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Remedial Parathyroid Localization: Utility of Real-time Selective Venous Sampling
*Amir H Lebastchi, *John E Aruny, *Patricia I Donovan, *Courtney E Quinn, *Glenda G Callender, *Tobias Carling, Robert Udelsman
Yale University, New Haven, CT

Objective:
Remedial cervical exploration for persistent or recurrent primary hyperparathyroidism (PHPT) can be technically difficult but is expedited by accurate pre-operative localization. We investigated the utility of real-time selective venous-localization studies (SVS) in the setting of negative non-invasive imaging modalities.
Design:
Retrospective analysis of a prospective database incorporating real-time SVS
Setting:
Tertiary academic medical center
Patients:
Between September 2001 and April 2014, 3,643 patients were referred for surgical treatment of hyperparathyroidism. Of these, 35 represented remedial patients who had undergone one (n = 29) or more (n = 6) prior cervical explorations and had noninformative, noninvasive preoperative localization studies.
Interventions:
We extended the utility of the rapid parathyroid hormone (PTH) assay to the interventional radiology suite, generating near real-time data facilitating on-site, venous localization by a dedicated interventional radiologist.
Main Outcome Measures:
Predictive value of real-time SVS localization was investigated
Results:
Overall, SVS correctly predicted the localization of the affected gland in 94% of cases.
Of 35 patients who underwent SVS, a significant PTH gradient was identified in 32 (92%), localizing specific venous drainage of a culprit gland. 32 patients underwent remedial exploration following SVS, and of these 31 (97%) were biochemically cured. 3 patients with negative SVS were also explored and cured.
Conclusions:
Preoperative parathyroid localization is of paramount importance in remedial cervical explorations. Real-time SVS is an informative localization technique for patients with persistent or recurrent hyperparathyroidism, when traditional noninvasive imaging studies fail. These results validate the utility and benefit of real-time SVS in guiding remedial parathyroid surgery.


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