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Janas A, Wojakowski W. Peregrine system infusion catheter for neurolytic renal denervation in hypertension: an overview of its safety and efficacy. Expert Rev Med Devices 2023; 20:179-186. [PMID: 36846949 DOI: 10.1080/17434440.2023.2183838] [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: 03/01/2023]
Abstract
INTRODUCTION Resistant hypertension (HTN), despite the tremendous advances in pharmacotherapy, is a major global problem. Transcatheter renal denervation (RDN) could be a pertinent strategy for resistant HTN and patients with poor pharmacotherapy adherence. Nonetheless, the adoption of energy-based RDN in clinical practice is slow and alternative approaches are needed. AREAS COVERED The review focuses on the assessment of the Peregrine System Infusion Catheters. The system is designed for chemically mediated transcatheter RDN by the infusion publications on the Peregrine system. The theoretical assumptions for chemically mediated RDN, design of the system, data from preclinical and clinical studies, and further perspectives are discussed. EXPERT OPINION Peregrine System Infusion Catheters are the only catheter on the market designed for chemically mediated RDN by the infusion of the neurolytic agent. Chemical neurolysis more efficiently destroys nerves around the renal artery in comparison to energy-based catheters, due to deeper tissue penetration and circumferential distribution resulting in a wider range of effective nerve injury. Chemically mediated RDN by the infusion of the neurolytic agent (alcohol) has an excellent safety profile as confirmed in initial clinical trials which also suggested high efficacy. Currently, there is an ongoing phase III sham-control study. Other possible applications of this technology include clinical settings like heart failure or atrial fibrillation.
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Affiliation(s)
- Adam Janas
- Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Cracow University, Kraków, Poland.,American Heart of Poland, Center of Cardiovascular Research and Development, Poland
| | - Wojciech Wojakowski
- Division of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
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2
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Present Evidence of Determinants to Predict the Efficacy of Renal Denervation. Int J Hypertens 2022; 2022:5694127. [PMID: 35992203 PMCID: PMC9391193 DOI: 10.1155/2022/5694127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 07/22/2022] [Indexed: 11/18/2022] Open
Abstract
Sympathetic overactivation is one of the main contributors to development and progress of hypertension. Renal denervation (RDN) has been evidenced by series of clinical trials for its efficacy and safety to treat overactivated sympathetic nervous system induced diseases. However, the results were inconsistent and not all patients benefited from RDN. Appropriate patient selection and intraoperative factors to improve the efficacy of RDN need to be solved urgently. Over the decade, research studies on the correlations between indicators and the antihypertensive effects have been conducted and made a fairly well progress. Herein, we comprehensively reviewed the research studies on how to make RDN more predictable or improve the efficacy of RDN and summarized these potential indicators or devices which might be applied in clinical settings.
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3
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Mahfoud F, Sievert H, Bertog S, Lauder L, Ewen S, Lengelé JP, Wojakowski W, Schmieder R, van der Giet M, Weber MA, Kandzari DE, Parise H, Fischell TA, Pathak A, Persu A. Long-Term Results up to 12 Months After Catheter-Based Alcohol-Mediated Renal Denervation for Treatment of Resistant Hypertension. Circ Cardiovasc Interv 2021; 14:e010075. [PMID: 34470501 PMCID: PMC8452324 DOI: 10.1161/circinterventions.120.010075] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Supplemental Digital Content is available in the text. Background: Primary results of this prospective, open-label, multicenter trial suggested that alcohol-mediated renal denervation with perivascular injection of dehydrated alcohol using the Peregrine System Infusion Catheter safely reduces blood pressure (BP) in patients with resistant hypertension. To date, maintenance of the BP-lowering effect beyond 6 months using this novel technology has not been reported. This article describes the final, 12-month follow-up data on the safety and efficacy of alcohol-mediated renal denervation in these patients. Methods: Forty-five patients with resistant hypertension on a stable regimen of on average 5.1±1.5 antihypertensive medications underwent successful bilateral renal denervation using the Peregrine Catheter with alcohol as the neurolytic agent (0.6 mL per renal artery). Apart from 2 vascular access pseudoaneurysms (both without sequelae), no major procedural complications occurred. Results: At 12 months post-procedure, mean 24-hour ambulatory systolic and diastolic BP were reduced by 10 mm Hg (95% CI, −16 to −5) and 7 mm Hg (−10 to −3), respectively (P<0.001). Office systolic/diastolic BP was reduced by 20/10 mm Hg (−27, −13/−14, −6; <0.001). Compared with baseline, the number of antihypertensive medications was reduced in 21% of patients, while it was increased in 19%. From baseline to 12 months, serum creatinine, urea, cystatin C, and spot urine albumin levels remained unchanged. The change in estimated glomerular filtration rates (−3.9±10.3 mL/minute per 1.73 m2 [95% CI, −7.1 to −0.75]; P=0.02) was within the expected range. There were no cases of renal artery stenosis up to 12-month follow-up. Conclusions: Catheter-based chemical renal denervation with dehydrated alcohol using the Peregrine Catheter seems to safely reduce BP at follow-up of up to 12 months. Further randomized and sham controlled studies are underway to further validate these findings. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02570113.
