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DCS Årsmøde 2011
Renal nerve ablation in the
management of systemic
hypertension
Henning Kelbæk
DSC 2011
History
- Cutting of the great splanchnic nerve (renal denervation)
induced ipsilateral diurese (Bernard 1859)
Electric stimulation of the peripheral cut end (renal
sympathetic stimulation) induced ipsilateral anti-diurese
- Renal denervation is associated with increased renal
blood flow (Starling 1908)
- Renal sympathetic nerve activity:
decreases renal blood flow
increases Renin secretion rate
increases tubular sodium reabsorption
Hypertension
An insidious disease
Background
- Increased SA is common in essential hypertension
- Sympathectomy reduces blood pressure efficiently
- The prevalence of hypertension is appr 10% in DK
- Long-term complications are stroke, MI, renal failure
- In >95% of all cases the hypertension is essential
- In some patients the blood pressure cannot be controlled
despite treatment with 5 different drugs
N Engl J Med 2009:361;9
Renal Nerve Ablation team,
Rigshospitalet
- Cardiology Clinic:
Lia E Bang, Mikael Sander, Jesper Hastrup
Svendsen, Henning Kelbæk
- Nephrology Clinic
Anne-Lise Kamper, Bo Feldt-Rasmussen
Renal Denervation
• Catheter based
transmural ablation
• Disruption of renal
sympathetic nervous
innervation
Symplicity Catheter
• Can be introduced percutaneously into the renal arteries
• Delivers radiofrequency energy
• Can ablate both efferent and afferent renal nerves
Targeting Renal Nerves
• Nerves arise from T10-L2
• The nerves arborize around the artery
and primarily lie within the adventitia
Vessel
Lumen
Media
Adventitia
10
Renal
Nerves
Lancet 2009:373;1275-81
Inclusion criteria:
- BP (office) > 160 on 3 drugs (incl. one diuretic) or
- Intolerance to medication
Exclusion criteria:
Secondary cause of hypertension
GFR < 45 ml/min/1.73m2
Type 1 DM
PM/ICD
Medical treatment (such as warfarin)
Renovascular disease
Lancet 2009;373:1275-81
50 patients (5 excluded due to renal vascular causes)
Office blood pressure prior: 177/101
Mean 4.7 anti-hypertension medications
- 96 % ACEI or AT2A or both
- 76 % betablocker
- 69 % calcium antagonist
- 18 % direct vasodilators
- 96 % diuretics
Lancet 2009;373:1275-81
Trial profile
Lancet 2009;373:1275-81
BP at 1 month: -14/-10
BP at 3 month: -21/-10
BP at 6 month: -22/-11
BP at 12 month: -27/-17
13 % non-responders
Lancet 2009;373:1275-81
Ablation lesions:
4.2 (right) and 3.7 (left Renal Artery)
Pain while energy administration
Mean reduction of renal NA spillover: 47 % (n = 10)
Angiogram (day 14-30; n 18): no stenosis
MRI (6 month; n = 14): no irregularities
1 renal artery dissection (prior to ablation)
1 femoral artery pseudoaneurysm
Lancet 2009;373:1275-81
Case report
Change in kidney NE
N Engl J Med 2009:361;932-4
Case report
Change in whole-body NE
N Engl J Med 2009:361;932-4
Case report
Change in sympathetic activity
N Engl J Med 2009:361;932-4
24 centres: 190 patients screened
106 included:
- 52 renal denervation
- 54 controls
Lancet 2010;376:1903-09
Trial profile
Lancet 2010;376:1903-09
Lancet 2010;376:1903-09
Change in blood pressure
Lancet 2010;376:1903-09
Change in renal function
Lancet 2010;376:1903-09
Data analysers were not masked to treatment assignment
Primary endpoint: Change in seated office-based measurement
of systolic blood pressure at 6 months
Lancet 2010;376:1903-09
Symplicity Catheter
Catheter Tip Features
5mm
Flexible Tip
(self-orienting)
12mm
Deflectable
Shaft
Catheter Handle Features
Deflect tip by pulling lever
towards back of handle
Straighten tip by pushing lever
towards front of handle
Shaft & electrode can rotate independent
from handle body
Renal Angiogram
29
Eligible Anatomy:
• Absence of flow limiting obstructions
• Diameter ≥ 4mm in targeted area
Targeting Renal Nerves
• Treat distal to proximal
• 4-6 focal treatments
• 2 min per treatment
• ≥ 5 mm between locations
• Stable, unique locations
• Circumferential coverage
• Common strategy (dependent on renal
anatomy):
• Distal: Inferior and inferolateral locations
• Proximal: Superior and superolateral locations
• Avoid purely lateral treatments (possible electrode
movement with respiration)
• PULL, ROTATE, ASSESS new location and prior
treatment site
30
Case
20-år gammel HF-elev henvist til renal ablation for hypertension
Disp:
Farmor har hypertension. Ingen med hypertension i ungdommen
Anamnese: Essentiel hypertension siden 11-års-alderen
Problemer med bivirkninger af diverse præpararter
Dårlig medicin compliance
Medicin:
Centyl m/KCl 2.5 mg x 1
Adalat Oros 60 mg x 1
Corodil 20 mg x 1
Objektivt::
Blodtryk 160/100 på begge arme
St.c. & p. : i.a.
Normale femoralispulse
EKG:
i.a.
Patienter med essentiel hypertension
-
hvis blodtryk ikke kan kontrolleres trods
med mindst 3 antihypertensiva
behandling
-
som har uacceptable bivirkninger af den
behandling
medicinske
kan henvises til
Hjertecentrets visitation,
Rigshospitalet
med angivelse af
- Kort anamnese med indikation
- Døgn-blodtryk monitorerings svar
- P-kreatinin
- Medicin liste
Spørgsmål:
Hvad er det sikreste
tegn på forår ?
Spørgsmål:
At pigerne går
Hvad
er sandaler
det sikreste
med
tegn på forår ?