Primary aldosteronism is the most frequent cause of secondary arterial hypertension. As adrenal imaging has been shown to have only limited value for differential diagnosis, adrenal vein sampling (AVS) has been implemented as a gold standard in the guidelines. However, AVS is a not well-standardized technique, and success rates vary in a wide range. Successful AVS procedures presuppose careful preparation and operational efficiency in an interdisciplinary team. Besides ruling out malignancy, multidetector-row helical computed tomography facilitates the localization of the adrenal veins. Rapid cortisol measurement has been shown to increase cannulation rates. The values of cosyntropin stimulation and bilateral simultaneous versus sequential catheterization remain unclear, but consistency is important. AVS should be performed in specialized centers by a limited number of radiologists in order to ensure success rates of at least 70%. Standardization of cutoff values should be accomplished through a consensus statement for consistent decision-making in patient care.