Download Radiofrequency Ablation of Aldosteronomas (Conn’s Syndrome): A New Application of IR

BIDMC, PACS
Stowasser, University of Queensland, AU
Radiofrequency Ablation of
Aldosteronomas (Conn’s Syndrome):
A New Application of IR
Leah Hawkins, HMS III
Gillian Lieberman, MD
December 13, 2010
Dupuy D E et al. Radiographics 2002;22:S259-S269
Leah Hawkins, MSIII
Gillian Lieberman, MD
Mayo-Smith W W et al Radiographics 2001;21:995-1012
Outline






Patient Presentation
Differential Diagnosis
Living Anatomy
Menu of Radiologic Tests/Imaging Algorithm
Diagnostic Interventions
Therapeutic Interventions
Leah Hawkins, MSIII
Gillian Lieberman, MD
Outline
Patient Presentation
 Differential Diagnosis
 Living Anatomy
 Menu of Radiologic Tests/Imaging Algorithm
 Diagnostic Interventions
 Therapeutic Interventions

Leah Hawkins, MSIII
Gillian Lieberman, MD
Patient 1: History and Physical Exam
History
PMH
Fam Hx
Meds
48yo M presents with refractory hypertension
associated with hypokalemia since age 30.
none
noncontributory
HCTZ, Amlodipine, Terazosin, Metoprolol, K
supplement
Leah Hawkins, MSIII
Gillian Lieberman, MD
Indications for Secondary HTN Screening
MRA: Severe Proximal Renal Artery Stenosis

Severe or refractory

(Refractory to 3+ bp meds)

Negative family history

Acute rise in bp or creatinine
Onset <puberty or >50
Asymmetry in renal disease
Abdominal bruit.



Kaplan, Rose. Screening for Renovascular or Other
Causes of Secondary Hypertension
UpToDate. 2010; 18.3
Leah Hawkins, MSIII
Gillian Lieberman, MD
Source: Dong Q et al. Radiographics 1999;19:1535-1554
Outline
Patient Presentation
 Differential Diagnosis
 Living Anatomy
 Menu of Radiologic Tests/Imaging Algorithm
 Diagnostic Interventions
 Therapeutic Interventions

Leah Hawkins, MSIII
Gillian Lieberman, MD
Differential Diagnosis of Secondary
Hypertension
Common




Uncommon
Primary Aldosteronism (PA)





Present in up to 10% patients with hypertension
Primary Renal disease
Renovascular Hypertension (RAS)
Pheochromocytoma
Cushing’s syndrome
Coarctation of the Aorta
(Other): Obesity, Alcoholism, Sleep apnea
Reninoma
Leah Hawkins, MSIII
Gillian Lieberman, MD
Rossi, G. Prevalence and Diagnosis of Primary
Aldosteronism. Current Hypertension Reports
2010; 12:342-348.
Patient 1’s Initial Workup

The first step in his workup for secondary
hypertension was a renal doppler ultrasound.

Images from this ultrasound were unavailable,
but similar images in a patient with the same
diagnosis will be described on the next slide.
Leah Hawkins, MSIII
Gillian Lieberman, MD
Companion Patient 1: Renal Doppler US
Shows no evidence of RAS
Left Kidney Doppler US
Right Kidney Doppler US
Source: BIDMC, PACS
Source: BIDMC, PACS


US assesses renal arteries anatomically and functionally
Best indicator of RAS is increased peak systolic velocity
Leah Hawkins, MSIII
Gillian Lieberman, MD
Williams, GJ et al. Comparitive accuracy of renal duplex
sonographic parameters in the diagnosis of renal artery
stenosis: paired and unpaired analysis. AJR. AM J
Roentgenol 2007; 188:798.
This raises the question: is a renal doppler
ultrasound indicated in the initial work-up
of a patient with refractory hypertension?
Leah Hawkins, MSIII
Gillian Lieberman, MD
ACR Appropriateness Criteria

Renal doppler US is an inappropriate first step in the
evaluation of secondary hypertension.

