Andrews, James C.

Abstract Disclosure: S. Mohan: None. O.A. Shariq: None. J.C. Andrews: None. W.F. Young: None. Background: Adrenal vein sampling (AVS) is performed in patients with primary aldosteronism (PA) to subtype surgically curable unilateral disease. During AVS, iodinated contrast is used to confirm catheterization of adrenal veins for accurate sampling. However, in patients with severe contrast allergy, the optimal method of safely and effectively confirming localization is debatable. Premedication with oral corticosteroids has raised concern for suppression of cortisol and confounding of AVS results. We therefore investigated our experience of AVS after corticosteroid premedication in patients with PA and iodine contrast allergy. Methods: Patients with PA who underwent AVS at our center under continuous cosyntropin infusion (50 mcg/hr started 30 minutes before sampling) between September 1990 - October 2023 were identified. Individuals with documented allergy to iodinated contrast who received corticosteroid premedication were matched 1:1 for age and sex with control patients without contrast allergy or premedication. Baseline demographics, biochemical variables, AVS results, and follow-up data were compared between groups. Results: 1273 AVS studies were performed in 1255 patients with PA and 35 (2.8%) patients received corticosteroid premedication for contrast allergy. Methylprednisolone was used in 32 (91.4%) patients while dexamethasone was used in the rest. No patients experienced a severe breakthrough allergic reaction. Mean age was similar in cases vs. controls (53.9 vs. 54.1 years, P=0.92) with 16 females (45.7%) per group. There were no significant differences in baseline aldosterone-to-renin ratios (57.7 vs. 49.3, P=0.57) or daily defined doses of antihypertensives (5.5 vs. 4.4, P=0.21) between the two groups. Absolute cortisol levels (mcg/dL) from both adrenal veins (AV) and the inferior vena cava (IVC) were similar between cases and controls (right AV: 752.5 vs. 813.7, P=0.48; left AV: 527.2 vs. 462.7, P=0.33; IVC: 23.1 vs. 24.5, P=0.18). The ratio of cortisol in the corresponding AV to the IVC (selectivity index) was >5 in all patients, confirming appropriate cannulation, with similar mean selectivity indices between groups (right AV: 33.0 vs. 33.7, P=0.86; left AV: 22.8 vs. 19.0 P=0.17). Unilateral disease (indicated by a lateralization index >4) was present in 20 (57.1%) patients who received premedication compared with 16 (45.7%) controls (P=0.34). Surgery for unilateral disease was performed in 16 cases and 12 controls, with similar post-op day 1 aldosterone levels in both groups (3.8 vs. 3.3, P=0.36), consistent with surgical cure. Conclusion: In patients with PA and iodine contrast allergy, premedication with corticosteroids prior to cosyntropin-stimulated AVS does not significantly suppress cortisol levels or affect interpretation of AVS results, with comparable rates of disease subtyping and surgical outcomes when compared to a control group. Presentation: 6/3/2024

Abstract Disclosure: A.Y. Chang: None. D.Z. Erickson: None. W.F. Young: None. K. Grennan: None. J.C. Andrews: None. E. Kapoor: None. Background: While mild androgen excess is frequently encountered in endocrine practices, severe symptoms, rapid onset or markedly abnormal biochemical testing lead to further evaluation for rare ovarian androgen-producing tumors, ovarian hyperthecosis or androgen-secreting adrenal tumors. Combined ovarian and adrenal vein sampling (COAVS) might be necessary to identify the source of androgen hypersecretion and guide treatment. The utility of COAVS has been studied in limited case series, combining case reports and different centers. There is no consensus regarding the testosterone gradient that localizes the androgen source or the added value of COAVS when a pathologic source of androgen excess is suspected. The additional clinical benefit of adrenal vein sampling (AVS) when combined with ovarian vein sampling (OVS) has also not been examined. Objectives: We sought to determine: a) the optimal total testosterone (TT) gradient for identifying unilateral vs bilateral source of hyperandrogenism and b) the utility of AVS in addition to OVS. Methods: We performed a retrospective chart review of all adult women who had COAVS at Mayo Clinic, Rochester from 1996 to 2023. Pathologic sources of androgen excess were defined as ovarian hyperthecosis (OH) as well as ovarian and adrenal tumors. We calculated the ratio of dominant OV or AV divided by the nondominant OV or AV. Results: 22 COAVS procedures from 7 premenopausal and 15 postmenopausal women were included in the study: 12 (55%) women had adrenal abnormalities seen on computed cross sectional imaging and 5 (23%) had unilateral ovarian imaging abnormalities. Of the 22 participants in the case series, successful 4-vessel catheterization was completed in 20 (1 right ovarian vein could not be cannulated, and 1 had bilateral oophorectomy). Nine (41%) women had unilateral and 10 (45%) bilateral ovarian androgen hypersecretion. Eleven (50%) women had pathologic causes for elevated TT (5 ovarian tumors, 6 cases of OH), 5 lacked follow-up pathology and 5 had benign pathology. AVS did not diagnose an adrenal source of androgen hypersecretion. TT concentrations were significantly greater in patients with unilateral compared to those with bilateral ovarian androgen hypersecretion (median 262.5 ng/dL [245- 401.5 IQR] vs 104 ng/dL [82-190], P = 0.01). In addition, TT concentrations were higher in those women with a pathologic source of TT hypersecretion compared to those with benign ovaries (349 ng/dL [251-538] vs 115 ng/dL [93-195], P = 0.03). All cases of unilateral ovarian disease had a dominant OV gradient of TT ≥ 2.1 compared to the nondominant OV. Conclusion: In a series of successful COAVS in women with androgen hypersecretion, an ovarian side-to-side gradient of ≥ 2.1 diagnosed all sources of unilateral ovarian pathology. AVS did not diagnose any pathologic source of adrenal androgen excess in this patient cohort. Presentation: 6/3/2024

