Intra-Adrenal Hemorrhage as a Complication of Adrenal Venography in Primary Aldosteronism

Abstract

In a recent article (5), we reported our experience with adrenal venography in 45 patients. At the present time, over 80 patients have been examined. Adrenal venography is proving to be safe and reliable except in primary aldosteronism, a condition in which we had expected it to be very helpful, On the contrary, in patients with primary aldosteronism the technic has some important limitations and hazards which constitute the basis of this report. Material Adrenal venography has been performed in 6 patients with primary aldosteronism. Both glands were examined in 3 and a single gland in 3, for a total of 9 venograms. Gross intra-adrenal extravasation of blood and contrast medium occurred bilaterally in one patient and unilaterally in two. In a fourth patient, minimal intra- and para-adrenal reaction, probably due to some venous rupture, was found at the time of surgery despite an apparently uncomplicated venogram. No apparent extravasation occurred in the other 2 patients. Thus, of 9 glands studied, gross extravasation occurred in 4 and minimal extravasation in 1. The most recent case of a complicating intra-adrenal hemorrhage is reported below. A 48-year-old man had been hypertensive for fourteen years. During previous hospitalizations, hypokalemia in the range of 3 mEq∕l had been detected. Physical examination was unremarkable except for a blood pressure which averaged 180∕130. Preoperative serum potassium, sodium, CO2, and chloride were 2.4, 145, 33, and 101 mEq∕l, respectively. Plasma renin activity values were less than 25 nanograms per cent (angiotension generation) after three days on a low salt diet and two hours of ambulation (normal 1,000 nanograms per cent). Urinary aldosterone excretion was 27.5 μg per twenty-four hours on a high salt diet (normal 10 μg per twenty-four hours). Adrenal venography was performed in an effort to localize an aldosteronoma. The left adrenal vein was catheterized without difficulty, and 3 cc of contrast medium was hand-injected with gradually increasing rapidity until the patient complained of slight discomfort. The adrenal venogram on this side was of adequate quality and suggested hyperplasia localized to the lower pole. Tumor was not demonstrated. After catheter exchange, the right adrenal vein was catheterized without difficulty. A test injection of 0.25 cc of contrast medium was made to confirm proper catheter placement. This injection produced slight intra-adrenal extravasation. The catheter was withdrawn slightly (still within the adrenal vein) and 0.5 cc of contrast medium was injected followed by serial films. The patient complained of moderate right flank pain after the injection. The pain persisted and intensified for twelve hours, requiring narcotics for relief. The right adrenal venogram demonstrated considerable intra-adrenal extravasation. No tumor was evident.