein sampling (AVS) and/or computed tomography (CT) are used for PA subclassification. Clinical and/or biochemical improvement after surgery, however, is not always achieved in patients with presumed unilateral PA. We aimed to identify the pitfalls in PA subclassification leading to surgical treatment failures.We retrospectively studied 208 patients who underwent adrenal vein sampling (AVS) for PA subclassification in a tertiary referral centre, between January 2009 and August 2016. Simultaneous bilateral AVS was performed before and after cosyntropin administration. We implemented immunohistochemistry for aldosterone synthase (CYP11B2) and 17α-hydroxylase/17,20 lyase (CYP17A1) in adrenal glands resected from patients without improvement of PA after surgical treatment and from those with limitations in AVS interpretation.Of 55 patients who underwent adrenalectomy, three (5.5%) had no improvement of PA. All three patients underwent partial adrenalectomy to remove a CT-detected nodule present on the same side with AVS lateralization. Immunohistochemistry revealed a CYP11B2-negative nodule in both cases available. All patients who underwent total adrenalectomy based on AVS lateralization benefitted from surgery, including three patients with unilateral unsuccessful AVS and aldosterone suppression in the catheterized side vs inferior vena cava.Radiographically identified adrenal nodules are not always a source of PA, even when ipsilateral with AVS lateralization. These data caution against reliance on imaging findings, either alone or in conjunction with AVS, to guide surgery for PA.

OBJECTIVETo comprehensively characterize androgens and androgen precursors in classic 21-hydroxylase deficiency (21OHD) and to gain insights into the mechanisms of their formation.DESIGNSerum samples were obtained from 38 patients (19 men) with classic 21OHD, aged 3-59, and 38 sex- and age-matched controls; 3 patients with 11β-hydroxylase deficiency; 4 patients with adrenal insufficiency; and 16 patients (8 men) undergoing adrenal vein sampling. Paraffin-embedded normal (n = 5) and 21OHD adrenal tissues (n = 3) were used for immunohistochemical studies.METHODSWe measured 11 steroids in all sera by liquid chromatography-tandem mass spectrometry. Immunofluroescence localized 3β-hydroxysteroid dehydrogenase type 2 (HSD3B2) and cytochrome b5 (CYB5A) within the normal and 21OHD adrenals.RESULTSFour 11-oxygenated 19-carbon (11oxC19) steroids were significantly higher in male and female 21OHD patients than in controls: 11β-hydroxyandrostenedione, 11-ketoandrostenedione 11β-hydroxytestosterone, and 11-ketotestosterone (3-4-fold, P < 0.0001). For 21OHD patients, testosterone and 11-ketotestosterone were positively correlated in females, but inversely correlated in males. All 11oxC19 steroids were higher in the adrenal vein than in the inferior vena cava samples from men and women and rose with cosyntropin stimulation. Only trace amounts of 11oxC19 steroids were found in the sera of patients with 11β-hydroxylase deficiency and adrenal insufficiency, confirming their adrenal origin. HSD3B2 and CYB5A immunoreactivities were sharply segregated in the normal adrenal glands, whereas areas of overlapping expression were identified in the 21OHD adrenals.CONCLUSIONSAll four 11oxC19 steroids are elevated in both men and women with classic 21OHD. Our data suggest that 11oxC19 steroids are specific biomarkers of adrenal-derived androgen excess.

The authors describe a case of Klippel-Trenaunay syndrome (KTS) with massive splenomegaly in a 29-year-old woman. Preoperative splenic artery embolization using the "double embolization technique" (a combination of distal selective splenic artery embolization and proximal splenic artery occlusion) facilitated open splenectomy.

BACKGROUND & AIMS: Percutaneous cholecystostomy (PC) is an effective treatment for acute cholecystitis (AC) in patients who are poor surgical candidates, although it is generally used as a bridge to cholecystectomy, given its long-term risks, the need for repeated procedures, and patient dissatisfaction. Ongoing patient comorbidity, however, might preclude cholecystectomy after recovery from the acute illness. METHODS: Four patients with AC who were poor immediate and long-term candidates for cholecystectomy underwent PC as primary therapy for AC, followed by endoscopic placement of a transpapillary gallbladder stent as definitive long-term management. RESULTS: All 4 patients were successfully treated for AC with PC. After recovery, the patients underwent endoscopic gallbladder stent placement and removal of the PC. In 2 cases, endoscopic transpapillary access to the gallbladder was facilitated by advancing a guidewire through the cholecystostomy tract into the duodenum. All patients had favorable outcomes. CONCLUSIONS: PC as a bridge to permanent therapy with endoscopic gallbladder stenting appears to be a viable strategy in the management of patients with AC who are poor immediate and long-term candidates for cholecystectomy.

The present report describes the safe retrieval of caudally migrated optional inferior vena cava (IVC) filters with significant IVC penetration. Three patients had optional IVC filters placed for deep vein thrombosis/pulmonary emboli and contraindications for anticoagulation. Subsequent imaging showed caudal migration and penetration of the filter legs through the IVC wall. All filters were removed without major complications. One patient experienced abdominal pain after filter removal, which required no treatment. Caudal migration of optional filters with IVC wall penetration by the filter legs may be more common with new filter designs in which the secondary and primary struts are separated.