Case selection of adrenal vein sampling in young patients with primary aldosteronism: a retrospective analysis of imaging and AVS concordance, and histopathological outcomes.

Background: Primary aldosteronism (PA) is a common, potentially curable cause of secondary hypertension. Determining disease laterality is critical to guide treatment decisions. Adrenal vein sampling (AVS) is the gold standard but may be unnecessary in patients aged 35 years or younger who meet defined strict biochemical and imaging criteria.

Objective: To assess concordance between imaging and AVS for lateralisation in young patients with PA and correlate findings with histopathology after adrenalectomy.

Methods: A retrospective analysis of 35 patients aged 35 years or younger with confirmed PA who underwent unstimulated AVS between 2011 and 2024. Cross-sectional imaging findings were compared with AVS results. Histopathological outcomes were reviewed for patients who underwent adrenalectomy.

Results: Imaging identified unilateral adrenal adenomas in 29 patients, with 86% (25/29) concordance with AVS. Four discordant cases were classified as bilateral by AVS; three did not meet the Endocrine Society criteria for 'marked' PA. Excluding these cases raised the concordance rate to 96%. All 25 patients with AVS-confirmed unilateral disease underwent adrenalectomy, with histopathology confirming aldosterone-producing adenomas.

Conclusion: Imaging accurately predicted unilateral PA in most young patients meeting strict biochemical and imaging criteria. Some patients could avoid AVS, although even with strict criteria, uncommon discordant cases highlight the importance of careful patient selection.