Optimizing the diagnosis of primary aldosteronism: The role of adrenal vein sampling and the need for high-expertise reference centers

Abstract

Adrenal vein sampling (AVS) is the cornerstone diagnostic procedure for subtype differentiation in primary hyperaldosteronism, guiding therapeutic decision-making and offering the possibility of curative surgery to a subset of patients. However, technical challenges limit its use, and success rates vary substantially across centers, restricting equitable access for all patients with primary hyperaldosteronism. To evaluate AVS success rates in major hospitals across Andalucía and to assess the clinical evolution of patients who underwent surgery, with the goal of identifying referral centers and optimizing patient care. A retrospective observational study was conducted across six centers in Andalucía. A total of 151 procedures were performed in 140 patients, with an overall success rate of 55.62%. Intercenter analysis revealed successful catheterization rates ranging from 25% to 75.5%. Among patients without a computed tomography-detected adenoma, 27.4% demonstrated unilateral or bilateral aldosterone secretion. In patients with a single adenoma, discordant lateralization was observed in 9.80%, and bilateral secretion in 11.76%. Half of the patients with bilateral adenomas exhibited unilateral secretion. In total, discordant results reached 21.57%. Following surgery, all patients with successful AVS discontinued potassium supplementation, accompanied by a significant reduction in antihypertensive medication requirements (p < .001). There were no significant differences among patients that underwent unilateral adrenalectomy based on imaging or AVS. Surgical management of primary hyperaldosteronism leads to significant clinical improvement, which is most accurately achieved when guided by successful AVS. Identifying and supporting expert centers is essential to improve access to AVS and enhance clinical outcomes for patients with primary hyperaldosteronism.