Adrenal Vein Sampling in Primary Aldosteronism-Is The Gold Standard Losing Its Luster?

Area of Science:

• Endocrinology
• Nephrology
• Surgical Oncology

Background:

• Primary aldosteronism (PA) diagnosis has evolved since the first case in 1954.
• Early PA management relied on palpable adenomas and limited imaging techniques.
• Adrenal vein sampling (AVS) emerged to localize aldosterone-producing adenomas (APAs) for surgical guidance.

Purpose of the Study:

• To discuss the evolving role of adrenal vein sampling (AVS) in primary aldosteronism (PA) management.
• To evaluate the continued relevance of AVS amidst advancements in imaging and understanding of PA pathophysiology.
• To explore the challenges and future directions for PA source localization.

Main Methods:

• Historical review of diagnostic modalities for PA.
• Analysis of the strengths and limitations of AVS.
• Discussion of advancements in cross-sectional imaging and their impact on PA diagnosis.
• Exploration of PA pathophysiology and its influence on diagnostic standards.

Main Results:

• AVS has historically been the gold standard for PA subtyping and surgical candidate identification.
• Despite limitations (invasive, costly, technically challenging), AVS remains trusted due to its accuracy in detecting small APAs.
• Cross-sectional imaging has improved significantly but has not fully replaced AVS for precise localization.
• Growing understanding of PA pathophysiology challenges the definitive role of AVS.

Conclusions:

• AVS continues to play a vital role in contemporary PA management, particularly for surgical planning.
• Limitations of AVS necessitate the development and validation of alternative localization methods.
• The future of PA diagnosis may involve integrated approaches combining imaging and functional assessments, potentially redefining the gold standard.