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Failure analysis in adrenal vein sampling (AVS)
JVIR
’
Scientific Session
Monday
3:48 PM
Abstract No. 129
Feasibility of barbed suture for incision closure in implantable chest ports O. Ahmed1, S. Zangan1, D. Jilani2, S. Sheth1, B. Funaki1, T. Van Ha1; 1University of Chicago, Chicago, IL; 2Wright State University Boonshoft School of Medicine, Dayton, OH Purpose: Barbed suture is a self-anchoring suture that allows for quicker, more efficient wound closure by obviating the need for knot tying. The purpose of this study is to investigate the feasibility of barbed suture closure of implanted chest ports. Materials and Methods: An IRB approved retrospective study at a single academic institution was performed on all chest ports placed in the section of interventional radiology between September 2011 and May 2013. Patient demographic information and suture material for incision closure (barbed versus non-barbed) were recorded. The electronic medical record was queried for instances of port removal secondary to wound dehiscence or infection. Results: A total of 923 chest ports were placed. 555 (60%) ports were closed with non-barbed suture compared to 368 (40%) with barbed suture. The technical success rate in both groups was 100% with no cases of immediate complication. On follow up, a statistically significant difference was seen in the rate of wound dehiscence in the non-barbed group (n ¼ 8) versus the barbed group (n¼ 0) [p ¼ 0.021]. Additionally, a significant difference was seen in the rate of infection requiring port removal in the non-barbed group (49/555 ¼ 8.9%) compared to the barbed group (17/368 ¼ 4.6%) [p ¼ 0.015]. These relationships held true when controlling for age, gender, and side of port placement among the two groups. Conclusion: Barbed suture is an effective technique for incision closure in implantable chest ports with lower rates of dehiscence and infection when compared to traditional nonbarbed suture.
3:57 PM
S63
Abstract No. 130
’ FEATURED ABSTRACT Cone beam CT venography vs. cortisol measurements to confirm selective right adrenal vein catheterization during adrenal vein sampling: does anatomical selectivity correlate with biochemical selectivity ratios? A. Sarwar, O.R. Brook, A. Brook, I. Brennan, M. Ahmed, S. Faintuch, F. Collares, B. Sacks; Radiology, Beth Israel Deaconess Medical Center/ Harvard Medical School, Boston, MA Purpose: Right adrenal vein (RAV) catheterization is a challenging component of adrenal venous sampling (AVS). Currently pre-procedure imaging, stat cortisol or selectivity ratios (SR) (RAV:IVC cortisol) confirm successful RAV catheterization. We confirm RAV location using intraprocedural cone-beam computed tomography (CCT) during contrast venography. We compare different SR in baseline and post-ACTH samples for accurate prediction of RAV selection. Materials and Methods: 76 patients underwent AVS for clinically/biochemically established hyperaldosteronism. Our AVS protocol involves bilateral venous catheters, sampling the IVC (representative of a peripheral level), selective catheterization of both adrenal veins and confirming the RAV catheterization by a CCT venogram. Simultaneous bilateral adrenal baseline (3 samples) and postcosyntropin (5, 10 and 15 minutes after injection) samples for both aldosterone and cortisol were obtained. A receiver operator curve analysis was used to evaluate the data. Results: 76 patients (50 yrs, 23-75 y, 58% male) underwent AVS with pre-sampling CCT to confirm catheterization. RAV catheterization was confirmed with cone-beam CT in 71/76 patients. SR (RAV:IVC cortisol) at baseline was a good predictor of RAV catheterization (AUC: 0.90). At baseline, a SR of 2.15 had 100% specificity (spec) and 70% sensitivity (sens) and SR of 1.56 had optimal accuracy (sens 89%, spec 86%). SRs of post-ACTH samples (post-ACTH RAV:IVC cortisol) was available in 72/76 patients. 5 minute post-ACTH SR was the best predictor of RAV catheterization (AUC 5min: 0.92, AUC 10 min: 0.82, AUC 15 min: 0.88). A 5 minute post-ACTH SR of 17.81 had 100% specificity and SR of 8.14 had optimal accuracy (sens 89%, spec 80%). A 10 minute post-ACTH threshold of 64.96 had 100% specificity and SR of 10 had optimal accuracy (sens 87%, spec 83%). A 15 minute post-ACTH threshold of 21.84 had 100% specificity and 14.42 had optimal accuracy (sens 86%, spec 75%). Conclusion: Five minute post-ACTH biochemical SR has the best accuracy in predicting RAV catheterization compared to an anatomical standard. A baseline SR threshold of 2 has 100% specificity but 70% sensitivity.
