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Bob-Manuel T, Amoran OE, Jenkins C, Obafemi O, Tutor A, Tafur J. Renal interventions in the management of hypertension. Curr Opin Cardiol 2021; 36:444-452. [PMID: 33929362 DOI: 10.1097/hco.0000000000000859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW In the present comprehensive review, we describe the pathophysiology, indications, and evidence for both renal artery stenting and renal artery denervation. We also discuss the procedural techniques, risks, benefits, and future directions of renal intervention in the management of hypertension (HTN). RECENT FINDINGS Hemodynamic confirmation of lesion severity in severe renal artery stenosis is a resting or hyperemic translesional systolic gradient >20, resting or hyperemic mean translesional gradient >10 and/or renal fractional flow reserve <0.8 are considered severe. Knowing that correct stent size was used is the best predictor of restenosis, intravascular ultrasound is effective and well tolerated for stent sizing. The main categories of renal denervation: radiofrequency ablation, ultrasound, chemical ablation, and brachytherapy have shown impressive outcomes in treating resistant HTN. SUMMARY Over the past decade, several studies have shown the safety and benefit of catheter-based renal interventions in managing HTN. Renal artery stenting and renal artery denervation are the leading alternative invasive treatment employed in managing HTN.
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Affiliation(s)
- Tamunoinemi Bob-Manuel
- John Ochsner Heart and Vascular Institute, Ochsner Medical Center, New Orleans, Louisiana
| | | | - Christopher Jenkins
- John Ochsner Heart and Vascular Institute, Ochsner Medical Center, New Orleans, Louisiana
| | - Olushola Obafemi
- John Ochsner Heart and Vascular Institute, Ochsner Medical Center, New Orleans, Louisiana
| | - Austin Tutor
- Ochsner Medical Center, New Orleans, Louisiana, USA
| | - Jose Tafur
- John Ochsner Heart and Vascular Institute, Ochsner Medical Center, New Orleans, Louisiana
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Gupta A, Prince M, Bob-Manuel T, Jenkins JS. Renal denervation: Alternative treatment options for hypertension? Prog Cardiovasc Dis 2019; 63:51-57. [PMID: 31884099 DOI: 10.1016/j.pcad.2019.12.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 12/23/2019] [Indexed: 12/17/2022]
Abstract
Hypertension affects millions of Americans and has adverse long-term consequences increasing morbidity and mortality. Resistant hypertension (RH) continues to be difficult to treat with medications alone which may be associated with significant side effects. Alternate therapies have been evaluated for treating RH and renal denervation has been investigated extensively. We review the data from renal denervation trials and other novel technologies which are not FDA approved to date.
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Affiliation(s)
- Aashish Gupta
- Department of Cardiology at Ochsner Clinic Foundation, Ochsner Clinical School-the University of Queensland School of Medicine, New Orleans, LA, United States of America.
| | - Marloe Prince
- Department of Cardiology at Ochsner Clinic Foundation, Ochsner Clinical School-the University of Queensland School of Medicine, New Orleans, LA, United States of America
| | - Tamunoinemi Bob-Manuel
- Department of Cardiology at Ochsner Clinic Foundation, Ochsner Clinical School-the University of Queensland School of Medicine, New Orleans, LA, United States of America
| | - J Stephen Jenkins
- Department of Cardiology at Ochsner Clinic Foundation, Ochsner Clinical School-the University of Queensland School of Medicine, New Orleans, LA, United States of America
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Abstract
Insufficient hepatic O2 in animal and human studies has been shown to elicit a hepatorenal reflex in response to increased hepatic adenosine, resulting in the stimulation of renal as well as muscle sympathetic nerve activity and activating the renin angiotensin system. Low hepatic ATP, hyperuricemia, and hepatic lipid accumulation reported in metabolic syndrome (MetS) patients may reflect insufficient hepatic O2 delivery, potentially accounting for the sympathetic overdrive associated with MetS. This theoretical concept is supported by experimental results in animals fed a high fructose diet to induce MetS. Hepatic fructose metabolism rapidly consumes ATP resulting in increased adenosine production and hyperuricemia as well as elevated renin release and sympathetic activity. This review makes the case for the hepatorenal reflex causing sympathetic overdrive and metabolic syndrome in response to exaggerated splanchnic oxygen consumption from excessive eating. This is strongly reinforced by the fact that MetS is cured in a matter of days in a significant percentage of patients by diet, bariatric surgery, or endoluminal sleeve, all of which would decrease splanchnic oxygen demand by limiting nutrient contact with the mucosa and reducing the nutrient load due to loss of appetite or dietary restriction.