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Affiliation(s)
- Felix Mahfoud
- Department of Internal Medicine III, Cardiology, Angiology, Intensive Care Medicine, Saarland University Medical Center, Homburg, Germany (F.M., L.L., S.E.)
| | - Horst Sievert
- CardioVascular Center Frankfurt, Germany; Anglia Ruskin University, Chelmsford, United Kingdom; University California San Francisco UCSF; and Yunnan Hospital Fuwai, Kunming, China (H.S.)
| | | | - Lucas Lauder
- Department of Internal Medicine III, Cardiology, Angiology, Intensive Care Medicine, Saarland University Medical Center, Homburg, Germany (F.M., L.L., S.E.)
| | - Sebastian Ewen
- Department of Internal Medicine III, Cardiology, Angiology, Intensive Care Medicine, Saarland University Medical Center, Homburg, Germany (F.M., L.L., S.E.)
| | - Jean-Philippe Lengelé
- Division of Cardiology, Department of Cardiovascular Diseases, Cliniques Universitaires Saint-Luc and Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium (J.-P.L., A.P.)
| | - Wojciech Wojakowski
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland (W.W.)
| | - Roland Schmieder
- University Hospital Erlangen, Friedrich-Alexander University Erlangen, Germany (R.S.)
| | - Markus van der Giet
- Department of Nephrology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Germany (M.v.d.G.)
| | - Michael A Weber
- Division of Cardiovascular Medicine, SUNY Downstate Medical Center, Brooklyn, NY (M.A.W.)
| | | | - Helen Parise
- Independent statistician, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT (H.P.)
| | | | - Atul Pathak
- Division of Cardiology, Department of Cardiovascular Diseases, Cliniques Universitaires Saint-Luc and Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium (J.-P.L., A.P.).,Department of Cardiovascular Medicine, INSERM 1048, Princess Grace Hospital, Monaco (A.P.)
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Flood SP, Aronow HD. Catheter-Based Alcohol-Mediated Renal Denervation for Treating Resistant Hypertension: Is the Peregrine Predator or Prey? Circ Cardiovasc Interv 2021; 14:e011293. [PMID: 34470499 DOI: 10.1161/circinterventions.121.011293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Shane P Flood
- Mater Private Network, City Gate, Mahon, Cork, Ireland (S.P.F.)
| | - Herbert D Aronow
- Warren Alpert Medical School of Brown University, Lifespan Cardiovascular Institute, Providence, RI (H.D.A.)
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Mahfoud F, Bertog S, Lauder L, Böhm M, Schmid A, Wojakowski W, Parise H, Fischell TA, Kandzari DE, Pathak A, Persu A, Sievert H. Blood pressure lowering with alcohol-mediated renal denervation using the Peregrine infusion Catheter is independent of injection site location. Catheter Cardiovasc Interv 2021; 98:E832-E838. [PMID: 34472656 DOI: 10.1002/ccd.29936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/09/2021] [Accepted: 08/21/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The current analysis utilized core laboratory angiographic data from a prospective, single-arm, open-label, multi-center feasibility study to ascertain whether the location of alcohol infusion within main renal arteries during renal denervation (RDN) had an impact on the BP-lowering effect at 6 months. BACKGROUND The influence of the location of alcohol infusion during RDN, within the main renal artery (proximal, middle, or distal), on the magnitude of the blood pressure (BP) lowering is unstudied. METHODS The Peregrine Catheter was used to perform alcohol-mediated RDN with an infusion of 0.6 mL of alcohol per artery as the neurolytic agent in 90 main arteries and four accessory arteries of 45 patients with hypertension. RESULTS No relationship between the site of alcohol infusion and change from baseline in both office systolic and 24-hour systolic ambulatory BP (ABP) at 6 months was observed. When analyzed at the artery level, the least squares (LS) mean changes ± SEM from baseline to 6 months post-procedure in 24-hour systolic ABP when analyzed by renal arterial location were -11.9 ± 2.4 mmHg (distal), -10 ± 1.6 mmHg (middle), and -10.6 ± 1.3 mmHg (proximal) (all p < 0.0001 for change from baseline within groups). The results were similar for office systolic BP. There was no difference between treated locations (proximal is reference). CONCLUSION In this post-hoc analysis, the location of alcohol infusion within the main renal artery using the Peregrine system, with alcohol as the neurolytic agent for chemical RDN, did not affect the magnitude of BP changes at 6 months.
