Centers of Excellence in Interventional Cardiology and Radiology

Interventional radiology

Renal Artery Denervation (RDN)

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Generalities

Arterial hypertension is a common affection wich have severe consequences. All over the world, it’s estimated that more than a thousand million people suffer from arterial hypertension; in Europe, almost half of people are hypertensive. These patients are at high risk to develop heart disease, myocardial infarction, stroke, renal disfunction.

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Arterial blood pressure has tho components:

1. systolic blood pressure – the pressure with wich heart is pumping the blood to the other organs

2. Diastolic blood pressure – is the vessel’s pressure when the heart is filling with the blood received from the entire body.

Hypertension’s treatment consists of an association of drugs, but also a healthy lifestyle, wich include a heaithy diet and exercises. These drugs must be administered daily; unfortunately, they also may have adverse effects affecting patient’s quality of life.

Blood pressure regulation is controled by the brain; thus, the brain sends signals to other organs, such as kidneys and blood vessels. There are some pressure receptors all over the body, principally in kidneys, and these receptors can “read” blood pressure. In some cases, kidney sends wrongs messages to the brain, such as a false lower blood pressure than normal values, so the brain sends signals to the organs involved in blood pressure regulation, increasing the blood pressure. But now the blood pressure will be high.5

Thus, instead of medical treatment, in this case, hypertension can be treated using a minimally invasive procedure, know as renal artery denervation.

Indications

Resistant hypertension despite medical treatment – blood pressure values above 140/90mmHg despite multiple drugs (three or more medications), at adequate doses, whence one is a diuretic

patients with type I diabetes mellitus have a theoretical risk of kidney’s disfunction, so they are not eligibles for this procedure

the major indication for renal denervation is in case of patients with type II diabetes mellitus; studies have showed a reduction in blood pressure values, but also the improvement of glucidic methabolism and insulin resistance.

Procedure

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Renal artery denervation is performed in ours catheterism labs, under local anesthesia, respecting the asepsy rules.

The interventionist chooses the adequate abord, in this case the groin where the femoral artery can be punctured, after local anesteshia. A catheter will be inserted through the femoral artery and advanced up to the renal arteriies, using X ray images for guidance.

Renal denervation is an endovascular procedure, using radiofrequency ablation. After engaging the renal artery, and angiography to evaluate the anatomy of the renal arteries, the ablation catheter is placed under fluoroscopic guidance in the distal segment of the renal artery. By applying radiofrequency pulses to the renal arteries, the nerves in the vascular wall (adventitia layer) can be denervated. This causes reduction of renal sympathetic afferent and efferent activity (the role of both afferent and efferent sympathetic renal nerves in the pathophysiology of hypertension has been recently reappraised, resistant hypertension especially). A series of 2-minute ablations are delivered along each renal artery (at least 4 differents points) to disrupt the nerves.56

When the procedure is done, the interventionist will remove the catheter.

The patient will leave the hospital the next day. No remarcable limitations are needed.

Several weeks after the procedure, more than 80% of patients with renal denervation have an average, long term, blood pressure reduction of 32/12mmHg. These patients will need less drugs or even no medical treatment.

Is it painful?

The procedure is performed under local anesthesia, so the patient will not feel any pain, and after the procedure it will received pain drugs.

How long does it take?

The procedure lasts about 45 minutes. The patient can leave the hospital the day afer procedure.

Risks

Possible complications are :

pseudoaneurysm or hematoma at the site of puncture (bed rest is required for 12 hours to avoid such a complication),

allergic reactions or nausea secondary to the injection of the contrast agent (transient complications)

renal function impairment secondary to contrast agent injection (avoided if the patient is adequately hydrated both orally and by intravenous infusions, which are administered before and after the procedure)

stroke, lower limb ischemia, renal ischemia (very rare complications)

very rare: renal artery dissection – treated during this procedure.

Before procedure

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Before the procedure, the interventional radiologist will thoroughly explain the intervention to the patient and will answer any question about it. The doctor must be informed about any current medication taken by the patient as well as any previous allergic reactions. Blood tests will be taken before the procedure to assess the coagulation, renal function, hemoglobin level, and other specific tests. If the patient is under anticoagulant therapy, this will be stopped before the procedure. The patient is admitted the day before the planned procedure. He/she should not eat/drink anything the day of the intervention.

After procedure

Bed rest is needed for 12 hours, and the patient must avoid bending the thigh in order to prevent any possible bleeding or hematoma formation.

Oral hydration is recommended after the procedure to help eliminate the injected contrast agent.

Blood pressure strict monitoring, because the decrease in blood pressure values may be important, so the antihypertensive therapy should be adjusted.

After discharge (usually the day after the procedure), you must be followed regularly by your cardiologist.

Important!

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Renal denervation is a modern procedure used for hypertension treatment. It’s important to exclude secondary forms of resistant hypertension (such as suprarenalian disfunction). This procedure has a high rate of succes (85-90%) wich doesn’t depend on quality’s procedure, but patient’s features – wich aren’t identified before the procedure.

Sometimes, the response is immediately and important; but usually the result is observed after several weeks.

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