Renal denervation in patients with uncontrolled hypertension and renal artery stenosis assessed by invasive physiology.

BACKGROUND: Renal artery stenosis is usually considered as a contraindication for renal denervation. Whether renal denervation can be safe and effective in the presence of a renal artery stenosis once secondary renovascular hypertension has been ruled-out has never been investigated to date. We report our experience with radiofrequency-based renal denervation in patients with moderate-to-severe renal artery stenosis. METHODS: Patients with uncontrolled hypertension eligible for renal denervation referred to our Center were evaluated for this study. Renal artery stenosis >50% as evaluated by quantitative angiography analysis underwent physiological evaluation (ratio of the distal pressure to aortic pressure: Pd/Pa). Those with Pd/Pa ≥ 0.90 underwent renal denervation, as did patients with normal kidney arteries. Patients with Pd/Pa < 0.90 were treated with renal artery stenting. Office systolic and diastolic blood pressure (BP) and estimated glomerular filtration rate (eGFR) were assessed and compared among patients with normal renal arteries (Group 1), those with non-hemodynamically significant renal artery stenosis (Group 2), and patients undergoing renal artery stenting (Group 3). RESULTS: All patients with at least one-year of follow-up were included (n = 139). Similar systolic BP reduction was reported in Groups 1 (n = 114) and 2 (n = 25) : -5.76 ± 3.50, -5.86 ± 3.74, -14.46 ± 3.6, -22.79 ± 27.12 mmHg and -14.93 ± 26.53, -11.29 ± 27.32, -17.38 ± 22.72 and -19.21 ± 23.70 mmHg at 3, 6, 12, and 24 months, respectively. Kidney function remained stable. The patients in group 3 (n = 9) showed significant BP lowering after renal artery stenting. CONCLUSIONS: Physiologic assessment of renal artery stenosis distinguished hemodynamically relevant lesions, responsible for renovascular hypertension and suitable to undergo revascularization, from lesions without significant hemodynamic impact, which may be encountered in patients with essential hypertension. An accurate algorithm for stenosis assessment allows the selection of the most appropriate treatment (ie, renal artery stenting or renal denervation).