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Affiliation(s)
- Felix Mahfoud
- Department of Internal Medicine III, Cardiology, Angiology, Intensive Care Medicine, Saarland University Medical Center, Homburg, Germany
| | - Stefan Bertog
- Department of Medicine, CardioVascular Center Frankfurt, Frankfurt, Germany
| | - Lucas Lauder
- Department of Internal Medicine III, Cardiology, Angiology, Intensive Care Medicine, Saarland University Medical Center, Homburg, Germany
| | - Michael Böhm
- Klinik für Innere Medizin III, Saarland University Hospital, Homburg, Germany
| | - Axel Schmid
- Institute of Radiology, Universitätsklinikum Erlangen, Erlangen, Germany
| | - Wojciech Wojakowski
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | - Helen Parise
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | | | - David E Kandzari
- Interventional Cardiology, Piedmont Heart Institute, Atlanta, Georgia, USA
| | - Atul Pathak
- Department of Cardiovascular Medicine, Princess Grace Hospital, Monaco, Monaco
| | - Alexandre Persu
- Division of Cardiology, Cliniques Universitaires Saint-Luc and Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Horst Sievert
- Department of Medicine, CardioVascular Center Frankfurt, Frankfurt, Germany.,Faculty of Medical Science, Anglia Ruskin University, Chelmsford, UK.,University of California San Francisco UCSF, San Francisco, California, USA.,Yunnan Hospital Fuwai, Kunming, China
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Mahfoud F, Weber M, Schmieder RE, Lobo MD, Blankestijn PJ, Persu A, Fischell TA, Parise H, Pathak A, Kandzari DE. Catheter-based alcohol-mediated renal denervation for the treatment of uncontrolled hypertension: design of two sham-controlled, randomized, blinded trials in the absence (TARGET BP OFF-MED) and presence (TARGET BP I) of antihypertensive medications. Am Heart J 2021; 239:90-99. [PMID: 34052211 DOI: 10.1016/j.ahj.2021.05.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 05/20/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Arterial hypertension is a common and life-threatening condition and poses a large global health burden. Device-based treatments have been developed as adjunctive or alternative therapy, to be used with or without antihypertensive medication for treating uncontrolled hypertension. The safety and feasibility of chemical renal denervation (RDN) using the Peregrine Catheter and alcohol were demonstrated in a first-in-man and open-label clinical trials, prompting the initiation of the ongoing TARGET BP OFF-MED and TARGET BP I trials. DESIGN The TARGET BP trials are randomized, blinded, sham-controlled trials designed to assess the safety and efficacy of alcohol-mediated RDN for the treatment of uncontrolled hypertension in the absence of antihypertensive medications (TARGET BP OFF-MED) or in addition to prescribed antihypertensive medications (TARGET BP I). Subjects with confirmed uncontrolled hypertension and suitable renal artery anatomy are randomized (1:1) to receive either RDN using the Peregrine Kit with alcohol (0.6 mL per renal artery) infused through the Peregrine Catheter or diagnostic renal angiography only (sham procedure). TARGET BP OFF-MED completed enrollment and randomized 96 subjects. TARGET BP I will randomize approximately 300 subjects and will transition to an open-label safety cohort of approximately 300 subjects receiving RDN once the primary efficacy endpoint of the Randomized Controlled Trial (RCT) cohort has been met. Primary endpoints are change in mean 24-hour ambulatory systolic blood pressure from baseline to 8 weeks (TARGET BP OFF-MED) and 3 months (TARGET BP I) post-procedure. CONCLUSION The TARGET BP trials are the first large-scale, international, randomized trials aimed to investigate the safety and BP lowering efficacy of a novel RDN method, with perivascular alcohol delivery using the Peregrine Kit.
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Affiliation(s)
- Felix Mahfoud
- Department of Internal Medicine III, Cardiology, Angiology, Intensive Care Medicine, Saarland University Medical Center, Homburg, Germany.
