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Click 52-year-old female patient with Cushing’s disease and double superior vena

TECHNIQUE:
Bilateral inferior petrosal sinus sampling (BIPSS) performed under fluoroscopy using a Siemens AXIOM Artis zee.
60ml of Iohexol (Omnipaque 350; GE Healthcare) was used as intravenous (IV) contrast media.
20ml of 1% lignocaine was used subcutaneously (SC) as local anaesthesia in the bilateral groins for accessing the common femoral veins (CFVs).

FINDINGS:
The venous system was accessed via the bilateral common femoral veins (CFVs) puncture. Using 5F vascular catheters and 2.5F microcatheters co-axially, the bilateral inferior petrosal sinuses were accessed for venous sampling.

After experienced difficulties in entering and crossing the left brachiocephalic vein, venogram performed via the small rudimentary left brachiocephalic vein (images 18 to 37), demonstrated a persistent left-sided superior vena cava (SVC) draining into the coronary sinus. Therefore left inferior petrosal sinus (IPS) was accessed via the right atrium, coronary sinus, persistent left SVC and the left IJV.
After confirming the final positions of the bilateral microcatheters, a fluoroscopic spot radiograph of the skull (image 87) was obtained before the commencement of the venous sampling.
The BIPSS result confirmed the presence of a functioning right sided pituitary microadenoma, confirming the diagnosis of Cushing’s disease.