Transfemoral transcaval adrenal biopsy: a technical report and review of adrenal biopsy approaches

Despite advances in cross-sectional imaging, adrenal biopsy plays a role in a small subset of lesions that remain indeterminate after complete imaging work-up or in which tissue diagnosis would alter management. Anatomic constraints around the adrenal glands can make safe percutaneous access technically challenging. This technical report describes a transfemoral transcaval approach to biopsy of a right adrenal mass directly abutting the inferior vena cava (IVC) that was not safely accessible by conventional percutaneous routes. Additionally, a concise review of contemporary adrenal biopsy indications and access routes is performed. Adapted from transfemoral transcaval liver biopsy, the technique uses right common femoral venous access, positioning of a reshaped metal guide cannula within the IVC at the level of the lesion adjacent to the right renal vein, and deployment of a core biopsy needle across the caval wall under combined fluoroscopic and ultrasound guidance, with cone-beam CT confirmation of needle position and completion venography to exclude caval injury. Diagnostic tissue was obtained without periprocedural complication; histopathology demonstrated an unexpected pheochromocytoma, a finding discussed here in detail due to its implications for pre-procedure biochemical evaluation. This limited experience demonstrates technical feasibility in carefully selected patients. The safety and comparative effectiveness of the technique require evaluation in larger series.