Setting yourself up for reoperative surgical success: Lessons learned from a 10-year experience with selective venous sampling for reoperative parathyroidectomy.

Background: Accurate preoperative localization is critical in preparing for reoperative parathyroidectomy. Given the limitations of noninvasive imaging modalities, we examined how parathyroid selective venous sampling aided in identification of hyperactive parathyroid tissue and facilitated operative cure in challenging parathyroidectomy cases.

Methods: We performed a retrospective review of patients who underwent selective venous sampling prior to reoperative parathyroidectomy between 2014 and 2024. Operative reports, imaging studies, and selective venous sampling results were analyzed to evaluate the utility of venous sampling for reoperative parathyroidectomy.

Results: 83 patients underwent selective venous sampling prior to reoperative parathyroidectomy. Before undergoing selective venous sampling, all patients underwent a neck ultrasonography and a 4-dimensional computed tomography, and 49% (n = 41) also underwent Tc-99m sestamibi scan. Imaging was negative or inconclusive in all patients. Selective venous sampling results showed lateralization to one side of the neck in 77% (n = 64), clear mediastinal location facilitating thoracic approach in 6% (n = 5), inferior location without lateralization in 11% (n = 9), multigland disease in 2% (n = 2), and equivocal results in 4% (n = 3). After reviewing the selective venous sampling results, potential targets were identified on noninvasive imaging in 62% (n = 51) of cases. Overall, 92% (n = 76) proceeded with further surgical exploration based on the selective venous sampling. At the time of reoperative surgery, an abnormal parathyroid gland concordant with selective venous sampling localization was found in 81% (n = 62) of patients.

Conclusions: Selective venous sampling can be a useful adjunct in reoperative parathyroidectomy when less invasive imaging modalities are inconclusive. Selective venous sampling requires significant expertise to do well and interpretation is nuanced and should be done in the context of additional imaging and a thorough understanding of patients' prior operations.