Adrenal Vein Sampling in Primary Aldosteronism - Is the Gold Standard Losing its Luster?

The first primary aldosteronism (PA) case, documented in 1954, was attributed to a sizable aldosterone-producing adenoma (APA), which was palpable during exploratory surgery. By the 1960s, expected APAs in several other, equally severe PA cases escaped localization with ether radiographic modalities available at the time (aortography and retroperitoneal pneumography) or during intraoperative exploration. Adrenal vein sampling (AVS) was, hence, introduced in an effort to accurately guide adrenalectomy. Computed tomography eventually became available in the 1970s, albeit with limited initial performance. Over the following decades, cross-sectional imaging underwent major advancements in spatial resolution, scanning time, and manufacturing capacity, broadening its use at a global scale. Nevertheless, AVS has remained the most trusted modality for identifying PA cases that could benefit from surgery. This clinical practice standard has been anchored in two major arguments: 1) a rising detection of nonfunctional incidentalomas, and 2) histological documentation of millimetric sources of clinically overt PA. Numerous limitations of AVS (an invasive, costly, and technically challenging procedure, with scarce availability) have driven efforts to develop alternative modalities to localize PA sources. In addition, growing understanding of PA pathophysiology has challenged the gold-standard status of AVS for PA subtyping. This perspective discusses the evolving role of AVS in contemporary PA management.