Objective To assess the feasibility and safety of adrenal venous sampling (AVS) via single antecubital venous access, bilateral antecubital venous access, and combined antecubital-femoral venous access, as well as the prognostic value of AVS for guiding laparoscopic surgery.

Methods This retrospective study included 220 patients with primary aldosteronism（PA）who underwent AVS at the First Affiliated Hospital of Fujian Medical University between January 2021 and June 2025. Based on the AVS approach, patients were categorized into three groups: single antecubital group (n=78), bilateral antecubital group (n=70), and combined femoral-antecubital group (n=72). Inter-group comparisons were performed for baseline characteristics, AVS success rate, radiation exposure time, procedure-related complications, catheter selection, and postoperative clinical and biochemical remission rates following laparoscopic adrenalectomy.

Results No significant differences were observed in baseline characteristics among the three groups. Compared to the single antecubital group, both the bilateral antecubital group and the combined femoral-antecubital group demonstrated significantly higher AVS success rates (bilateral antecubital group vs single antecubital group: 90.00% vs. 71.80%, x²=7.761, P = 0.015; combined femoral-antecubital group vs. single antecubital group: 88.90% vs. 71.80%, x²=6.838, P = 0.027) and significantly shorter radiation exposure times (bilateral antecubital group vs. single antecubital group: 11.90 ± 3.04 vs. 16.03 ± 3.55 min, t=7.547, P ＜ 0.001, combined femoral-antecubital group vs. single antecubital group: 8.45 ± 2.65 vs. 16.03 ± 3.55 min, t=14.693, P ＜ 0.001).Compared to the bilateral antecubital group, the combined femoral-antecubital group demonstrated comparable AVS success rates (P ＞ 0.05) but significantly shorter radiation exposure times (P＜0.001). Procedure-related complications demonstrated a lower incidence of puncture site events in the bilateral antecubital group versus the combined femoral-antecubital group (5.71% vs. 12.50%, x²=1.965, P＞0.05), though this difference was not statistically significant. Regarding catheter selection for right AVS, the combined femoral-antecubital approach demonstrated greater catheter diversity. For left AVS, both single and bilateral antecubital approaches predominantly utilized TIG catheters versus preferential MP catheter use in the combined femoral-antecubital group.The choice among the three AVS pathways showed no statistically significant difference in clinical and biochemical outcomes for PA patients following laparoscopic adrenalectomy.

Conclusion Both bilateral antecubital approach and combined antecubital-femoral approach enable efficient AVS completion. Moreover, the combined antecubital-femoral approach demonstrates reduced radiation exposure time.