1
|
Hwang J, Shin H, Jung M, Kang HW. Investigations of Laser-Assisted Renal Denervation for Treatment of Resistant Hypertension. Lasers Surg Med 2024. [PMID: 38965757 DOI: 10.1002/lsm.23823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Revised: 05/29/2024] [Accepted: 06/20/2024] [Indexed: 07/06/2024]
Abstract
BACKGROUND AND OBJECTIVES Renal denervation (RDN) is an emerging surgical treatment for resistant hypertension. However, the current RDN using radiofrequency can cause undesirable thermal damage to the medial and luminal layers due to direct contact between the arterial lumen and energy source. The aim of this study is to evaluate the feasibility of the new laser-assisted RDN by exploring the potential treatment conditions. METHODS For ex vivo testing, six different treatment conditions (10 and 20 W applied for delivery of 300, 450, and 600 J) were tested on the porcine liver and renal artery (RA) by using a continuous wave 1064 nm laser wavelength. The ablated area in the liver tissue was measured to estimate the extent of the coagulated area. Histological evaluation was performed on the treated RA tissues to confirm the extent of thermal nerve damage. RESULTS The ablated depth, length, and area in the liver tissue increased with laser power and total energy. According to the histological results, 20 W groups yielded more significant damage to the RA nerves than 10 W groups at the total energy of 300 J (0.0 ± 0.0 mm for 10 W vs. 2.9 ± 1.0 mm for 20 W), 450 J (1.9 ± 0.6 mm for 10 W vs. 6.8 ± 1.5 mm for 20 W), and 600 J (2.9 ± 0.4 mm for 10 W vs. 7.3 ± 0.8 mm for 20 W). The treated RA exhibited insignificant medial injury in depth (medial thinning ≤ 25%), and no difference in the medial thinning was found among the six groups (p = 0.4). CONCLUSION The current study demonstrated that the 1064 nm laser at 20 W with delivery of 450 J could effectively damage the RA nerves with no or minimal injury to the surrounding tissue. The proposed laser-assisted RDN may enhance physiological effects with insignificant complications in in vivo situations. Further in vivo studies will be conducted to validate the current findings by evaluating the extent of blood pressure reduction and norepinephrine changes after the laser-assisted RDN on a large animal model.
Collapse
Affiliation(s)
- Junghyun Hwang
- Major of Biomedical Engineering, Division of Smart Healthcare, College of Information Technology and Convergence, Pukyong National University, Busan, Republic of Korea
- Marine-Integrated Biomedical Technology Center, Pukyong National University, Busan, Republic of Korea
| | - Hwarang Shin
- Marine-Integrated Biomedical Technology Center, Pukyong National University, Busan, Republic of Korea
- Industry 4.0 Convergence Bionics Engineering, Pukyong National University, Busan, Republic of Korea
| | - Minwoo Jung
- Major of Biomedical Engineering, Division of Smart Healthcare, College of Information Technology and Convergence, Pukyong National University, Busan, Republic of Korea
| | - Hyun Wook Kang
- Major of Biomedical Engineering, Division of Smart Healthcare, College of Information Technology and Convergence, Pukyong National University, Busan, Republic of Korea
- Marine-Integrated Biomedical Technology Center, Pukyong National University, Busan, Republic of Korea
- Industry 4.0 Convergence Bionics Engineering, Pukyong National University, Busan, Republic of Korea
- Applied R&D, TeCure, Inc., Busan, Republic of Korea
| |
Collapse
|
2
|
Baik J, Seo S, Lee S, Yang S, Park SM. Circular Radio-Frequency Electrode With MEMS Temperature Sensors for Laparoscopic Renal Sympathetic Denervation. IEEE Trans Biomed Eng 2021; 69:256-264. [PMID: 34166182 DOI: 10.1109/tbme.2021.3092035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Laparoscopic renal denervation (LRDN) ablates sympathetic nerves on the outer wall of a renal artery to treat autonomic nervous system disorders such as hypertension and arrhythmia. Here, we developed a new circular radio frequency (RF) electrode for LRDN using micro-electro-mechanical systems (MEMS) technology. METHODS The electrode consists of a parallel bipolar MEMS electrode, two MEMS thermocouples, and a shape-memory alloy (SMA) substrate. The electrode is automatically wrapped and unwrapped under actuation controlled by the heat generated by RF energy on the electrode-tissue interface. The electrode was designed through a computational simulation analysis, and its actuation and temperature-sensing performance were tested in laboratory experiments and a porcine animal study. RESULTS In an in-vivo study of porcine renal arteries, the electrode could automatically wrap and unwrap around an artery during LRDN. The bipolar MEMS electrode required 13 Vrms for heat generation up to 60°C, while the two MEMS thermocouples reliably measured the temperature without noise signals (a temperature coefficient of 38.3 or 38.5 µV/°C and an accuracy of ±0.44 or ±0.49°C). As revealed in a histological analysis using hematoxylin and eosin staining and Masson's trichrome staining, the renal artery was intact after LRDN. CONCLUSION The circular RF electrode improves the safety of LRDN by reliably measuring the electrode temperature of the electrode during RDN and enhances the effectiveness of LRDN by reducing the complicated manipulations of the surgical instrument. SIGNIFICANCE The developed circular RF electrode will pave the way for LRDN treatment of autonomic nervous system disorders.
Collapse
|
3
|
Bertog S, Sharma A, Mahfoud F, Pathak A, Schmieder RE, Sievert K, Papademetriou V, Weber MA, Haratani N, Lobo MD, Saxena M, Kandzari DE, Fischell TA, Sievert H. Alcohol-Mediated Renal Sympathetic Neurolysis for the Treatment of Hypertension: The Peregrine™ Infusion Catheter. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2020; 24:77-86. [PMID: 32958438 DOI: 10.1016/j.carrev.2020.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 08/15/2020] [Accepted: 09/01/2020] [Indexed: 01/12/2023]
Abstract
Renal sympathetic denervation using conventional non-irrigated radiofrequency catheters has potential technical shortcomings, including limited penetration depth and incomplete circumferential nerve damage, potentially impacting therapeutic efficacy. Against this background, second generation multi-electrode, radiofrequency and ultrasound renal denervation systems have been developed to provide more consistent circumferential nerve ablation. Irrigated catheters may allow deeper penetration while minimizing arterial injury. In this context, catheter-based chemical denervation, with selective infusion of alcohol, a potent neurolytic agent, into the perivascular space, may minimize endothelial, intimal and medial injury while providing circumferential neurolysis. Animal studies demonstrate pronounced renal norepinephrine level reductions and consistent renal nerve injury after perivascular alcohol infusion using the Peregrine Catheter. Early clinical studies demonstrated significant blood pressure reductions and a reasonable safety profile. Randomized sham-controlled trials (NCT03503773, NCT02910414) are underway to examine whether the aforementioned theoretical advantages of alcohol-medicated denervation with the Peregrine System™ Kit translate into clinical benefits.
Collapse
Affiliation(s)
- Stefan Bertog
- CardioVascular Center Frankfurt, Frankfurt, Germany; Minneapolis Veterans Affairs Medical Center, Minneapolis, USA
| | - Alok Sharma
- Minneapolis Veterans Affairs Medical Center, Minneapolis, USA
| | - Felix Mahfoud
- Saarland University Hospital, Internal Medicine III, Cardiology, Angiology, Intensive Care Medicine, Homburg/Saar, Germany; Institute of Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Atul Pathak
- Department of Cardiovascular Medicine, Princess Grace Hospital, Monaco
| | - Roland E Schmieder
- University Hospital of the Friedrich Alexander University Erlangen-Nürnberg, Germany
| | - Kolja Sievert
- CardioVascular Center Frankfurt, Frankfurt, Germany; Johannes Gutenberg Universität, Mainz, Germany
| | | | | | | | - Melvin D Lobo
- Barts NIHR Biomedical Research Centre, William Harvey Research Institute, Queen Mary University, London, UK
| | - Manish Saxena
- Barts NIHR Biomedical Research Centre, William Harvey Research Institute, Queen Mary University, London, UK
| | | | | | - Horst Sievert
- CardioVascular Center Frankfurt, Frankfurt, Germany; Anglia Ruskin University, Chelmsford, UK.
| |
Collapse
|
4
|
Development and Evaluation of a Disease Large Animal Model for Preclinical Assessment of Renal Denervation Therapies. Animals (Basel) 2020; 10:ani10091446. [PMID: 32824935 PMCID: PMC7552649 DOI: 10.3390/ani10091446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 08/18/2020] [Indexed: 11/17/2022] Open
Abstract
New-generation catheters-based renal denervation (RDN) is under investigation for the treatment of uncontrolled hypertension (HTN). We assessed the feasibility of a large animal model of HTN to accommodate the human RDN devices. Ten minipigs were instrumented to measure blood pressure (BP) in an awake-state. HTN was induced with subcutaneous 11-deoxycorticosterone (DOCA, 100 mg/kg) implants. Five months after, the surviving animals underwent RDN with the Symplicity® system. Norepinephrine (NE) renal gradients were determined before and 1 month after RDN. Renal arteries were processed for histological (hematoxylin-eosin, Movat pentachrome) and immunohistochemical (S100, tyrosine-hydroxylase) analyses. BP significantly rose after DOCA implants. Six animals died prematurely, mainly from infectious causes. The surviving animals showed stable BP levels after 5 months. One month after RDN, nerve damage was showed in three animals, with impedance drop >10%, NE gradient drop and reduction in BP. The fourth animal showed no nerve damage, impedance drop <10%, NE gradient increase and no change in BP. In conclusion, the minipig model of DOCA-induced HTN is feasible, showing durable effects. High mortality should be addressed in next iterations of this model. RDN may partially offset the DOCA-induced HTN. Impedance drop and NE renal gradient could be markers of RDN success.
Collapse
|
5
|
Townsend RR, Walton A, Hettrick DA, Hickey GL, Weil J, Sharp AS, Blankenstijn PJ, Böhm M, Mancia G. Review and meta-analysis of renal artery damage following percutaneous renal denervation with radiofrequency renal artery ablation. EUROINTERVENTION 2020; 16:89-96. [DOI: 10.4244/eij-d-19-00902] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
|
6
|
Su E, Zhao L, Yang X, Zhu B, Liu Y, Zhao W, Wang X, Qi D, Zhu L, Gao C. Aggravated endothelial endocrine dysfunction and intimal thickening of renal artery in high-fat diet-induced obese pigs following renal denervation. BMC Cardiovasc Disord 2020; 20:176. [PMID: 32295540 PMCID: PMC7161153 DOI: 10.1186/s12872-020-01472-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 04/07/2020] [Indexed: 12/11/2022] Open
Abstract
Background Renal denervation (RDN) targeting the sympathetic nerves in the renal arterial adventitia as a treatment of resistant hypertension can cause endothelial injury and vascular wall injury. This study aims to evaluate the risk of atherosclerosis induced by RDN in renal arteries. Methods A total of 15 minipigs were randomly assigned to 3 groups: (1) control group, (2) sham group, and (3) RDN group (n = 5 per group). All pigs were fed a high-fat diet (HFD) for 6 months after appropriate treatment. The degree of intimal thickening of renal artery and the conversion of endothelin 1 (ET-1) receptors were evaluated by histological staining. Western blot was used to assess the expression of nitric oxide (NO) synthesis signaling pathway, ET-1 and its receptors, NADPH oxidase 2 (NOX2) and 4-hydroxynonenal (4-HNE) proteins, and the activation of NF-kappa B (NF-κB). Results The histological staining results suggested that compared to the sham treatment, RDN led to significant intimal thickening and significantly promoted the production of endothelin B receptor (ETBR) in vascular smooth muscle cells (VSMCs). Western blotting analysis indicated that RDN significantly suppressed the expression of AMPK/Akt/eNOS signaling pathway proteins, and decreased the production of NO, and increased the expression of endothelin system proteins including endothelin-1 (ET-1), endothelin converting enzyme 1 (ECE1), endothelin A receptor (ETAR) and ETBR; and upregulated the expression of NOX2 and 4-HNE proteins and enhanced the activation of NF-kappa B (NF-κB) when compared with the sham treatment (all p < 0.05). There were no significant differences between the control and sham groups (all p > 0.05). Conclusions RDN aggravated endothelial endocrine dysfunction and intimal thickening, and increased the risk of atherosclerosis in renal arteries of HFD-fed pigs.