| | | | - Roland E Schmieder
- Universitätsklinik Erlangen, Friedrich Alexander University Erlangen/Nürnberg, Germany
| | - Melvin D Lobo
- Barts NIHR Biomedical Research Centre, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Peter J Blankestijn
- Department of Nephrology, University Medical Center, Utrecht, The Netherlands
| | - Alexandre Persu
- Division of Cardiology, Cliniques Universitaires Saint-Luc and Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | | | | | - Atul Pathak
- Department of Cardiovascular Medicine, Princess Grace Hospital, Monaco
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Cheng Y, Liu H, Tian Z, Zhang M, Liu Y, Nan Q. Evaluating the thermal performance of a balloon-based renal sympathetic denervation system with array electrodes: a finite element study. Electromagn Biol Med 2021; 40:488-501. [PMID: 34352188 DOI: 10.1080/15368378.2021.1961266] [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: 10/20/2022]
Abstract
Renal denervation transmits radiofrequency (RF) energy through an electrode to treat resistant hypertension (RH), applying ablation in the renal artery. Several experimental studies have shown that this treatment has been used effectively to treat RH. The aim of this paper is to investigate the effect of ablation parameters (i.e., electrode length, applied voltage, ablation time, and blood flow) on the temperature distribution using a balloon-based array electrodes system. A simplified three-dimensional model including four electrodes and a balloon was established. The balloon diameter was 3 mm and placed in a 5 mm diameter renal artery for forming intra-arterial occlusion. Four electrodes were mounted on the balloon and distributed in the same plane to mimic circumferential RF ablation. Computer simulations were conducted to investigate the thermal performances of the device by setting different electrode configurations, treatment protocols, and physiological factors. The thermal performances including the thermal distribution, maximum lesion depth, length, and area were analyzed. The lesion shape of the array RF electrodes was approximately a sphere with a 100% circumference coverage rate of the renal artery. The lesion depth and length increase with each factor except for blood velocity. Increasing the electrode length from 2 to 4 mm or 2 to 6 mm, the lesion depth increases by 1.15 mm and 0.54 mm at 60 s. The corresponding lesion length increases by 2.65 mm and 2.34 mm, respectively. The range of effective lesion depth is 1.90-4.90 mm, at a voltage of 15-30 V. But the peak temperature at the arterial outer wall exceeded 100 °C when the voltage is above 25 V. In tissue, the degree of thermal injury in the 2 mm area reached 100%, but in blood was not more than 5%. There was no significant difference at different flow conditions because the difference value in lesion depth was not exceeded 0.5 mm. The results showed that the balloon-based four electrodes system is expected to overcome the difficulty of incomplete ablation. In clinical application, 2 mm-electrode is recommended to avoid long wall damage as much as possible and control the voltage below 25 V. This treatment has little thermal injury on the blood, which means it may avoid coagulation formation. Moreover, the application of this device does not need to consider the difference in individual blood velocity.
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Affiliation(s)
- Yanyan Cheng
- College of Life Science and Chemistry, The Faculty of Environment and Life ScienceBeijing University of Technology, Beijing, China
| | - Hongxing Liu
- College of Life Science and Chemistry, The Faculty of Environment and Life ScienceBeijing University of Technology, Beijing, China
| | - Zhen Tian
- College of Life Science and Chemistry, The Faculty of Environment and Life ScienceBeijing University of Technology, Beijing, China
| | - Meng Zhang
- College of Life Science and Chemistry, The Faculty of Environment and Life ScienceBeijing University of Technology, Beijing, China
| | - Youjun Liu
- College of Life Science and Chemistry, The Faculty of Environment and Life ScienceBeijing University of Technology, Beijing, China
| | - Qun Nan
- College of Life Science and Chemistry, The Faculty of Environment and Life ScienceBeijing University of Technology, Beijing, China
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Abstract
Despite the use of renal denervation to treat hypertension, the anatomy of the renal nervous system remains poorly understood. We performed a detailed quantitative analysis of the human renal nervous system anatomy with the goal of optimizing renal denervation procedural safety and efficacy. Sixty kidneys from 30 human cadavers were systematically microdissected to quantify anatomic variations in renal nerve patterns. Contrary to current clinical perception, not all renal innervation followed the main renal artery. A significant portion of the renal nerves (late arriving nerves) frequently reached the kidney (73% of the right kidney and 53% of the left kidney) bypassing the main renal artery. The ratio of the main renal artery length/aorta-renal hilar distance proved to be a useful variable to identify the presence/absence of these late arriving nerves (odds ratio, 0.001 (95% CI, 0.00002–0.0692;
P
: 0.001) with a cutoff of 0.75 (sensitivity: 0.68, specificity: 0.83, area under ROC curve at threshold: 0.76). When present, polar arteries were also highly associated with the presence of late arriving nerve. Finally, the perivascular space around the proximal main renal artery was frequently occupied by fused ganglia from the solar plexus (right kidney: 53%, left kidney: 83%) and/or by the lumbar sympathetic chain (right kidney: 63%, left kidney: 60%). Both carried innervation to the kidneys but importantly also to other abdominal and pelvic organs, which can be accidentally denervated if the proximal renal artery is targeted for ablation. These novel anatomic insights may help guide future procedural treatment recommendations to increase the likelihood of safely reaching and destroying targeted nerves during renal denervation procedures.