Renovascular HTN is not the most common cause of
secondary HTN.
Kahn, S. Techniques in Vascular and Interventional Radiology 2010; 13.2: 110-125

Even if Renovascular HTN suspected:


C+ MRA and/or CTA  Rating of 8
US Kidney +Doppler Rating of 6
Prasad S et al. Renovascular Hypertension, ACR Appropriateness Criteria. American
College of Radiology; 2009; 1-8. accessed 12.9.2010
Leah Hawkins, MSIII
Gillian Lieberman, MD
Patient 1 MRA: No evidence of RAS
Patent Renal Arteries
bilaterally
Accessory Left
Renal Artery
Source: BIDMC, PACS Courtesy of Dr. Knutson
Leah Hawkins, MSIII
Gillian Lieberman, MD
Patient 1 MRA: Incidental Adrenal Nodule
Left Adrenal Mass:
Source: BIDMC, PACS
Leah Hawkins, MSIII
Gillian Lieberman, MD
Outline
Patient Presentation
 Differential Diagnosis
 Living Anatomy
 Menu of Radiologic Tests/Imaging Algorithm
 Diagnostic Interventions
 Therapeutic Interventions

Leah Hawkins, MSIII
Gillian Lieberman, MD
Origin of the Adrenals (Embryology)
Source: http://www.autismpedia.org/wiki/index.php?title=Image:Adrenal-core.gif
Leah Hawkins, MSIII
Gillian Lieberman, MD
Adrenals in the body (Gross Anatomy)
•Diaphragms
•Adrenals
•Kidneys
Leah Hawkins, MSIII
Gillian Lieberman, MD
Source: Drake et al. Gray’s anatomy. Pp.320-328.
Adrenals on MRI (Living anatomy)
Left Adrenal
Right Adrenal
IVC
Aorta
Source: BIDMC, PACS Courtesy of Dr. Knutson
Adrenals: wispy, y-shaped, low signal masses
Leah Hawkins, MSIII
Gillian Lieberman, MD
Adrenal Mass: Etiologies
Benign Lesions
 Cysts
 Myelolipomas
 Sequelae of previous trauma

Adrenal Hyperplasia
Benign Neoplasms

Pheochromocytoma

Adenomas
-nonfunctioning
-hormone-secreting
Malignant Neoplasms
 Metastases
 Lymphoma
 Adrenocortical carcinoma
 Angiosarcomas
 Neuroblastoma
Pheochromocytoma
Source: http://healthpictures.com/images/Pheochromocytoma.jpg
Leah Hawkins, MSIII
Gillian Lieberman, MD
Not So Fast!!! “Pseudolesions” include:

GI




Colon
Pancreas
Liver
Stomach
Reticuloendothelial




Gastric diverticulum
Gastric fundus
Dilated colon
Hepatic mass
Splenules
Splenic lobulations
Renal
Artery
Left Adrenal Mass
Vascular (noncontrast)


Varices
Splenic, Renal a.
aneurysm
Spleen
Source: BIDMC, PACS Courtesy of Dr. Knutson
Leah Hawkins, MSIII
Gillian Lieberman, MD
Johnson. Pamela T, Horton, Karen M. Adrenal Mass Imaging with
Multidetector CT: Pathologic Conditions, Pearls, and Pitfalls.
Radiographics 2009;29:1333-1351.
Outline
Patient Presentation
 Differential Diagnosis
 Living Anatomy
 Menu of Radiologic Tests/Imaging Algorithm
 Diagnostic Interventions
 Therapeutic Interventions

Leah Hawkins, MSIII
Gillian Lieberman, MD
Adrenal Gland: Menu of Radiologic Tests

CT +/- contrast



MRI +/- contrast



Better soft tissue differentiation
Chemical Shift imaging evaluates lesions not adequately characterized by CT
Radiography


Modality of choice for initial characterization of adrenals but is nonspecific for masses
3-Phase (delayed contrast) CT evaluates washout characteristics of adrenal masses
Fluoroscopy-guided procedures
Less Commonly used tests:

Ultrasound


Only readily identifies large masses
Nuclear Scintigraphy


I-131 meta-iodobenzylguanidine (MIBG) assesses medullary function
I-131 6-beta-iodomethyl-19-norcholesterol (NP-59) assesses cortex
Leah Hawkins, MSIII
Gillian Lieberman, MD
C- CT is nonspecific for Adrenalomas

In majority of adenomas, CT is inaccurate or
noncontributory.


