Bleeding Adrenal: Adrenal Hemorrhage as a Complication of Adrenal Venous Sampling

Program: Abstracts - Orals, Featured Poster Presentations, and Posters
Session: SAT 53-73-Primary Aldosteronism & Mineralocorticoid Excess
Clinical
Saturday, June 15, 2013: 1:45 PM-3:45 PM
Expo Halls ABC (Moscone Center)

Poster Board SAT-62
Jalaja Joseph*1, Charalampos Lyssikatos1, Andreas Moraitis2, Mitra Lynn Rauschecker3, Smita Baid Abraham4 and Constantine A Stratakis5
1National Institutes of Health, Bethesda, MD, 2University of Michigan Health System, Ann Arbor, MI, 3NIH, Bethesda, MD, 4Natl Institutes of Hlth, Bethesda, MD, 5National Institutes of Health (NIH), Bethesda, MD
Background: Adrenal venous sampling (AVS) 1 is considered as the gold standard in distinguishing unilateral from bilateral adrenal disease, in patients with primary hyperaldostreronism (PA). Although it is a relatively safe procedure, few centers in the US perform this procedure successfully. The technical difficulty in cannulating the right adrenal vein dictates the success rate. This procedure is associated with minimal complications varying from 5-10 % to less than 0.2% in centers depending on the volume of cases performed 2.  Adrenal hemorrhage from thrombosis or transection of the vein is a complication that may be seen in PA patients.

We report the case of a 56-year-old African American female who was diagnosed with hypertension at the age of 21 after she presented with hypertension. Since then, she has been on multiple medications with inadequate control. Hypokalaemia was noted at the age of 51 years. Laboratory evaluation revealed an aldosterone of 16.5ng/dL (normal 1-21ng/dL) and plasma rennin activity less than 0.15ng/ml/hr (normal <= 0.6-3) with an aldosterone-renin ratio of 1104. Her medical history was also significant for obesity, temporal lobe epilepsy, vitamin D insufficiency and secondary hyperparathyroidism. The patient underwent two inconclusive saline suppression tests, with plasma aldosterone of 5.2 and 7.6 ng/dL. 24 hour urine aldosterone level during the second saline suppression was elevated at 21mcg/24h (normal 2-20 mcg/24h) and the sodium excretion was appropriate at 251mmol/24 h.  MRI of the adrenals showed nodular hyperplasia of the adrenal glands, most notably in the lateral limb of the left adrenal. Subsequently, the patient underwent AVS. Two hours status post procedure, the patient complained of severe right upper quadrant pain radiating to the right shoulder. Examination was significant for rigidity and rebound tenderness in the right upper quadrant. Laboratory evaluation was significant for normal hematocrit and CT scan of the abdomen revealed right adrenal hemorrhage. Patient was managed conservatively and with repeat serial imaging; by 6 months, there was an almost complete resolution of the hemorrhage.

Conclusion: Adrenal hemorrhage from transection of adrenal vein is an uncommon complication after adrenal venous sampling. Most of the time, patients require non-invasive monitoring and pain control. There are very few cases reported in the literature and physicians need to be aware of this potential complication of AVS.

Kahn SL & Angle JF 2010 Adrenal vein sampling. Tech Vasc Interv Radiol 13 110-125 Daunt N 2005 Adrenal vein sampling: how to make it quick, easy, and successful. Radiographics 25 Suppl 1 S143-158

Nothing to Disclose: JJ, CL, AM, MLR, SBA, CAS

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