4. Discussion
adrenal venous blood, hemodilution
PRIMARY ALDOSTERONISM, BENDING, POSTOPERATIVE COMPLICATIONS
In this study, we perceptively explored the safety and efficacy of single-path AVS and multipath AVS via the femoral vein and cubital vein for primary aldosteronism. The findings were as follows: (1) Multipath AVS via the cubital vein and femoral vein significantly improved the success rate of AVS and had comparable safety compared to single-path AVS. (2) The TIG catheter improved the success rate when the RAV was opened towards the III quadrant. (3) The multipath AVS approach expanded catheter options. The results showed that the multipath AVS technique (simultaneous adrenal vein sampling through the calf vein and femoral vein) allowed simultaneous collection of bilateral adrenal vein blood samples and shortened the X-ray exposure time. Moreover, this method expanded the catheter selection without increasing the cost of the procedure or postoperative complications.The multipath AVS technique was performed via the cubital vein and femoral vein synchronously. The modified multipath of AVS improved the success rate of AVS and enhanced the accuracy of diagnosis. AVS were initially performed using the SIMON catheter via the femoral vein single-path and later adopted single-path via the cubital vein by using a MPA catheter and a TIG catheter [The disadvantages of single-path AVS were fewer catheter options and the inability to perform simultaneous bilateral adrenal venous blood collection. To address the problem of fluctuating cortisol secretion during AVS, asynchronous AVS was used in the early days, followed by stimulation of AVS with ACTH [However, in many studies, the prognosis of patients with AVS-guided PA was not superior to that of patients with CT-guided prognosis. Huang [The AVS-guided prognostic analysis of PA is only of guiding value with accurate AVS results. While single-path AVS only allowed asynchronous extraction of adrenal blood, multipath AVS enabled synchronous blood extraction and allowed catheter selection based on the different opening positions of the adrenal veins in the planar quadrant. Only highly reliable AVS results were instructive for surgery. While single-path AVS only allowed asynchronous extraction of adrenal blood, multipath AVS enabled synchronous blood extraction and allowed catheter selection based on the different opening positions of the adrenal veins in the planar quadrant.The right-sided adrenal had a variable opening, and route and catheter diversification improved the success of cannulation. When the left-sided adrenal veins opening was deep or overlapped with the phrenic vein, diversification avoided imprecise cannulation and hemodilution caused by the single use of TIG catheters. Multipath AVS via the cubital vein and femoral vein significantly improved the success rate of AVS. ACTH stimulation was not required, which can reflect the results of lateral secretion. Also, incorrect typing diagnosis due to fluctuations in aldosterone and cortisol secretion in asynchronous AVS can be avoided.There were no reports on the use of TIG catheters in the AVS to access the RAV. We defined the axial location of the RAV opening and found a significant increase in the use of TIG catheters in the III quadrant. Multipath AVS expanded the options for alternative catheters, especially when MPA catheters cannot be inserted into the adrenal vein in conventional AVS. Due to the multipath AVS approach, alternative catheters such as TIG, SIMON, or VER 135° catheters can be used when the MPA catheter cannot be inserted into the adrenal vein.The TIG catheter improved the success of the operation because the TIG catheter had the advantage of bending upward proximally, and the second curvature of the catheter provided support when the TIG catheter was formed in the inferior vena cava. Therefore, we found that for patients with RAV opening in the III quadrant, the TIG catheter was more suitable for RAV implantation via the cubital vein.Our previous studies demonstrated the safety and feasibility of multipath AVS [We observed an interesting phenomenon. After the TIG entered the RAV via the cubital vein, we attempted a right anterior oblique 30° angiogram as the RAV almost overlapped the inferior vena cava on anterior-posterior fluoroscopy (In single-path AVS, the RAV is reached using an MPA catheter, and a TIG catheter was the only option for hooking the LAV opening. Sometimes only the first branch of the adrenal vein can be hooked through the cubital vein. For deeper openings in the left adrenal vein or openings overlapped with the phrenic vein, a microcatheter was required. The above were the reasons why single-path AVS was costlier. The variety of paths and catheters avoided imprecision of cannulation and hemodilution. Multipath access expanded the choice of catheters. The lower cost of the procedure and fewer postoperative complications demonstrated the superiority of multipath AVS.