Evaluation of adrenal vein anatomy by adrenal venous sampling in patients with primary aldosteronism in Chinese

Abstract

Accurate cannulation of the adrenal vein is challenging during adrenal venous sampling (AVS) because of the variations in adrenal vein anatomy. This study aimed to investigate the adrenal venous morphology in Chinese and improve the success rate of AVS. A total of 221 participants with primary aldosteronism (PA) who underwent AVS were enrolled. Compare the morphology among subgroups divided according to sex, body mass index (BMI), and with or without adenoma. The success rate of right, left, and bilateral AVS was 98.60%, 97.20%, and 96.85%, respectively. The triangular pattern was the most common (39.37%) on the right side, while the glandlike pattern (70.14%) on the left. The proportion of adrenal venous morphology varies among patients with different sexes (χ ² = 21.335, P < .001), BMI (χ ² = 10.642 P = .031), and with or without adenoma (χ ² = 10.637, P = .031) on the right side, and the male, obese and adenoma group showed a higher proportion of glandlike pattern than triangular pattern. If only dependent on computed tomography, 9.05% of patients incorrectly diagnose the dominant side, 14.48% of patients would have inappropriate surgery meanwhile 25.34% of patients would miss the surgical opportunity. In conclusion, the most common types of right and left adrenal venous morphology were triangular pattern and glandlike pattern, respectively. Sex, BMI, and the presence of adenoma affected right adrenal venous morphology. Adequate knowledge of the adrenal venous morphology is critical for improving the success rate of AVS and making an appropriate treatment for PA.

1. INTRODUCTION

Primary aldosteronism (PA) is a common cause of secondary hypertension ¹ which was described by Conn during the treatment of a female patient with hypertension combined with hypokalemia. ² The prevalence of PA in patients with resistant hypertension is about 20% ³ and in newly diagnosed hypertensive patients in China is at least 4%. ⁴ There is growing evidence of a higher incidence of cardiovascular events in patients with PA compared to patients with essential hypertension. ⁵ , ⁶ The common subtypes of PA are idiopathic hyperaldosteronism (IHA) and aldosterone‐producing adenoma (APA) which are treated differently. Mineralocorticoid receptor antagonist (MRA) is often used for IHA treatment while adrenalectomy is recommended for APA treatment. ⁷ , ⁸ Therefore, it is particularly important to distinguish the APA and IHA for selecting the appropriate therapeutic strategies.

Adrenal imaging is dominantly evaluated by computed tomography (CT) and magnetic resonance imaging (MRI). However, a retrospective analysis showed that unilateral abnormality in 14.6% of PA patients diagnosed by CT/MRI was actually a bilateral hyperplasia lesion that was confirmed by adrenal venous sampling (AVS). ⁹ If the treatment strategy was determined solely based on CT/MRI results, they would suffer from inappropriate surgical treatment. In 19.1% of patients with CT/MRI showed a bilateral or no abnormality was actually a unilateral abnormality confirmed by AVS, they would have missed the opportunity for surgical treatment based on CT/MRI results alone. ⁹ Therefore, AVS is currently recognized as the “gold standard” for differentiating dominant secretion in PA. ⁷ , ¹⁰ , ¹¹

The successful rate of AVS is variable because of the anatomical variations of the adrenal vein, which also poses a challenge in terms of intraoperative identification of vessels. The right adrenal vein can enter the inferior vena cava (IVC) at different angles and sometimes form a common trunk with the accessory hepatic vein. ¹² In addition, the right adrenal vein is very short ¹³ and has a variable position of orifice. Studies have demonstrated that the orifice of the right adrenal vein was located between the 10th thoracic vertebra (T10) and the 1st lumbar vertebra (L1), ¹² , ¹⁴ and higher body mass index (BMI) was associated with higher adrenal vein orifice location, ¹⁴ , ¹⁵ which often results in a failure of the AVS on the right side. The left adrenal vein receives inferior phrenic vein and enters the left renal vein, and has a more stable location. However, studies have shown that failure of the left AVS was also associated with adrenal vein anatomical variation. ¹⁶

In addition, the adrenal veins exhibit a diverse venous morphology. Daunt and colleagues proposed five patterns of right adrenal venous morphology according to more than 800 AVS procedures, ¹⁷ however, the study did not describe the population distribution of the various adrenal venous morphology, and there was no discussion on whether the proportion of each adrenal venous morphology differs in different characteristic populations.

