CASE

REPORT

Distal Renal Artery Stenosis After Percutaneous Renal Denervation Leading to Renal Impairment but Normotension Christian Koppelstaetter, MD, PhD;1 Julia Kerschbaum, MD;1 Michael Lenzhofer, MD;1 Bernhard Glodny, MD;2 Regina Esterhammer, MD;2 Matthias Frick, MD;3 Hannes Alber, MD;3,4 Gert Mayer, MD1 From the Department of Internal Medicine IV, Nephrology and Hypertension, Medical University Innsbruck, Innsbruck, Austria;1 Department of Radiology, Medical University Innsbruck, Innsbruck, Austria;2 Department of Internal Medicine III, Cardiology, Medical University Innsbruck, Innsbruck, €nster in Tyrol, Austria4 Austria;3 and Department of Cardiology, Rehabilitation Clinic Mu

Renal denervation (RDN) is a novel tool that may be used in patients with resistant hypertension. The Renal Denervation in Patients With Uncontrolled Hypertension (Simplicity HTN-1 and HTN-2) trials show promising results with a low incidence of complications.1,2

CASE REPORT A 68-year-old woman was referred to our department for treatment-resistant hypertension. The patient was receiving extended-release metoprolol 95 mg, aliskiren 300 mg, and indapamide 1.5 mg per day. Because of intolerance, treatment with calcium antagonists (edema) and angiotensin-converting enzyme inhibitors (cough) was not possible. Ambulatory blood pressure (BP) measurement showed elevated mean daytime values of 151/97 mm Hg (and slightly elevated values of 124/ 70 mm Hg during night). At that time, serum creatinine was 0.89 mg/dL and the patient was normoalbuminuric. Compliance with antihypertensive medication was judged as good, and when rilmenidine (2 mg per day) was added and aliskiren was replaced by 80 mg valsartan, BP slightly decreased to 145/90 mm Hg. Together with the patient and after exclusion of contraindications, we came to the decision to perform RDN. RDN was performed using the Symplicity RDN system by Medtronic (Sandy Hook, CT). After the intervention, vasospasms of the left renal artery were noticed close to the bifurcation, which did not resolve after intravasal donation of nitroglycerin, and continued until the end of the procedure. Over the next 2 days, BP stayed unchanged and no rise in serum creatinine was detected. After 1 month, serum creatinine was 0.87 mg/dL and office BP was 149/90 mm Hg; therefore, doses of valsartan were raised to 160 mg/d. During the following months, serum creatinine increased and hypertension worsened despite an increase in medication (valsartan 320 mg/d, torasemid 10 mg/d, rilmenidine 2 mg/d, nebivolol 5 mg/d, and terazosin 4 mg/d).

€tter, MD, PhD, Medical Address for correspondence: Christian Koppelsta University Innsbruck, Department of Internal Medicine IV, Nephrology and Hypertension, Anichstrasse 35, 6020 Innsbruck, Austria Email: [email protected] Manuscript received: October 15, 2014; accepted: October 28, 2014 DOI: 10.1111/jch.12456

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Magnetic resonance imaging angiography 10 months after RDN revealed an hourglass-like short distance stenosis of the left renal artery and a reduction in length of the left kidney of 1.2 cm. Serum creatinine was 1.65 mg/dL. Reevaluation of renal angiography at the time of the RDN procedure exhibited that the de novo stenosis was located at the position of the acute subendothelial edema. The angiotensin receptor blocker was stopped and serum creatinine subsequently decreased to 1.51 mg/dL and 24-hour measurement of BP exhibited a mean value of 129/79 mm Hg. For quantification of functional significance of the stenosis, isotopic side separate renal clearance was conducted under furosemide stimulation. Overall, glomerular filtration rate was 61 mL/min/1.73m², with a 77% contribution of the right and 23% of the left kidney. The test was repeated 3 weeks after stop of renin-angiotensin system inhibiton (75 mL/min/1.73m²; 75% right/25% left kidney), suggesting an influence of renin-angiotensin system blockade on both kidneys. Initially, serum creatinine decreased to 1.16 mg/dL but BP rose to 160/90 mm Hg. When valsartan was reinstituted, BP again was sufficiently controlled leading to a slight rise in serum creatinine to 1.31 mg/dL. In order to improve vascularization and function of the left kidney, we decided to perform angioplasty of the stenosis with a drug eluting balloon, which was successfully performed 12 months after RDN (Figures 1 and 2). One week after dismission, the patient was under sufficient therapy (ambulatory BP revealed a mean value of 133/81 mm Hg) with a combination of four antihypertensives (nebivolol 5 mg, rilmenidine 2 mg, valsartan 80 mg, and torasemide 10 mg) and stable serum creatinine of 1.26 mg/dL.

DISCUSSION Our patient initially presented with resistant hypertension. The patient was carefully selected for RDN according to the guidelines.3 Renal arteries were evaluated by computed tomography and magnetic resonance imaging angiography to guarantee a minimum of 2 cm in length and 4 mm in diameter as suggested by the ablation catheter producing company. During the RDN procedure, a spasm of the left renal artery did not appear to resolve until the end of the procedure. Even though such spasms have been described previously, most disappear during the time of the procedure. The principle of this method goes back to intense research about the role of sympathetic nerve

Renal Artery Stenosis but Normotension After RDN | Koppelstaetter et al.