On CT, Adenomas are:




Magill SB, Raff H, Shaker JL, et al. Comparison of adrenal vein sampling and computed tomography in
the differentiation of primary aldosteronism. J Clin Endocrinol Metab 2001;86:1066-1071
Small but can be large (4-6cm)
Homogenously enhancing or heterogenous if hemorrhage
Lipid-rich (HU<10) or up to 25HU if lipid-poor
3 Phase C+ CT increases specificity:
Adenomas demonstrate rapid washout (APW >60%, RPW
>40%) but not absolute, requires contrast administration
Leah Hawkins, MSIII
Gillian Lieberman, MD
3-Phase CT: calculating APW, RPW

“Washout” = Comparison of Attenuation
Measurements during 3 phases of C+ CT





Absolute Percent Washout = APW = X/Y
Relative Percent Washout=RPW=X/ HUPortal Venous Phase



1- Precontrast
2- Portal Venous
3- Delayed phase
HUPortal Venous Phase – HUPrecontrast Phase = Y
HUPortal Venous Phase – HUDelayed Phase = X
Typically, Adenomas have APW >60% and RPW >40%
Johnson. Pamela T, Horton, Karen M. Adrenal Mass Imaging
with Multidetector CT: Pathologic Conditions, Pearls, and
Leah Hawkins, MSIII
Gillian Lieberman, MD
Pitfalls. Radiographics 2009;29:1333-1351.
Imaging Algorithm for Adrenal Incidentalomas
Leah Hawkins, MSIII
Gillian Lieberman, MD
Mayo-Smith 2001; 21:995-1012

The Imaging Algorithm for Adrenal
Incidentalomas is not useful in Patient 1’s
case, as he had an MRA before CT.

Let’s return to his MRA in attempts to
further characterize his adrenal mass.
Leah Hawkins, MSIII
Gillian Lieberman, MD
Our Patient: Incidental Adrenal Nodule on MRA
Left Adrenal Mass:
Source: BIDMC, PACS
Leah Hawkins, MSIII
Gillian Lieberman, MD
Our Patient: Shift Imaging reveals adenoma
Out of Phase MRI
In Phase MRI
Source: BIDMC, PACS
Low signal mass
Source: BIDMC, PACS
Leah Hawkins, MSIII
Gillian Lieberman, MD
Lower signal, similar
to spleen
MR Chemical Shift Imaging: The Basics

Protons in fat and water resonant at different
frequencies

Tissue containing lipid and water (spleen, kidneys,
adenomas) demonstrate lower signal density on outof-phase (destructive) than in-phase (additive)
images
Mayo-Smith 2001;21:995-1012
http://www.green-planet-solarenergy.com/images/water-molecule.gif
water
fat

Chemical Shift Imaging is sensitive for differentiating
adenomas from metastases
Chong et al. Radiographics 2006; 26:1811-1826
Leah Hawkins, MSIII
Gillian Lieberman, MD
Moran A, Mobley HLT. H. Pylori: Physiology & Genetics. 2001
Outline









Patient Presentation
Differential Diagnosis
Living Anatomy
Menu of Radiologic Tests/Imaging Algorithm
Diagnostic Interventions

Classification: What kind of adenoma is this?

