Letter to the Editor Bilateral Renal Artery Stenosis After Renal Denervation Fernando Jaén Águila, Juan Diego Mediavilla García, Eduardo Molina Navarro, Jose Antonio Vargas Hitos, Celia Fernández-Torres To the Editor: Renal artery stenosis after renal sympathetic denervation (RDN) with radiofrequency ablation in patients with resistant hypertension is a rare complication of this medical procedure. In a study of 153 patients,1 only 1 new renal artery stenosis was reported at 3 years after renal denervation. In a study of 88 patients, no renal artery stenosis was reported at 6 month follow-up.2 To date there are few reports of renal stenosis after RDN.3,4 We present a 39-year-old patient with high blood pressure (BP) of 10-year evolution, left ventricular hypertrophy, and left putaminal hypertensive intracranial hemorrhage, which occurred 1 year before denervation. On examination, BP was 170/100 mm Hg, despite treatment with 6 antihypertensive drugs. Resistant hypertension was confirmed by 24-h ambulatory blood pressure monitoring (ABPM). Mean 24-hour ABPM measurement was 144/91 mm Hg (diurnal BP 155/99 mm Hg; nocturnal BP 128/79 mm Hg). Secondary hypertension was excluded, and no renal artery stenosis was found. Seven radiofrequency ablations were applied on the right side and 5 on the left side (Figures 1 and 2). Ablations were applied in a spiral pattern at a minimum distance of 5 mm.5 Renal artery alterations were visible immediately after denervation. A vasospasm occurred in both renal arteries directly after RDN (Figures 1 and 2); in the right side, it resolved with intravenous nitroglycerin, but there was no response in left side. The patient was asymptomatic within the days after denervation, and renal function remained normal. A Doppler ultrasound study performed after 48 hours showed an increase of velocity in the middle third of both renal arteries, slightly higher than normal. One month later, there were no changes in the renal function; however, in the 24-hour ABPM measurement, BP was raised considerably (24-hour ABPM: 167/98 mm Hg; diurnal BP 183/108 mm Hg; nocturnal BP 149/85 mm Hg). Two months later, ultrasound showed an increase of peak velocity of 338 m/s in the left renal artery. Computed tomographic angiography showed 75% stenosis in the left renal artery and 30% in the right renal artery (Figure 3). RDN is an increasingly common therapeutic option for patients with refractory hypertension in spite of medical therapy. Currently available data1–4,6–8 indicate that the procedure is effective in lowering BP in selected cases, showing few adverse events (2%). The renal artery stenosis has been reported only in 2 cases,9,10 one at 3 months, and the other at 5 months after RDN. Our case shows the development of a bilateral renal artery stenosis after RDN. We found an early renal artery spasm, which was probably caused by direct manipulation of the catheter (Figures 1 and 2). This renal artery alteration continued in the patient follow-up. We then assumed that the stenosis detected by computed tomographic angiogram (Figure 3) could have been caused by RDN. No atheroma or edema was found during the RDN procedure. In
this case, BP raised considerably. Extending this technique is likely to increase the frequency of this complication, so we consider that early image follow-up and control of renal arteries could be appropriate in these patients.