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Zhang H, Li LY, Xiao RX, Zhang TC, Liu ZJ, Gao JQ. Effects of different ablation points of renal denervation on the efficacy of resistant hypertension. PeerJ 2020; 8:e9842. [PMID: 32983640 PMCID: PMC7500320 DOI: 10.7717/peerj.9842] [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: 06/17/2020] [Accepted: 08/10/2020] [Indexed: 11/20/2022] Open
Abstract
Objective To explore the blood pressure response to different ablation points of renal denervation (RDN) in patients with resistant hypertension Methods A total of 42 cases with resistant hypertension treated by RDN in our center from 2013 to 2015 were retrospectively analyzed. The patients were divided into two groups according to the different ablation points of RDN: the standard treatment group (spiral ablation from near to proximal, with less than 8 points per artery) and the intensive treatment group (from near to far by spiral ablation, with at least 8 points per artery), with 21 patients in each group. The ablation parameters, including points, impedance, actual wattage, and actual temperature, were recorded intraoperatively. Renal angiography was performed again after RDN. Ambulatory blood pressure (ABP) images were taken for all patients at the baseline and 6 months after operation. Results The mean 24-h blood pressure of the standard treatment group was lower than that of the baseline (24-h systolic blood pressure decreased by 7.4 ± 10.6 mmHg and 24-h diastolic blood pressure decreased by 4.6 ± 6.1 mmHg), and the mean 24-h blood pressure decreased significantly from baseline to 6 months in the intensive treatment group (24–h systolic blood pressure decreased by 27.4 ± 11.4 mmHg, P < 0.0001; 24–h diastolic blood pressure decreased by 10.9 ± 9.6 mmHg, P = 0.005). There was a positive correlation between the decrease of systolic/diastolic 24-hour mean and the number of ablation points used in the procedure. The mean value of systolic and diastolic blood pressure was positively correlated with ablation points at 24-hour (R2 = 0.777 and 0.633 respectively, P < 0.01). There were no adverse events in either group after the operation and during the follow-up. Conclusions RDN could significantly reduce BP in patients with resistant hypertension. Our study showed that the antihypertensive effect appeared to be positively correlated with the number of ablation points.
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Affiliation(s)
- Hua Zhang
- Department of Cardiology, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Ling-Yan Li
- Department of Cardiology, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Rong-Xue Xiao
- Shanghai Putuo Center Clinical College, Anhui Medical University, Shanghai, China
| | - Ting-Chuan Zhang
- Department of Cardiology, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Zong-Jun Liu
- Shanghai Putuo Center Clinical College, Anhui Medical University, Shanghai, China
| | - Jun-Qing Gao
- Department of Cardiology, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
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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.
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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.
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Baik J, Song WH, Yim D, Lee S, Yang S, Lee HY, Choi EK, Jeong CW, Park SM. Laparoscopic Renal Denervation System for Treating Resistant Hypertension: Overcoming Limitations of Catheter-Based Approaches. IEEE Trans Biomed Eng 2020; 67:3425-3437. [PMID: 32310758 DOI: 10.1109/tbme.2020.2987531] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
GOAL In a pivotal clinical trial, the percutaneous catheter-based renal denervation system developed to treat resistant hypertension did not show effectiveness in reducing blood pressure because of its fundamental limitation to ablate deeper nerves present around the renal artery. METHODS We propose a new renal denervation strategy called laparoscopicdenervation system (LDS) based-on laparoscopy procedure to ablate the renal nerves completely but inhibit the thermal arterial damage.The system has flexible electrodes to bend around the arterial wall to ablate nervesThe simulation study using validated in-silico models evaluated the heat distributionon the outer arterial wall,and an acute animal study (swine model) was conducted to demonstrate the feasibility of LDS in vivo. RESULTS The simulation studyconfirmedthat LDS could localize the heat distributionbetween the electrode and the outer arterial wall. In the animal study, we could maximize nerve denervation by the localizing ablation energy within the renal nerves and achieve nerve denaturationand decrease in neural density by 20.78% (P < 0.001), while maintaining a constant tip temperature of 65 °C for the duration of 70 s treatment. The study confirmed intact lumen artery through histological analysis and acute reduction in systolic blood pressure by 9.55 mmHg (p < 0.001) Conclusion: The LDS presented here has potential to effectively and safely ablate the renal nerves, independent of anatomical variation and nerve distribution, to control hypertension in real clinical conditions. SIGNIFICANCE LDS approach is innovative, inventive, and presents a novel technique totreat hypertension.
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12
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Renal Artery Denervation in Resistant Hypertension: The Good, The Bad and The Future. Heart Lung Circ 2020; 29:94-101. [DOI: 10.1016/j.hlc.2019.06.723] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 06/04/2019] [Accepted: 06/24/2019] [Indexed: 02/05/2023]
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Sakaoka A, Terao H, Nakamura S, Hagiwara H, Furukawa T, Matsumura K, Sakakura K. Accurate Depth of Radiofrequency-Induced Lesions in Renal Sympathetic Denervation Based on a Fine Histological Sectioning Approach in a Porcine Model. Circ Cardiovasc Interv 2019; 11:e005779. [PMID: 29440276 PMCID: PMC5828376 DOI: 10.1161/circinterventions.117.005779] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 01/08/2018] [Indexed: 11/16/2022]
Abstract
Background— Ablation lesion depth caused by radiofrequency-based renal denervation (RDN) was limited to <4 mm in previous animal studies, suggesting that radiofrequency-RDN cannot ablate a substantial percentage of renal sympathetic nerves. We aimed to define the true lesion depth achieved with radiofrequency-RDN using a fine sectioning method and to investigate biophysical parameters that could predict lesion depth. Methods and Results— Radiofrequency was delivered to 87 sites in 14 renal arteries from 9 farm pigs at various ablation settings: 2, 4, 6, and 9 W for 60 seconds and 6 W for 120 seconds. Electric impedance and electrode temperature were recorded during ablation. At 7 days, 2470 histological sections were obtained from the treated arteries. Maximum lesion depth increased at 2 to 6 W, peaking at 6.53 (95% confidence interval, 4.27–8.78) mm under the 6 W/60 s condition. It was not augmented by greater power (9 W) or longer duration (120 seconds). There were statistically significant tendencies at 6 and 9 W, with higher injury scores in the media, nerves, arterioles, and fat. Maximum lesion depth was positively correlated with impedance reduction and peak electrode temperature (Pearson correlation coefficients were 0.59 and 0.53, respectively). Conclusions— Lesion depth was 6.5 mm for radiofrequency-RDN at 6 W/60 s. The impedance reduction and peak electrode temperature during ablation were closely associated with lesion depth. Hence, these biophysical parameters could provide prompt feedback during radiofrequency-RDN procedures in the clinical setting.