4:06 PM
Abstract No. 131
Failure analysis in adrenal vein sampling (AVS) S. Trerotola, M. Asmar, Y. Yan; Radiology, University of Pennsylvania Medical Center, Philadelphia, PA
MONDAY: Scientific Sessions
in relation to the transverse axis of the underlying vertebral body. Regression analysis was performed to determine if there were statistically significant relationships between catheter tip migration distances and innominate vein angles, internal jugular vein access locations, subcutaneous pocket locations, number of catheter lumens and various patient demographics. Results: The range of catheter tip migration distances for the entire population was -4.01 to 9.97 cm with a mean of 1.49 cm ⫾ 1.97. There was a statistically significant positive relationship between catheter tip migration distance and age (P¼0.0319), body mass index (BMI) (P¼0.0244), innominate vein angle (P¼0.0028) and dual compared to single lumen ports (P¼0.0199). Whereas port pocket location, venous access site, gender and number of days between initial placement and follow-up radiograph did not demonstrate statistical significance. Conclusion: Increased age, increased BMI, increased innominate vein angle and dual vs single lumen ports predict increased positional catheter tip migration for left internal jugular subcutaneous central venous ports. This information can be useful during initial port placement and also when deciding whether or not to revise a port with a catheter that has been inadvertently cut short.
’
MONDAY: Scientific Sessions
S64
’
Monday
Scientific Session
Purpose: Reported failure rates for AVS exceed 50%. We sought to analyze failure modes in a large-volume AVS practice in an effort to identify preventable causes of nondiagnostic sampling. Materials and Methods: A retrospective database was constructed containing 343 AVS procedures performed over a 10year period. Each non-diagnostic AVS was carefully reviewed for failure mode(s) and correlated with results of any repeat AVS. Data collected included selectivity index (SI ¼ adrenal cortisol / IVC cortisol; Z 5 was diagnostic), lateralization index (LI ¼ higher aldosterone to cortisol [A/C] ratio / lower A/C ratio; Z 4 triggered adrenalectomy), adrenalectomy outcomes, if performed, and AVS procedural details including catheter and/or microcatheter used. All AVS were performed post-cosyntropin stimulation, using sequential technique by a single operator. Results: AVS was non-diagnostic in 12/343 (3.5%) of primary procedures. Second AVS was performed in 5 patients and was diagnostic in 4/5 (80%), and third AVS was diagnostic in 1/1 (100%). Failure was right-sided in 7 (58%), left sided in 4 (33%), bilateral in 1, and not lateralized in 1 (lab error). Failure modes included: diluted sample from correctly identified vein (n¼6, 46%; 2 right and 4 left), another vessel misidentified as adrenal vein (n¼3, 23%; all right), failure to locate adrenal vein (n¼2, 15%; all right), cosyntropin stimulation failure (n¼1, 8%; diagnostic by non-stimulated criteria), and lab error (lost specimen, n¼1, 8%). Of the 7 patients without repeat AVS, 3 underwent unilateral adrenalectomy based on diluted AVS samples and were cured of their primary aldosteronism. Two of the 4 successful secondary AVS has CT venograms done to guide the second procedure. Conclusion: In a high-volume AVS practice, failure can be limited to o5%. While most of the AVS literature focuses on right-sided failure, a substantial percentage of failures occurred on the left, all related to dilution. Even when technically nondiagnostic per strict criteria, some “failed” AVS were sufficient to guide subsequent therapy. Repeat AVS, potentially guided by CT, has a high yield.