Due to anatomical variation and multiple adrenal venous morphology, AVS has variable success rates and has not yet been widely used. In this study, we aimed to investigate the adrenal venous morphology by AVS in patients with PA from China to improve the success rate of AVS.

2. METHODS

2.1. Study participants and clinical data collection

Patients who were diagnosed with PA and underwent AVS at the First Affiliated Hospital of Dalian Medical University from January 2019 to September 2022 were collected. All patients with confirmed PA who were willing to undergo surgery were examined by AVS to differentiate whether there was unilateral adrenal dominance secretion. Patients with abnormal cortisol levels (diagnosed as Cushing's syndrome or subclinical Cushing's syndrome by the low‐dose dexamethasone suppression test) and those who were allergic to iodine contrast agents, suffered from primary malignant or metastatic adrenal tumors, had severe cardiovascular and cerebrovascular diseases such as aortic coarctation, acute coronary syndrome, acute heart failure, stroke, and had severe hepatic or renal dysfunction were excluded. Patients whose adrenal venous morphology was not obtained also were excluded. This study was approved by the ethical committee of First Affiliated Hospital of Dalian Medical University and approved by the ethics committee to waive informed consent for all participants.

The clinical diagnosis of PA was made according to the Endocrine Society guidelines, ⁷ antihypertensive agents, including nondihydropyridine calcium‐channel blocks and terazosin, were used in hypertensive patients that did not affect renin and aldosterone measurements. PA was diagnosed if the plasma aldosterone concentration was > 10 ng/dL after saline infusion test (SIT) ⁷ or > 11 ng/dL after captopril challenge test (CCT), ¹⁸ or plasma aldosterone suppressed by captopril < 30% compared to the predose level. ⁷ All patients had their blood potassium supplemented to at least 4.0 mmol/L prior to the confirmatory test. Clinical data, including age, sex, height, weight, blood pressure, and fasting blood samples were collected. Obesity (BMI ≥ 28 kg/m²) as defined by the Expert Consensus on Obesity Prevention and Treatment in China. ¹⁹ Adrenal enhanced CT was performed, and patients were classified as having an APA, IHA, and unilateral adrenal hyperplasia (UAH) according to the radiographic results.

2.2. AVS

AVS procedures via antecubital access were performed by two experienced interventionalists according to the following protocol. ²⁰ , ²¹ Patients were in a supine position for at least 1 h and sedated with diazepam prior to the procedure. The entire procedure was guided by digital subtraction angiography (DSA). A 5F introducer sheath (10 cm, Terumo Corporation, Japan) was inserted into the right median cubital vein. A 5F MPA1 catheter (100 cm, Cordis, USA) was inserted into the right adrenal vein and a 5F TIG catheter (100 cm, Terumo Corporation, Japan) was replaced into the left adrenal vein for blood sampling. Control blood samples were obtained from the superior and inferior vena cava. The successful AVS was defined by a selectivity index (SI) ≥ 2.0. The SI was calculated as the ratio of each adrenal vein cortisol level to the inferior vena cava cortisol level. Lateralization index (LI) ≥ 2.0 (as the ratio of aldosterone/cortisol on the dominant side to the nondominant side) indicates the presence of laterality without adrenocorticotropic hormone (ACTH) stimulation (Figure 1).

FIGURE 1.

Trial profile. PA, primary aldosteronism; AVS, adrenal venous sampling; SI, selectivity index.

2.3. Adrenal venous morphology

The images were interpreted using the Radiant DICOM Viewer workstation. The right adrenal venography morphology was divided into five patterns ¹⁷ : Glandlike pattern: a main central vein with multiple branches, the angles between the branches and the central vein usually <90°. Triangular pattern: the vessels are very dense and like a brush. Delta pattern: adrenal vein shows a delta shape with fewer internal veins. Spidery pattern: a main central vein with multiple branches at different angles, and have a stellate or spidery appearance. Irregular pattern: difficult to define adrenal vessels, but the catheter position is consistent with enhanced CT appearance. The left adrenal venography morphology was divided into four patterns ²² : Linear pattern: only one or more venous trunks and with no obvious branches. Glandlike pattern, spidery pattern, and irregular pattern are similar in form to the right. All the images were reviewed independently by two experienced interventionalists. If there was any disagreement, a third interventionalist re‐evaluated and eventually reached a consensus.

2.4. Statistical analysis

All data were analyzed using the software SPSS 25.0 (SPSS Inc, Chicago, IL). Normally distributed data were described as the mean ± SD, and non‐normally distributed data were described as the median (interquartile range). Categorical data were described as absolute numbers and percentages, analyzed by Chi‐Square or Fisher exact test. P < .05 was considered statistically different.