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Affiliation(s)
- Atsushi Sakaoka
- From Evaluation Center, R&D Administration and Promotion Department, Terumo Corporation, Kanagawa, Japan (A.S., H.T., S.N., H.H.); Graduate School of Engineering, Osaka Institute of Technology, Japan (A.S., K.M.); Biostatistical Research Co, Ltd, Tokyo, Japan (T.F.); and Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan (K.S.).
| | - Hisako Terao
- From Evaluation Center, R&D Administration and Promotion Department, Terumo Corporation, Kanagawa, Japan (A.S., H.T., S.N., H.H.); Graduate School of Engineering, Osaka Institute of Technology, Japan (A.S., K.M.); Biostatistical Research Co, Ltd, Tokyo, Japan (T.F.); and Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan (K.S.)
| | - Shintaro Nakamura
- From Evaluation Center, R&D Administration and Promotion Department, Terumo Corporation, Kanagawa, Japan (A.S., H.T., S.N., H.H.); Graduate School of Engineering, Osaka Institute of Technology, Japan (A.S., K.M.); Biostatistical Research Co, Ltd, Tokyo, Japan (T.F.); and Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan (K.S.)
| | - Hitomi Hagiwara
- From Evaluation Center, R&D Administration and Promotion Department, Terumo Corporation, Kanagawa, Japan (A.S., H.T., S.N., H.H.); Graduate School of Engineering, Osaka Institute of Technology, Japan (A.S., K.M.); Biostatistical Research Co, Ltd, Tokyo, Japan (T.F.); and Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan (K.S.)
| | - Toshihito Furukawa
- From Evaluation Center, R&D Administration and Promotion Department, Terumo Corporation, Kanagawa, Japan (A.S., H.T., S.N., H.H.); Graduate School of Engineering, Osaka Institute of Technology, Japan (A.S., K.M.); Biostatistical Research Co, Ltd, Tokyo, Japan (T.F.); and Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan (K.S.)
| | - Kiyoshi Matsumura
- From Evaluation Center, R&D Administration and Promotion Department, Terumo Corporation, Kanagawa, Japan (A.S., H.T., S.N., H.H.); Graduate School of Engineering, Osaka Institute of Technology, Japan (A.S., K.M.); Biostatistical Research Co, Ltd, Tokyo, Japan (T.F.); and Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan (K.S.)
| | - Kenichi Sakakura
- From Evaluation Center, R&D Administration and Promotion Department, Terumo Corporation, Kanagawa, Japan (A.S., H.T., S.N., H.H.); Graduate School of Engineering, Osaka Institute of Technology, Japan (A.S., K.M.); Biostatistical Research Co, Ltd, Tokyo, Japan (T.F.); and Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan (K.S.)