4:15 PM
Abstract No. 132
The collateral adrenal vein: a reliable landmark for right adrenal vein sampling M.P. Kohi, V.K. Agarwal, D.M. Naeger, A.G. Taylor, K. Kolli, N. Fidelman, J.M. LaBerge, R.K. Kerlan, Jr.; UCSF, San Francisco, CA Purpose: To compare the rate of successful right adrenal vein sampling (AVS) in the presence of the collateral adrenal vein (CAV). Materials and Methods: Retrospective review of all consecutive patients with primary hyperaldosteronism (PA) who underwent AVS between April 2009 and April 2012 was performed. A total of 30 patients were identified. Procedural images, cortisol and aldosterone values obtained from sampling of the right adrenal vein (RAV) and inferior vena cava (IVC) were reviewed. Cortisol measurements obtained from RAV samples were divided by measurements from the infra-renal IVC blood samples in order to calculate the selectivity index (SI). An SI 4 3 was considered indicative of technically successful RAV sampling. Results: RAV sampling was considered technically successful in 29 out of 30 cases (97%). In cases of successful RAV sampling (29 patients), the CAV was identified in 25 patients (86%). The
’
JVIR
CAV was visualized in isolation in 16 patients (64%), and in conjunction with visualization of the RAV or right adrenal gland stain in 9 patients (36%). The CAV was not visualized in the one case of unsuccessful right AVS. Visualizing the CAV had a sensitivity of 86.2% for successful right AVS. Conclusion: Visualization of the CAV in isolation or conjunction with visualization of the right adrenal gland or RAV, is likely an excellent indicator of successful catheterization of the RAV. Furthermore, non-visualization of the CAV, the RAV or staining of the right adrenal gland should persuade the operator to continue the search for the RAV.
4:24 PM
Abstract No. 133
Bilateral inferior petrosal sinus sampling: clinical experience in 327 patients A.R. Deipolyi, B. Alexander, R. Oklu; Interventional Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA Purpose: Bilateral inferior petrosal sinus sampling (BIPSS) is a minimally invasive test performed by interventional radiologists to evaluate challenging cases of Cushing syndrome and diagnose an ACTH-secreting pituitary lesion. We sought to evaluate the overall experience at our tertiary care center in 327 patients. Materials and Methods: This IRB approved, HIPAAcompliant study involved a search of the radiology department’s electronic database to identify all BIPSS procedures from 1990 to 2013. Electronic medical records were used to identify demographics, clinical history, endocrine test results, surgical and pathology findings and follow up results for each patient. All available angiograms were reviewed to evaluate variations in petrosal sinus anatomy. Results: Between 1990 and 2013, 333 BIPSS procedures were performed in 327 patients (254 F, 73 M), with an average age of 40.8 (range 7-81) years. Forty-three (n¼41) were performed without stimulation, and 290 (n¼286) used stimulation by CRH or DDAVP. In 40 cases (n¼39) both inferior petrosal veins could not be cannulated; 41 (n¼39) had incomplete medical records or were lost to follow up; and 29 (n¼28) lacked conformation of disease etiology. Among cases with pathological confirmation, 20 (n¼20) without stimulation had a sensitivity of 100% and specificity of 66.7%, 202 (n¼201) with stimulation had a sensitivity of 98% and specificity of 80%. Overall, sensitivity was 98.1% with a positive predictive value of 99.1% and specificity was 75% with a negative predictive value of 60%. Conclusion: BIPSS is a procedure used to distinguish pituitary ACTH hypersecretion (Cushing’s disease) from ectopic ACTH sources. In our experience, BIPSS sensitivity and concordance with pathological findings approach 100%, with higher specificity using CRH or DDAVP stimulation.
