| Objective:Adrenal venous sampling(AVS)is the gold standard for the classification and diagnosis of primary aldosteronism(PA).However,the right adrenal vein is a difficult problem in AVS because of its short vessel,many anatomical variations and its direct influx into the inferior vena cava at an acute angle,and the left adrenal vein often fails to take blood because of the abnormal anatomy of the left renal vein.In order to improve the success rate of AVS and reduce complications,this study summarized the intraoperative images of AVS and discussed the anatomy and variation of bilateral adrenal veins.Methods:A total of 120 patients(49 males and 71 females)with AVS in hypertension ward of the First Affiliated Hospital of Guangxi Medical University from June 2017 to January 2019 were enrolled.The aldosterone to renin ratio(ARR)in peripheral blood at standing position was calculated to be more than 30.They were diagnosed as PA by saline load test or captopril inhibition test.Among them,6 patients(1 male and 5 females)were failed in the right AVS,and the left AVS failed in 3 patients(2 males and 1 female).The RadiAntViewer software was used to retrospectively analyze the intraoperative imaging data of 120 patients with bilateral adrenal veins,including 114 patients with right adrenal vein and 117 patients with left adrenal vein.The related data of right adrenal vein include:the position of right adrenal venous orifice,the transverse distribution of orifice position,the diameter of right adrenal vein trunk,the angle between right adrenal vein trunk and inferior vena cava,the distance between orifice position and right accessory hepatic vein,the longitudinal distance between orifice position and the inferior edge of the liver shadow,the vertical distance between orifice position and the inferior edge of the liver shadow,and the distance between orifice position and spine.The related data of the left adrenal vein include:the orific position of left renal vein,the length of co-trunk of left adrenal vein and inferior phrenic vein,the diameter of co-trunk of left adrenal vein and inferior phrenic vein,the angle between left renal vein and the co-trunk,the angle between left adrenal vein and inferior phrenic vein,the diameter of inferior phrenic vein,the diameter of left adrenal vein,the distance between co-trunk orifice and spine.The image anatomy and variation data,the success rate and the complications of AVS were analyzed and evaluated.The data were analyzed by t test,X~2 test,one-way ANOVA and Fisher's exact probability method.SPSS22.0 was used for statistical analysis.Results:(1)The orifice of right adrenal vein is located between the 11th rib and the 12 rib,mainly between the middle 1/3 of the 11-12 intercostal space and below the 12th rib,accounting for 85.1%.The transverse distribution of the orifice position is between the 9 o'clock and the 1 o'clock,mainly between the10 o'clock and the 12 o'clock,accounting for 83.3%.(2)The pattern of right adrenal venography is mainly triangular,accounting for 48.2%.In addition,in patients with adrenal gland space-occupying lesions indicated by CT findings,if there is a"tumor shape"during AVS operation,can also be confirmed in place.(3)There were significant differences in the location of right adrenal vein orifice and the distance between right adrenal vein orifice and spine in different BMI groups(P<0.05).The larger the BMI,the higher the position of right adrenal vein orifice and the greater the distance between right adrenal vein orifice and spine.(4)The diameter of right adrenal vein trunk is 1.34±0.39 mm(0.39-2.76mm).The average angle between right adrenal vein trunk and inferior vena cava is 37.94±32.02 degrees(0-130.6 degrees).The average distance between orifice position and right accessory hepatic vein is 10.21±8.29 mm(0-32.21 mm).The average longitudinal distance between orifice position and the inferior edge of the liver shadow is 14.04±7.18 mm(2.12-32.00mm).The average vertical distance between orifice position and the inferior edge of the liver shadow is 12.01±6.57 mm(2.43-28.29 mm),and the average distance between orifice position and spine is 11.38±4.35 mm(1.29-22.38 mm).(5)Both left adrenal vein and inferior phrenic veins merge into common trunk vein and then into left renal vein.The orifice of left renal vein mainly distribute at the level of the first lumbar spine,accounting for 74.4%.(6)The average length of co-trunkofleftadrenalveinandinferiorphrenicveinis15.36±4.57mm(4.09-30.44 mm),the average diameter of co-trunk of left adrenal vein and inferior phrenic vein is 3.42±0.70mm(2.06-5.69mm),and the average angle between left renal vein and the co-trunk is 114.98±15.41 degrees(85-135degrees),the average angle between left adrenal vein and inferior phrenic vein is28.10±12.42 degrees(5-50 degrees),and the average diameter of inferior phrenic vein is 2.15±0.69mm(0.60-4.30 mm),the average diameter of left adrenal vein is 2.24±0.59 mm(0.82-4.55 mm),and the average distance between co-trunk orifice and spine is 4.68±3.85 mm(0-18.63 mm).(7)The success rate of right AVS is 95.0%,that of left AVS is 97.5%,and that of bilateral AVS is92.5%.All complications of AVS occurred in right adrenal vein with the incidence rate of 3.3%.The complications were adrenal vein rupture and hematoma,manifested by local retention of contrast medium and lumbar back pain.The complications were self-healing.(8)The anatomical variation rate of the right adrenal vein is 5.26%.All cases showed that the right adrenal vein entered the accessory right hepatic vein and then into the inferior vena cava.The anatomical variation rate of left adrenal vein is 4.27%.One rare case is that the left renal vein converged to the semiazygos vein and then to the inferior vena cava.The other cases were that the left unknown vein converged to the co-trunk of left adrenal vein and inferior phrenic vein or the left adrenal vein and then to the left renal vein.Conclusions:(1)The orifice of right adrenal vein is located between the11th rib and the 12 rib,and mainly between the middle 1/3 of the 11-12intercostal space and below the 12th rib.The transverse distribution of the orifice position is between the 9 o'clock and the 1 o'clock,mainly between the10 o'clock and the 12 o'clock.The orifice of right adrenal vein is located below the right accessory hepatic vein,most of which is located below the inferior edge of the liver shadow,and the orifice is located at the right posterior side of the spine.(2)The larger the BMI,the higher the position of the right adrenal vein orifice,the greater the distance between the right adrenal vein orifice and the spine.(3)The left adrenal vein jointly opens to the left renal vein after confluence with the inferior phrenic vein.The orifice of the left renal vein is mainly located at the level of the first lumbar vertebra.(4)To fully understand the anatomy and the variation of adrenal vein,to be familiar with the morphology of right adrenal venography,to perform thin-slice contrast-enhanced CT and rapid cortisol determination during AVS operation before operation can improve the success rate of AVS. |
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