FIGURE 1. Maximum intensity projection image of magnetic resonance imaging angiography after intravenous application of 8-mL gadobutrol using a fat-saturated three-dimensional fast low angle shot technique (T1-FL3D). Before renal denervation (a) and 10 months after renal denervation (b) with distally located stenosis of the left renal artery and delayed contrast enhancement of the left kidney. Digital subtraction angiography of the left renal artery before (c) and after (d) balloon angioplasty.

influence in the formation of arterial hypertension.4 In 2009, the first-in-man data of 45 successfully treated patients with therapy-refractory hypertension and RDN were presented.5 In 2010, a randomized controlled trial ascertaining these results in a randomly assigned cohort of 106 patients.2 Measuring the office-based BP 6 months after the intervention showed a reduction of BP in the RDN group by 32/12 mm Hg. In both studies, no severe side effects were shown. Only possible progression of an underlying atherosclerotic lesion was described. Besides all of these very promising results, several cases of post-denervation side effects on renal arteries were suspected. One patient presented a secondary rise in serum creatinine after RDN showing a progressive atherosclerotic lesion,6 two patients showed stenosis identified in routine controls,7 and a late renal artery stenosis was observed 28 months after renal denervation even though no changes in the renal artery were detected by magnetic resonance angiography 6 months after procedure.8 Templin and colleagues9 used optical coherence tomography in 32 patients to test for any changes in the renal arteries after the ablation procedure. Vasospasms, edema, thrombus formation, and even dissections were detected.9 Since all of these findings may lead to the formation of fibrosis, we suspected that either a small dissection or prolonged edema resulted in distal stenosis in our patient. Neither computed tomography nor magnetic resonance imaging could visualize new formation of atherosclerosis in the area of stenosis.

FIGURE 2. Digital subtraction angiography of the left renal artery before (a) and after (b) balloon angioplasty.

In our patient, renal impairment resulted from a lack of renal perfusion caused by stenosis of the left renal artery. However, the right kidney seemed to be at least, in part, altered by general vasosclerosis since it could not adequately compensate the harmed kidney. Hence, we decided to perform balloon angioplasty to reduce further cardiovascular risks caused by impaired renal function.

CONCLUSIONS In our patient, the amelioration of BP beside a progressive renal artery stenosis suggests a beneficial effect of RDN on overall BP by downregulation of sympathetic nerve activity. Even though the recently published HTN-3 trial could not show significant reduction of BP by RDN in patients compared with a sham operation, it is an ongoing discussion that patients might profit by this novel method.10,11 As a result of our experience presented in this case, we strongly suggest a pre-interventional as well as a short-term post-interventional visualization (3 months after RDN) of renal arteries, particularly in patients with evident vasospasm after an ablation procedure. The Journal of Clinical Hypertension

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Acknowledgments and disclosures: This project was supported by an unrestricted research grant from Medtronic. This company was not involved in writing or revising of the manuscript. There are no conflicts of interest to disclose.

References 1. Krum H, Schlaich M, Whitbourn R, et al. Catheter-based renal sympathetic denervation for resistant hypertension: a multicentre safety and proof-of-principle cohort study. Lancet. 2009;373:1275– 1281. 2. Symplicity HTNI, Esler MD, Krum H, et al. Renal sympathetic denervation in patients with treatment-resistant hypertension (The Symplicity HTN-2 Trial): a randomised controlled trial. Lancet. 2010;376:1903–1909. 3. Mahfoud F, Vonend O, Bruck H, et al. [Expert consensus statement on interventional renal sympathetic denervation for hypertension treatment]. Dtsch Med Wochenschr. 2011;136:2418. 4. Schlaich MP, Sobotka PA, Krum H, et al. Renal denervation as a therapeutic approach for hypertension: novel implications for an old concept. Hypertension. 2009;54:1195–1201.

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5. Schlaich MP, Sobotka PA, Krum H, et al. Renal sympathetic-nerve ablation for uncontrolled hypertension. N Engl J Med. 2009;361: 932–934. 6. Vonend O, Antoch G, Rump LC, Blondin D. Secondary rise in blood pressure after renal denervation. Lancet. 2012;380:778. 7. Kaltenbach B, Id D, Franke JC, et al. Renal artery stenosis after renal sympathetic denervation. J Am Coll Cardiol. 2012;60:2694– 2695. 8. Lambert T, Blessberger H, Grund M, Steinwender C. Late renal artery stenosis after percutaneous renal denervation. J Cardiovasc Med. 2014Aug 1 [Epub ahead of print]. 9. Templin C, Jaguszewski M, Ghadri JR, et al. Vascular lesions induced by renal nerve ablation as assessed by optical coherence tomography: pre- and post-procedural comparison with the Simplicity catheter system and the EnligHTN multi-electrode renal denervation catheter. Eur Heart J. 2013;34:2141–2148. 10. Bhatt DL, Bakris GL. Renal denervation for resistant hypertension. N Engl J Med. 2014;371:184. 11. Bakris G, Nathan S. Renal denervation and left ventricular mass regression: a benefit beyond blood pressure reduction? J Am Coll Cardiol. 2014;63:1924–1925.

Distal renal artery stenosis after percutaneous renal denervation leading to renal impairment but normotension.

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