###### Initial Clinic Meeting **New Med List! **Preferred BP Meds**: the meds with little to no effect on renin/aldosterone levels: - Calcium channel blockers (Nifedipine, amlodipine, felodipine, diltiazem, verapamil) - Alpha- blockers (Doxazosin, prazosin, terazosin) - Direct vasodilators (Hydralazine, minoxidil **Unacceptable Meds**: the drugs most likely to stimulate renin and mask lateralization. These typically should be held for at least 4-6 weeks prior to AVS testing. - MRA antagonists (Spironolactone, Eplerenone) - K sparing Na channel blockers (Amiloride, Triamterene) - Thiazide and thiazide-like diuretics (HCTZ, chlorthalidone, metolazone, indapamide) - Loop diuretics (Furosemide, bumetanide, torsemide, ethacrynic acid) - Aldosterone synthase inhibitors (Baxfendy – *BRAND NEW first-in-class BP med approved in 2026) **Acceptable BP Meds**: drugs that can affect renin/aldo levels but are generally considered acceptable to continue prior to AVS testing. These tend to LOWER RENIN levels which can sometimes affect the screening aldo/renin ratio. They should NOT, however, prevent lateralization on AVS testing. - Beta blockers (Atenolol, metoprolol, carvedilol, nevibolol) - Central alpha-2 agonists (Clonidine, methyldopa) **“Gray area” BP meds**: best to hold these ~ 2 weeks if clinically feasible. These meds increase renin and may blunt lateralization. - ACE inhibitors (Lisinopril, quinapril, ramipril, enalapril) - ARBs (Losartan, valsartan, telmisartan, candesartan) - Direct renin inhibitors (Aliskiren) NOTE: sometimes these meds may need to be continued due to severe HTN, hypokalemia, etc. In these cases, a renin level can be checked immediately prior to testing. As long as this remains suppressed, it is okay to proceed with AVS. ###### ACTH Stimulation - 0.25 mg Cortrosyn in 500 mL NS at 100 mL/hr - Start 1 hr before procedure (As soon as IV access is obtained) and continue throughout procedure ###### Labs: - Aldosterone, potassium, renin - Ask lab to titrate to max cortisol level Sample a minimum of 8 mL (4 mL for each tube) from each side. ###### Right side: - 5F renal double curve (RDC) - Vingan: USL, cobra1, MiKaelson, Sim1, Sim2 - Side hole 1 mm from tip on the superior surface - Place catheter up into IVC past adrenal vein - Turn posteriorly 1/8 turn (7 to 8 o'clock) - Look for deflection while pulling down - Look for inferior accessory hepatic vein, adrenal vein will be within 1 cm ###### Left side: - Simmons 3 or 2 - Use suture to form - Small hole on undersurface of the catheter - Phrenic-adrenal trunk - Always look for phrenic Selectivity index=Adrenal cortisol/IVC cortisol Needs to be >= 3 (or 5) Lateralization index = A/C (high)/A/C (low) Needs to be >= 4 for surgery ###### Example | | A | C | A/C | |-----|------|-----|-----| | R | 5000 | 500 | 10 | | L | 500 | 500 | 1 | | IVC | 100 | 50 | 2 | SI>3 (or 5) LI>4 ![[Adrenal Vein Sampling Trerotola.mp4]] Adrenal Vein Sampling Video - `URL:` https://www.youtube.com/watch?v=te5pvrOQWXs - `Description:` JVIR Adrenal Vein Sampling Final Cut - `Publish Date:` 05 October 2014 - `Duration`: 10:08 To follow up on your additional questions for AVS sampling at Quest: - The required specimen for this test is either a **red top** (serum without a separator gel), or **lavender top** (EDTA tube).  - I would recommend the red top, since that is more resistant to hemolysis. - The optimum volume is **2 mL serum/plasma** (~4 mL whole blood).  - The absolute minimum would be **0.5 mL serum/plasma** (1 mL whole blood). However, I would recommend collecting more than that, since it would be impossible to retest.  - Here is the link to the test available at quest: [Aldosterone/Cortisol Ratio, Adrenal Vein Sampling, 1 Site | Test Detail | Quest Diagnostics](https://testdirectory.questdiagnostics.com/test/test-detail/19573/aldosteronecortisol-ratio-adrenal-vein-sampling-1-site?p=r&q=adrenal%20venous%20sampling&cc=MASTER) For ordering, I believe you should be able to order these the same way as before. However, you could put the comment: "**Send to Quest. Test 19573**" just in case. Make sure to write diagnosis code **E26.09 Primary Hyperaldosteronism** on the lab order sheet.