Collapse
Affiliation(s)
- Enyong Su
- Department of Cardiology, Zhengzhou University People's Hospital, No.7 Weiwu road, Jinshui District, Zhengzhou, 450003, Henan, China.,Department of Cardiology, Huazhong Fuwai Hospital, Zhengzhou, 451464, Henan, China
| | - Linwei Zhao
- Department of Cardiology, Zhengzhou University People's Hospital, No.7 Weiwu road, Jinshui District, Zhengzhou, 450003, Henan, China.,Department of Cardiology, Huazhong Fuwai Hospital, Zhengzhou, 451464, Henan, China
| | - Xiaohang Yang
- Department of Cardiology, Zhengzhou University People's Hospital, No.7 Weiwu road, Jinshui District, Zhengzhou, 450003, Henan, China
| | - Binbin Zhu
- Department of Cardiology, Zhengzhou University People's Hospital, No.7 Weiwu road, Jinshui District, Zhengzhou, 450003, Henan, China.,Department of Cardiology, Huazhong Fuwai Hospital, Zhengzhou, 451464, Henan, China
| | - Yahui Liu
- Department of Cardiology, Huazhong Fuwai Hospital, Zhengzhou, 451464, Henan, China
| | - Wen Zhao
- Zhengzhou University School of Pharmaceutical Sciences, Zhengzhou, 450001, Henan, China
| | - Xianpei Wang
- Department of Cardiology, Zhengzhou University People's Hospital, No.7 Weiwu road, Jinshui District, Zhengzhou, 450003, Henan, China.,Department of Cardiology, Huazhong Fuwai Hospital, Zhengzhou, 451464, Henan, China
| | - Datun Qi
- Department of Cardiology, Zhengzhou University People's Hospital, No.7 Weiwu road, Jinshui District, Zhengzhou, 450003, Henan, China.,Department of Cardiology, Huazhong Fuwai Hospital, Zhengzhou, 451464, Henan, China
| | - Lijie Zhu
- Department of Cardiology, Zhengzhou University People's Hospital, No.7 Weiwu road, Jinshui District, Zhengzhou, 450003, Henan, China.,Department of Cardiology, Huazhong Fuwai Hospital, Zhengzhou, 451464, Henan, China
| | - Chuanyu Gao
- Department of Cardiology, Zhengzhou University People's Hospital, No.7 Weiwu road, Jinshui District, Zhengzhou, 450003, Henan, China. .,Department of Cardiology, Huazhong Fuwai Hospital, Zhengzhou, 451464, Henan, China.
| |
Collapse
|
7
|
Lee YS. Is Renal Denervation Using Radiofrequency a Treatment Option for the Ventricular Arrhythmia Following Acute Myocardial Infarction? Korean Circ J 2020; 50:50-51. [PMID: 31854156 PMCID: PMC6923229 DOI: 10.4070/kcj.2019.0361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 11/20/2019] [Indexed: 01/04/2023] Open
Affiliation(s)
- Young Soo Lee
- Department of Cardiology, College of Medicine Catholic University of Daegu, Daegu, Korea.
| |
Collapse
|
8
|
Gong L, Jiang F, Zhang Z, Wang X, Li H, Kuang Y, Yang G. Catheter-Based Renal Denervation Attenuates Kidney Interstitial Fibrosis in a Canine Model of High-Fat Diet-Induced Hypertension. Kidney Blood Press Res 2019; 44:628-642. [PMID: 31291627 DOI: 10.1159/000500918] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 05/12/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS Catheter-based renal denervation (RDN) has emerged as an innovative interventional approach for reducing blood pressure (BP), suppressing ventricular substrate remodeling, and attenuating heart failure, which suggests that it might reduce kidney fibrosis in a canine model of high-fat diet-induced hypertension. This study thus sought to assess whether RDN could reduce kidney fibrosis and halt the progression of renal impairment in a canine model of high-fat diet-induced hypertension. METHODS Thirty-two beagles were randomized into either the normal control group (normal diet, n = 10) or the hypertension group (high-fat diet, n = 22). After successful establishment of the model, the hypertension model group was randomized to either the RDN group (n = 9) or the sham-surgery group (n = 8). Renal artery angiography, BP, heart rate (HR), and blood and urine biochemistry results were assessed at 1, 3, and 6 months after surgery. Canines were sacrificed at 6 months after surgery. The extent of kidney interstitial fibrosis, transforming growth factor-beta 1, alpha-smooth muscle actin, connective tissue growth factor, and E-cadherin protein were measured. RESULTS The group fed a high-fat diet had significantly (p ˂ 0.05) increased body weight, BP, and HR and higher levels of urine albumin, serum noradrenaline (NE), and angiotensin II (AngII) than the control group. The sham-surgery group and RDN group also had higher levels than the control group (p ˂ 0.05). Compared with the sham-surgery group, the RDN group had lower BP, urine albumin, serum NE, and AngII and less fibrotic tissue (all p ˂ 0.05). CONCLUSION RDN reduced BP, slowed progression of albuminuria, and suppressed renal remodeling in a canine model of high-fat diet-induced hypertension.
Collapse
Affiliation(s)
- Liying Gong
- Department of Cardiology, The Third Xiangya Hospital of Central South University, Changsha, China.,Department of Clinical Pharmacology Center, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Fenglin Jiang
- Department of Cardiology, The Third Xiangya Hospital of Central South University, Changsha, China,
| | - Zhihui Zhang
- Department of Cardiology, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Xinguo Wang
- Department of Cardiology, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Hui Li
- Department of Cardiology, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Yan Kuang
- Department of Cardiology, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Guoping Yang
- Department of Clinical Pharmacology Center, The Third Xiangya Hospital of Central South University, Changsha, China
| |
Collapse
|
9
|
Hoogerwaard AF, Elvan A. Is renal denervation still a treatment option in cardiovascular disease? Trends Cardiovasc Med 2019; 30:189-195. [PMID: 31147257 DOI: 10.1016/j.tcm.2019.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 05/13/2019] [Accepted: 05/16/2019] [Indexed: 11/19/2022]
Abstract
The role of renal sympathetic denervation (RDN) has been the topic of ongoing debate ever since the impressive initial results. The rationale of RDN is strong and supported by non-clinical studies, which lies in uncoupling the autonomic nervous crosstalk between the kidneys and the central nervous system. Since we know that cardiovascular diseases, such as hypertension, atrial, ventricular arrhythmias and heart failure (HF) are related to sympathetic (over)activity, modulation of the renal nerve activity appears to be a reasonable and attractive therapeutic target in these patients. This review will focus on the existing evidence and potential future perspectives for RDN as treatment option in cardiovascular disease.
Collapse
Affiliation(s)
- Annemiek F Hoogerwaard
- Department of Cardiology, Isala Heart Centre, Isala Hospital, Dr. Van Heesweg 2, 8025 AB Zwolle, The Netherlands
| | - Arif Elvan
- Department of Cardiology, Isala Heart Centre, Isala Hospital, Dr. Van Heesweg 2, 8025 AB Zwolle, The Netherlands.
| |
Collapse
|
10
|
Su E, Zhao L, Gao C, Zhao W, Wang X, Qi D, Zhu L, Yang X, Zhu B, Liu Y. Acute changes in morphology and renal vascular relaxation function after renal denervation using temperature-controlled radiofrequency catheter. BMC Cardiovasc Disord 2019; 19:67. [PMID: 30902047 PMCID: PMC6431051 DOI: 10.1186/s12872-019-1053-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 03/18/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Resistant hypertension and renal sympathetic hyperactivity are closely linked, and catheter-based renal denervation (RDN) is regarded as a new treatment strategy. However, the acute changes in vascular morphology and relaxation function have yet to be evaluated, and these may be important for the efficacy and safety of the procedure. In this study, we explored these questions by conventional temperature-controlled cardiac radiofrequency catheter-based RDN in a pig model. METHODS Six mini-pigs were randomly divided into the renal denervation (RDN) group (n = 3) and the Sham-RDN group (n = 3). Animals in the RDN group underwent unilateral radiofrequency ablation, and those in the Sham-RDN group underwent the same procedure except for the ablation. The pigs were examined by angiography pre- and post-RDN and were euthanized immediately thereafter. Renal arteries were processed for histological and molecular biology analyses as well as for in vitro vascular tension testing. RESULTS Compared with the Sham-RDN group, the RDN caused vascular intima and media injury, renal nerve vacuolization, mild collagen fiber hyperplasia and elastic fiber cleavage (all p < 0.05). The RDN group also significantly exhibited nitric oxide synthase pathway inhibition and decreased endothelium-independent vascular relaxation function Compared to the Sham-RDN group (all p < 0.05). CONCLUSIONS In this porcine model, renal artery denervation led to vascular wall injury and endothelial dysfunction in the acute phase, which negatively affected vascular relaxation function. Thus, this process may be detrimental to the prognosis and progress of hypertension patients.
Collapse
Affiliation(s)
- Enyong Su
- Department of Cardiology, Zhengzhou University People's Hospital, No.7 Weiwu road, Jinshui District, Zhengzhou, 450003, China
| | - Linwei Zhao
- Department of Cardiology, Zhengzhou University People's Hospital, No.7 Weiwu road, Jinshui District, Zhengzhou, 450003, China
| | - Chuanyu Gao
- Department of Cardiology, Zhengzhou University People's Hospital, No.7 Weiwu road, Jinshui District, Zhengzhou, 450003, China.
| | - Wen Zhao
- Zhengzhou University School of Pharmaceutical Sciences, Zhengzhou, 450003, Henan, China
| | - Xianpei Wang
- Department of Cardiology, Zhengzhou University People's Hospital, No.7 Weiwu road, Jinshui District, Zhengzhou, 450003, China
| | - Datun Qi
- Department of Cardiology, Zhengzhou University People's Hospital, No.7 Weiwu road, Jinshui District, Zhengzhou, 450003, China
| | - Lijie Zhu
- Department of Cardiology, Zhengzhou University People's Hospital, No.7 Weiwu road, Jinshui District, Zhengzhou, 450003, China
| | - Xiaohang Yang
- Department of Cardiology, Zhengzhou University People's Hospital, No.7 Weiwu road, Jinshui District, Zhengzhou, 450003, China
| | - Binbin Zhu
- Department of Cardiology, Zhengzhou University People's Hospital, No.7 Weiwu road, Jinshui District, Zhengzhou, 450003, China
| | - Yahui Liu
- Department of Cardiology, Zhengzhou University People's Hospital, No.7 Weiwu road, Jinshui District, Zhengzhou, 450003, China
| |
Collapse
|
11
|
Táborský M, Richter D, Tonar Z, Kubíková T, Herman A, Peregrin J, Husková Z, Kopkan L. Evaluation of later morphologic alterations in renal artery wall and renal nerves in response to catheter-based renal denervation in sheep: comparison of the single-point and multiple-point ablation catheters. Physiol Res 2018; 67:891-901. [PMID: 30204473 DOI: 10.33549/physiolres.933903] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
This study evaluated the subacute morphologic alterations in renal artery wall and renal nerves in response to catheter-based renal denervation (RDN) in sheep and also compared the efficiency of single-point and multiple-point ablation catheters. Effect of each ablation catheter approved for the clinical use (Symplicity Flex(TM), Medtronic, Inc., or EnligHTN(TM), St. Jude Medical, INC.) was compared to intact contralateral renal artery in 12 sheep by histopathology and immunohistochemistry evaluation after a 10-day period post-RDN procedure. The safety was verified by extensive evaluation of kidney morphology. Vascular wall lesions and nerve injuries were more pronounced in those animals treated with multi-point EnligHTN catheter when compared with animals treated with single-point Symplicity Flex catheter. However, neither RDN procedure led to complete renal nerve ablation. Both systems, tested in the present study, provided only incomplete renal nerve ablation in sheep. Moreover, no appreciable progression of the nerve disintegration in subacute phase post-RDN procedure was observed. This study further supports the notion that the effectiveness remains fully dependent on anatomical inter-individual variability of the sympathetic nerve plexus accompanying the renal artery. Therefore, new systems providing deeper penetrance to targeted perivascular structure would be more efficient.
Collapse
Affiliation(s)
- M Táborský
- Department of Internal Medicine I, Cardiology, University Hospital Olomouc and Palacký University, Olomouc, Czech Republic.
| | | | | | | | | | | | | | | |
Collapse
|
12
|
Kataoka Y, Delacroix S, Sidharta S, Andrews J, Nicholls SJ, Tsioufis CP, Papademetriou V, Worthley SG. Serial changes in vessel walls of renal arteries after catheter-based renal artery denervation: insights from volumetric computed tomography analysis. Int J Nephrol Renovasc Dis 2018; 11:259-266. [PMID: 30310302 PMCID: PMC6166743 DOI: 10.2147/ijnrd.s161313] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Aim Radiofrequency ablation of peri-arterial renal autonomic nerves has been studied as a potential therapeutic option for resistant hypertension. While recent clinical trials have reported its efficacy, there is paucity of data addressing the effects of the procedure on renal arteries, such as changes in vessel and lumen areas. Herein, the effect of atheroma burden on renal arteries after renal denervation was assessed using computed tomography (CT) imaging. Materials and methods Serial renal artery CT imaging was conducted in 38 patients from the EnligHTN™ I study, a prospective, multicenter study evaluating the efficacy of the EnligHTN multi-electrode radiofrequency ablation catheter in resistant hypertensive subjects. Cross-sectional images of renal arteries at 1 mm intervals were acquired using commercially available software (3mensio Structural Heart version 5.1). Vessel and lumen areas were manually traced in each image. Vessel wall volume (VWV) and percent vessel wall volume (P-VWV) were calculated. The measurements within the ablation (first 30 mm segments) and the non-ablation (subsequent 30 mm segment after the first bifurcation of renal arteries) zones were compared. Results On serial evaluation, greater increase in P-VWV and VWV was observed in the ablation zone (change in P-VWV, 6.7%±5.1% vs 3.6%±2.8%, P=0.001; change in VWV, 106.3±87.4 vs 23.0±18.2 mm3, P=0.001). Receiver-operating characteristic analysis demonstrated baseline P-VWV in the ablation zone >37.1% as an optimal cutoff value to predict its substantial progression after the procedure (area under the curve=0.88, sensitivity 89.8%, specificity 79.1%). Conclusion Change in vessel wall was greater within the segments receiving renal artery denervation. Baseline VWV predicted its substantial increase after the procedure. These observations suggest that atheroma burden within the renal arteries is a potential contributing factor to vascular changes after renal sympathetic denervation.