Functioning



Nonfunctioning



Cortex- Conn’s, Cushing’s, hyperandrogenism
Medulla- Pheochromocytoma
Cysts, myelolipomas, previous trauma
Therapeutic Interventions
Leah Hawkins, MSIII
Gillian Lieberman, MD
Classifying Adenomas: Size differential provides
clues but is a nonspecific indicator of functionality
Abdominal MRI T2 Fat Sat Axial cut shows Right Pheochromocytoma
Pheochromocyoma
-Large, heterogenous adrenal
mass with increased signal
Atrophied
contralateral
adrenal
Source: Mayo-Smith W W et al. Radiographics 2001;21:995-1012
Leah Hawkins, MSIII
Gillian Lieberman, MD
Patient 1: Lab data, PMH concerns for PA


Our Patient’s lab results showed an elevated
aldo:renin ratio. In concert with his history of
hypokalemia, this concerns for primary
aldosteronism.
The gold standard for diagnosis of primary
aldosteronism is Adrenal Venous Sampling.
Leah Hawkins, MSIII
Gillian Lieberman, MD
Why Adrenal venous sampling (AVS)?

Gold Standard for Diagnosis of PA

Nuclear Scintigraphy (NP-59) can also assesses cortical function but is
expensive and results are less specific and quantitative.


Determines Laterality


Kahn, S. Adrenal Vein Sampling. Techniques in Vascular and Interventional Radiology
2010; 13.2: 110-125.
Daunt, Nicholas. Adrenal Vein Sampling: How to Make It Quick, Easy, and Successful.
Peripheral Vascular Diagnosis and Interventions. RadioGraphics 2005;25:S143-S158
Determines Treatment Options

Rossi, G. Prevalence and Diagnosis of Primary Aldosteronism. Current Hypertension
Reports 2010; 12:342-348.
Leah Hawkins, MSIII
Gillian Lieberman, MD
Indications for and Risks of AVS

Indications

Primary Aldosteronism

Adenoma vs. Hyperplasia
Pheochromocytoma
Adrenal Cushing’s



Contraindications


General
Complications



Adrenal Hemorrhage/venous
perforation
Adrenal Infarction
Hypertensive crisis
Source: Stowasser. University of Queensland, AU.
http://www.uq.edu.au/news/?article=11854
Thomson, Kenneth and Given, Mark. Image-guided Interventions, Chapter: Adrenal
Venous Sampling. Philadelphia, Pennsylvania: Saunders Elsevier; 2008; Vol 1:
Leah Hawkins, MSIII
Gillian Lieberman, MD
AVS Procedure

1- Planning


2- Vascular Access




Inject contrast
Sample adrenal veins b/l (baseline measurement)
4- Sampling



Via Seldinger technique
Sample IVC below, above level of adrenal veins
3- Ensure entry into adrenal vein


Venous Imaging via CT or MR venography
Inject ACTH
Remove samples b/l at 5min, 10min, 15min
5- Interpretation of Results
Leah Hawkins, MSIII
Gillian Lieberman, MD
Pre-procedure Venography Identifies
Adrenal Vein Anatomy
Right Adrenal Vein Variants
Left Adrenal Vascular Supply
Source Elsayes K M et al. Radiographics 2004;24:S73-S86
Source: Daunt N Radiographics 2005;25:S143-S158
Leah Hawkins, MSIII
Gillian Lieberman, MD
Rationale for Pre-AVS Venography

Right Adrenal Vein


Can arise:
 1-Directly off IVC (most commonly)

-branches at variable angles
 2- Branch of R renal vein
 3- Branch of accessory hepatic vein
Left adrenal vein of less concern because



Larger size
Less variable anatomy
Arises as branch of Left renal vein
3
1
2
Matsuura Tomonori et al. Radiologic Anatomy of the Right
Adrenal Vein: Preliminary Experience with MDCT. American
Journal of Radiology. 2008; 191:402–408
Netter, H Atlas of Human Anatomy, 4E: 2006
Leah Hawkins, MSIII
Gillian Lieberman, MD
Elsevier Netteranatomy.com
Companion Patient 2: CT illustrates most
common origin of R adrenal vein off IVC
Right
Adrenal
Vein
IVC
Aorta
Source: Daunt, N. Radiographics 2005; 25:S143-S158
Leah Hawkins, MSIII
Gillian Lieberman, MD
After preprocedure imaging has been interpreted
and incorporated into procedural planning (to
reduce risk of venous perforation), we achieve
access via the Seldinger technique.
Leah Hawkins, MSIII
Gillian Lieberman, MD
AVS Procedure: Step 2