4:33 PM
Abstract No. 134
’ Dr. Constantin Cope Medical Student Research Award
Should adrenal venous sampling precede crosssectional imaging in the evaluation of primary aldosteronism? M. Asmar, Y. Yan, S. Trerotola; University of Pennsylvania Medical Center, Philadelphia, PA
’
Scientific Session
Monday
3:48 PM
Abstract No. 129
Feasibility of barbed suture for incision closure in implantable chest ports O. Ahmed1, S. Zangan1, D. Jilani2, S. Sheth1, B. Funaki1, T. Van Ha1; 1University of Chicago, Chicago, IL; 2Wright State University Boonshoft School of Medicine, Dayton, OH Purpose: Barbed suture is a self-anchoring suture that allows for quicker, more efficient wound closure by obviating the need for knot tying. The purpose of this study is to investigate the feasibility of barbed suture closure of implanted chest ports. Materials and Methods: An IRB approved retrospective study at a single academic institution was performed on all chest ports placed in the section of interventional radiology between September 2011 and May 2013. Patient demographic information and suture material for incision closure (barbed versus non-barbed) were recorded. The electronic medical record was queried for instances of port removal secondary to wound dehiscence or infection. Results: A total of 923 chest ports were placed. 555 (60%) ports were closed with non-barbed suture compared to 368 (40%) with barbed suture. The technical success rate in both groups was 100% with no cases of immediate complication. On follow up, a statistically significant difference was seen in the rate of wound dehiscence in the non-barbed group (n ¼ 8) versus the barbed group (n¼ 0) [p ¼ 0.021]. Additionally, a significant difference was seen in the rate of infection requiring port removal in the non-barbed group (49/555 ¼ 8.9%) compared to the barbed group (17/368 ¼ 4.6%) [p ¼ 0.015]. These relationships held true when controlling for age, gender, and side of port placement among the two groups. Conclusion: Barbed suture is an effective technique for incision closure in implantable chest ports with lower rates of dehiscence and infection when compared to traditional nonbarbed suture.
3:57 PM
S63
Abstract No. 130
’ FEATURED ABSTRACT Cone beam CT venography vs. cortisol measurements to confirm selective right adrenal vein catheterization during adrenal vein sampling: does anatomical selectivity correlate with biochemical selectivity ratios? A. Sarwar, O.R. Brook, A. Brook, I. Brennan, M. Ahmed, S. Faintuch, F. Collares, B. Sacks; Radiology, Beth Israel Deaconess Medical Center/ Harvard Medical School, Boston, MA Purpose: Right adrenal vein (RAV) catheterization is a challenging component of adrenal venous sampling (AVS). Currently pre-procedure imaging, stat cortisol or selectivity ratios (SR) (RAV:IVC cortisol) confirm successful RAV catheterization. We confirm RAV location using intraprocedural cone-beam computed tomography (CCT) during contrast venography. We compare different SR in baseline and post-ACTH samples for accurate prediction of RAV selection. Materials and Methods: 76 patients underwent AVS for clinically/biochemically established hyperaldosteronism. Our AVS protocol involves bilateral venous catheters, sampling the IVC (representative of a peripheral level), selective catheterization of both adrenal veins and confirming the RAV catheterization by a CCT venogram. Simultaneous bilateral adrenal baseline (3 samples) and postcosyntropin (5, 10 and 15 minutes after injection) samples for both aldosterone and cortisol were obtained. A receiver operator curve analysis was used to evaluate the data. Results: 76 patients (50 yrs, 23-75 y, 58% male) underwent AVS with pre-sampling CCT to confirm catheterization. RAV catheterization was confirmed with cone-beam CT in 71/76 patients. SR (RAV:IVC cortisol) at baseline was a good predictor of RAV catheterization (AUC: 0.90). At baseline, a SR of 2.15 had 100% specificity (spec) and 70% sensitivity (sens) and SR of 1.56 had optimal accuracy (sens 89%, spec 86%). SRs of post-ACTH samples (post-ACTH RAV:IVC cortisol) was available in 72/76 patients. 5 minute post-ACTH SR was the best predictor of RAV catheterization (AUC 5min: 0.92, AUC 10 min: 0.82, AUC 15 min: 0.88). A 5 minute post-ACTH SR of 17.81 had 100% specificity and SR of 8.14 had optimal accuracy (sens 89%, spec 80%). A 10 minute post-ACTH threshold of 64.96 had 100% specificity and SR of 10 had optimal accuracy (sens 87%, spec 83%). A 15 minute post-ACTH threshold of 21.84 had 100% specificity and 14.42 had optimal accuracy (sens 86%, spec 75%). Conclusion: Five minute post-ACTH biochemical SR has the best accuracy in predicting RAV catheterization compared to an anatomical standard. A baseline SR threshold of 2 has 100% specificity but 70% sensitivity.