3. RESULTS

3.1. Baseline characteristics of the population

A total of 221 patients confirmed PA with normal cortisol levels who underwent successful bilateral AVS and had clear adrenal venous morphology were included in the study. The average age was 52.48 ± 10.92 years and 57.01% were male. The average BMI was 26.88 ± 3.52 kg/m². Serum sodium and potassium were 142.42 ± 2.14 mmol/L and 3.47 ± 0.49 mmol/L, respectively. Urine sodium and potassium for the 24‐hour‐quantitative were 160.77 ± 69.51 mmol/24 h and 53.72 ± 19.94 mmol/24 h, respectively. There were 52.49% of patients combined with hypokalemia (Table 1).

TABLE 1.

Demographic, clinical, and biochemical characteristics of the 221 patients.

Characteristics	Value
Age, years	52.48 ± 10.92
Sex, male, No.%	126 (57.01)
BMI, kg/m2	26.88 ± 3.52
Duration of hypertension, years	8 (2.00,13.00)
Smoking, No.%	57 (25.79)
Drinking, No.%	49 (22.17)
Hypokalemia, No.%	116 (52.49)
SBP, mmHg	151.95 ± 19.09
DBP, mmHg	94.86 ± 13.48
HR, bpm	70.49 ± 9.16
ALT, U/L	19.00 (12.00,26.75)
AST, U/L	17.00 (14.00,21.00)
Serum sodium, mmol/L	142.42 ± 2.14
Serum potassium, mmol/L	3.47 ± 0.49
Serum creatinine, µmol/L	65.48 ± 15.43
eGFR, mL/min/1.73 m2	100.25 ± 12.85
FPG, mmol/L	4.88 (4.48,5.35)
TC, mmol/L	4.51 ± 0.93
TG, mmol/L	1.19 (0.91,1.66)
HDL‐C, mmol/L	1.11 ± 0.25
LDL‐C, mmol/L	2.46 ± 0.66
DRC, uIU/mL	3.87 (1.46,7.86)
PAC, ng/dL	22.20 (16.73,29.28)
Urine sodium for 24‐hour‐quantitative, mmol/24h	160.77 ± 69.51
Urine potassium for 24‐hour‐quantitative, mmol/24h	53.72 ± 19.94

Note: Values are mean ± SD, or median, and IQ range or n(%). BMI, body mass index; SBP, systolic blood pressure; DBP, diastolic blood pressure; HR, heart rate; ALT, alanine aminotransferase; AST, aspartate aminotransferase; eGFR, estimated glomerular filtration rate; FPG, fasting plasma glucose; TC, total cholesterol; TG, triglyceride; HDL‐C, high‐density lipoprotein cholesterol; LDL‐C, low‐density lipoprotein cholesterol; DRC, direct renin concentration; PAC, plasma aldosterone concentration.

3.2. Adrenal venous morphology

The success rate of AVS was 98.60% and 97.20% for the right and left sides, respectively. The bilateral success rate was 96.85%. The orifice of the right adrenal vein was located between the level of the upper segment of the T11 vertebra and the middle segment of the L1 vertebra, and mainly (81.45%) between the lower segment of the T11 vertebra and the lower segment of the T12 vertebra. The orifice of the left adrenal vein was located between the level of the middle segment of the T11 vertebra and the intervertebral space of the L1 and L2 vertebrae, and mainly (80.09%) between the middle segment of the T12 vertebra and the upper segment of the L1 vertebra (Figure 2).

FIGURE 2.

The location of the orifice of adrenal veins during AVS.

The right adrenal venous morphology had five different patterns (Figure 3A‐E) and the left adrenal venous morphology had four different patterns (Figure 3F‐I). On the right side, the triangular pattern was the most common (39.37%), followed by the glandlike pattern (27.60%), irregular pattern (14.48%), spidery pattern (11.31%), and delta pattern (7.24%) (Figure 4A). On the left side, the glandlike pattern was the most common (70.14%) type, followed by the spidery pattern (19.91%), irregular pattern (5.43%), and linear pattern (4.52%) (Figure 4B).

FIGURE 3.

Adrenal venous morphology. (A) triangular pattern, (B) (F) glandlike pattern, (C) (H) irregular pattern, (D) (G) spidery pattern, (E) delta pattern, (I) linear pattern.

FIGURE 4.

The proportion of different adrenal venous morphology. (A) right side, (B) left side.