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Weber MA, Mahfoud F, Schmieder RE, Kandzari DE, Tsioufis KP, Townsend RR, Kario K, Böhm M, Sharp AS, Davies JE, Osborn JW, Fink GD, Euler DE, Cohen DL, Schlaich MP, Esler MD. Renal Denervation for Treating Hypertension. JACC Cardiovasc Interv 2019; 12:1095-1105. [DOI: 10.1016/j.jcin.2019.02.050] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 01/22/2019] [Accepted: 02/26/2019] [Indexed: 12/14/2022]
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15
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Renal Artery Branch Denervation: Evaluation of Lesion Characteristics Using a Thermochromic Liquid Crystal Phantom Model. Heart Lung Circ 2019; 29:445-451. [PMID: 30967336 DOI: 10.1016/j.hlc.2019.03.001] [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: 10/06/2018] [Revised: 01/17/2019] [Accepted: 03/01/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND Lately, combined main vessel and branch ablation has been recommended during radiofrequency (RF) renal artery denervation. Utilising a validated renal artery phantom model, we aimed (1) to determine thermal injury extent (lesion depth, width and circumferential coverage) and electrode-tissue interface temperature for branch renal artery ablation, and (2) to compare the extent of thermal injury for branch versus main vessel ablation using the same RF System. METHODS We employed a gel based renal artery phantom model simulating variable vessel diameter and flow, which incorporated a temperature sensitive thermochromic-liquid-crystal (TLC) film for assessing RF ablation thermodynamics. Ablations in a branch renal artery model (n = 32) were performed using Symplicity Spyral (Medtronic, Minneapolis, MN, USA). Lesion dimensions defined by the 51 °C isotherm, circumferential injury coverage, and electrode-tissue interface temperature were measured for all ablations at 60 seconds. RESULTS Lesion dimensions were 2.13 ± 0.13 mm and 4.13 ± 0.18 mm for depth and width, respectively, involving 23% of the vessel circumference. Maximum electrode-tissue interface temperature was 68.31 ± 2.29 °C. No significant difference in lesion depth between branch and main vessel ablations was found (Δ = 0.02 mm, p = 0.60). However, lesions were wider in the branch (Δ=0.49 mm, p < 0.001) with a larger circumferential coverage compared to main vessel (arc angle of 82.02±3.27° versus 54.90±4.36°, respectively). CONCLUSIONS In the phantom model, branch ablations were of similar depth but had larger width and circumferential coverage compared to main vessel ablations. Concerning safety, no overheating at the electrode-tissue interface was observed.
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16
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Choe WS, Song WH, Jeong CW, Choi EK, Oh S. Anatomic Conformation of Renal Sympathetic Nerve Fibers in Living Human Tissues. Sci Rep 2019; 9:4831. [PMID: 30886195 PMCID: PMC6423056 DOI: 10.1038/s41598-019-41159-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 02/25/2019] [Indexed: 01/07/2023] Open
Abstract
Renal denervation using radiofrequency catheter ablation is known to eliminate the renal sympathetic nerve and to lower blood pressure in patients with resistant hypertension. We sought to investigate the detailed anatomic conformation of the peri-renal arterial sympathetic nerve fibers with living human specimens. Peri-renal arterial tissue was harvested from patients undergoing elective radical or simple nephrectomy. Digital images of each section from the distal arterial bifurcation to the proximal margin were obtained and analyzed after immunohistochemical staining with anti-tyrosine hydroxylase antibodies. A total of 3,075 nerve fibers were identified from 84 sections of peri-renal arterial tissue from 28 patients (mean age 62.5 ± 10.2 years, male 68%). Overall, 16% of nerve fibers were located at distances greater than 3 mm from the endoluminal surface of the renal artery. The median distance from the arterial lumen to the nerve fibers of the proximal, middle, and distal renal arterial segments was 1.51 mm, 1.48 mm, and 1.52 mm, respectively. The median diameter of the nerve fibers was 65 μm, and there was no significant difference between the segments. A substantial proportion of the sympathetic nerve fibers were located deeper in the peri-arterial soft tissue than in the lesion depth created by the conventional catheter-based renal sympathetic denervation system.
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Affiliation(s)
- Won-Seok Choe
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Won Hoon Song
- Department of Urology, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea.,Department of Urology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Chang Wook Jeong
- Department of Urology, Seoul National University Hospital, Seoul, Republic of Korea.
| | - Eue-Keun Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea.
| | - Seil Oh
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
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17
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Renal Denervation by Transaortic Periarterial Ethanol Injection: An Experimental Study in Porcines. Cardiovasc Intervent Radiol 2018; 41:1943-1951. [PMID: 30088063 DOI: 10.1007/s00270-018-2045-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 07/23/2018] [Indexed: 10/28/2022]
Abstract
AIMS To evaluate the feasibility, safety and efficacy of renal sympathetic denervation via endoluminal transaortic periarterial ethanol injection. METHODS AND RESULTS In 11 normotensive pigs transaortic puncture was performed with a 90-cm 21G needle with subsequent unilateral ethanol injection to the periarterial space. Needle placement was achieved using a 7F steerable sheath fluoroscopically positioned slightly above the renal artery origin. Blood pressure measurements and abdominal CT scans were performed immediately pre- and postintervention and 4 weeks later. After euthanasia norepinephrine concentration of both kidneys (RTNEC) was determined and renal arteries and surrounding tissues histologically examined to assess induced nerve fibre degeneration. RESULTS All but one procedure were technically successful. One major complication with accidental ethanol injection into the renal artery and subsequent infarction occurred. One pig died from no intervention-related cardiac arrest. The 4-week follow-up was uneventful in the remaining 10 animals. RTNEC was significantly lower on the treated side in eight of ten pigs (mean decrease 36.6%) with correlating histopathological signs of nerve degeneration. CONCLUSIONS Renal sympathicolysis by transaortic periarterial ethanol injection was feasible and effective in a porcine model. This approach may be an alternative to catheter-based RFA or other methods of renal denervation.