Collapse
Affiliation(s)
- Yu Kataoka
- Vascular Research Center, South Australian Health and Medical Research Institute, University of Adelaide, Adelaide, SA, Australia
| | - Sinny Delacroix
- Department of Medicine, Cardiovascular Research Center, Royal Adelaide Hospital, University of Adelaide, Adelaide, SA, Australia,
| | - Samuel Sidharta
- Department of Medicine, Cardiovascular Research Center, Royal Adelaide Hospital, University of Adelaide, Adelaide, SA, Australia,
| | - Jordan Andrews
- Vascular Research Center, South Australian Health and Medical Research Institute, University of Adelaide, Adelaide, SA, Australia
| | - Stephen J Nicholls
- Vascular Research Center, South Australian Health and Medical Research Institute, University of Adelaide, Adelaide, SA, Australia
| | - Costas P Tsioufis
- 1st Department of Cardiology, University of Athens, Hippokration Hospital, Athens, Greece
| | - Vasilios Papademetriou
- Center for hypertension, kidney and vascular research, VA and Georgetown University Medical Centers, Washington DC, USA
| | - Stephen G Worthley
- Department of Medicine, Cardiovascular Research Center, Royal Adelaide Hospital, University of Adelaide, Adelaide, SA, Australia,
| |
Collapse
|
13
|
de Jong MR, Hoogerwaard AF, Adiyaman A, Smit JJJ, Ramdat Misier AR, Heeg JE, van Hasselt BAAM, Van Gelder IC, Crijns HJGM, Lozano IF, Toquero Ramos JE, Javier Alzueta F, Ibañez B, Rubio JM, Arribas F, Porres Aracama JM, Brugada J, Mont L, Elvan A. Treatment of atrial fibrillation in patients with enhanced sympathetic tone by pulmonary vein isolation or pulmonary vein isolation and renal artery denervation: clinical background and study design : The ASAF trial: ablation of sympathetic atrial fibrillation. Clin Res Cardiol 2018; 107:539-547. [PMID: 29487995 DOI: 10.1007/s00392-018-1214-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 02/08/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Hypertension is an important, modifiable risk factor for the development of atrial fibrillation (AF). Even after pulmonary vein isolation (PVI), 20-40% experience recurrent AF. Animal studies have shown that renal denervation (RDN) reduces AF inducibility. One clinical study with important limitations suggested that RDN additional to PVI could reduce recurrent AF. OBJECTIVE The goal of this multicenter randomized controlled study is to investigate whether RDN added to PVI reduces AF recurrence. METHODS The main end point is the time until first AF recurrence according to EHRA guidelines after a blanking period of 3 months. Assuming a 12-month accrual period and 12 months of follow-up, a power of 0.80, a two-sided alpha of 0.05 and an expected drop-out of 10% per group, 69 patients per group are required. We plan to randomize a total of 138 hypertensive patients with AF and signs of sympathetic overdrive in a 1:1 fashion. Patients should use at least two antihypertensive drugs. Sympathetic overdrive includes obesity, exercise-induced excessive blood pressure (BP) increase, significant white coat hypertension, hospital admission or fever induced AF, tachycardia induced AF and diabetes mellitus. The interventional group will undergo PVI + RDN and the control group will undergo PVI. RESULTS Patients will have follow-up for 1 year, and continuous loop monitoring is advocated. CONCLUSION This randomized, controlled study will elucidate if RDN on top of PVI reduces AF recurrence.
Collapse
Affiliation(s)
- Mark R de Jong
- Department of Cardiology, Isala Hospital, Zwolle, The Netherlands
| | | | - Ahmet Adiyaman
- Department of Cardiology, Isala Hospital, Zwolle, The Netherlands
| | - Jaap Jan J Smit
- Department of Cardiology, Isala Hospital, Zwolle, The Netherlands
| | | | - Jan-Evert Heeg
- Department of Internal Medicine, Isala Hospital, Zwolle, The Netherlands
| | | | | | - Harry J G M Crijns
- Department of Cardiology, Maastricht Universitair Medisch Centrum, Maastricht, The Netherlands
| | - Ignacio Fernández Lozano
- Department of Arrhythmia Unit, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - Jorge E Toquero Ramos
- Department of Arrhythmia Unit, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - F Javier Alzueta
- Department of Arrhythmia Unit, Hospital Universitario Virgen de la Victoria, Málaga, Spain
| | - Borja Ibañez
- Department of Cardiology, Hospital Fundación Jimenez Díaz, Madrid, Spain
| | - José M Rubio
- Department of Cardiology, Hospital Fundación Jimenez Díaz, Madrid, Spain
| | - Fernando Arribas
- Department of Cardiology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | | | - Josep Brugada
- Arrhythmia Unit, Cardiovascular Institute, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Lluís Mont
- Arrhythmia Unit, Cardiovascular Institute, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Arif Elvan
- Department of Cardiology, Isala Hospital, Zwolle, The Netherlands.
| |
Collapse
|
14
|
Sakaoka A, Takami A, Onimura Y, Hagiwara H, Terao H, Kumagai F, Matsumura K. Acute changes in histopathology and intravascular imaging after catheter-based renal denervation in a porcine model. Catheter Cardiovasc Interv 2017. [PMID: 28639746 PMCID: PMC6585757 DOI: 10.1002/ccd.27158] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES We first aimed to identify the histopathological changes occurring immediately after renal denervation (RDN) with radiofrequency energy, and then to assess the feasibility of determining procedural success using currently available clinical intravascular imaging techniques. BACKGROUND Catheter-based RDN has been used as an alternative therapy for hypertension. However, no practical endpoint to determine procedural success during treatment has been established. METHODS A total of 39 ablation lesions were induced in vivo in eight porcine renal arteries and a total of 15 ablation lesions were induced ex vivo in five excised porcine renal arteries with a radiofrequency delivery device. Acute histological changes and appearance on intravascular imaging of the lesions were investigated with light microscopy, transmission electron microscopy, intravascular ultrasound (IVUS), and optical frequency domain imaging (OFDI). RESULTS Marked changes were noted in media, adventitia, and perirenal-arterial nerves immediately after in vivo ablation. Changes visualized on IVUS were characterized by focal adventitial thickening comprising a relatively echogenic layer around a heterogeneously hypoechoic interior region, and on OFDI as disappearance of the external elastic membrane signals with high scattering of signals in the surface layer. The changes after ex vivo ablation were histopathologically identical to those from in vivo ablation. There were statistically significant positive correlations in measured dimensions (area, depth, width, and diameter) of ablation lesions between histopathology and IVUS/OFDI findings (Pearson correlation coefficients = 0.69-0.77). CONCLUSIONS These findings suggest that observation of treated renal arteries by IVUS or OFDI immediately after RDN improves the success rate of RDN.
Collapse
Affiliation(s)
- Atsushi Sakaoka
- R&D Headquarters, Terumo Corporation, Tokyo, Japan.,Graduate School of Engineering, Osaka Institute of Technology, Osaka, Japan
| | - Akiyuki Takami
- Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Yuji Onimura
- R&D Headquarters, Terumo Corporation, Tokyo, Japan
| | | | - Hisako Terao
- R&D Headquarters, Terumo Corporation, Tokyo, Japan
| | - Fumiaki Kumagai
- Laboratory of Safety Evaluation, Division of Safety, Hatano Research Institute, Food and Drug Safety Center, Kanagawa, Japan
| | - Kiyoshi Matsumura
- Graduate School of Engineering, Osaka Institute of Technology, Osaka, Japan
| |
Collapse
|
15
|
Bönner F, Haberkorn S, Behm P, Schnackenburg B, Krüger S, Weiss S, Meyer C, Kelm M, Neizel-Wittke M. Magnetic resonance guided renal denervation using active tracking: first in vivo experience in Swine. Int J Cardiovasc Imaging 2017; 34:431-439. [DOI: 10.1007/s10554-017-1244-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 09/08/2017] [Indexed: 10/18/2022]
|
16
|
Abstract
Hypertension continues to be a major contributor to global morbidity and mortality, fuelled by an abundance of patients with uncontrolled blood pressure despite the multitude of pharmacological options available. This may occur as a consequence of true resistant hypertension, through an inability to tolerate current pharmacological therapies, or non-adherence to antihypertensive medication. In recent years, there has been a rapid expansion of device-based therapies proposed as novel non-pharmacological approaches to treating resistant hypertension. In this review, we discuss seven novel devices—renal nerve denervation, baroreflex activation therapy, carotid body ablation, central iliac arteriovenous anastomosis, deep brain stimulation, median nerve stimulation, and vagal nerve stimulation. We highlight how the devices differ, the varying degrees of evidence available to date and upcoming trials. This review also considers the possible factors that may enable appropriate device selection for different hypertension phenotypes.
Collapse
Affiliation(s)
- Fu L Ng
- Barts BP Centre of Excellence, Barts Heart Centre, St Bartholomew's Hospital, W Smithfield, London, EC1A 7BE, UK.,Barts NIHR Cardiovascular Biomedical Research Unit, Charterhouse Square, William Harvey Research Institute, Queen Mary University London, London, EC1M 6BQ, UK
| | - Manish Saxena
- Barts BP Centre of Excellence, Barts Heart Centre, St Bartholomew's Hospital, W Smithfield, London, EC1A 7BE, UK.,Barts NIHR Cardiovascular Biomedical Research Unit, Charterhouse Square, William Harvey Research Institute, Queen Mary University London, London, EC1M 6BQ, UK
| | - Felix Mahfoud
- Department of Internal Medicine, Cardiology, Angiology, Intensive Care Medicine, Saarland University Hospital, Homburg/Saar, Germany
| | - Atul Pathak
- Department of Cardiovascular Medicine, Hypertension and Heart Failure Unit, Health Innovation Lab (Hi-Lab) Clinique Pasteur, Toulouse, France
| | - Melvin D Lobo
- Barts BP Centre of Excellence, Barts Heart Centre, St Bartholomew's Hospital, W Smithfield, London, EC1A 7BE, UK. .,Barts NIHR Cardiovascular Biomedical Research Unit, Charterhouse Square, William Harvey Research Institute, Queen Mary University London, London, EC1M 6BQ, UK.
| |
Collapse
|
17
|
Changes in renal artery dimensions are associated with clinical response to radiofrequency renal denervation: a series of studies using quantitative angiography and intravascular ultrasound. J Hypertens 2017; 35:2069-2076. [PMID: 28505064 DOI: 10.1097/hjh.0000000000001409] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Renal denervation (RDN) can cause focal (notches) and global (spasms) changes in renal artery dimensions. We quantified these changes and related them to renal norepinephrin tissue content in animals and to blood pressure (BP) changes in patients. METHODS We measured renal artery dimensions pre-RDN and post-RDN, utilizing quantitative renal angiography (QRA) in a porcine model and in a retrospective patient cohort, and intravascular ultrasound (IVUS) in a prospective patient cohort. Focal and global measurements were minimum and mean diameter/area/volume with QRA, minimum lumen/vessel/wall area and volume with IVUS. BP was assessed with 24-h ambulatory monitoring, norepinephrin content with liquid chromatography. RESULTS In 36 pigs treated unilaterally with RDN, norepinephrin content of the treated right kidney was 48.2% of the untreated left kidney. QRA measurements following RDN were associated with norepinephrin content only of the (treated) right kidney. In the human QRA study (n = 43 patients), mean 24-h BP fell by 8/4 and 12/6 mmHg at 1 and 12 months, respectively. More pronounced changes in QRA measurements were associated with a more pronounced BP drop. In multiple regression models, the change in minimum diameter was independently associated with BP changes at 12 months. In the prospective IVUS study (n = 17 patients), a larger decrease in minimum lumen/vessel area and larger increase of wall area/volume were associated with a larger BP drop. CONCLUSION Focal and global changes in renal arteries following RDN can be quantified, using QRA or IVUS, and may serve as markers of a successful procedure.
Collapse
|
18
|
Ellenbroek GHJM, van Hout GPJ, de Jager SCA, Timmers L, Vink A, Goldschmeding R, van der Kraak P, Pasterkamp G, Hoefer IE, Doevendans PA, Appelman Y. Radiofrequency Ablation of the Atherosclerotic Plaque: a Proof of Concept Study in an Atherosclerotic Model. J Cardiovasc Transl Res 2017; 10:221-232. [PMID: 28364193 PMCID: PMC5437141 DOI: 10.1007/s12265-017-9743-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 03/21/2017] [Indexed: 01/28/2023]
Abstract
Increased plaque vascularization is causatively associated with the progression of unstable atherosclerotic vessel disease. We investigated the safety and efficacy of heat-generating radiofrequency ablation (RFA) in reducing the number of vessels in the plaque and adventitia and its effect on plaque size and composition. To this end, New Zealand White rabbits were fed a cholesterol-enriched diet and subjected to balloon denudation of the infrarenal aorta to induce atherosclerotic plaque formation. After 13 weeks, the proximal or distal half of the infrarenal aorta was exposed to transluminal RFA. The untreated half served as an intra-individual control. Optical coherence tomography (OCT) was performed directly after RFA. We found that RFA on the rabbit atherosclerotic plaque is safe and leads to decreased intraplaque vessel density and smooth muscle cell content but does not affect other components of plaque composition or size.