3.2.1. Adrenal venous morphology in different sex

There was a significant difference between sexes in adrenal venous morphology on the right (χ ² = 21.335, P < .001). In male patients, glandlike (30.95%) and triangular (30.16%) were the most common patterns, followed by the spidery pattern (15.08%), delta pattern (11.90%), and irregular pattern (11.90%), which was different from the distribution in the overall population. While in female patients, the triangular pattern was most common (51.58%), followed by the glandlike pattern (23.16%), irregular pattern (17.89%), spidery pattern (6.32%), and delta pattern (1.05%) (Figure 5A), which was consistent with the distribution in the overall population.

FIGURE 5.

Adrenal venous morphology in different sex (A, B), BMI (C, D), and with or without adenoma (E, F) on the right (A, C, E) and left side (B, D, F). BMI, body mass index.

There was no significant difference between sexes in adrenal venous morphology on the left (χ ² = 1.537, P = .674). In both male and female patients, the glandlike pattern was the most common pattern on the left side (72.22% and 67.37%). The spidery pattern was almost the same in males (19.84%) and females (20.00%), followed by the irregular pattern (3.97% and 7.37%), linear pattern (3.97% and 5.26%), which was consistent with the distribution in the overall population (Figure 5B).

3.2.2. Adrenal venous morphology in different BMI

A total of 84 patients (38.01%) were obese. There was a significant difference among different BMIs in adrenal venous morphology on the right side (χ ² = 10.642 P = .031). The glandlike pattern was the most common (38.10%) in patients with obesity, followed by the triangular pattern (28.57%), spidery pattern (13.10%), irregular pattern (11.90%), and delta pattern (8.33%). This was different from the distribution in the overall population. Patients without obesity had a triangular pattern most commonly (45.99%), followed by the glandlike pattern (21.17%), irregular pattern (16.06%), spidery pattern (10.22%), and delta pattern (6.57%) (Figure 5C).

Whether obese or not, the glandlike pattern was more commonly found on the left (76.19% and 66.42%), followed by the spidery pattern (17.86% and 21.17%), irregular pattern (3.57% and 6.57%) and linear pattern (2.38% and 5.84%), which was consistent with the distribution in the overall population. There was no significant difference between BMI in adrenal venous morphology on the left (χ ² = 2.946, P = .398) (Figure 5D).

3.2.3. Adrenal venous morphology in patients with or without adenoma

According to the results of enhanced CT, 33.48% of patients with adenoma on the right side, and 43.89% of patients with adenoma on the left side.

There was a significant difference between patients with or without adenoma in adrenal venous morphology on the right (χ ² = 10.637, P = .031). There was a significant increase (33.78%) in the glandlike pattern compared to the triangular pattern (27.03%) in patients with right adenoma, followed by the irregular pattern (17.57%), delta pattern (12.16%), and spidery pattern (9.46%). This was different from the distribution in the overall population, in which the proportion of triangular pattern decreased, while the proportion of delta pattern was greater than that of spidery pattern. The triangular pattern was most common in patients without adenoma (45.58%), followed by the glandlike pattern (24.49%), irregular pattern (12.93%), spidery pattern (12.24%), and delta pattern (4.76%) (Figure 5E), which was consistent with the distribution in the overall population. Meanwhile, we further explored whether the combination of a left adrenal adenoma would not affect the right adrenal venous morphology (χ ² = 0.381, P = .984) (Supplementary Figure S1 online).

On the left, the glandlike pattern was the most common type (65.98% and 73.39%) regardless of the presence of adenomas. In patients with adenoma, the second common type was the spidery pattern (22.68%), then the irregular pattern (7.22%) and linear pattern (4.12%). In patients without adenoma, the second most common type was the spidery pattern (17.74%), then the linear pattern (4.84%) and irregular pattern (4.03%). There was no significant difference between adenoma and not in adrenal venous morphology on the left side (χ ² = 2.170, P = .538) (Figure 5F).

3.3. Comparison of CT results and AVS results

According to the enhanced CT results, 51.58% of patients were diagnosed with APA, 42.99% with IHA, and 5.43% with UAH. After AVS, APA was diagnosed in 38.91% of patients and IHA in 54.75%. There 6.33% of patients were UAH (Figure 6A). There was a significant difference in treatment choice under enhanced CT or AVS (χ ² = 6.121, P = .013) (Figure 6B). AVS changed the diagnosis of the dominant side in 9.05% of the PA patients who would have had the wrong procedure based on enhanced CT findings. In 14.48% of patients would suffer from inappropriate and 25.34% of patients would miss surgical treatment according to enhanced CT results alone. The rate of AVS disagreement with enhanced CT was 48.87%.

