When Does Adrenal Venous Sampling Add Value? Experience in Patients With Primary Aldosteronism and Unilateral Adrenal Imaging

Background Guidelines recommend adrenal venous sampling (AVS) for lateralization in patients over 35 with primary aldosteronism (PA). Its value in patients who already have a unilateral adrenal lesion on cross-sectional imaging is less well defined. We examined how often AVS provided additional actionable information in this setting. Methods We retrospectively reviewed patients over 35 with PA who underwent AVS at a single institution from May 2015 to December 2022. AVS results were classified as concordant, discordant, bilateral, or non-diagnostic. Biochemical cure was defined as aldosterone-to-renin ratio <30; clinical cure as reduced antihypertensive medication use. Results 84 procedures in 73 patients were analyzed. A unilateral mass was identified on imaging in 61 cases. AVS was concordant in 22 (36%), non-diagnostic in 14 (23%), discordant in 5 (8%), and bilateral in 20 (33%). Among 35 patients with unilateral imaging who underwent adrenalectomy, AVS was concordant in 22 (63%) and non-contributory in 13 (37%). Of three discordant cases that had surgery, one achieved biochemical cure and none achieved clinical cure. Conclusions In patients with PA and a unilateral adrenal mass, AVS was non-diagnostic in 23% and non-contributory in 37% of surgical cases and its incremental value varied by clinical context. These findings support individualized, multidisciplinary use of AVS rather than uniform application, and are best interpreted along with current guideline recommendations.