1- Planning



2- Vascular Access




Venous
Venous Imaging
Imaging via
via CT
CT or
or MR
MR venography
venography
Achieve vascular access via the Seldinger technique
Sample IVC inferior and superior to level of the adrenal veins
3- Ensure entry into adrenal vein
Inject
Inject contrast
contrast

 Sample
Sample adrenals
adrenals b/l
b/l (baseline
(baseline measurement)
measurement)




4- Sampling
Inject
Inject ACTH
ACTH

 Remove
Remove samples
samples b/l
b/l at
at 5min,
5min, 10min,
10min, 15min
15min




5- Interpretation of Results
Leah Hawkins, MSIII
Gillian Lieberman, MD
Vascular Access in Adrenal Vein Sampling

Seldinger
Technique




Micropuncture
Femoral vein
Pass small
guidewire
Pass catheter
over guidewire
Remove wire
Hocking, G. Central Venous Acess and Monitoring. Practical Procedures,
Issue 12 (2000), 13: 1-6.
Leah Hawkins, MSIII
Gillian Lieberman, MD
Cannulation of Adrenal veins Schematic
http://www.ucumberlands.edu/
Leah Hawkins, MSIII
Gillian Lieberman, MD
AVS Procedure: Step 3

 1- Planning

 Venous Imaging via CT or MR venography

 2- Vascular Access

 Peripheral, Femoral

 Obtain baseline IVC samples above, below adrenal veins

3- Ensure entry into adrenal vein
Leah Hawkins, MSIII
Gillian Lieberman, MD
Companion Patient 3: Fluoroscopy aids
in confirmation of catheter position
Contrast injection
confirms position in
right adrenal vein
Source: Melby, J. NEJM 1967; 277:1050-1056
Leah Hawkins, MSIII
Gillian Lieberman, MD
Mayo-Smith W W et al. Radiographics 2001;21:995-1012
AVS Procedure: Step 4

 1- Planning

 Venous Imaging via CT or MR venography

 2- Vascular Access

 3- Ensure entry into adrenal vein

 Inject contrast

 Sample adrenals b/l (baseline measurement)

4- Sampling
Inject ACTH
 Remove samples b/l at 5min, 10min, 15min


 5- Interpretation of Results
Leah Hawkins, MSIII
Gillian Lieberman, MD
Our Patient: Fluoroscopy-Guided AVS
1- Inject ACTH
2- Venous
Samples
collected at 5,
10, 15min
Right adrenal vein
arising from tertiary
R hepatic vein
T10
T11
Level of
renal
veins
T12
L1
Left Adrenal
Vein
Sampling
Source: BIDMC, PACS Courtesy of Dr. Faintuch
Leah Hawkins, MSIII
Gillian Lieberman, MD
AVS Procedure: Step 5

 1- Planning

 Venous Imaging via CT or MR venography

 2- Vascular Access

 3- Ensure entry into adrenal vein

 Inject contrast

 Sample adrenals b/l (baseline measurement)

 4- Sampling

 Inject ACTH

 Remove samples b/l at 5min, 10min, 15min

5- Interpretation of Results
Ensure quality samples
 Assess laterality

Leah Hawkins, MSIII
Gillian Lieberman, MD
Interpreting AVS Results

Quality
[cortisol]adrenal vein :[cortisol]peripheral vein >2-3

Laterality
[aldo]/[cortisol]dominant :[aldo]/[cortisol]nondominant adrenal vein >4
Daunt, Nicholas. Adrenal Vein Sampling: How to Make It Quick, Easy, and Successful.
Peripheral Vascular Diagnosis and Interventions. RadioGraphics 2005;25:S143-S158
Leah Hawkins, MSIII
Gillian Lieberman, MD
Patient 1’s AVS Results
Our patient’s results returned (as they are a
send-out lab):
Left Adrenal vein produced >20times
the aldosterone made by the right adrenal
gland!
Leah Hawkins, MSIII
Gillian Lieberman, MD
Outline