FIGURE 6.

Comparison of AVS results with CT results. APA, aldosterone‐producing adenoma; IHA, idiopathic hyperaldosteronism; UAH, unilateral adrenal hyperplasia; CT, computed tomography; AVS, adrenal venous sampling.

4. DISCUSSION

We performed AVS via the antecubital access and achieved a high success rate. The AVSTAT study included six centers in Japan and ten centers in Europe and showed a success rate of 89.3% for AVS. ²³ In 2016, Jiang and colleagues introduced a new approach to antecubital access. ²⁰ Using this method, Xu and colleagues achieved a bilateral success rate of 93.80% (100.00% on the left side and 93.80% on the right side). ²¹ A recent multicenter study that underwent AVS via antecubital access showed that the success rate of right, left, and bilateral sampling was 94.9%, 95.1%, and 91.5%, respectively. ²⁴ Our study also confirmed that a high success rate was achieved via antecubital access. The new method via antecubital access also showed advantages such as shortened hospitalization time, and more simple catheter selection and operation ²⁰ , ²⁴ which is beneficial for both patients and operators.

According to the adrenal venography during AVS, we summarized the adrenal venous morphology and found that the glandlike pattern on the left side (70.14%) was the most common type, while on the right side, the pattern of triangular (39.37%) was the most common type. A previous study reported by Daunt and colleagues ¹⁷ proposed the right adrenal venous morphology patterns but did not describe the proportion of each pattern. Jiang and colleagues ²⁰ described the adrenal venous morphology and found that the glandlike pattern was the most common on both the left (66.70%) and right (40.70%) sides, while the left side was consistent with our results but the right side was different from our results. In our study, the glandlike pattern of the right side was 27.60% which was less than the triangular pattern. To find the reason, we perform the subgroup analysis.

We compared the adrenal venous morphology in different sexes and found that in the female subgroup, the triangular pattern was more than half (51.58%) on the right side. The possible reason is that in Jiang and colleagues study, there were 35.1% female subjects, while in our study 42.99% of the patients were female. Given that our result indicated that on the right side triangular pattern was a more predominant pattern than the glandlike pattern. Differences in sex representation lead to different results. Considering that sex may lead to differences in adrenal vein typing ratios, a balanced sex proportion was chosen for our subjects.

Our study found that in individuals with obesity, the proportion of glandlike patterns exceeded the triangular pattern on the right side, which was different from the distribution in the overall population. This may be associated with changes in adrenal vein orifice location and angles due to elevated BMI. Higher BMI was associated with higher adrenal vein orifice location, ¹⁴ , ¹⁵ and higher adrenal vein orifice location will result in a larger venous axial angle, ¹⁵ which may affect adrenal venous morphology.

It was reported that an adenoma can cause displacement and distortion of the adrenal veins, which may result in atypical adrenal vein morphology, ¹⁷ , ²⁵ and in markedly hyperplastic adrenal glands, a marked elongation of the adrenal veins may be demonstrated. ²⁵ In addition, previous studies have confirmed that vascular endothelial growth factor (VEGF) levels are elevated in APAs. ²⁶ , ²⁷ VEGF has strong proangiogenic effects, which may play a role in tumor growth and metastasis by mediating the neovascularization of tumors. ²⁸ Thus, elevated VEGF levels may affect venous morphology in the adrenal with an adenoma by causing neovascularization. The above reasons may be responsible for the fact that the different percentages of each adrenal venous morphology in the right adrenal adenoma group compared to the overall population.

There are numerous venous openings around the right adrenal vein opening and the leading cause of AVS failure on the right side is the confusion of hepatic lobular veins and adrenal veins, ¹⁷ and the over selection is another common cause ¹⁷ , ²⁵ (Supplementary Figure S2 online). Rapid identification of typical adrenal venous morphology helps to quickly determine whether the catheter is in the right place. We can distinguish whether it is hepatic lobular veins and when the catheter is already located at the adrenal vein but lacks a typical image, we need to consider that the catheter was placed in the branch but not the trunk which may result in overselection. In addition, if the most common pattern is not seen, other typical patterns may be sought again in turn, thus confirming the catheter position, which helps to improve the success rate of AVS.