Collapse
MESH Headings
- Angioplasty, Balloon
- Animals
- Aorta, Abdominal/diagnostic imaging
- Aorta, Abdominal/pathology
- Aorta, Abdominal/surgery
- Aortic Diseases/diagnostic imaging
- Aortic Diseases/etiology
- Aortic Diseases/pathology
- Aortic Diseases/surgery
- Aortography
- Atherosclerosis/diagnostic imaging
- Atherosclerosis/etiology
- Atherosclerosis/pathology
- Atherosclerosis/surgery
- Catheter Ablation
- Cholesterol, Dietary
- Diet, High-Fat
- Disease Models, Animal
- Male
- Muscle, Smooth, Vascular/pathology
- Muscle, Smooth, Vascular/surgery
- Myocytes, Smooth Muscle/pathology
- Neovascularization, Pathologic
- Plaque, Atherosclerotic
- Proof of Concept Study
- Rabbits
- Time Factors
- Tomography, Optical Coherence
Collapse
Affiliation(s)
- Guilielmus H J M Ellenbroek
- Laboratory of Experimental Cardiology, University Medical Center Utrecht, Heidelberglaan 100, Internal mail no G03.550, 3508 GA, Utrecht, The Netherlands.
| | - Gerardus P J van Hout
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Saskia C A de Jager
- Laboratory of Experimental Cardiology, University Medical Center Utrecht, Heidelberglaan 100, Internal mail no G03.550, 3508 GA, Utrecht, The Netherlands
| | - Leo Timmers
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Aryan Vink
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Roel Goldschmeding
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Petra van der Kraak
- Laboratory of Experimental Cardiology, University Medical Center Utrecht, Heidelberglaan 100, Internal mail no G03.550, 3508 GA, Utrecht, The Netherlands
| | - Gerard Pasterkamp
- Department of Clinical Chemistry and Hematology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Imo E Hoefer
- Laboratory of Experimental Cardiology, University Medical Center Utrecht, Heidelberglaan 100, Internal mail no G03.550, 3508 GA, Utrecht, The Netherlands
- Department of Clinical Chemistry and Hematology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Petrus A Doevendans
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
- Netherlands Heart Institute, Utrecht, The Netherlands
| | - Yolande Appelman
- Department of Cardiology, VU Medical Center, Amsterdam, The Netherlands
| |
Collapse
|
19
|
Beeftink MMA, Spiering W, De Jong MR, Doevendans PA, Blankestijn PJ, Elvan A, Heeg JE, Bots ML, Voskuil M. Renal denervation beyond the bifurcation: The effect of distal ablation placement on safety and blood pressure. J Clin Hypertens (Greenwich) 2017; 19:371-378. [DOI: 10.1111/jch.12989] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 11/13/2016] [Accepted: 11/19/2016] [Indexed: 01/09/2023]
Affiliation(s)
| | - Wilko Spiering
- Department of Vascular Medicine; University Medical Center Utrecht; Utrecht the Netherlands
| | - Mark R. De Jong
- Department of Cardiology; Isala Hospital; Zwolle the Netherlands
| | - Pieter A. Doevendans
- Department of Cardiology; University Medical Center Utrecht; Utrecht the Netherlands
| | - Peter J. Blankestijn
- Department of Nephrology; University Medical Center Utrecht; Utrecht the Netherlands
| | - Arif Elvan
- Department of Cardiology; Isala Hospital; Zwolle the Netherlands
| | - Jan-Evert Heeg
- Department of Internal Medicine; Isala Hospital; Zwolle the Netherlands
| | - Michiel L. Bots
- Julius Center for Health Sciences and Primary Care; University Medical Center Utrecht; Utrecht the Netherlands
| | - Michiel Voskuil
- Department of Cardiology; University Medical Center Utrecht; Utrecht the Netherlands
| |
Collapse
|
20
|
Bertog S, Fischel T, Vega F, Ghazarossian V, Pathak A, Vaskelyte L, Kent D, Sievert H, Ladich E, Yahagi K, Virmani R. Randomised, blinded and controlled comparative study of chemical and radiofrequency-based renal denervation in a porcine model. EUROINTERVENTION 2017; 12:e1898-e1906. [DOI: 10.4244/eij-d-16-00206] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
|
21
|
Chen W, Du H, Lu J, Ling Z, Long Y, Xu Y, Xiao P, Gyawali L, Woo K, Yin Y, Zrenner B. Renal Artery Vasodilation May Be An Indicator of Successful Sympathetic Nerve Damage During Renal Denervation Procedure. Sci Rep 2016; 6:37218. [PMID: 27849014 PMCID: PMC5110962 DOI: 10.1038/srep37218] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Accepted: 10/26/2016] [Indexed: 12/23/2022] Open
Abstract
Autonomic nervous system plays a crucial role in maintaining and regulating vessel tension. Renal denervation (RDN) may induce renal artery vasodilation by damaging renal sympathetic fibers. We conducted this animal study to evaluate whether renal artery vasodilation could be a direct indicator of successful RDN. Twenty-eight Chinese Kunming dogs were randomly assigned into three groups and underwent RDN utilizing temperature-controlled catheter (group A, n = 11) or saline-irrigated catheter (group B, n = 11) or sham procedure (group C, n = 6). Renal angiography, blood pressure (BP) and renal artery vasodilation measurements were performed at baseline, 30-minute, 1-month, and 3-month after interventions. Plasma norepinephrine concentrations were tested at baseline and 3-month after intervention. Results showed that, in addition to significant BP reduction, RDN induced significant renal artery vasodilation. Correlation analyses showed that the induced renal artery vasodilation positively correlated with SBP reduction and plasma norepinephrine reduction over 3 months after ablation. Post hoc analyses showed that saline-irrigated catheter was superior to TC catheter in renal artery vasodilation, especially for the acute dilatation of renal artery at 30-minute after RDN. In conclusion, renal artery vasodilation, induced by RDN, may be a possible indicator of successful renal nerve damage and a predictor of blood pressure response to RDN.
Collapse
Affiliation(s)
- Weijie Chen
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing Cardiac Arrhythmias Therapeutic Service Center, Chongqing, China
| | - Huaan Du
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing Cardiac Arrhythmias Therapeutic Service Center, Chongqing, China
| | - Jiayi Lu
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing Cardiac Arrhythmias Therapeutic Service Center, Chongqing, China
| | - Zhiyu Ling
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing Cardiac Arrhythmias Therapeutic Service Center, Chongqing, China
| | - Yi Long
- Department of Cardiolgy, Chongqing Province Hospital of Traditional Chinese Medicine, Chongqing, China
| | - Yanping Xu
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing Cardiac Arrhythmias Therapeutic Service Center, Chongqing, China
| | - Peilin Xiao
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing Cardiac Arrhythmias Therapeutic Service Center, Chongqing, China
| | - Laxman Gyawali
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing Cardiac Arrhythmias Therapeutic Service Center, Chongqing, China
| | - Kamsang Woo
- School of Life Sciences, the Chinese University of Hong Kong, Hong Kong, China
| | - Yuehui Yin
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing Cardiac Arrhythmias Therapeutic Service Center, Chongqing, China
| | - Bernhard Zrenner
- Medizinische Klinik I, Krankenhaus Landshut-Achdorf, Landshut, Germany
| |
Collapse
|
22
|
A Perspective on the Delivery of Renal Denervation Therapy Based on Pre-Clinical Data. JACC Basic Transl Sci 2016; 1:288-295. [PMID: 30167517 PMCID: PMC6113343 DOI: 10.1016/j.jacbts.2016.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 03/22/2016] [Accepted: 03/28/2016] [Indexed: 11/24/2022]
|
23
|
Erne P, Sudano I, Resink TJ, Lüscher TF. Interventional therapy for hypertension: Back on track again? Crit Rev Clin Lab Sci 2016; 54:18-25. [PMID: 27282628 DOI: 10.1080/10408363.2016.1194367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Treatment-resistant hypertension, or resistant hypertension, is defined as blood pressure that remains above target despite concurrent use of at least three antihypertensive agents from different classes at optimal doses, one of which should be a diuretic. Important considerations in the diagnosis of treatment-resistant hypertension include the exclusion of pseudoresistance and the evaluation of potential secondary causes of hypertension and of concomitant conditions that maintain high blood pressure. The ability to diagnose true treatment-resistant hypertension is important for selection of patients who may be appropriately treated with an invasive therapy. Currently, there are three interventional approaches to treat resistant hypertension, namely: (1) reduction of the activity of the sympathetic nervous system by renal nerve ablation, (2) stimulation of baroreceptors and (3) creation of a peripheral arterial venous anastomosis. This review focuses on the rationale behind these invasive approaches and the clinical results.
Collapse
Affiliation(s)
- Paul Erne
- a Department of Biomedicine , Basel University Hospital , Basel , Switzerland and
| | - Isabella Sudano
- b Cardiology, University Heart Center, University Hospital Zurich , Zurich , Switzerland
| | - Therese J Resink
- a Department of Biomedicine , Basel University Hospital , Basel , Switzerland and
| | - Thomas F Lüscher
- b Cardiology, University Heart Center, University Hospital Zurich , Zurich , Switzerland
| |
Collapse
|
24
|
Sanders MF, Blankestijn PJ. Chronic Kidney Disease As a Potential Indication for Renal Denervation. Front Physiol 2016; 7:220. [PMID: 27375498 PMCID: PMC4896963 DOI: 10.3389/fphys.2016.00220] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Accepted: 05/26/2016] [Indexed: 01/08/2023] Open
Abstract
Renal denervation is being used as a blood pressure lowering therapy for patients with apparent treatment resistant hypertension. However, this population does not represent a distinct disease condition in which benefit is predictable. In fact, the wide range in effectiveness of renal denervation could be a consequence of this heterogeneous pathogenesis of hypertension. Since renal denervation aims at disrupting sympathetic nerves surrounding the renal arteries, it seems obvious to focus on patients with increased afferent and/or efferent renal sympathetic nerve activity. In this review will be argued, from both a pathophysiological and a clinical point of view, that chronic kidney disease is particularly suited to renal denervation.
Collapse
Affiliation(s)
- Margreet F Sanders
- Department of Nephrology and Hypertension, University Medical Centre Utrecht Utrecht, Netherlands
| | - Peter J Blankestijn
- Department of Nephrology and Hypertension, University Medical Centre Utrecht Utrecht, Netherlands
| |
Collapse
|
25
|
Silva JD, Costa M, Gersh BJ, Gonçalves L. Renal denervation in the era of HTN-3. Comprehensive review and glimpse into the future. ACTA ACUST UNITED AC 2016; 10:656-70. [PMID: 27319336 DOI: 10.1016/j.jash.2016.05.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2016] [Revised: 05/16/2016] [Accepted: 05/24/2016] [Indexed: 12/17/2022]
Abstract
The pathophysiological role of sympathetic overactivity in conditions such as hypertension has been well documented. Catheter-based renal denervation (RDN) is a minimally invasive percutaneous procedure which aims to disrupt sympathetic nerve afferent and efferent activity through the application of radiofrequency energy directly within the renal artery wall. This technique has emerged as a very promising treatment with dramatic effects on refractory hypertension but also in other conditions in which a sympathetic influence is present. Several studies have evaluated the safety and efficacy of this procedure, presently surrounded by controversy since the recent outcome of Symplicity HTN-3, the first randomized, sham-control trial, which failed to confirm RDN previous reported benefits on BP and cardiovascular risk lowering. Consequently, although some centers halted their RDN programs, research continues and both the concept of denervation and treatment strategies are being redefined to identify patients who can drive the most benefit from this technology. In the United States, the Food and Drug Administration (FDA) has appropriately mandated that RDN remains an investigative procedure and a new generation of sham-controlled trials are ongoing and aimed to assess not only its efficacy against pharmacotherapy but also trials in drug free patients with the objective of demonstrating once and for all whether the procedure actually does lower BP in comparison to a placebo arm. In this article, we present an overview of the sympathetic nervous system and its role in hypertension, examine the current data on RDN, and share some insights and future expectations.
Collapse
Affiliation(s)
- Joana Delgado Silva
- Faculty of Medicine, University of Coimbra, Portugal; Department of Cardiology, Coimbra's Hospital and University Centre, General Hospital, Coimbra, Portugal.
| | - Marco Costa
- Department of Cardiology, Coimbra's Hospital and University Centre, General Hospital, Coimbra, Portugal
| | - Bernard J Gersh
- Division of Cardiovascular Diseases, Mayo Clinic and Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Lino Gonçalves
- Faculty of Medicine, University of Coimbra, Portugal; Department of Cardiology, Coimbra's Hospital and University Centre, General Hospital, Coimbra, Portugal
| |
Collapse
|
26
|
Chen W, Ling Z, Du H, Song W, Xu Y, Liu Z, Su L, Xiao P, Yuan Y, Lu J, Zhang J, Li Z, Shao J, Zhong B, Zhou B, Woo K, Yin Y. The effect of two different renal denervation strategies on blood pressure in resistant hypertension: Comparison of full-length versus proximal renal artery ablation. Catheter Cardiovasc Interv 2016; 88:786-795. [PMID: 27219520 DOI: 10.1002/ccd.26594] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Revised: 03/07/2016] [Accepted: 05/01/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND Renal denervation (RDN) is used to manage blood pressure (BP) in patients with resistant hypertension (rHT), but effectiveness is still a concern, and key arterial portion for successful RDN is not clear. OBJECTIVE The aim of this study was to investigate the efficacy and safety of proximal versus full-length renal artery ablation in patients with resistant hypertension (rHT). METHODS Forty-seven patients with rHT were randomly assigned to receive full-length ablation (n = 23) or proximal ablation (n = 24) of the renal arteries. All lesions were treated with radiofrequency energy via a saline-irrigated catheter. Office BP was measured during 12 months of follow-up and ambulatory BP at baseline and 6 months (n = 15 in each group). RESULTS Compared with full-length ablation, proximal ablation reduced the number of ablation points in both the right (6.1 ± 0.7 vs. 3.3 ± 0.6, P < 0.001) and the left renal arteries (6.2 ± 0.7 vs. 3.3 ± 0.8, P < 0.001), with significantly shorter RF delivery time (P < 0.001), but higher RF power (P = 0.011). Baseline office BPs was 179.4 ± 13.7/102.8 ± 9.4 mm Hg in the full-length group and 181.9 ± 12.8/103.5 ± 8.9 mm Hg in the proximal group (P > 0.5). Similar office BPs was reduced by -39.4 ± 11.5/-20.9 ± 7.1 mm Hg at 6 months and -38.2 ± 10.3/-21.5 ± 5.8 mm Hg at 12 months in the full-length group (P < 0.001), -42.0 ± 11.6/-21.4 ± 7.9 mm Hg at 6 months and -40.9 ± 10.3/-22.1 ± 5.6 mm Hg at 12 months in the proximal group (P < 0.001), and progressive BP reductions were observed over the 6 months (P < 0.001) in both groups. The drop in ambulatory 24-hr SBP and DBP were significantly less than the drop in office BP (P < 0.001). No renovascular or other adverse complications were observed. CONCLUSIONS The results indicate that proximal RDN has a similar efficacy and safety profile compared with full-length RDN, and propose the proximal artery as the key portion for RDN. © 2016 Wiley Periodicals, Inc.
