Catheterization and Cardiovascular Interventions 84:1180–1183 (2014)

Case Report Renal Artery Stenosis Following Renal Percutaneous Denervation Paul Bhamra-Ariza, MBBS, MD, MRCP, Sriram Rao, MBBS, and David W Muller*, MBBS, MD, FRACP Renal denervation has been shown to be safe and effective in reducing blood pressure in treatment-resistant hypertensive patients. We describe a 65-year-old lady with essential hypertension who underwent renal denervation using the VessixTM single shot multielectrode system. Twelve months later renal duplex scanning documented increased velocities in the left renal artery and repeat angiography confirmed the development of a new stenosis. Although renal denervation is a promising therapy, we advise caution as large randomized blinded studies with long-term follow-up are still ongoing. VC 2014 Wiley Periodicals, Inc. Key words: renal artery disease; hypertension; ablation; catheter/cryoblation/radio frequency

INTRODUCTION

CASE REPORT

Although the cause of essential hypertension is multifactorial, there is an abundance of clinical evidence linking overactivity of the sympathetic nervous system to its development [1,2]. In the past, surgical sympathectomy was performed as a treatment for hypertension, albeit with a 4% perioperative mortality rate and a 5-year survival of 70–80% [3]. The development of effective anti-hypertensive medication meant that high-risk surgical procedures were no longer required. Resistant hypertension (defined as blood pressure >140/90 mm Hg, >130– 139/80–85 mm Hg in diabetes mellitus or >130/ 80 mm Hg in chronic kidney disease in the presence of three or more anti-hypertensive medications of different classes, including a diuretic, at maximal or the highest tolerated dose) has a prevalence of less than 10% [4]. The underlying etiology of resistance to medical therapy includes patient and clinician-related factors such as patients’ noncompliance to anti-hypertensive treatment [5]. Therefore, the ability to reduce blood pressure with an interventional procedure appeals to both physicians and patients. We describe a patient with essential hypertension who developed a de novo renal artery stenosis following renal denervation.

A 65-year-old lady with essential hypertension refractory to medical therapy was referred for renal artery denervation. Her medications included atenolol 50-mg daily, candesartan 32-mg daily, lisinopril hydrochlorothiazide 20/12.5-mg daily, and moxonidine 400mcg daily. Prior serology and renal artery duplex scanning confirmed normal renal function, and no evidence of renal artery stenosis. The resistive indices were normal bilaterally. Under local anesthesia and sedation a 6 Fr introducer sheath was inserted into the right femoral artery. Prior to performing renal denervation,

C 2014 Wiley Periodicals, Inc. V

Interventional Fellow at St Vincents Hospital, Sydney, Australia Conflict of interest: Professor Muller is a Consultant/trialist for Medtronic Corevalve, Abbott MitraClip and Vessix, He receives funding from all of the mentioned organisations. Dr. Bhamra-Ariza and Dr. Rao have no financial disclosures to report. *Correspondence to: David Muller, MBBS, MD, FRACP, Cardiology Department, St Vincent’s Hospital, Victoria St, Darlinghurst, NSW 2010. E-mail: [email protected] Received 2 January 2014; Revision accepted 11 May 2014 DOI: 10.1002/ccd.25546 Published online 14 May 2014 (wileyonlinelibrary.com)

in Wiley Online Library

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Fig. 1. (A) Angiography demonstrating widely unobstructed left renal artery prior to denervation, (B) radio frequency of left renal artery using noncompliant balloon denervation system with six bipolar electrodes, (C) angiography immediately following angiography demonstrating absence of vessel trauma or stenosis, and (D) repeat angiography 10 months later confirms the development of new stenosis.

angiography confirmed the absence of renovascular disease and using quantitative angiography, the caliber of both the left and right renal arteries was measured to be 5 mm (Fig. 1A). Using an 8 Fr introducer and standard 0.01400 guidewire, an over the wire noncompliant balloon (5  25 mm) denervation system with six electrodes (Vessix V2 renal denervation systemTM) was inserted into the left and then into the right proximal renal artery and inflated to 3 atm. Angiography confirmed good apposition of the balloon against the vessel wall and occlusion of the artery prior to delivering a single 30 sec RF energy pulse (Fig. 1B). Angiography immediately after denervation showed no apparent dissection or vessel wall injury (Fig. 1C). At 6 months follow-up, the patient was noted to have continuing high blood pressure, although at 12 months review her blood pressure had normalized. Renal artery duplex scanning at 6 months and at 12 months showed increased velocities at the origin and along the

proximal to mid segments of the left renal artery (3.6 m/s in the left renal artery compared to 1.2 m/s in the right renal artery). Per protocol, follow-up angiography was performed at 6 months after the administration of intrarenal nitroglycerin and confirmed the development of a new stenosis of moderate severity in the proximal left renal artery (Fig. 1D). The renal artery pressure was recorded distal to the lesion through the lumen of an over the wire balloon catheter after the 0.01400 wire was removed, and simultaneously at the origin of the renal artery. This revealed no pressure gradient across the stenosis. The renal artery lesion is, therefore, being managed medically. DISCUSSION

Recent guidelines have embraced catheter-based renal denervation as a therapy for drug resistant hypertension [6]. The SYMPLICITY HTN-2 randomized

Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).

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patients with severe drug resistant hypertension to renal denervation or medical therapy [7]. At 6 months 41 (84%) of 49 patients in the denervation group had a reduction in systolic blood pressure (SBP) of 10 mm Hg or more, compared with 18 (35%) of 51 controls (P < 00001). Thirty-four patients were followed up for 3 years with mean SBP changes postdenervation of 33.1 6 13.3 mm Hg. The reduction in ambulatory BP measurement was 11/7 mm Hg, standard deviation (SD) 15/11; P < 0.006 in the renal denervation group (n ¼ 20) versus no change in the control group (n ¼ 25) [8]. Importantly no serious procedure-related or devicerelated complications occurred although one patient who had renal denervation had possible progression of an underlying atherosclerotic lesion, which did not require treatment. Our patient had no history of prior renal artery stenosis as demonstrated by previous angiography, and therefore, one can only assume the stenosis developed as a consequence of the denervation procedure. At present the stenosis is not haemodynamically significant and her BP is well controlled. Other investigators have experienced similar observations using single unipolar electrode catheters rather than using a single shot system with multibipolar electrode catheters [9,10]. In theory, use of the latter allows shorter procedure times and a lower power outputs (

Renal artery stenosis following renal percutaneous denervation.

Renal denervation has been shown to be safe and effective in reducing blood pressure in treatment-resistant hypertensive patients. We describe a 65-ye...
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