4:06 PM
Abstract No. 131
Failure analysis in adrenal vein sampling (AVS) S. Trerotola, M. Asmar, Y. Yan; Radiology, University of Pennsylvania Medical Center, Philadelphia, PA
MONDAY: Scientific Sessions
in relation to the transverse axis of the underlying vertebral body. Regression analysis was performed to determine if there were statistically significant relationships between catheter tip migration distances and innominate vein angles, internal jugular vein access locations, subcutaneous pocket locations, number of catheter lumens and various patient demographics. Results: The range of catheter tip migration distances for the entire population was -4.01 to 9.97 cm with a mean of 1.49 cm ⫾ 1.97. There was a statistically significant positive relationship between catheter tip migration distance and age (P¼0.0319), body mass index (BMI) (P¼0.0244), innominate vein angle (P¼0.0028) and dual compared to single lumen ports (P¼0.0199). Whereas port pocket location, venous access site, gender and number of days between initial placement and follow-up radiograph did not demonstrate statistical significance. Conclusion: Increased age, increased BMI, increased innominate vein angle and dual vs single lumen ports predict increased positional catheter tip migration for left internal jugular subcutaneous central venous ports. This information can be useful during initial port placement and also when deciding whether or not to revise a port with a catheter that has been inadvertently cut short.
’
MONDAY: Scientific Sessions
S64
’
Monday
Scientific Session
Purpose: Reported failure rates for AVS exceed 50%. We sought to analyze failure modes in a large-volume AVS practice in an effort to identify preventable causes of nondiagnostic sampling. Materials and Methods: A retrospective database was constructed containing 343 AVS procedures performed over a 10year period. Each non-diagnostic AVS was carefully reviewed for failure mode(s) and correlated with results of any repeat AVS. Data collected included selectivity index (SI ¼ adrenal cortisol / IVC cortisol; Z 5 was diagnostic), lateralization index (LI ¼ higher aldosterone to cortisol [A/C] ratio / lower A/C ratio; Z 4 triggered adrenalectomy), adrenalectomy outcomes, if performed, and AVS procedural details including catheter and/or microcatheter used. All AVS were performed post-cosyntropin stimulation, using sequential technique by a single operator. Results: AVS was non-diagnostic in 12/343 (3.5%) of primary procedures. Second AVS was performed in 5 patients and was diagnostic in 4/5 (80%), and third AVS was diagnostic in 1/1 (100%). Failure was right-sided in 7 (58%), left sided in 4 (33%), bilateral in 1, and not lateralized in 1 (lab error). Failure modes included: diluted sample from correctly identified vein (n¼6, 46%; 2 right and 4 left), another vessel misidentified as adrenal vein (n¼3, 23%; all right), failure to locate adrenal vein (n¼2, 15%; all right), cosyntropin stimulation failure (n¼1, 8%; diagnostic by non-stimulated criteria), and lab error (lost specimen, n¼1, 8%). Of the 7 patients without repeat AVS, 3 underwent unilateral adrenalectomy based on diluted AVS samples and were cured of their primary aldosteronism. Two of the 4 successful secondary AVS has CT venograms done to guide the second procedure. Conclusion: In a high-volume AVS practice, failure can be limited to o5%. While most of the AVS literature focuses on right-sided failure, a substantial percentage of failures occurred on the left, all related to dilution. Even when technically nondiagnostic per strict criteria, some “failed” AVS were sufficient to guide subsequent therapy. Repeat AVS, potentially guided by CT, has a high yield.