Our study showed that the orifice of the right adrenal vein was usually located between the level of the upper segment of the T11 and the middle segment of the L1 vertebrae, which was similar to the previous studies. ¹² , ²⁹ In addition, we also evaluated the location of the orifice of the left adrenal vein, which was considered easier to find during AVS compared to the right adrenal vein. A recent study showed that the location of the left adrenal vein was a guide for the right AVS. ³⁰ After locating the left adrenal vein, the orifice of the right adrenal vein can be accurately located. Understanding the location of the adrenal vein may help improve the success rate of AVS.

In our study, the rate of AVS disagreement with enhanced CT was 48.87%. A previous study showed that the diagnostic accuracy of CT was 53%. ³¹ In 21.7% of patients might have missed the opportunity for surgery. This could be due to aldosterone‐producing cell clusters (APCCs) located beneath the adrenal capsule, which can present in the normal adrenal gland, IHA, or in conjunction with APA ³² , ³³ , ³⁴ and may not display on CT scans. APCCs have aldosterone synthase (CYP11B2) immunoreactivity ³³ , ³⁵ and are often considered to have aldosterone‐producing ability. In addition, a previous study showed that CT misdiagnosis APA in 24.7% of PA patients who might have undergone unnecessary surgery. ³¹ A retrospective study showed that 14.6% of PA patients will suffer from unnecessary surgery because of misdiagnosis as unilateral disease by CT/MRI. ⁹ Although diagnosed with PA, there are still some patients with AVS indicating that the adenoma is nonfunctional. A recent study showed that 69.3% of patients who completed endocrine testing and confirmed have a nonfunctioning adrenal adenoma. ³⁶ This shows the importance of AVS in improving the diagnosis of PA subtypes. A study has confirmed that patients undergoing surgery guided by the AVS have a higher cure rate than those without AVS guidance. ³⁷ Familiarity with adrenal venous morphology based on different characteristics before the AVS procedure, which facilitates rapid intraoperative identification and localization of the adrenal vein and improves the success rate of AVS.

There are some limitations in our study. First is that patients with or without adenomas were grouped according to enhanced CT, which may have missed microadenomas and may have included nonfunctioning adenomas, resulting in an incorrect grouping. In the future, CXC chemokine receptor type 4 (CXCR4) ligand imaging could be used as a noninvasive method to detect APA. ³⁸ , ³⁹ Second, intraoperative visualization of the adrenal vein with more than one orifice in a small number of patients, with double or multiple vessels. However, since all patients had successful bilaterally AVS and had typical adrenal venous morphology, we did not search each adrenal vein. Third, since the study population was all Chinese, we were unable to explore whether there were differences in the percentage of each pattern and the effects of sex, BMI, and the presence or absence of adenoma in different populations. Further studies are still necessary to explore and compare different adrenal venous morphology among different populations.

In conclusion, we performed AVS via antecubital access and achieved high success rates. The triangular pattern is the most common type on the right side while the glandlike pattern is the most common type on the left side. Sex, BMI, and the presence of adenoma will affect right adrenal venous morphology. The inconsistent rate between AVS and CT diagnosis suggests the importance of AVS in the differentiation of PA subtypes. Adequate knowledge of the adrenal venous morphology is critical for rapid intraoperative confirmation of catheter location, which can improve the success rate of AVS.

AUTHOR CONTRIBUTIONS

Yang Yu and Wei Song drafted the manuscript. Minghui Yang, Minghui Gong, and Ying Zhang participated in data collection, analysis, and interpretation of the results. Yang Yu and Wei Song Visualization. Minghui Yang, Ying Zhang and Wei Song completed the AVS procedure. Wei Song conceived the study and Wei Song and Yinong Jiang supervision. All authors contributed to the study and approved the submitted version.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

DISCLOSURE STATEMENT

The authors have nothing to disclose.

PATIENT CONSENT STATEMENT

This study was approved by the ethics committee to waive informed consent for all participants.

PERMISSION TO REPRODUCE MATERIAL FROM OTHER SOURCES

Not applicable. This study was not include material from other sources.

CLINICAL TRIAL REGISTRATION

Not applicable.

Supporting information

Supporting Information

Yu Y, Yang M, Gong M, Zhang Y, Jiang Y, Song W. Evaluation of adrenal vein anatomy by adrenal venous sampling in patients with primary aldosteronism in Chinese. J Clin Hypertens. 2024;26:912–920. 10.1111/jch.14860

DATA AVAILABILITY STATEMENT

The original contributions presented in the study are included in the article, further inquiries can be directed to the corresponding author.