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18
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Effects of Multi-Electrode Renal Denervation on Insulin Sensitivity and Glucose Metabolism in a Canine Model of Type 2 Diabetes Mellitus. J Vasc Interv Radiol 2018; 29:731-738.e2. [DOI: 10.1016/j.jvir.2017.12.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 12/05/2017] [Accepted: 12/12/2017] [Indexed: 11/18/2022] Open
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19
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Fudim M, Sobotka AA, Yin YH, Wang JW, Levin H, Esler M, Wang J, Sobotka PA. Selective vs. Global Renal Denervation: a Case for Less Is More. Curr Hypertens Rep 2018; 20:37. [PMID: 29717380 DOI: 10.1007/s11906-018-0838-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW Review the renal nerve anatomy and physiology basics and explore the concept of global vs. selective renal denervation (RDN) to uncover some of the fundamental limitations of non-targeted renal nerve ablation and the potential superiority of selective RDN. RECENT FINDINGS Recent trials testing the efficacy of RDN showed mixed results. Initial investigations targeted global RDN as a therapeutic goal. The repeat observation of heterogeneous response to RDN including non-responders with lack of a BP reduction, or even more unsettling, BP elevations after RDN has raised concern for the detrimental effects of unselective global RDN. Subsequent studies have suggested the presence of a heterogeneous fiber population and the potential utility of renal nerve stimulation to identify sympatho-stimulatory fibers or "hot spots." The recognition that RDN can produce heterogeneous afferent sympathetic effects both change therapeutic goals and revitalize the potential of therapeutic RDN to provide significant clinical benefits. Renal nerve stimulation has emerged as potential tool to identify sympatho-stimulatory fibers, avoid sympatho-inhibitory fibers, and thus guide selective RDN.
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Affiliation(s)
- Marat Fudim
- Duke University Medical Center, Durham, NC, USA.,Duke Clinical Research Institute, Durham, NC, USA
| | | | - Yue-Hui Yin
- The 2nd Affiliated Hospital of Chongqing Medical University, Chongqin, China
| | | | | | - Murray Esler
- Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Jie Wang
- Columbia University, New York, NY, USA.,SyMap Medical Ltd., Suzhou, China
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20
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Al Raisi S, Barry M, Qian P, Bhaskaran A, Pouliopoulos J, Kovoor P. Comparison of new-generation renal artery denervation systems: assessing lesion size and thermodynamics using a thermochromic liquid crystal phantom model. EUROINTERVENTION 2017; 13:1242-1247. [DOI: 10.4244/eij-d-17-00278] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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21
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Barber-Chamoux N, Esler MD. Predictive factors for successful renal denervation: should we use them in clinical trials? Eur J Clin Invest 2017; 47:860-867. [PMID: 28771706 DOI: 10.1111/eci.12792] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2017] [Accepted: 07/29/2017] [Indexed: 01/01/2023]
Abstract
Renal denervation (RDN) is facing various challenges to its initial claimed value in hypertension treatment. Major concerns are the choice of the patients and the technical efficacy of the RDN. Different factors have been described as predicting the capacity of RDN to decrease blood pressure. These factors are related to the patients, the procedure and the tools to confirm successful neural ablation. Their use in future trials should help to improve RDN trials understanding and outcomes. This review summarizes the different predictive factors available and their potential benefits in patient selection and in procedure guidance.
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Affiliation(s)
- Nicolas Barber-Chamoux
- Cardiology Department, Clermont-Ferrand University Hospital, Clermont-Ferrand, France.,Human Neurotransmitters Laboratory, Baker IDI Heart and Diabetes Institute, Melbourne, Vic., Australia
| | - Murray D Esler
- Human Neurotransmitters Laboratory, Baker IDI Heart and Diabetes Institute, Melbourne, Vic., Australia.,Heart Centre, Alfred Hospital, Melbourne, Vic., Australia
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22
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Toutouzas K, Synetos A, Pietri P, Stefanadis C. Chemical renal denervation: an effective method to treat resistant hypertension? EUROINTERVENTION 2017; 13:e1129-e1130. [PMID: 29033389 DOI: 10.4244/eij-d-16-01000l] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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23
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Bertog S, Vega F, Ghazarossian V, Pathak A, Vaskelyte L, Sievert H, Ladich E, Yahagi K, Virmani R. Chemical sympathetic denervation: promising, but important distinctions between agents and methods. EUROINTERVENTION 2017; 13:e1131-e1132. [PMID: 29033390 DOI: 10.4244/eij-d-16-01000r] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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24
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de Jager RL, Casteleijn NF, de Beus E, Bots ML, Vonken EJE, Gansevoort RT, Blankestijn PJ. Catheter-based renal denervation as therapy for chronic severe kidney-related pain. Nephrol Dial Transplant 2017. [DOI: 10.1093/ndt/gfx086] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Affiliation(s)
- Rosa L de Jager
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Niek F Casteleijn
- Department of Urology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Esther de Beus
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Michiel L Bots
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Evert-Jan E Vonken
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ron T Gansevoort
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Peter J Blankestijn
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
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