Patient Presentation
Differential Diagnosis
Living Anatomy
Menu of Radiologic Tests/Imaging Algorithm
Diagnostic Interventions
Therapeutic Interventions

Medical Management



Familial Adrenal Hyperplasia glucocorticoids
Idiopathic b/l adrenal hyperplasia aldosterone receptor antagonist
Adrenalectomy


Surgical
CT-guided RFA
Leah Hawkins, MSIII
Gillian Lieberman, MD
Elevated, Nonsuppressable
Aldo/Plasma Renin Ratio
Elevated ratio not suppressed by:
1- IV saline load
2- Fludrocortisone suppression test
AVS
Lateralization
No Lateralization
Aldosterone-secreting
adenoma
Idiopathic b/l adrenal
hyperplasia
Adrenalectomy
Medical Mgmt
RFA
Surgical Adrenalectomy
Leah Hawkins, MSIII
Gillian Lieberman, MD
Why Radiofrequency Ablation (RFA)?
 Curative

Adrenalectomy cures hypertension in majority of cases of
Conn’s Syndrome, improves blood pressure in remainder.


Stowasser M. et al. Diagnosis and Management of Primary Aldosteronism.
Journal of the Renin-Angiotensin-Aldosterone System. 2001; 2.3: 156-169.
Potential for Better Outcomes


An outpatient procedure that spares more of the healthy
adrenal gland and can be repeated prn.
CT-guided RFA promises reduced morbidity, mortality and
cost compared to surgical adrenalectomy.

Dupuy D. et al. Clinical Applications of Radio-Frequency Ablation in the Thorax.
Radiographics 2002; 22:S259-S269.
Leah Hawkins, MSIII
Gillian Lieberman, MD
Indications for, Risks of RFA of
Adrenal Adenomas



Indications
 Benign tumors
 Small malignancies
 Debulking procedures
Contraindications
 General
Risks:
 Bleeding, pain, infection,
CVA/MI, damage to adjacent
structures, death, incomplete
treatment
Leah Hawkins, MSIII
Gillian Lieberman, MD
Dupuy D. et al. Clinical Applications of Radio-Frequency Ablation in
the Thorax. Radiographics 2002; 22:S259-S269.
Adrenal RFA Procedure: Step 1

1- Preprocedure Imaging




CT estimates position
2- Gain Access


Paraspinal Approach
Superior
Superior to
to rib
rib (12
(12thth))

 Lateral
Lateral to
to spinous
spinous process
process of
of T12
T12




3- Ablation




Deliver pulses in 5min intervals
4- Post-contrast CT


Retarget areas of incomplete ablation
Leah Hawkins, MSIII
Gillian Lieberman, MD
Patient 1 CT: Classic Appearance of Adenoma
Left Lateral Decubitus C- CT Axial slice at Level of T12
Classic Adenoma CT Findings:
Adrenal Adenoma
1- Small (<1cm)
2- Homogenous
3- Hypodense
<10HU (lipid-rich)
20-25HU (lipid-poor)
Source: BIDMC, PACS
Leah Hawkins, MSIII
Gillian Lieberman, MD
Johnson, P et al. Adrenal Mass Imaging with Multidetector CT:
Pathologic Conditions, Pearls, and Pitfalls. Radiographics
2009;29:1333-1351.
Patient 1 CT: Measurement estimates
probe trajectory
Aorta
Adrenal Adenoma
Left Kidney
Pancreas
Leah Hawkins, MSIII
Gillian Lieberman, MD
Source: BIDMC, PACS
Adrenal RFA Procedure: Step 2


1- Preprocedure Imaging



CT estimates position
2- Gain Access

Paraspinal Approach




3- Ablation




Superior to rib (12th)
Lateral to spinous process of T12
Deliver pulses in 5min intervals
4- Post-contrast CT