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Affiliation(s)
- Michael D Wider
- Department of Physiology, Wayne State University School of Medicine, Detroit, Michigan, USA
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Abstract
Insufficient hepatic O2 in animal and human studies has been shown to elicit a hepatorenal reflex in response to increased hepatic adenosine, resulting in stimulation of renal as well as muscle sympathetic nerve activity and activating the renin angiotensin system. Low hepatic ATP, hyperuricemia, and hepatic lipid accumulation reported in metabolic syndrome (MetS) patients may reflect insufficient hepatic O2 delivery, potentially accounting for the sympathetic overdrive associated with MetS. This theoretical concept is supported by experimental results in animals fed a high fructose diet to induce MetS. Hepatic fructose metabolism rapidly consumes ATP resulting in increased adenosine production and hyperuricemia as well as elevated renin release and sympathetic activity. This review makes the case for the hepatorenal reflex causing sympathetic overdrive and metabolic syndrome in response to exaggerated splanchnic oxygen consumption from excessive eating. This is strongly reinforced by the fact that MetS is cured in a matter of days in a significant percentage of patients by diet, bariatric surgery, or endoluminal sleeve, all of which would decrease splanchnic oxygen demand by limiting nutrient contact with the mucosa and reducing the nutrient load due to the loss of appetite or dietary restriction.
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Affiliation(s)
- Michael D Wider
- Department of Physiology, Wayne State University School of Medicine, Detroit, Michigan, USA
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Chemical Renal Denervation: The Pursuit for Simplicity. JACC Cardiovasc Interv 2016; 9:599-601. [PMID: 27013160 DOI: 10.1016/j.jcin.2016.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 01/07/2016] [Accepted: 01/14/2016] [Indexed: 11/23/2022]
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Abstract
Resistant hypertension, defined as inadequate blood pressure control despite three or more antihypertensive medications at maximally tolerated doses, is strongly linked to increased cardiovascular morbidity and mortality. Increased renal afferent and efferent sympathetic activity carried by nerves which arborize the adventitia of the renal arteries, appears to be central to the pathobiology of resistant hypertension. Historical experience indicates that surgical denervation and/or sympathectomy often dramatically reduced blood pressure in patients with malignant hypertension. Catheter-based radio-frequency renal denervation was developed in the past decade as a percutaneous adaptation of surgical denervation. Percutaneous renal denervation using a variety of systems has demonstrated to date, in non-randomized and unblinded studies, dramatic reductions in office-based blood pressure, but more modest impact on ambulatory blood pressure. The only single, appropriately powered, blinded, sham-controlled study of renal denervation conducted to date, however, failed to meet its primary endpoint, casting doubt on the value of the therapy. Ancillary benefits of renal denervation have been described in such conditions as diabetes mellitus, heart failure, and sleep apnea but require further study. While renal denervation is already widely available outside of the USA for commercial use, its utility in resistant hypertension must be vetted by further rigorous investigation before its use can be routinely recommended.
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Affiliation(s)
- Sandeep Nathan
- Department of Medicine, Section of Cardiology and ASH Comprehensive Hypertension Center, Section of Endocrinology, Diabetes and Metabolism, The University of Chicago Medicine, 5841 South Maryland Avenue, MC 1027, Chicago, IL, 60637, USA
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Bausback Y, Friedenberger J, Hertting K, Werner M, Branzan D, Freitas B, Piorkowski M, Schmidt A, Scheinert D. Renal denervation for hypertension refractory to renal artery stenting. J Endovasc Ther 2014; 21:181-90. [PMID: 24754276 DOI: 10.1583/13-4566r.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE To investigate the effect of renal denervation (RDN) on blood pressure and renal function in refractory hypertension after renal artery recanalization and optimal medical therapy. METHODS Ten patients (6 women; mean age 70.0±5.1 years) with an office systolic blood pressure >160 mmHg despite taking ≥3 antihypertensive drugs and uni- or bilateral renal artery stenting were treated with RDN. Radiofrequency (RF) energy was delivered to the native segment of the artery keeping a 5-mm safe distance from the stented segments. Standardized office (OBP) and ambulatory (ABP) blood pressure measurements, medication, and renal assessment, including renal duplex ultrasound and renal function, were determined at baseline and on follow-up to 12 months. RESULTS OBP (systolic/diastolic) at baseline was 190.0±20.4 / 84.2±10.1 mmHg. It decreased to 171.1±28.7* / 82.2±8.7, 165.5±28.4(†) / 76.1±7.4, and 158.3±14.2(†) / 75.5±9.5(†) mmHg (*p<0.001; (†)p<0.01) at 3, 6, and 12 months after RDN, respectively. Average ABP (systolic/diastolic) after 6 and 12 months decreased by -7.6(‡) / -3.1 and -11.3(‡) / -5.1(‡) mmHg ((‡)p<0.05). There was no renal artery (re)stenosis, dissection, or aneurysm within 12 months. Creatinine, cystatin C, and glomerular filtration rate remained unchanged. Urine albumin excretion decreased in 4/10 patients. Renal resistive indices improved in native, but not in stented renal arteries within the follow-up period. CONCLUSION This proof-of-concept study demonstrates that RF-based RDN can be safely and effectively delivered in patients with resistant hypertension and previous renal artery stenting.