Collapse
Affiliation(s)
- Weijie Chen
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhiyu Ling
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Huaan Du
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wenxin Song
- Department of Cardiology, Chongqing Dazu District People's Hospital, Chongqing, China
| | - Yanping Xu
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zengzhang Liu
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Li Su
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Peilin Xiao
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yuelong Yuan
- Department of Cardiology, Chongqing Yongchuan District People's Hospital, Chongqing, China
| | - Jiayi Lu
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jianhong Zhang
- Department of Cardiology, Chongqing Tongliang, Chinese Traditional Medicine Hospital, Chongqing, China
| | - Zhifeng Li
- Department of Cardiology, the Affiliated Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Jiang Shao
- Department of Cardiology, Chongqing Three Gorges Central Hospital, Chongqing, China
| | - Bin Zhong
- Department of Cardiology, Chongqing Fifth People's Hospital, Chongqing, China
| | - Bei Zhou
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Kamsang Woo
- School of Life Sciences, the Chinese University of Hong Kong, Hong Kong, China
| | - Yuehui Yin
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| |
Collapse
|
27
|
Karanasos A, Van Mieghem N, Bergmann MW, Hartman E, Ligthart J, van der Heide E, Heeger CH, Ouhlous M, Zijlstra F, Regar E, Daemen J. Multimodality Intra-Arterial Imaging Assessment of the Vascular Trauma Induced by Balloon-Based and Nonballoon-Based Renal Denervation Systems. Circ Cardiovasc Interv 2016; 8:e002474. [PMID: 26156150 DOI: 10.1161/circinterventions.115.002474] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Renal denervation is a new treatment considered for several possible indications. As new systems are introduced, the incidence of acute renal artery wall injury with relation to the denervation method is unknown. We investigated the acute repercussion of renal denervation on the renal arteries of patients treated with balloon-based and nonballoon-based denervation systems by quantitative angiography, intravascular ultrasound, and optical coherence tomography (OCT). METHODS AND RESULTS Twenty-five patients (50 renal arteries) underwent bilateral renal denervation with 5 different systems, 3 of which balloon-based (Paradise [n=5], Oneshot [n=6], and Vessix V2 [n=5)]) and 2 nonballoon-based (Symplicity [n=6] and EnligHTN [n=3]). Analysis included quantitative angiography and morphometric intravascular ultrasound measurements pre and post procedure and assessment of vascular trauma (dissection, edema, or thrombus) by OCT after denervation. A significant reduction in lumen size by quantitative angiography and intravascular ultrasound was observed in nonballoon denervation but not in balloon denervation. By postdenervation OCT, dissection was seen in 14 arteries (32.6%). The percentage of frames with dissection was higher in balloon-based denervation catheters. Thrombus and edema were detected in 35 (81.4%) and 32 (74.4%) arteries, respectively. In arteries treated with balloon-based denervation that had dissection by OCT, the balloon/artery ratio was higher (1.24 [1.17-1.32] versus 1.10 [1.04-1.18]; P<0.01). CONCLUSIONS A varying extent of vascular injury was observed after renal denervation in all systems; however, different patterns were identified in balloon-based and in nonballoon-based denervation systems. In balloon denervation, the presence of dissections by OCT was associated with a higher balloon/artery ratio.
Collapse
Affiliation(s)
- Antonios Karanasos
- From the Department of Interventional Cardiology, Thoraxcenter, Erasmus Medical Center (A.K., N.V.M., E.H., J.L., E.v.d.H., F.Z., E.R., J.D.), Department of Radiology (M.O.), Rotterdam, The Netherlands; and Department of Interventional Cardiology, St. Georg Asklepios Klinik, Hamburg, Germany (M.W.B., C.-H.H.)
| | - Nicolas Van Mieghem
- From the Department of Interventional Cardiology, Thoraxcenter, Erasmus Medical Center (A.K., N.V.M., E.H., J.L., E.v.d.H., F.Z., E.R., J.D.), Department of Radiology (M.O.), Rotterdam, The Netherlands; and Department of Interventional Cardiology, St. Georg Asklepios Klinik, Hamburg, Germany (M.W.B., C.-H.H.)
| | - Martin W Bergmann
- From the Department of Interventional Cardiology, Thoraxcenter, Erasmus Medical Center (A.K., N.V.M., E.H., J.L., E.v.d.H., F.Z., E.R., J.D.), Department of Radiology (M.O.), Rotterdam, The Netherlands; and Department of Interventional Cardiology, St. Georg Asklepios Klinik, Hamburg, Germany (M.W.B., C.-H.H.)
| | - Eline Hartman
- From the Department of Interventional Cardiology, Thoraxcenter, Erasmus Medical Center (A.K., N.V.M., E.H., J.L., E.v.d.H., F.Z., E.R., J.D.), Department of Radiology (M.O.), Rotterdam, The Netherlands; and Department of Interventional Cardiology, St. Georg Asklepios Klinik, Hamburg, Germany (M.W.B., C.-H.H.)
| | - Jurgen Ligthart
- From the Department of Interventional Cardiology, Thoraxcenter, Erasmus Medical Center (A.K., N.V.M., E.H., J.L., E.v.d.H., F.Z., E.R., J.D.), Department of Radiology (M.O.), Rotterdam, The Netherlands; and Department of Interventional Cardiology, St. Georg Asklepios Klinik, Hamburg, Germany (M.W.B., C.-H.H.)
| | - Elco van der Heide
- From the Department of Interventional Cardiology, Thoraxcenter, Erasmus Medical Center (A.K., N.V.M., E.H., J.L., E.v.d.H., F.Z., E.R., J.D.), Department of Radiology (M.O.), Rotterdam, The Netherlands; and Department of Interventional Cardiology, St. Georg Asklepios Klinik, Hamburg, Germany (M.W.B., C.-H.H.)
| | - Christian-H Heeger
- From the Department of Interventional Cardiology, Thoraxcenter, Erasmus Medical Center (A.K., N.V.M., E.H., J.L., E.v.d.H., F.Z., E.R., J.D.), Department of Radiology (M.O.), Rotterdam, The Netherlands; and Department of Interventional Cardiology, St. Georg Asklepios Klinik, Hamburg, Germany (M.W.B., C.-H.H.)
| | - Mohamed Ouhlous
- From the Department of Interventional Cardiology, Thoraxcenter, Erasmus Medical Center (A.K., N.V.M., E.H., J.L., E.v.d.H., F.Z., E.R., J.D.), Department of Radiology (M.O.), Rotterdam, The Netherlands; and Department of Interventional Cardiology, St. Georg Asklepios Klinik, Hamburg, Germany (M.W.B., C.-H.H.)
| | - Felix Zijlstra
- From the Department of Interventional Cardiology, Thoraxcenter, Erasmus Medical Center (A.K., N.V.M., E.H., J.L., E.v.d.H., F.Z., E.R., J.D.), Department of Radiology (M.O.), Rotterdam, The Netherlands; and Department of Interventional Cardiology, St. Georg Asklepios Klinik, Hamburg, Germany (M.W.B., C.-H.H.)
| | - Evelyn Regar
- From the Department of Interventional Cardiology, Thoraxcenter, Erasmus Medical Center (A.K., N.V.M., E.H., J.L., E.v.d.H., F.Z., E.R., J.D.), Department of Radiology (M.O.), Rotterdam, The Netherlands; and Department of Interventional Cardiology, St. Georg Asklepios Klinik, Hamburg, Germany (M.W.B., C.-H.H.)
| | - Joost Daemen
- From the Department of Interventional Cardiology, Thoraxcenter, Erasmus Medical Center (A.K., N.V.M., E.H., J.L., E.v.d.H., F.Z., E.R., J.D.), Department of Radiology (M.O.), Rotterdam, The Netherlands; and Department of Interventional Cardiology, St. Georg Asklepios Klinik, Hamburg, Germany (M.W.B., C.-H.H.).
| |
Collapse
|
28
|
Effects of Renal Denervation on Renal Artery Function in Humans: Preliminary Study. PLoS One 2016; 11:e0150662. [PMID: 27003912 PMCID: PMC4803336 DOI: 10.1371/journal.pone.0150662] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Accepted: 02/16/2016] [Indexed: 11/24/2022] Open
Abstract
Aim To study the effects of RD on renal artery wall function non-invasively using magnetic resonance. Methods and Results 32 patients undergoing RD were included. A 3.0 Tesla magnetic resonance of the renal arteries was performed before RD and after 6-month. We quantified the vessel sharpness of both renal arteries using a quantitative analysis tool (Soap-Bubble®). In 17 patients we assessed the maximal and minimal cross-sectional area of both arteries, peak velocity, mean flow, and renal artery distensibility. In a subset of patients wall shear stress was assessed with computational flow dynamics. Neither renal artery sharpness nor renal artery distensibility differed significantly. A significant increase in minimal and maximal areas (by 25.3%, p = 0.008, and 24.6%, p = 0.007, respectively), peak velocity (by 16.9%, p = 0.021), and mean flow (by 22.4%, p = 0.007) was observed after RD. Wall shear stress significantly decreased (by 25%, p = 0.029). These effects were observed in blood pressure responders and non-responders. Conclusions RD is not associated with adverse effects at renal artery level, and leads to an increase in cross-sectional areas, velocity and flow and a decrease in wall shear stress.
Collapse
|
29
|
Andrea BR, Atié J, Desh S, Lurz P, Hindricks G. Safety and feasibility of transcatheter renal sympathetic denervation using different types of catheter and various radiofrequency settings. IJC HEART & VASCULATURE 2016; 11:35-42. [PMID: 28616523 PMCID: PMC5441361 DOI: 10.1016/j.ijcha.2016.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 03/04/2016] [Indexed: 10/26/2022]
Abstract
BACKGROUND To evaluate in vivo the feasibility and safety of renal sympathetic denervation (RSD) with different catheters and various radiofrequency protocols. METHODS AND RESULTS Twenty-two pigs were included. First 2 pigs were enrolled in a feasibility protocol using one catheter and power from 5 W to 20 W. The next 10 pigs underwent RSD with three different catheters and four different RF-power settings of 5 W, 8 W, 10 W and 12 W in one minute per lesion (Protocol 1). The following 10 (Pigs 13 to 22) underwent RSD with five types of catheters (including the Symplicity® catheter), powers of 8 W and 10 W and two minutes RF-application (Protocol 2). Angiographic data were obtained at baseline, during and after RSD. At last, renal arteries were excised and analyzed macroscopically. The first pig developed severe renal stenoses with lesions of 15 to 20 W correlated with macroscopic alterations. The second feasibility pig did not develop renal stenosis with 5 and 8 W. In Protocol 1 from 60 RF-lesions, we observed 7 stenoses (≥ 30%). Three were severe (one of 80% with 10 W and two of 80% with 12 W). In Protocol 2 from 57 lesions we observed only 1 stenosis of 50% with 8 W with Symplicity® catheter. Severe stenosis was not observed. CONCLUSION In this study, renal sympathetic denervation showed safety using five types of catheters when applying RF-energy less than 10 W, within main stems of arteries larger than 3.0 mm diameter and a distance between lesions of at least 1 time catheter tip length.
