Adrenal Venous Sampling Versus Computed Tomographic Scan to Determine Treatment in Primary Aldosteronism (The SPARTACUS Trial)
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In patients confirmed to have primary aldosteronism (PA), routine adrenal venous sampling (AVS) is recommended by the current international guidelines1,2 with 2 caveats. The first is in patients unable or unwilling to undergo surgery, the treatment of choice for unilateral disease, most commonly an aldosterone-producing adenoma (APA). The second exception can be for young patients with undetectable plasma renin, very high plasma aldosterone concentration, profound hypokalemia, and a unilateral adenoma on imaging as illustrated in the flow chart in the recent Endocrine Society guideline.2
AVS is technically demanding, with catheterization requiring a dedicated interventionist, usually a radiologist; in addition, interpretation of the results similarly requires experience.3 The procedure is thus not widely available, despite its being safe and minimally invasive, and is in both private and public health systems relatively expensive.4 Given those issues, it is not surprising that currently there are many studies directed at reducing the need for AVS to a gray zone, by measurement in peripheral plasma of markers with high levels strongly indicative of a unilateral cause, mostly an APA, and low levels of bilateral adrenal hyperplasia.3
This incrementalist approach was not that taken by Dekkers et al5 in the recent SPARTACUS trial (Subtyping Primary Aldosteronism: A Randomized Trial Comparing Adrenal Vein Sampling and Computed Tomography Scan). There is clear consensus that all patients confirmed positive for PA should undergo imaging, preferably by computed tomography (CT), ostensibly to exclude carcinoma, practically offering some guide to the interventionist.2,3 SPARTACUS recruited 200 patients with florid PA, of whom 184 completed follow-up and were randomly assigned to 2 groups of 92, to have lateralization …