Sampling

The most common causes of primary hyperparathyroidism are a solitary parathyroid adenoma, accounting for 80–85% of cases; four-gland hyperplasia, representing 10–15%; the presence of two or more adenomas, about 5%; and parathyroid carcinoma, less than 1%. Less frequently, primary hyperparathyroidism is associated with a history of childhood head and neck irradiation, long-term lithium therapy, or multiple endocrine neoplasia types 1 and 2A. The condition has an incidence of approximately 22 cases per 100,000 persons annually, with the highest occurrence in the seventh decade of life and a female-to-male ratio of roughly 3:1.

Presentation

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Anatomy

The anatomy of the parathyroid veins is intricate, and the venous anatomy after surgery can be even more complex. Despite the challenges posed by postoperative changes, it is crucial to sample from all potential sources of abnormal PTH production to accurately localize the overactive parathyroid tissue.

Indications

Venous sampling becomes valuable when initial treatment, such as bilateral neck exploration, fails to resolve hyperparathyroidism. The most common reason for failure is missing a single adenoma. Due to altered anatomy from scarring caused by the original surgery, repeat procedures carry a higher risk of complications, including recurrent laryngeal nerve injury, permanent hypoparathyroidism, bleeding, and anesthesia-related issues. Using parathyroid venous sampling,

Contra Indications

None specific

Workup

Preproduceral

DRUGS TO STOP

Material

Essentials

Right common femoral vein access equipment
4-F or 5-F angled catheter
High-flow microcatheter for selective catheterization and confirmatory venography
Containers for blood samples
Labels for careful identification of each sample

Non Essentials

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Positioning

Supine

Steps

Access the right common femoral vein
Position a 4-F or 5-F angled catheter into the right atrium
Obtain a blood sample
Use the catheter for nonselective sampling of large thoracic and neck veins
Use a high-flow microcatheter to perform selective catheterization and confirmatory venography of target tributaries
Collect samples from each targeted site
Each sample should be carefully labeled

Tips & Tricks

The number of veins sampled depends on individual anatomy and may include:
* High, middle, and low internal jugular veins (IJVs)
* Superior, middle, and inferior thyroid veins
* Bilateral brachiocephalic veins
* Superior thymic vein
* Occasionally, internal mammary veins