Collapse
Affiliation(s)
- Bruno Rustum Andrea
- Electrophysiology Department, Heart Center Leipzig, Leipzig, Sachsen, Germany.,Electrophysiology Department, Clementino Fraga Filho University Hospital - UFRJ, Rio de Janeiro, RJ, Brazil
| | - Jacob Atié
- Electrophysiology Department, Clementino Fraga Filho University Hospital - UFRJ, Rio de Janeiro, RJ, Brazil
| | - Steffen Desh
- Cardiology Department, Heart Center Leipzig, Leipzig, Sachsen, Germany
| | - Phillip Lurz
- Cardiology Department, Heart Center Leipzig, Leipzig, Sachsen, Germany
| | - Gerhard Hindricks
- Electrophysiology Department, Heart Center Leipzig, Leipzig, Sachsen, Germany
| |
Collapse
|
30
|
Roleder T, Skowerski M, Wiecek A, Adamczak M, Czerwienska B, Wanha W, Jadczyk T, Partyka L, Smolka G, Kuczmik W, Ochała A, Dudek D, Tendera M, Gasior Z, Wojakowski W. Long-term follow-up of renal arteries after radio-frequency catheter-based denervation using optical coherence tomography and angiography. Int J Cardiovasc Imaging 2016; 32:855-62. [PMID: 26883432 DOI: 10.1007/s10554-016-0853-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 02/08/2016] [Indexed: 11/30/2022]
Abstract
Optical coherence tomography (OCT) imaging at the time of renal denervation (RDN) showed that procedure might cause spasm, intimal injury or thrombus formation. In the present study, we assessed the healing of renal arteries after RDN using OCT and renal angiography in long-term follow-up. OCT and renal angiography were performed in 12 patients (22 arteries) 18.41 ± 5.83 months after RNS. There were no adverse events or complications during the long-term follow-up. In ten patients (83 %), significant reductions of blood pressure was achieved without a change of the antihypertensive medications. We demonstrated the presence of 26 areas of focal intimal thickening identified by OCT in 10 (83 %) patients and in 14 (63 %) arteries. The mean area of focal intimal thickening was 0.054 ± 0.033 mm(2). No vessel dissection, thrombus, intimal tear or acute vasospasm were observed during the OCT analysis. Also, the quantitative angiography analysis revealed a significant reduction of the minimal and proximal lumen diameters at follow-up as compared to measurements obtained before RDN. Renal arteries have a favorable "long-term" vessel healing response after RDN. Focal intimal thickening and a modest reduction of the minimal lumen diameter may be observed after RF denervation. Further studies are needed to determine whether intravascular imaging may be helpful in evaluating the vessel healing of RF RDN.
Collapse
Affiliation(s)
- Tomasz Roleder
- Chair and Department of Cardiology, Medical University of Silesia, 45/47 Ziolowa Street, 40-635, Katowice, Poland.
| | - Mariusz Skowerski
- Chair and Department of Cardiology, Medical University of Silesia, 45/47 Ziolowa Street, 40-635, Katowice, Poland
| | - Andrzej Wiecek
- Department of Nephrology, Transplantology, and Internal Diseases, Medical University of Silesia, 45/47 Ziolowa Street, 40-635, Katowice, Poland
| | - Marcin Adamczak
- Department of Nephrology, Transplantology, and Internal Diseases, Medical University of Silesia, 45/47 Ziolowa Street, 40-635, Katowice, Poland
| | - Beata Czerwienska
- Department of Nephrology, Transplantology, and Internal Diseases, Medical University of Silesia, 45/47 Ziolowa Street, 40-635, Katowice, Poland
| | - Wojciech Wanha
- Third Department of Cardiology, Medical University of Silesia, 45/47 Ziolowa Street, 40-635, Katowice, Poland
| | - Tomasz Jadczyk
- Third Department of Cardiology, Medical University of Silesia, 45/47 Ziolowa Street, 40-635, Katowice, Poland
| | - Lukasz Partyka
- Krakow Cardiovascular Research Institute, 5 Miechowska Street, 30-055, Krakow, Poland
| | - Grzegorz Smolka
- Third Department of Cardiology, Medical University of Silesia, 45/47 Ziolowa Street, 40-635, Katowice, Poland
| | - Wacław Kuczmik
- Division of Vascular Surgery, Medical University of Silesia, 45/47 Ziolowa Street, 40-635, Katowice, Poland
| | - Andrzej Ochała
- Third Department of Cardiology, Medical University of Silesia, 45/47 Ziolowa Street, 40-635, Katowice, Poland
| | - Dariusz Dudek
- Institute of Cardiology, Jagiellonian University Medical College, 80 Pradnicka Street, 31-202, Krakow, Poland
| | - Michał Tendera
- Third Department of Cardiology, Medical University of Silesia, 45/47 Ziolowa Street, 40-635, Katowice, Poland
| | - Zbigniew Gasior
- Chair and Department of Cardiology, Medical University of Silesia, 45/47 Ziolowa Street, 40-635, Katowice, Poland
| | - Wojciech Wojakowski
- Third Department of Cardiology, Medical University of Silesia, 45/47 Ziolowa Street, 40-635, Katowice, Poland
| |
Collapse
|
31
|
Koopmann M, Shea J, Kholmovski E, de Bever J, Minalga E, Holbrook M, Merrill R, Hadley JR, Owan T, Salama ME, Marrouche NF, Payne A. Renal sympathetic denervation using MR-guided high-intensity focused ultrasound in a porcine model. J Ther Ultrasound 2016; 4:3. [PMID: 26848390 PMCID: PMC4741025 DOI: 10.1186/s40349-016-0048-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 01/27/2016] [Indexed: 12/15/2022] Open
Abstract
Background Initial catheter-based renal sympathetic denervation (RSD) studies demonstrated promising results in showing a significant reduction of blood pressure, while recent data were less successful. As an alternative approach, the objective of this study was to evaluate the feasibility of using magnetic resonance-guided high-intensity focused ultrasound (MRgHIFU) to perform RSD in a porcine model. Methods An intravascular fiber optic temperature probe was used to confirm energy delivery during MRgHIFU. This technique was evaluated both in a vascular phantom and in a normotensive pig model. Five animals underwent unilateral RSD using MRgHIFU, and both safety and efficacy were assessed. MRI was used to evaluate the acoustic window, target sonications, monitor the near-field treatment region using MR thermometry imaging, and assess the status of tissues post-procedure. An intravascular fiber optic temperature probe verified energy delivery. Animals were sacrificed 6 to 9 days post-treatment, and pathological analysis was performed. The norepinephrine present in the kidney medulla was assessed post-mortem. Results All animals tolerated the procedure well with no observed complications. The fiber optic temperature probe placed in the target renal artery confirmed energy delivery during MRgHIFU, measuring larger temperature rises when the MRgHIFU beam location was focused closer to the tip of the probe. Following ablation, a significant reduction (p = 0.04) of cross-sectional area of nerve bundles between the treated and untreated renal arteries was observed in all of the animals with treated nerves presenting increased cellular infiltrate and fibrosis. A reduction of norepinephrine (p = 0.14) in the kidney medulla tissue was also observed. There was no indication of tissue damage in arterial walls. Conclusions Performing renal denervation non-invasively with MRgHIFU was shown to be both safe and effective as determined by norepinephrine levels in a porcine model. This approach may be a promising alternative to catheter-based strategies.
Collapse
Affiliation(s)
- Matthias Koopmann
- CARMA Center, Department of Cardiology, University of Utah, 30 North 1900 East, Salt Lake City, UT 84132 USA
| | - Jill Shea
- Department of Surgery, University of Utah, 30 North 1900 East, Salt Lake City, UT 84132 USA
| | - Eugene Kholmovski
- Department of Radiology, University of Utah, 729 Arapeen Drive, Salt Lake City, UT 84108 USA
| | - Joshua de Bever
- Department of Radiology, University of Utah, 729 Arapeen Drive, Salt Lake City, UT 84108 USA
| | - Emilee Minalga
- Department of Radiology, University of Utah, 729 Arapeen Drive, Salt Lake City, UT 84108 USA
| | - Matthew Holbrook
- Department of Bioengineering, University of Utah, 36 S. Wasatch Drive, Rm. 3100, Salt Lake City, UT 84112 USA
| | - Robb Merrill
- Department of Radiology, University of Utah, 729 Arapeen Drive, Salt Lake City, UT 84108 USA
| | - J Rock Hadley
- Department of Radiology, University of Utah, 729 Arapeen Drive, Salt Lake City, UT 84108 USA
| | - Theophilus Owan
- Department of Cardiology, University of Utah, 30 North 1900 East, Salt Lake City, UT 84132 USA
| | - Mohamed E Salama
- Department of Pathology, University of Utah, 15 North Medical Drive East Ste #1100, Salt Lake City, UT 84112 USA
| | - Nassir F Marrouche
- CARMA Center, Department of Cardiology, University of Utah, 30 North 1900 East, Salt Lake City, UT 84132 USA
| | - Allison Payne
- Department of Radiology, University of Utah, 729 Arapeen Drive, Salt Lake City, UT 84108 USA
| |
Collapse
|
32
|
Tzafriri AR, Keating JH, Markham PM, Spognardi AM, Stanley JRL, Wong G, Zani BG, Highsmith D, O'Fallon P, Fuimaono K, Mahfoud F, Edelman ER. Arterial microanatomy determines the success of energy-based renal denervation in controlling hypertension. Sci Transl Med 2016; 7:285ra65. [PMID: 25925684 DOI: 10.1126/scitranslmed.aaa3236] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Renal denervation (RDN) is a treatment option for patients with hypertension resistant to conventional therapy. Clinical trials have demonstrated variable benefit. To understand the determinants of successful clinical response to this treatment, we integrated porcine and computational models of intravascular radiofrequency RDN. Controlled single-electrode denervation resulted in ablation zone geometries that varied in arc, area, and depth, depending on the composition of the adjacent tissue substructure. Computational simulations predicted that delivered power density was influenced by tissue substructure, and peaked at the conductivity discontinuities between soft fatty adventitia and water-rich tissues (media, lymph nodes, etc.), not at the electrode-tissue interface. Electrode irrigation protected arterial wall tissue adjacent to the electrode by clearing heat that diffuses from within the tissue, without altering periarterial ablation. Seven days after multielectrode treatments, renal norepinephrine and blood pressure were reduced. Blood pressure reductions were correlated with the size-weighted number of degenerative nerves, implying that the effectiveness of the treatment in decreasing hypertension depends on the extent of nerve injury and ablation, which in turn are determined by the tissue microanatomy at the electrode site. These results may explain the variable patient response to RDN and suggest a path to more robust outcomes.
Collapse
Affiliation(s)
- Abraham R Tzafriri
- Departments of Applied Sciences and Pathology, CBSET, Lexington, MA 02421, USA.
| | - John H Keating
- Departments of Applied Sciences and Pathology, CBSET, Lexington, MA 02421, USA
| | - Peter M Markham
- Departments of Applied Sciences and Pathology, CBSET, Lexington, MA 02421, USA
| | | | - James R L Stanley
- Departments of Applied Sciences and Pathology, CBSET, Lexington, MA 02421, USA
| | - Gee Wong
- Departments of Applied Sciences and Pathology, CBSET, Lexington, MA 02421, USA
| | - Brett G Zani
- Departments of Applied Sciences and Pathology, CBSET, Lexington, MA 02421, USA
| | - Debby Highsmith
- Biosense Webster Inc., a Johnson & Johnson Company, Irwindale, CA 91765, USA
| | - Patrick O'Fallon
- Biosense Webster Inc., a Johnson & Johnson Company, Irwindale, CA 91765, USA
| | - Kristine Fuimaono
- Biosense Webster Inc., a Johnson & Johnson Company, Irwindale, CA 91765, USA
| | - Felix Mahfoud
- Department of Internal Medicine III, Saarland University, Homburg/Saar 66421, Germany
| | - Elazer R Edelman
- Institute for Medical Engineering and Science, MIT, Cambridge, MA 02139 , USA. Brigham and Women's Hospital, Boston, MA 02115, USA
| |
Collapse
|
33
|
Efficacy and safety of a novel multi-electrode radiofrequency ablation catheter for renal sympathetic denervation in pigs. JOURNAL OF GERIATRIC CARDIOLOGY : JGC 2016; 12:618-25. [PMID: 26788038 PMCID: PMC4712367 DOI: 10.11909/j.issn.1671-5411.2015.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Objective To investigate the safety and efficacy of a self-developed novel multi-electrode radiofrequency ablation catheter (Spark) for catheter-based renal denervation (RDN). Methods A total of 14 experimental miniature pigs were randomly divided into four groups (55°& 5-watt, 55°& 8-watt, 65°& 5-watt, and 65° & 8-watt groups). Spark was used for left and right renal artery radiofrequency ablation. Blood samples collected from renal arteries and veins as well as renal arteriography were performed on all animals before, immediately after, and three months after procedure to evaluate the effects of Spark on the levels of plasma renin, aldosterone, angiotensin I, and angiotensin II as well as the pathological changes of renal arteries. Results One pig died of an anesthetic accident, 13 pigs successfully underwent the bilateral renal artery ablation. Compared with basic measurements, pigs in all the four groups had significantly decreased mean arterial pressure after procedure. Histopathological analysis showed that this procedure could result in intimal hyperplasia, significant peripheral sympathetic nerve damage in the renal arteries such as inflammatory cell infiltration and fibrosis in perineurium, uneven distribution of nerve fibers, tissue necrosis, severe vacuolization, fragmented and unclear nucleoli myelin degeneration, sparse axons, and interruption of continuity. In addition, the renal artery radiofrequency ablation could significantly reduce the levels of plasma renin, aldosterone, angiotensin I, and angiotensin II in pigs. Conclusions The results suggest that this type of multi-electrode catheter-based radiofrequency ablation could effectively remove peripheral renal sympathetic nerves and reduce the activity of systemic renin-angiotensin system in pigs, thus facilitating the control of systemic blood pressure in pigs.
