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Adrenal vein sampling (AVS) is the only reliable means to distinguish between aldosterone-producing adenoma and bilateral adrenal hyperplasia, the two most common subtypes of primary aldosteronism (PA). To distinguish between unilateral and bilateral disease is of fundamental importance because it allows to allocate patients to the correct management: unilateral adrenalectomy for aldosterone-producing adenoma or pharmacotherapy with mineralocorticoid receptor antagonists for individuals with bilateral adrenal hyperplasia. A rare but serious complication of AVS is an adrenal hemorrhage (AH).

Design and method:

We retrospectively evaluated 24 cases of AH after AVS that occurred in 6 tertiary referral hypertension centers in Italy,Germany, Japan and Australia. The control group comprised 1388 PA patients who underwent AVS in the different centers participating in the study during a similar period of time as when the patients experienced AH during AVS.


In our case-series, AH more often affected the right adrenal (n = 18) than the left (n = 5, P < 0.001), 1 was bilateral. Patients experiencing AH were older than patients who underwent uncomplicated AVS procedures. None of the other assessed clinical or biochemical and hormonal parameters were significantly different between the AH group and the controls. Median duration of experience of the radiologist in AVS at the time of AH was 5.0 years (0.6–7.8) and AH occurred with both highly experienced (>10 years) and less experienced radiologists. Of 9 AH in the gland contralateral to an aldosterone-producing adenoma and who underwent complete (n = 6) or partial (n = 3) unilateral adrenalectomy, only one resulted in adrenal insufficiency and the patient required long-term corticosteroid replacement therapy. No reduction in blood pressure or biochemical resolution of PA occurred in any of those patients who experienced AH in the gland ipsilateral to an aldosterone-producing adenoma (n = 6) or who had bilateral adrenal hyperplasia (n = 9). No patient required blood transfusion or invasive approaches to control bleeding.


AH, despite being the most dreaded complication of AVS, usually has a positive outcome causing minor or no permanent effects on adrenal function and should not discourage clinicians from using AVS for subtype differentiation in PA patients.

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