Retarget areas of incomplete ablation
Leah Hawkins, MSIII
Gillian Lieberman, MD
Source: Netter, H Atlas of Human Anatomy,
4E: 2006 Elsevier Netteranatomy.com
Patient 1: CT-fluoro from RFA Procedure
Pre-ablation



Grounding pads on chest
(ground electric field)
Local anesthesia, advance probe
CT-fluoro allows for 3-D confirmation
of probe placement (Axially,
Craniocaudally)
Ablation




1- Begin longitudinally in deepest
portion of tumor
2- Ablate in 5min intervals (to 60-65ºC)
3- Reposition in new plane
4- Repeat until ablation cylinders
overlap
Source: BIDMC, PACS
Dupuy D. et al. Clinical Applications of Radio-Frequency Ablation in the Thorax.
Radiographics 2002; 22:S259-S269.
Leah Hawkins, MSIII
Gillian Lieberman, MD
RFA Electrode: General Information

RF electrode



Insulated shaft, uninsulated tip
Internal 200-watt generator
Internally cooled with perfusion
pump (10ºC-20ºC)


Circulates ice water at
80mL/min
*if tumor >4cm, can use
“cluster” RFA electrode (3
electrodes spaced 5mm apart)
Leah Hawkins, MSIII
Gillian Lieberman, MD
Dupuy D E et al. Radiographics 2002;22:S259-S269
Dupuy D. et al. Clinical Applications of Radio-Frequency
Ablation in the Thorax. Radiographics 2002; 22:S259-S269.
Adrenal RFA Procedure: Step 4


1- Preprocedure Imaging




CT estimates position
2- Gain Access


Paraspinal Approach
Superior
Superior to
to rib
rib (12
(12thth))

 Lateral
Lateral to
to spinous
spinous process
process of
of T12
T12




3- Ablation



Deliver pulses in 5min intervals
4- Post-ablation CT with contrast


Coagulation necrosis = evidence of ablation
Retarget areas of incomplete ablation
Leah Hawkins, MSIII
Gillian Lieberman, MD
Our Patient: Follow-up

He recovered well from RFA but represented
over 1 year later with increasing hypertension.

Repeat AVS Left aldo-secreting adenoma

Repeat RFA 6mm lesion was ablated

f/u on ½ as many anti-hypertensive meds
Leah Hawkins, MSIII
Gillian Lieberman, MD
Take Home Points

1- Refractory HTN = Knee-Jerk Renal US
-PA = most common cause of Secondary HTN

http://www.conn-register.de
2- Normal Adrenals-wispy, Y-shaped Unicorns
-If an incidentaloma is large, heterogenous or hyperdense (HU >20-25), consider 3-phase
(delayed contrast) CT or MR shift imaging

3- IR’s role in the diagnosis and treatment of PA
AVS gold standard for diagnosis
RFA new treatment option with proposed better outcomes
Leah Hawkins, MSIII
Gillian Lieberman, MD
Elevated, Nonsuppressable
Aldo/Plasma Renin Ratio
Elevated ratio not suppressed by:
1- IV saline load
2- Fludrocortisone suppression test
AVS
Lateralization
No Lateralization
Aldosterone-secreting
adenoma
Idiopathic b/l adrenal
hyperplasia
Adrenalectomy
Medical Mgmt
RFA
Surgical Adrenalectomy
Leah Hawkins, MSIII
Gillian Lieberman, MD
Acknowledgements
•Dr. Sal Faintuch
•Dr. James Knutson
•Dr. Ammar Sarwar
•Dr. Gill Lieberman
•Emily Hanson
•Dr. Mai-Lan Ho
•Beth Israel Deaconess Radiology Dept
•HMS III Classmates:
Sun Mi Yoo, Ben Oldfield, Vishwan Pamarthi
Leah Hawkins, MSIII
Gillian Lieberman, MD
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Leah Hawkins, MSIII
Gillian Lieberman, MD
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Leah Hawkins, MSIII
Gillian Lieberman, MD
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Leah Hawkins, MSIII
Gillian Lieberman, MD