CE: Namrta; JCM-D-13-00449; Total nos of Pages: 2;

JCM-D-13-00449

Images in cardiovascular medicine

Late renal artery stenosis after percutaneous renal denervation Thomas Lambert, Hermann Blessberger, Michael Grund and Clemens Steinwender Renal denervation has been adopted as an additional treatment option to pharmacological antihypertensive therapy in patients with resistant hypertension. However, concerns have been raised with regard to the possible occurrence of renal artery stenosis. Our patient developed renal artery stenosis late after renal denervation, as magnetic resonance angiography 6 months after the procedure had showed no stenosis. Invasive reangiography, which revealed the stenosis, was performed due to recurrent resistant hypertension 28 months after renal denervation. Review of the saved loops of the denervation

A 39-year-old woman suffering from resistant arterial hypertension was treated by percutaneous renal denervation (RDN) using the Symplicity RDN System (Medtronic Inc., Minneapolis, Minnesota, USA) after exclusion of secondary causes. The procedure was completed successfully without any complications on 9 November 2010. Baseline magnetic resonance (MR) angiography of both renal arteries is illustrated in Fig. 1. For antihypertensive treatment, the patient was under treatment of metoprolol 95 mg, aliskiren 300 mg, hydrochlorothiazide 25 mg, spironolactone 50 mg. No further medication was taken. Treatment success was followed by repetitive measurements of office blood pressure (OBP) and ambulatory blood pressure monitoring (ABPM). Six months postprocedure, the systolic blood pressure showed a drop of 34 mmHg in OBP and of 21 mmHg in ABPM.

procedure showed that the stenosis was located near the most proximal ablation point. J Cardiovasc Med 2014, 15:000–000 Keywords: percutaneous renal denervation, renal artery stenosis, resistant arterial hypertension Department of Cardiology, Linz General Hospital, Academic Teaching Hospital of the Universities of Vienna and Innsbruck, Vienna and Innsbruck, Austria Correspondence to Thomas Lambert, MD, Krankenhausstraße 9, 4020 Linz, Austria Tel: +43 732 7806 73430; fax: +43 732 7806 6205; e-mail: [email protected] Received 11 August 2013 Revised 1 November 2013 Accepted 28 February 2014

lower levels again (OBP: 118/75 mmHg, mean ABPM: 112/69 mmHg). RDN is a novel treatment option for patients with resistant arterial hypertension. Radiofrequency energy delivery results in sympathetic nerve ablation,1,2 but may also give rise to tissue fibrosis within the vessel wall and consecutive stenosis. Up to now there is only one report about a renal artery stenosis 5 months after RDN.3 We report the late development of renal artery stenosis, as MR angiography 6 months after RDN showed no narrowing of the vessel lumen. As the renal artery stenosis in our patient was also located near to the ostium and not Fig. 1

At 6 months’ follow-up, routine MR angiography of both renal arteries excluded renal artery stenosis caused by the renal denervation procedure. However, 28 months after renal denervation, blood pressure values rose continuously (OBP: 175/90 mmHg). A reevaluation by conventional angiography revealed a 90% stenosis 5 mm distal the ostium of the left renal artery (Fig. 2). Review of the saved loops of the RDN procedure showed that the stenosis is located near the most proximal ablation point within the left renal artery (Fig. 3). A drug eluting stent was implanted without any complication. One month after revascularization, blood pressure dropped to 1558-2027 ß 2014 Italian Federation of Cardiology

Baseline magnetic resonance angiography of both renal arteries.

DOI:10.2459/JCM.0000000000000095

Copyright © Italian Federation of Cardiology. Unauthorized reproduction of this article is prohibited.

CE: Namrta; JCM-D-13-00449; Total nos of Pages: 2;

JCM-D-13-00449

2 Journal of Cardiovascular Medicine 2014, Vol 00 No 00

Fig. 2

Fig. 3

Renal angiography showing a 90% stenosis within the left renal artery.

Renal angiography showing the most proximal ablation point at renal denervation.

within the shaft of the vessel, caution may be warranted, when delivering radiofrequency energy too close to the offspring of the renal arteries from the abdominal aorta.

References 1

2

Acknowledgements Conflicts of interest

There are no conflicts of interest.

3

Krum H, Schlaich M, Withbourn R, et al. Catheter based renal sympathetic denervation for resistant hypertension: a multicenter safety and proof-ofprinciple cohort study. Lancet 2009; 373:1275–1281. Esler MD, Krum H, Sobotka PA, Schlaich MP, Schmieder RE, Bo¨hm M. Symplicity HTN-2 investigators. Renal sympathetic denervation in patients with treatment-resistant hypertension: a randomized controlled trial. Lancet 2010; 376:1903–1909. Kaltenbach B, Id D, Franke JC, et al. Renal artery stenosis after renal sympathetic denervation. JACC 2012; 60:2694–2695.

Copyright © Italian Federation of Cardiology. Unauthorized reproduction of this article is prohibited.

Late renal artery stenosis after percutaneous renal denervation.

: Renal denervation has been adopted as an additional treatment option to pharmacological antihypertensive therapy in patients with resistant hyperten...
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