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Affiliation(s)
- Yvonne Bausback
- Centre of Vascular Medicine: Angiology and Vascular Surgery, Park Hospital Leipzig, Germany
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Aronow HD, Li J, Parikh SA. Where and when device therapy may be useful in the management of drug-resistant hypertension. Curr Cardiol Rep 2014; 16:546. [PMID: 25326400 DOI: 10.1007/s11886-014-0546-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Device therapy for the treatment of uncontrolled and resistant hypertension has evolved significantly over the past several decades. Both renal artery disease and sympathetic hyperactivity have been linked to resistant hypertension. This manuscript will review the current evidence base supporting device therapy (e.g., renal artery revascularization, sympathetic nervous system modulation) for resistant hypertension.
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Affiliation(s)
- Herbert D Aronow
- Michigan Heart, 5325 Elliott Dr., Ste. #202, Ypsilanti, MI, 48197, USA,
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Kannan A, Medina RI, Nagajothi N, Balamuthusamy S. Renal sympathetic nervous system and the effects of denervation on renal arteries. World J Cardiol 2014; 6:814-823. [PMID: 25228960 PMCID: PMC4163710 DOI: 10.4330/wjc.v6.i8.814] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Revised: 03/18/2014] [Accepted: 06/11/2014] [Indexed: 02/06/2023] Open
Abstract
Resistant hypertension is associated with chronic activation of the sympathetic nervous system resulting in various comorbidities. The prevalence of resistant hypertension is often under estimated due to various reasons. Activation of sympathetic nervous system at the renal- as well as systemic- level contributes to the increased level of catecholamines and resulting increase in the blood pressure. This increased activity was demonstrated by increased muscle sympathetic nerve activity and renal and total body noradrenaline spillover. Apart from the hypertension, it is hypothesized to be associated with insulin resistance, congestive heart failure and obstructive sleep apnea. Renal denervation is a novel procedure where the sympathetic afferent and efferent activity is reduced by various techniques and has been used successfully to treat drug-resistant hypertension improvement of various metabolic derangements. Renal denervation has the unique advantage of offering the denervation at the renal level, thus mitigating the systemic side effects. Renal denervation can be done by various techniques including radiofrequency ablation, ultrasound guided ablation and chemical ablation. Various trials evaluated the role of renal denervation in the management of resistant hypertension and have found promising results. More studies are underway to evaluate the role of renal denervation in patients presenting with resistant hypertension in different scenarios. Appropriate patient selection might be the key in determining the effectiveness of the procedure.
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Maliha G, Townsend RR. An Update on Treatment Options for Drug Resistant Hypertension. CURRENT CARDIOVASCULAR RISK REPORTS 2014. [DOI: 10.1007/s12170-014-0394-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Feldmann KJ, Silver MJ. The role of renal denervation in the treatment of hypertension. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2014; 16:321. [PMID: 24872084 DOI: 10.1007/s11936-014-0321-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OPINION STATEMENT Resistant hypertension remains a difficult clinical disease to treat. It is known to place a patient at higher risk for developing significant cardiovascular, renal, and cerebrovascular disease. There is a current surge in research investigating renal denervation as potential treatment for resistant hypertension, as an overactive renal sympathetic system is known to exert an influence on the underlying pathophysiology. Several small studies have been published, with more underway, evaluating multiple different catheter-based systems that utilize radiofrequency ablation or ultrasound wave energy. These studies are showing promising results, with reduction in office blood pressure for the majority of patients. However, it appears that this does not always translate into definitive real-world observational effects. Variability exists in the number of patients that are able to reduce the amount of medication they take for hypertension, with some requiring an increase in medication. As a result, a more intensive screening process has been proposed, evaluating specific key predictors that may translate into a more favorable clinical response to renal denervation. We recommend that individuals with resistant hypertension continue to be optimized medically, adequately screened for secondary causes of hypertension, and that they consider participation in a renal denervation clinical trial to aid in further advancing the field.
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Affiliation(s)
- Kyle J Feldmann
- Division of Internal Medicine, Riverside Methodist Hospital, Columbus, OH, USA,
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Frishman WH, Glicklich D. The Role of Nonpharmacologic Device Interventions in the Management of Drug-Resistant Hypertension. Curr Atheroscler Rep 2014; 16:405. [DOI: 10.1007/s11883-014-0405-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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