Percutaneous and endovascular procedures in adrenal disease: indications, technique, and outcomes

Adrenal masses are found on roughly 4-5% of abdominal imaging studies, and the proportion rises with age. Most are benign, non-functioning adenomas that need imaging characterization and hormonal screening but no intervention. The remainder, comprising metastases, adrenocortical carcinoma, pheochromocytoma and hormonally active adenomas, raise questions that computed tomography and magnetic resonance imaging cannot always settle; in these cases image-guided procedures can help. Percutaneous biopsy is reserved for hormonally inactive lesions whose benignity imaging has not established and whose histology would change management. Adrenal venous sampling remains the reference method for lateralizing aldosterone excess in primary aldosteronism and therefore decides who is offered adrenalectomy, although success depends heavily on operator experience and local protocol. Thermal ablation has produced biochemical and blood-pressure responses in selected aldosterone-producing adenomas and local control of limited metastases, but the evidence is largely nonrandomized and does not establish equivalence with surgery. Transarterial embolization serves three purposes: hemostasis in adrenal hemorrhage, devascularization before resection of hypervascular tumors, and functional treatment of aldosteronism, now supported by one small randomized trial. Each procedure carries hazards peculiar to the gland (catecholamine crisis, adrenal insufficiency after bilateral treatment, non-target embolization) that shape patient selection and periprocedural monitoring. This review covers indications, technique, outcomes and complications for each. Surgery remains the treatment of choice for most operable patients. Interventional radiology is most useful when the indications for sampling, ablation or embolization are recognized early and discussed at the multidisciplinary meeting, not only after surgery has been declined.