Arteriovenous malformations (AVMs) in mesenteric vessels are exceptionally rare. These congenital vascular anomalies lead to direct vascular flow between the highly pressured arterial system and the low-pressure venous system. We describe the case of a patient with prior left colectomy for splenic flexure colonic adenocarcinoma presenting with persistent abdominal pain after developing multiple mesenteric thromboses. CT and colonoscopy showed left hemicolon congestion, anastomotic stenosis and mucosal oedema. Mesenteric angiogram revealed AVMs in the right colic and left colic arteries. Embolisation of the left colic AVM led to symptom resolution without recurrence at interval follow-up.

Abstract Background. —The reported operating characteristics of the plasma fibrin D-dimer level for the diagnosis of acute pulmonary embolism vary widely. Objective. —To determine the sensitivity, specificity, predictive value, and clinical utility of the D-dimer for the diagnosis of pulmonary embolism, and to describe the effect of D-dimer assay method (enzyme-linked immunosorbent assay [ELISA], latex agglutination, membrane ELISA) and discriminate level, patient location at onset, comorbid disease, duration and intensity of concurrent heparin administration, and duration of symptoms on these operating characteristics. Design. —Prospective laboratory investigation. Setting. —Community and tertiary care teaching hospital. Patients. —Consecutive patients with suspected acute pulmonary embolism referred for pulmonary angiography from April 1993 through March 1996. Measurements. —Baseline characteristics, the duration and intensity of heparin anticoagulation, the time interval between symptom onset and plasma D-dimer testing, pulmonary angiography, and the D-dimer level on the day of pulmonary angiography. Results. —Of 105 consenting patients, 33 (31%) had a positive pulmonary angiogram. The D-dimer sensitivity/negative predictive value for the ELISA, latex agglutination (American Bioproducts Co/Diagnostica Stago and Biopool International), and membrane ELISA were 100%/100%, 94%/94%, 100%/100%, and 97%/96%, respectively, at a discriminate level of 250 μg/L or less. The clinical utility, defined as the prevalence of a negative test, ranged from 17% to 33%. D-dimer sensitivity was unaffected by patient location at onset, comorbid disease, or heparin therapy but was inversely related to the duration of symptoms. Conclusions. —The sensitivity of the plasma fibrin D-dimer for the diagnosis of pulmonary embolism depends on the assay method, the assay-specific discriminate level, and the duration of symptoms. At the appropriate discriminate level, the plasma D-dimer is a sensitive but nonspecific test for the diagnosis of pulmonary embolism.

Objective: Endoleaks are critical complications of endovascular abdominal aortic aneurysm repair (EVAR). This study sought to determine the frequency and nature of intraoperative endoleaks and their impact on postoperative endoleak-related events. Methods: A retrospective chart review was performed of all patients who underwent EVAR at our institution. The impact of intraoperative endoleaks on postoperative endoleak rates and endoleak-related reintervention rates were assessed. Results: From December 18, 1996, to May 21, 2003, 241 patients underwent EVAR. An endoleak was observed during 126 (52.3%) procedures. Type I endoleaks were observed in 63 (26.1%) cases: 35 proximal and 31 distal endoleaks (3 cases at both attachments). Angioplasty, additional cuff placement, or stenting corrected 59 (89.4%) of these endoleaks. A total of 71 type II intraoperative endoleaks (29.5%) and 8 type IV endoleaks (3.3%) were observed without any attempted corrective maneuvers. Ten type III endoleaks (4.2%) occurred but all resolved with angioplasty or additional cuff placement. In all, 86 (35.7%) endoleaks persisted on completion angiogram. Patients with a type I or type II intraoperative endoleak were more likely to have an endoleak at 1.5 years (31.4% vs. 21.6%, P = .018). Reinterventions were required more often after an intraoperative type I endoleak (10% vs. 4%, P = .003). Patients with intraoperative endoleaks demonstrated a trend toward less postoperative aneurysm diameter reduction at 2 years (43.8% vs. 74.5%, P = .104). Conclusion: The presence of a type I or a type II endoleak during EVAR significantly increases the likelihood of a postoperative endoleak and should prompt a high degree of suspicion during follow-up.