4:15 PM
Abstract No. 132
The collateral adrenal vein: a reliable landmark for right adrenal vein sampling M.P. Kohi, V.K. Agarwal, D.M. Naeger, A.G. Taylor, K. Kolli, N. Fidelman, J.M. LaBerge, R.K. Kerlan, Jr.; UCSF, San Francisco, CA Purpose: To compare the rate of successful right adrenal vein sampling (AVS) in the presence of the collateral adrenal vein (CAV). Materials and Methods: Retrospective review of all consecutive patients with primary hyperaldosteronism (PA) who underwent AVS between April 2009 and April 2012 was performed. A total of 30 patients were identified. Procedural images, cortisol and aldosterone values obtained from sampling of the right adrenal vein (RAV) and inferior vena cava (IVC) were reviewed. Cortisol measurements obtained from RAV samples were divided by measurements from the infra-renal IVC blood samples in order to calculate the selectivity index (SI). An SI 4 3 was considered indicative of technically successful RAV sampling. Results: RAV sampling was considered technically successful in 29 out of 30 cases (97%). In cases of successful RAV sampling (29 patients), the CAV was identified in 25 patients (86%). The
’
JVIR
CAV was visualized in isolation in 16 patients (64%), and in conjunction with visualization of the RAV or right adrenal gland stain in 9 patients (36%). The CAV was not visualized in the one case of unsuccessful right AVS. Visualizing the CAV had a sensitivity of 86.2% for successful right AVS. Conclusion: Visualization of the CAV in isolation or conjunction with visualization of the right adrenal gland or RAV, is likely an excellent indicator of successful catheterization of the RAV. Furthermore, non-visualization of the CAV, the RAV or staining of the right adrenal gland should persuade the operator to continue the search for the RAV.
4:24 PM
Abstract No. 133
Bilateral inferior petrosal sinus sampling: clinical experience in 327 patients A.R. Deipolyi, B. Alexander, R. Oklu; Interventional Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA Purpose: Bilateral inferior petrosal sinus sampling (BIPSS) is a minimally invasive test performed by interventional radiologists to evaluate challenging cases of Cushing syndrome and diagnose an ACTH-secreting pituitary lesion. We sought to evaluate the overall experience at our tertiary care center in 327 patients. Materials and Methods: This IRB approved, HIPAAcompliant study involved a search of the radiology department’s electronic database to identify all BIPSS procedures from 1990 to 2013. Electronic medical records were used to identify demographics, clinical history, endocrine test results, surgical and pathology findings and follow up results for each patient. All available angiograms were reviewed to evaluate variations in petrosal sinus anatomy. Results: Between 1990 and 2013, 333 BIPSS procedures were performed in 327 patients (254 F, 73 M), with an average age of 40.8 (range 7-81) years. Forty-three (n¼41) were performed without stimulation, and 290 (n¼286) used stimulation by CRH or DDAVP. In 40 cases (n¼39) both inferior petrosal veins could not be cannulated; 41 (n¼39) had incomplete medical records or were lost to follow up; and 29 (n¼28) lacked conformation of disease etiology. Among cases with pathological confirmation, 20 (n¼20) without stimulation had a sensitivity of 100% and specificity of 66.7%, 202 (n¼201) with stimulation had a sensitivity of 98% and specificity of 80%. Overall, sensitivity was 98.1% with a positive predictive value of 99.1% and specificity was 75% with a negative predictive value of 60%. Conclusion: BIPSS is a procedure used to distinguish pituitary ACTH hypersecretion (Cushing’s disease) from ectopic ACTH sources. In our experience, BIPSS sensitivity and concordance with pathological findings approach 100%, with higher specificity using CRH or DDAVP stimulation.
4:33 PM
Abstract No. 134
’ Dr. Constantin Cope Medical Student Research Award
Should adrenal venous sampling precede crosssectional imaging in the evaluation of primary aldosteronism? M. Asmar, Y. Yan, S. Trerotola; University of Pennsylvania Medical Center, Philadelphia, PA