Collapse
|
34
|
Renal Denervation for Treatment of Hypertension: a Second Start and New Challenges. Curr Hypertens Rep 2016; 18:6. [DOI: 10.1007/s11906-015-0610-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
|
35
|
Sakakura K, Roth A, Ladich E, Shen K, Coleman L, Joner M, Virmani R. Controlled circumferential renal sympathetic denervation with preservation of the renal arterial wall using intraluminal ultrasound: a next-generation approach for treating sympathetic overactivity. EUROINTERVENTION 2015; 10:1230-8. [PMID: 25349043 DOI: 10.4244/eijy14m10_14] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
AIMS The Paradise Ultrasound Renal Denervation System is a next-generation catheter-based device which was used to investigate whether the target ablation area can be controlled by changing ultrasound energy and duration to optimise nerve injury while preventing damage to the arterial wall. METHODS AND RESULTS Five ultrasound doses were tested in a thermal gel model. Catheter-based ultrasound denervation was performed in 15 swine (29 renal arteries) to evaluate five different doses in vivo, and animals were euthanised at seven days for histopathologic assessment. In the gel model, the peak temperature was highest in the low power-long duration (LP-LD) dose, followed by the mid-low power-mid duration (MLP-MD) dose and the mid-high power-short duration (MHP-SD) dose, and lowest in the mid power-short duration (MP-SD) dose and the high power-ultra short duration (HP-USD) dose. In the animal study, total ablation area was significantly greater in the LP-LD group, followed by the MLP-MD group, and it was least in the HP-USD, MP-SD and MHP-SD groups (p=0.02). Maximum distance was significantly greater in the LP-LD group, followed by the MLP-MD group, the MHP-SD group, and the HP-USD group, and shortest in the MP-SD group (p=0.007). The short spare distance was not different among the five groups (p=0.38). Renal artery damage was minimal, while preserving significant nerve damage in all groups. CONCLUSIONS The Paradise Ultrasound Renal Denervation System is a controllable system where total ablation area and depth of ablation can be optimised by changing ultrasound power and duration while sparing renal arterial tissue damage but allowing sufficient peri-arterial nerve damage.
Collapse
|
36
|
Wang Z, Chen S, Zhou T, Su L, Ling Z, Fan J, Chen W, Du H, Lu J, Xu Y, Tan Z, Yang H, Hu X, Li C, Yan X, Hu G, Liu C, Yin Y. Comparison of Saline-Irrigated Catheter vs. Temperature-Controlled Catheter for Renal Denervation in a Canine Model. Am J Hypertens 2015; 28:1434-43. [PMID: 25934968 DOI: 10.1093/ajh/hpv051] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2014] [Accepted: 12/30/2014] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The effectiveness of catheter-based renal denervation (RDN) remains controversial. Although the reasons for this have not yet been elucidated, ineffective denervation appears to be an important factor. The present study aimed to investigate the difference in RDN between a saline-irrigated catheter (SIC) and a temperature-controlled catheter (TCC). METHODS Dogs (n = 6) from the Kunming province in Chinese were ablated; the SIC was introduced into the right renal artery, while the TCC was introduced into the left renal artery. After 6 months, histopathology and renal angiography were performed, and the change in neural density was evaluated using morphometric software. The average values of heart rate (HR), blood pressure (BP), and catecholamine metabolites were assessed at baseline and follow-up. RESULTS Histopathology showed nerve demyelination and denaturation, as well as interstitial hyperplasia, although these changes were more pronounced when the SIC was used. The change in neural density was greater and ablation was deeper when the SIC was used. Intimal hyperplasia was greater when the TCC was used, whereas medial hyperplasia was greater when the SIC was used. A trend toward a decrease in HR, BP, metanephrine, and normetanephrine between baseline and follow-up was observed. CONCLUSIONS Our findings suggest that SIC ablation results in more extensive neural degeneration, deeper penetration, and less extensive intimal hyperplasia than TCC ablation for RDN.
Collapse
Affiliation(s)
- Zhenglong Wang
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | | | - Tingquan Zhou
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Li Su
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhiyu Ling
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jinqi Fan
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Weijie Chen
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Huaan Du
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jiayi Lu
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yanping Xu
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhen Tan
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Hanxuan Yang
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xinyu Hu
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Chengzhi Li
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xue Yan
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Guangxin Hu
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Chang Liu
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yuehui Yin
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China;
| |
Collapse
|
37
|
Verloop WL, Hubens LEG, Spiering W, Doevendans PA, Goldschmeding R, Bleys RLAW, Voskuil M. The Effects of Renal Denervation on Renal Hemodynamics and Renal Vasculature in a Porcine Model. PLoS One 2015; 10:e0141609. [PMID: 26587981 PMCID: PMC4654519 DOI: 10.1371/journal.pone.0141609] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Accepted: 10/09/2015] [Indexed: 12/20/2022] Open
Abstract
Rationale Recently, the efficacy of renal denervation (RDN) has been debated. It is discussed whether RDN is able to adequately target the renal nerves. Objective We aimed to investigate how effective RDN was by means of functional hemodynamic measurements and nerve damage on histology. Methods and Results We performed hemodynamic measurements in both renal arteries of healthy pigs using a Doppler flow and pressure wire. Subsequently unilateral denervation was performed, followed by repeated bilateral hemodynamic measurements. Pigs were terminated directly after RDN or were followed for 3 weeks or 3 months after the procedure. After termination, both treated and control arteries were prepared for histology to evaluate vascular damage and nerve damage. Directly after RDN, resting renal blood flow tended to increase by 29±67% (P = 0.01). In contrast, renal resistance reserve increased from 1.74 (1.28) to 1.88 (1.17) (P = 0.02) during follow-up. Vascular histopathology showed that most nerves around the treated arteries were located outside the lesion areas (8±7 out of 55±25 (14%) nerves per pig were observed within a lesion area). Subsequently, a correlation was noted between a more impaired adventitia and a reduction in renal resistance reserve (β: -0.33; P = 0.05) at three weeks of follow-up. Conclusion Only a small minority of renal nerves was targeted after RDN. Furthermore, more severe adventitial damage was related to a reduction in renal resistance in the treated arteries at follow-up. These hemodynamic and histological observations may indicate that RDN did not sufficiently target the renal nerves. Potentially, this may explain the significant spread in the response after RDN.
Collapse
Affiliation(s)
- Willemien L. Verloop
- Department of Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Lisette E. G. Hubens
- Department of Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Wilko Spiering
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Pieter A. Doevendans
- Department of Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Roel Goldschmeding
- Department of Pathology, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Michiel Voskuil
- Department of Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
- * E-mail:
| |
Collapse
|
38
|
Schmid A, Schmieder R, Lell M, Janka R, Veelken R, Schmieder RE, Uder M, Ott C. Mid-Term Vascular Safety of Renal Denervation Assessed by Follow-up MR Imaging. Cardiovasc Intervent Radiol 2015; 39:426-32. [DOI: 10.1007/s00270-015-1192-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Accepted: 06/18/2015] [Indexed: 11/29/2022]
|
39
|
Rousselle SD, Brants IK, Sakaoka A, Hubbard B, Jackson ND, Wicks JR, Dillon KN, Naiche L, Hart R, Garza JA, Tellez A. Neuromatous Regeneration as a Nerve Response After Catheter-Based Renal Denervation Therapy in a Large Animal Model. Circ Cardiovasc Interv 2015; 8:CIRCINTERVENTIONS.114.002293. [DOI: 10.1161/circinterventions.114.002293] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Serge D. Rousselle
- From the Alizée Pathology, LLC, Thurmont, MD (S.D.R., N.D.J., J.R.W., K.N.D., L.A.N., R.H., J.A.G., A.T.); Translational Testing and Training (T3) Laboratories, Atlanta, GA (I.K.B., B.H.); and Terumo Corporation, Kanagawa, Japan (A.S.)
| | - Irena K. Brants
- From the Alizée Pathology, LLC, Thurmont, MD (S.D.R., N.D.J., J.R.W., K.N.D., L.A.N., R.H., J.A.G., A.T.); Translational Testing and Training (T3) Laboratories, Atlanta, GA (I.K.B., B.H.); and Terumo Corporation, Kanagawa, Japan (A.S.)
| | - Atsushi Sakaoka
- From the Alizée Pathology, LLC, Thurmont, MD (S.D.R., N.D.J., J.R.W., K.N.D., L.A.N., R.H., J.A.G., A.T.); Translational Testing and Training (T3) Laboratories, Atlanta, GA (I.K.B., B.H.); and Terumo Corporation, Kanagawa, Japan (A.S.)
| | - Brad Hubbard
- From the Alizée Pathology, LLC, Thurmont, MD (S.D.R., N.D.J., J.R.W., K.N.D., L.A.N., R.H., J.A.G., A.T.); Translational Testing and Training (T3) Laboratories, Atlanta, GA (I.K.B., B.H.); and Terumo Corporation, Kanagawa, Japan (A.S.)
| | - Nicolette D. Jackson
- From the Alizée Pathology, LLC, Thurmont, MD (S.D.R., N.D.J., J.R.W., K.N.D., L.A.N., R.H., J.A.G., A.T.); Translational Testing and Training (T3) Laboratories, Atlanta, GA (I.K.B., B.H.); and Terumo Corporation, Kanagawa, Japan (A.S.)
| | - Joan R. Wicks
- From the Alizée Pathology, LLC, Thurmont, MD (S.D.R., N.D.J., J.R.W., K.N.D., L.A.N., R.H., J.A.G., A.T.); Translational Testing and Training (T3) Laboratories, Atlanta, GA (I.K.B., B.H.); and Terumo Corporation, Kanagawa, Japan (A.S.)
| | - Krista N. Dillon
- From the Alizée Pathology, LLC, Thurmont, MD (S.D.R., N.D.J., J.R.W., K.N.D., L.A.N., R.H., J.A.G., A.T.); Translational Testing and Training (T3) Laboratories, Atlanta, GA (I.K.B., B.H.); and Terumo Corporation, Kanagawa, Japan (A.S.)
| | - L.A. Naiche
- From the Alizée Pathology, LLC, Thurmont, MD (S.D.R., N.D.J., J.R.W., K.N.D., L.A.N., R.H., J.A.G., A.T.); Translational Testing and Training (T3) Laboratories, Atlanta, GA (I.K.B., B.H.); and Terumo Corporation, Kanagawa, Japan (A.S.)
| | - Randy Hart
- From the Alizée Pathology, LLC, Thurmont, MD (S.D.R., N.D.J., J.R.W., K.N.D., L.A.N., R.H., J.A.G., A.T.); Translational Testing and Training (T3) Laboratories, Atlanta, GA (I.K.B., B.H.); and Terumo Corporation, Kanagawa, Japan (A.S.)
| | - Javier A. Garza
- From the Alizée Pathology, LLC, Thurmont, MD (S.D.R., N.D.J., J.R.W., K.N.D., L.A.N., R.H., J.A.G., A.T.); Translational Testing and Training (T3) Laboratories, Atlanta, GA (I.K.B., B.H.); and Terumo Corporation, Kanagawa, Japan (A.S.)
| | - Armando Tellez
- From the Alizée Pathology, LLC, Thurmont, MD (S.D.R., N.D.J., J.R.W., K.N.D., L.A.N., R.H., J.A.G., A.T.); Translational Testing and Training (T3) Laboratories, Atlanta, GA (I.K.B., B.H.); and Terumo Corporation, Kanagawa, Japan (A.S.)
| |
Collapse
|
40
|
Evaluation of renal nerve morphological changes and norepinephrine levels following treatment with novel bipolar radiofrequency delivery systems in a porcine model. J Hypertens 2015; 32:1678-91; discussion 1691-2. [PMID: 24875181 PMCID: PMC4323552 DOI: 10.1097/hjh.0000000000000236] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate the safety and effectiveness of different bipolar radiofrequency system algorithms in interrupting the renal sympathetic nerves and reducing renal norepinephrine in a healthy porcine model. METHODS A porcine model (N = 46) was used to investigate renal norepinephrine levels and changes to renal artery tissues and nerves following percutaneous renal denervation with radiofrequency bipolar electrodes mounted on a balloon catheter. Parameters of the radiofrequency system (i.e. electrode length and energy delivery algorithm), and the effects of single and longitudinal treatments along the artery were studied with a 7-day model in which swine received unilateral radiofrequency treatments. Additional sets of animals were used to examine norepinephrine and histological changes 28 days following bilateral percutaneous radiofrequency treatment or surgical denervation; untreated swine were used for comparison of renal norepinephrine levels. RESULTS Seven days postprocedure, norepinephrine concentrations decreased proportionally to electrode length, with 81, 60 and 38% reductions (vs. contralateral control) using 16, 4 and 2-mm electrodes, respectively. Applying a temperature-control algorithm with the 4-mm electrodes increased efficacy, with a mean 89.5% norepinephrine reduction following a 30-s treatment at 68°C. Applying this treatment along the entire artery length affected more nerves vs. a single treatment, resulting in superior norepinephrine reduction 28 days following bilateral treatment. CONCLUSION Percutaneous renal artery application of bipolar radiofrequency energy demonstrated safety and resulted in a significant renal norepinephrine content reduction and renal nerve injury compared with untreated controls in porcine models.