Disclosures None. 1. Krum H, Schlaich MP, Böhm M, Mahfoud F, Rocha-Singh K, Katholi R, Esler MD. Percutaneous renal denervation in patients with treatment-resistant hypertension: final 3-year report of the Symplicity HTN-1 study. Lancet. 2013; 140:62192–62193. 2. Mahfoud F, Cremers B, Janker J, Link B, Vonend O, Ukena C, Linz D, Schneider R, Rump LC, Kindermann I, Sobotka PA, Krum H, Scheller B, Schlaich M, Laufus U, Böhm M. Renal hemodynamics and renal function after catheter-based renal sympathetic denervation in patients with resistant hypertension. Hypertension. 2012; 60:419–424. 3. Benamer H, Mylotte D, Garcia-Alonso C, Unterseeh T, Garot P, Louvard Y, Lefevre T, Morice MC; ICV-GVM la Roseraie. Renal denervation a treatment for resistant hypertension: A French experience. Ann Cardiol Angeiol (Paris). 2013;62:384–391. 4. Persu A, Jin Y, Azizi M, Baelen M, Völz S, Elvan A, Severino F, Rosa J, Adiyaman A, Fadl-Elmula FE, Taylor A, Pechère-Bertschi A, Wuerzner G, Jokhaji F, Kahan T, Renkin J, Monge M, Widimský P, Jacobs L, Burnier M, Mark PB, Kjeldsen SE, Andersson B, Sapoval M, Staessen JA. Blood pressure changes after renal at 10 European expert centers. J Hum Hypertens (advance online publication). 2013; In Press. 5. Expert consensus document from the European Society of Cardiology on catheter-based renal denervation. Eur Heart J. 2013; 34:2149–2157. 6. Brinkmann J, Heusser K, Schmidt BM, Menne J, Klein G, Bauersachs J, Haller H, Sweep FC, Diedrich A, Jordan J, Tank J. Catheter-based renal nerve ablation and centrally generated sympathetic activity in difficult-to-control hypertensive patients: prospective case series. Hypertension. 2012;60:1485–1490. 7. Krum H, Schlaich M, Whitbourn R, Sobotka PA, Sadowski J, Bartus K, Kapelak B, Walton A, Sievert H, Thambar S, Abraham WT, Esler M. Catheter-based renal sympathetic denervation for resistant hypertension: a multicentre safety and proof-of-principle cohort study. Lancet. 2009;373:1275–1281. 8. Esler MD, Krum H, Sobotka PA, Schlaich MP, Schmieder RE, Bohm M. Renal sympathetic denervation in patients with treatment-resistant hypertension (The Symplicity HTN-2 Trial): a randomised controlled trial. Lancet. 2010;376:1903–1909. 9. Vonend O, Antoch G, Rump LC, Blondin D. Secondary rise in blood pressure after renal denervation. Lancet. 2012;380:778. 10. Kaltenbach B, Id D, Franke JC, Sievert H, Hennersdorf M, Maier J, Bertog SC. Renal artery stenosis after renal sympathetic denervation. J Am Coll Cardiol. 2012;60:2694–2695.
From the Hypertension (F.J.Á., J.D.M.G., J.A.V.H., C.F.-T.) and Hemodynamics Unit (E.M.N.) Virgen de las Nieves University Hospital, Granada, Spain. (Hypertension. 2014;63:e126-e127.) © 2014 American Heart Association, Inc. Hypertension is available at http://hyper.ahajournals.org
DOI: 10.1161/HYPERTENSIONAHA.113.03065
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Águila et al Bilateral Stenosis After Renal Denervation e127
Figure 1. Left renal sympathetic denervation (RDN) angiogram. A, Pre-RDN procedure. Left renal artery. B and C, Ablation areas on left renal artery. D, Left renal spasm after RDN.
Figure 2. Right renal sympathetic denervation (RDN) angiogram. A, Pre-RDN procedure. Right renal artery. B and C, Ablation areas on right renal artery. D, Right renal spasm after RDN.
Figure 3. Computed tomographic renal angiography control, 2 months after renal sympathetic denervation.
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Bilateral Renal Artery Stenosis After Renal Denervation Fernando Jaén Águila, Juan Diego Mediavilla García, Eduardo Molina Navarro, Jose Antonio Vargas Hitos and Celia Fernández-Torres Hypertension. 2014;63:e126-e127; originally published online March 24, 2014; doi: 10.1161/HYPERTENSIONAHA.113.03065 Hypertension is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Copyright © 2014 American Heart Association, Inc. All rights reserved. Print ISSN: 0194-911X. Online ISSN: 1524-4563
The online version of this article, along with updated information and services, is located on the World Wide Web at: http://hyper.ahajournals.org/content/63/5/e126
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this case, BP raised considerably. Extending this technique is likely to increase the frequency of this complication, so we consider that early image follow-up and control of renal arteries could be appropriate in these patients.
