Renal Denervation in Uncontrolled Hypertensive Patients With Renal Artery Stenosis Assessed by Invasive Physiology

Objective: Renal artery stenosis is usually considered a contraindication to renal denervation (RDN). We evaluated whether invasive renal physiology can safely identify patients with angiographically moderate-to-severe renal artery stenosis who may still benefit from radiofrequency RDN once hemodynamically significant renovascular hypertension is excluded.Design and method: Consecutive patients with uncontrolled hypertension referred for RDN underwent selective renal angiography. Lesions visually >50% underwent quantitative angiographic analysis and wire-based translesional physiology using the distal-to-aortic pressure ratio (Pd/Pa). Patients with Pd/Pa >=0.90 underwent RDN (together with patients with angiographically normal renal arteries). Patients with Pd/Pa <0.90 underwent renal artery stenting (RAS). Office blood pressure (BP) and renal function (eGFR, CKD-EPI) were assessed at 3, 6, 12 and 24 months. Results: Patients with at least 1-year follow-up were included (n=139). Patients with normal renal arteries treated with RDN were n=114. Twenty-five patients had angiographic stenosis and underwent physiology: Pd/Pa was >=0.90 in 16 (treated with RDN) and <0.90 in 9 (treated with RAS). Systolic BP reduction after RDN was comparable between patients with normal arteries and those with non-significant stenosis (3/6/12/24 months: -5.76/-5.86/-14.46/-22.79 mmHg vs -14.93/-11.29/-17.38/-19.21 mmHg). Renal function remained substantially stable during follow-up. Patients treated with physiology-guided RAS also showed BP improvement (mean follow-up 18 months: systolic/diastolic change about -21/-12 mmHg). No major procedural complications were observed. Conclusions: Physiologic assessment of renal artery stenosis discriminates hemodynamically significant lesions suitable for revascularization from non-significant disease in which RDN appears feasible, effective, and renally safe. An integrated physiology-guided algorithm may expand access to RDN in uncontrolled hypertension while supporting appropriate selection for RAS.