Collapse
|
41
|
Olsen LK, Kamper AL, Svendsen JH, Feldt-Rasmussen B. Renal denervation. Eur J Intern Med 2015; 26:95-105. [PMID: 25676808 DOI: 10.1016/j.ejim.2015.01.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Revised: 01/14/2015] [Accepted: 01/23/2015] [Indexed: 01/18/2023]
Abstract
PURPOSE OF REVIEW Renal denervation (RDN) has, within recent years, been suggested as a novel treatment option for patients with resistant hypertension. This review summarizes the current knowledge on this procedure as well as limitations and questions that remain to be answered. RECENT FINDINGS The Symplicity HTN-1 (2009) and HTN-2 (2010) studies re-introduced an old treatment approach for resistant hypertension and showed that catheter-based RDN was feasible and resulted in substantial blood pressure (BP) reductions. However, they also raised questions of durability of BP reduction, correct patient selection, anatomical and physiological effects of RDN as well as possible beneficial effects on other diseases with increased sympathetic activity. The long awaited Symplicity HTN-3 (2014) results illustrated that the RDN group and the sham-group had similar reductions in BP. SUMMARY Initial studies demonstrated that RDN in patients with resistant hypertension was both feasible and safe and indicated that RDN may lead to impressive reductions in BP. However, recent controlled studies question the BP lowering effect of RDN treatment. Large-scale registry data still supports the favorable BP reducing effect of RDN. We suggest that, in the near future, RDN should not be performed outside clinical studies. The degree of denervation between individual operators and between different catheters and techniques used should be clarified. The major challenge ahead is to identify which patients could benefit from RDN, to clarify the lack of an immediate procedural success parameter, and to establish further documentation of overall effect of treatment such as long-term cardiovascular morbidity and mortality.
Collapse
Affiliation(s)
- Lene Kjær Olsen
- Department of Nephrology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Anne-Lise Kamper
- Department of Nephrology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Jesper Hastrup Svendsen
- Deparment of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, DK-2100 Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark; Danish Arrhythmia Research Centre, University of Copenhagen, Denmark
| | - Bo Feldt-Rasmussen
- Department of Nephrology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, DK-2100 Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark.
| |
Collapse
|
42
|
Sakakura K, Tunev S, Yahagi K, O’Brien AJ, Ladich E, Kolodgie FD, Melder RJ, Joner M, Virmani R. Comparison of Histopathologic Analysis Following Renal Sympathetic Denervation Over Multiple Time Points. Circ Cardiovasc Interv 2015; 8:e001813. [DOI: 10.1161/circinterventions.114.001813] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Background—
The pathology of radiofrequency-derived sympathetic renal denervation has not been studied over time and may provide important understanding of the mechanisms resulting in sustained blood pressure reduction. The purpose of this study was to investigate chronological changes after radiofrequency-renal denervation in the swine model.
Methods and Results—
A total of 49 renal arteries from 28 animals with 4 different time points (7, 30, 60, and 180 days) were examined. Semiquantitative histological assessment of arteries and associated tissue was performed to characterize the chronological progression of the radiofrequency lesions. Arterial medial circumferential injury (%) was greatest at 7 days (38±13%), followed by 30 days (31±6%) and 60 days (31±15%), and least at 180 days (21±12%) (
P
=0.046). Nerve injury score was significantly greater (
P
<0.001) at 7 days (3.9±0.4) compared with 30 days (2.5±0.5), 60 days (2.6±0.5), and 180 days (1.9±0.9). Tyrosine hydroxylase score, which assesses functional nerve damage, was significantly less after 7 (1±1) and 30 days (0.7±0.6) compared with 60 (2.7±0.6) and 180 days (2.7±0.6;
P
=0.01). Focal nerve regeneration at the sites of radiofrequency ablation was observed in 17% of renal arteries at 60 days and 71% of 180 days.
Conclusions—
Nerve injury after radiofrequency ablation was greatest at 7 days, with maximum functional nerve damage sustained ≤30 days. Focal terminal nerve regeneration was observed only at the sites of ablation as early as 60 days and continued to 180 days. Renal artery and peri-arterial soft tissue injury is greatest in the subacute phase, and least in the chronic phase, suggesting gradual recovery of the renal arterial wall and surrounding tissue.
Collapse
Affiliation(s)
- Kenichi Sakakura
- From the CVPath Institute, Inc, Gaithersburg, MD (K.S., K.Y., E.L., F.D.K., M.J., R.V.); and Medtronic Cardiovascular, Santa Rosa, CA (S.T., A.J.O’B., R.J.M.)
| | - Stefan Tunev
- From the CVPath Institute, Inc, Gaithersburg, MD (K.S., K.Y., E.L., F.D.K., M.J., R.V.); and Medtronic Cardiovascular, Santa Rosa, CA (S.T., A.J.O’B., R.J.M.)
| | - Kazuyuki Yahagi
- From the CVPath Institute, Inc, Gaithersburg, MD (K.S., K.Y., E.L., F.D.K., M.J., R.V.); and Medtronic Cardiovascular, Santa Rosa, CA (S.T., A.J.O’B., R.J.M.)
| | - Amanda J. O’Brien
- From the CVPath Institute, Inc, Gaithersburg, MD (K.S., K.Y., E.L., F.D.K., M.J., R.V.); and Medtronic Cardiovascular, Santa Rosa, CA (S.T., A.J.O’B., R.J.M.)
| | - Elena Ladich
- From the CVPath Institute, Inc, Gaithersburg, MD (K.S., K.Y., E.L., F.D.K., M.J., R.V.); and Medtronic Cardiovascular, Santa Rosa, CA (S.T., A.J.O’B., R.J.M.)
| | - Frank D. Kolodgie
- From the CVPath Institute, Inc, Gaithersburg, MD (K.S., K.Y., E.L., F.D.K., M.J., R.V.); and Medtronic Cardiovascular, Santa Rosa, CA (S.T., A.J.O’B., R.J.M.)
| | - Robert J. Melder
- From the CVPath Institute, Inc, Gaithersburg, MD (K.S., K.Y., E.L., F.D.K., M.J., R.V.); and Medtronic Cardiovascular, Santa Rosa, CA (S.T., A.J.O’B., R.J.M.)
| | - Michael Joner
- From the CVPath Institute, Inc, Gaithersburg, MD (K.S., K.Y., E.L., F.D.K., M.J., R.V.); and Medtronic Cardiovascular, Santa Rosa, CA (S.T., A.J.O’B., R.J.M.)
| | - Renu Virmani
- From the CVPath Institute, Inc, Gaithersburg, MD (K.S., K.Y., E.L., F.D.K., M.J., R.V.); and Medtronic Cardiovascular, Santa Rosa, CA (S.T., A.J.O’B., R.J.M.)
| |
Collapse
|
43
|
van Brussel PM, Lieve KVV, de Winter RJ, Wilde AAM. Cardiorenal axis and arrhythmias: Will renal sympathetic denervation provide additive value to the therapeutic arsenal? Heart Rhythm 2015; 12:1080-7. [PMID: 25640633 DOI: 10.1016/j.hrthm.2015.01.046] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2014] [Indexed: 11/30/2022]
Abstract
Disruption of sympathetic tone may result in the occurrence or maintenance of cardiac arrhythmias. Multiple arrhythmic therapies that intervene by influencing cardiac sympathetic tone are common in clinical practice. These vary from pharmaceutical (β-blockers, angiotensin-converting enzyme inhibitors, and calcium antagonists) to percutaneous/surgical (cardiac sympathetic denervation) interventions. In some patients, however, these therapies have insufficient prophylactic and therapeutic capabilities. A safe and effective additional therapy wherein sympathetic drive is further attenuated would be expedient. Recently, renal sympathetic denervation (RSD) has been subject of research for various sympathetic nervous system-related diseases. By its presumed afferent and efferent sympatholytic effects, RSD might indirectly attenuate sympathetic outflow via the brain to the heart but might also reduce systemic catecholamine excretion and might therefore reduce catecholamine-sensitive arrhythmias. RSD is subject of research for various sympathetically driven arrhythmias, both supraventricular and ventricular. In this review, we give an overview of the rationale behind RSD as potential therapy in mediating arrhythmias that are triggered by a disrupted sympathetic nervous system and discuss the presently available results from animal and human studies.
Collapse
Affiliation(s)
- Peter M van Brussel
- Heart Centre, Department of Clinical and Experimental Cardiology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Krystien V V Lieve
- Heart Centre, Department of Clinical and Experimental Cardiology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Robbert J de Winter
- Heart Centre, Department of Clinical and Experimental Cardiology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Arthur A M Wilde
- Heart Centre, Department of Clinical and Experimental Cardiology, Academic Medical Centre, Amsterdam, The Netherlands; Princess Al-Jawhara Al-Brahim Centre of Excellence in Research of Hereditary Disorders, Jeddah, Kingdom of Saudi Arabia.
| |
Collapse
|
44
|
Renal denervation: a new therapeutic approach for resistant hypertension. Chin Med J (Engl) 2014. [DOI: 10.1097/00029330-201409200-00020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
|
45
|
Alexander VV, Shi Z, Iftekher F, Welsh MJ, Gurm HS, Rising G, Yanovich A, Walacavage K, Islam MN. Renal denervation using focused infrared fiber lasers: A potential treatment for hypertension. Lasers Surg Med 2014; 46:689-702. [DOI: 10.1002/lsm.22290] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/29/2014] [Indexed: 11/06/2022]
Affiliation(s)
- Vinay V. Alexander
- Electrical and Computer Engineering Department; University of Michigan; Ann Arbor Michigan 48109
| | - Zhennan Shi
- Electrical and Computer Engineering Department; University of Michigan; Ann Arbor Michigan 48109
| | - Fariha Iftekher
- Electrical and Computer Engineering Department; University of Michigan; Ann Arbor Michigan 48109
| | - Michael J. Welsh
- Department of Cell and Developmental Biology; University of Michigan; Ann Arbor Michigan 48109
| | - Hitinder S. Gurm
- Department of Internal Medicine; University of Michigan Medical School; Ann Arbor Michigan 48109
| | - Gail Rising
- Unit for Laboratory and Animal Medicine; University of Michigan Medical School; Ann Arbor Michigan 48109
| | - Amber Yanovich
- Unit for Laboratory and Animal Medicine; University of Michigan Medical School; Ann Arbor Michigan 48109
| | - Kim Walacavage
- Unit for Laboratory and Animal Medicine; University of Michigan Medical School; Ann Arbor Michigan 48109
| | - Mohammed N. Islam
- Electrical and Computer Engineering Department; University of Michigan; Ann Arbor Michigan 48109
- Department of Internal Medicine; University of Michigan Medical School; Ann Arbor Michigan 48109
| |
Collapse
|
46
|
Machino T, Murakoshi N, Sato A, Xu D, Hoshi T, Kimura T, Aonuma K. Anti-hypertensive effect of radiofrequency renal denervation in spontaneously hypertensive rats. Life Sci 2014; 110:86-92. [DOI: 10.1016/j.lfs.2014.06.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Revised: 06/06/2014] [Accepted: 06/14/2014] [Indexed: 11/15/2022]
|
47
|
Raman B, Pathik B, Bridgman C. Recurrent pulmonary oedema after percutaneous radiofrequency renal denervation. Int J Cardiol 2014; 174:e42-3. [DOI: 10.1016/j.ijcard.2014.04.053] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Accepted: 04/02/2014] [Indexed: 10/25/2022]
|
48
|
Limited destruction of renal nerves after catheter-based renal denervation: results of a human case study. Nephrol Dial Transplant 2014; 29:1608-10. [DOI: 10.1093/ndt/gfu192] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
|
49
|
Versaci F, Trivisonno A, Olivieri C, Magri G, Caranci F, Prati F. Is an Abnormal Vascular Response After Renal Sympathetic Denervation Predictive of Permanent Damage? An Unusual Case of Late Renal Artery Stenosis After Energy Delivery. J Endovasc Ther 2014; 21:191-6. [DOI: 10.1583/13-4574mr.1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|
50
|
Angle JF, Prince EA, Matsumoto AH, Lohmeier TE, Roberts AM, Misra S, Razavi MK, Katholi RE, Sarin SN, Sica DA, Shivkumar K, Ahrar K. Proceedings from the Society of Interventional Radiology Foundation Research Consensus Panel on Renal Sympathetic Denervation. J Vasc Interv Radiol 2014; 25:497-509. [PMID: 24674208 DOI: 10.1016/j.jvir.2013.12.572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Revised: 12/27/2013] [Accepted: 12/27/2013] [Indexed: 10/25/2022] Open
Affiliation(s)
- John F Angle
- Department of Radiology, Division of Vascular and Interventional Radiology, University of Virginia Health System, 1215 Lee Street, Charlottesville, VA 22908.
| | - Ethan A Prince
- Department of Radiology, Division of Vascular and Interventional Radiology, Brown University, Providence, Rhode Island
| | - Alan H Matsumoto
- Department of Radiology, Division of Vascular and Interventional Radiology, University of Virginia Health System, 1215 Lee Street, Charlottesville, VA 22908
| | - Thomas E Lohmeier
- Department of Physiology, University of Mississippi, Jackson, Mississippi
| | - Andrew M Roberts
- Department of Physiology, University of Louisville, Louisville, Kentucky
| | - Sanjay Misra
- Department of Radiology, Division of Vascular and Interventional Radiology, Mayo Clinic, Rochester, Minnesota
| | - Mahmood K Razavi
- Vascular & Interventional Specialists of Orange County, Inc., Los Angeles, California
| | - Richard E Katholi
- Department of Cardiology, Prairie Heart Institute at St. John's Hospital, Springfield, Illinois
| | - Shawn N Sarin
- Department of Radiology, Division of Vascular and Interventional Radiology, George Washington University, Washington, D.C
| | - Domenic A Sica
- Department of Internal Medicine, Division of Nephrology, Virginia Commonwealth University, Richmond, Virginia
| | - Kalyanam Shivkumar
- Department of Internal Medicine, Division of Cardiology, University of California, Los Angeles, Los Angeles, California
| | - Kamran Ahrar
- Department of Radiology, Division of Vascular and Interventional Radiology, University of Texas, MD Anderson Cancer Center, Houston, Texas
| |
Collapse
|