Disclosures None. 1. Krum H, Schlaich MP, Böhm M, Mahfoud F, Rocha-Singh K, Katholi R, Esler MD. Percutaneous renal denervation in patients with treatment-resistant hypertension: final 3-year report of the Symplicity HTN-1 study. Lancet. 2013; 140:62192–62193. 2. Mahfoud F, Cremers B, Janker J, Link B, Vonend O, Ukena C, Linz D, Schneider R, Rump LC, Kindermann I, Sobotka PA, Krum H, Scheller B, Schlaich M, Laufus U, Böhm M. Renal hemodynamics and renal function after catheter-based renal sympathetic denervation in patients with resistant hypertension. Hypertension. 2012; 60:419–424. 3. Benamer H, Mylotte D, Garcia-Alonso C, Unterseeh T, Garot P, Louvard Y, Lefevre T, Morice MC; ICV-GVM la Roseraie. Renal denervation a treatment for resistant hypertension: A French experience. Ann Cardiol Angeiol (Paris). 2013;62:384–391. 4. Persu A, Jin Y, Azizi M, Baelen M, Völz S, Elvan A, Severino F, Rosa J, Adiyaman A, Fadl-Elmula FE, Taylor A, Pechère-Bertschi A, Wuerzner G, Jokhaji F, Kahan T, Renkin J, Monge M, Widimský P, Jacobs L, Burnier M, Mark PB, Kjeldsen SE, Andersson B, Sapoval M, Staessen JA. Blood pressure changes after renal at 10 European expert centers. J Hum Hypertens (advance online publication). 2013; In Press. 5. Expert consensus document from the European Society of Cardiology on catheter-based renal denervation. Eur Heart J. 2013; 34:2149–2157. 6. Brinkmann J, Heusser K, Schmidt BM, Menne J, Klein G, Bauersachs J, Haller H, Sweep FC, Diedrich A, Jordan J, Tank J. Catheter-based renal nerve ablation and centrally generated sympathetic activity in difficult-to-control hypertensive patients: prospective case series. Hypertension. 2012;60:1485–1490. 7. Krum H, Schlaich M, Whitbourn R, Sobotka PA, Sadowski J, Bartus K, Kapelak B, Walton A, Sievert H, Thambar S, Abraham WT, Esler M. Catheter-based renal sympathetic denervation for resistant hypertension: a multicentre safety and proof-of-principle cohort study. Lancet. 2009;373:1275–1281. 8. Esler MD, Krum H, Sobotka PA, Schlaich MP, Schmieder RE, Bohm M. Renal sympathetic denervation in patients with treatment-resistant hypertension (The Symplicity HTN-2 Trial): a randomised controlled trial. Lancet. 2010;376:1903–1909. 9. Vonend O, Antoch G, Rump LC, Blondin D. Secondary rise in blood pressure after renal denervation. Lancet. 2012;380:778. 10. Kaltenbach B, Id D, Franke JC, Sievert H, Hennersdorf M, Maier J, Bertog SC. Renal artery stenosis after renal sympathetic denervation. J Am Coll Cardiol. 2012;60:2694–2695.
From the Hypertension (F.J.Á., J.D.M.G., J.A.V.H., C.F.-T.) and Hemodynamics Unit (E.M.N.) Virgen de las Nieves University Hospital, Granada, Spain. (Hypertension. 2014;63:e126-e127.) © 2014 American Heart Association, Inc. Hypertension is available at http://hyper.ahajournals.org
DOI: 10.1161/HYPERTENSIONAHA.113.03065
Downloaded from http://hyper.ahajournals.org/ ate126 University of Michigan--Ann Arbor on June 14, 2015
Águila et al Bilateral Stenosis After Renal Denervation e127
Figure 1. Left renal sympathetic denervation (RDN) angiogram. A, Pre-RDN procedure. Left renal artery. B and C, Ablation areas on left renal artery. D, Left renal spasm after RDN.
Figure 2. Right renal sympathetic denervation (RDN) angiogram. A, Pre-RDN procedure. Right renal artery. B and C, Ablation areas on right renal artery. D, Right renal spasm after RDN.
Figure 3. Computed tomographic renal angiography control, 2 months after renal sympathetic denervation.
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Bilateral Renal Artery Stenosis After Renal Denervation Fernando Jaén Águila, Juan Diego Mediavilla García, Eduardo Molina Navarro, Jose Antonio Vargas Hitos and Celia Fernández-Torres Hypertension. 2014;63:e126-e127; originally published online March 24, 2014; doi: 10.1161/HYPERTENSIONAHA.113.03065 Hypertension is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Copyright © 2014 American Heart Association, Inc. All rights reserved. Print ISSN: 0194-911X. Online ISSN: 1524-4563
The online version of this article, along with updated information and services, is located on the World Wide Web at: http://hyper.ahajournals.org/content/63/5/e126
Permissions: Requests for permissions to reproduce figures, tables, or portions of articles originally published in Hypertension can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial Office. Once the online version of the published article for which permission is being requested is located, click Request Permissions in the middle column of the Web page under Services. Further information about this process is available in the Permissions and Rights Question and Answer document. Reprints: Information about reprints can be found online at: http://www.lww.com/reprints Subscriptions: Information about subscribing to Hypertension is online at: http://hyper.ahajournals.org//subscriptions/
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