经“子母”导管行去肾交感神经治疗顽固性高血压二例

目的 探讨经“子母冶导管行肾动脉交感神经治疗顽固性高血压的方法及疗效。方法 2例顽固性高血压患者,于局麻下使用7F肾动脉指引导管套5F消融导管对其行经导管去肾交感神经术,螺旋式消融肾动脉内膜4~ 6个点,术中消融指标：每点消融时间累积120 s,消融功率8 W,消融阻抗150 ~250 赘,消融温度45益。结果 2例血压由术前170 /100,175/98 mmHg降至术后出院时的130/82,134/84 mm Hg,术后4个月随访期间平均血压分别为130/82,134/84 mm Hg。 2例患者术后降压药的用量和种类减少。结论 使用“子母冶导管行经导管去肾交感神经术治疗顽固性高血压安全、有效。     

24h动态血压监测预测和评估经皮经导管射频消融去肾交感神经术的降压作用

<正>经皮经导管射频消融去肾交感神经术治疗难治性高血压(renal denervation for resistant hypertension,DENERHTN)临床试验显示,明确诊断的难治性高血压患者经英国指南推荐的标准化阶梯降压治疗(standardized stepped-care antihypertensive treatment,SSAHT)加上使用Symplicity导管的经皮经导管射频消融去肾交感神经术(renal denervation,RDN),随访     

经皮导管射频消融去肾脏交感神经术治疗顽固性高血压的治疗现状

对于顽固性高血压患者,药物治疗不能较好地控制血压。肾脏交感神经活性增强是高血压发生、发展和靶器官损害的重要危险因素。近年来研究表明,经皮导管射频消融去肾交感神经术有助于治疗顽固性高血压。     

经皮经导管射频消融去肾交感神经术治疗难治性高血压:有应用必要吗?

<正>刘蔚(北京医院心内科,北京100730)迄今为止,高血压的治疗多以药物治疗为主,但部分患者尽管服用≥3种降压药(包括利尿剂),血压仍难以达标。因此,人们在不断研发新的降压药和新的治疗技术。2009年Symplicity HTN-1试验结果发表以来,经皮经导管射频消融去肾交感神经术(renal denervation,RDN)成为难治性高血压(resistant hypertension,RH)治疗领域最引人关注的话题之一,并有很多     

肾交感神经及去交感神经对血压影响的研究

研究表明交感神经的过度激活在高血压发生、发展中起重要作用,特别是肾交感神经的活性增加。经导管肾去交感神经消融术﹙RSD﹚是经导管消融肾动脉,去除其周围部分传入和传出神经的新兴微创介入技术。Symplicity HTN-1和Symplicity HTN-2研究已经分别公布了3年和1年的随访跟踪结果,结果显示RSD治疗难治性高血压的短期、长期效果都很显著,展示了巨大的应用前景。 然而,最近Symplicity HTN-3 研究公布的半年研究结果显示,消融组和假手术组血压降低值并无显著差异,RSD对顽固性高血压没有明显治疗作用。     

SYMPLICITY HTN-3后时代,经皮导管消融去肾交感神经术治疗顽固性高血压路在何方？

顽固性高血压是一种特殊类型的高血压,在应用包括利尿剂在内的3种或以上的足量降压药后血压仍难以达标或至少需4种降压药,血压才能达标,可导致严重的靶器官损伤和心血管风险,治疗十分棘手[1]。近年来,一项前瞻性队列研究和随机对照研究表明,经皮导管消融去肾交感神经术（RDN）对于部分顽固性高血压患者具有显著持久的降压作用,且很少发生严重的操作相关不良事件,为顽固性高血压患者的血压管理带来新的曙光[2-4]。     

经导管射频消融去肾脏交感神经术治疗难治性高血压研究现状

经导管射频消融去肾脏交感神经术是一种治疗难治性高血压的新兴非药物手段,作为一种微创手术,可以选择性消融肾交感神经纤维,阻断中枢交感神经和肾脏之间神经冲动的传递,从而达到控制血压的目的。目前关于经导管射频消融去肾脏交感神经术治疗难治性高血压的研究较多,但具有一定的争议性,现就经导管射频消融去肾脏交感神经术治疗高血压开展的有关研究现状做一综述。     

经导管射频消融去肾交感神经术的现状

许多研究已证实肾交感神经活动参与高血压的发病与维持,尤其在顽固性高血压中,因此选择性肾交感神经阻断被认为是治疗顽固性高血压的一个重要手段。经导管射频消融去肾交感神经术采用血管介入方法高选择性阻断支配肾脏传入和传出交感神经,从而降低肾交感活性达到降压的目的。该操作创伤小、并发症少、不影响生理性心肺功能,不损伤机体应激反应能力。经动物实验及临床实践发现其除了对于顽固性高血压有显著而持续的降压作用外,还有改善心功能、糖代谢、左室质量等效益。现就经导管射频消融去肾交感神经术的现状做一综述。     

单导管消融改良肾交感神经治疗顽固性高血压的初步探讨

目的:探讨以单导管消融改良肾交感神经治疗高血压疗效。方法:2011年11月至2013年10月期间,在本院因顽固性高血压行单导管消融改良肾交感神经治疗的30例患者(男性16例)。导管消融同步检测腹主动脉压力,以峰值压力降低20%~30%,来判断靶神经(肾交感神经)的消融效果。观察术前、术后1,3,6,12及18个月血压,并在术前、术后即刻及术后3个月行X线断层肾动脉成像(CTA)或肾动脉造影了解肾动脉情况。结果:患者术前平均诊室血压(160±15)/(95±10)mmHg(1mmHg=0.133kPa),平均随访8个月,术后1,3,6,12及18个月,血压分别减低20/10mmHg、22/11mmHg、25/10,mmHg、26/11mmHg和28/17mmHg,与基础血压比较,差异有统计学意义(P0.05)。所有患者均未出现肾动脉狭窄,夹层,穿孔及其他严重并发症。结论:本组以单导管消融术改良肾交感神经,治疗顽固性高血压是行之有效且安全的,对于顽固性高血压患者具有比较显著且持久的降压作用。     

肾交感神经射频消融治疗顽固性高血压的护理

目的探讨肾交感神经消融治疗顽固性高血压的护理方法。方法对2例顽固性高血压患者进行肾交感神经射频消融，并对其进行针对性护理。结果全部患者病情稳定，血压较术前明显下降，服用药物减少，并未出现任何并发症。结论肾交感神经消融治疗顽固性高血压安全有效，对患者进行针对性的护理，有利于患者尽早康复。     

Unilateral Catheter-based Renal Sympathetic Denervation in Resistant Arterial Hypertension Shows No Blood Pressure-lowering Effect

A 68-year-old woman with resistant essential arterial hypertension despite the regular use of four antihypertensive drugs was referred to the catheter-based renal sympathetic denervation. Due to the complicated anatomy, insertion of the guiding catheter into the left renal artery was not stable. Thus, renal denervation of only the right renal artery was performed. Before and after renal denervation, the patient’s blood pressure was monitored by home blood pressure (BP) telemonitoring. The average 7-day home BP telemonitoring values before and 1, 2, and 3 months after denervation were 187.1/124.1, 193.3/123.1, 198.3/129.6, and 195.2/128.0 mm Hg. After unilateral renal denervation, no BP decrease occurred. This unique case suggests that unilateral catheter-based renal sympathetic denervation in resistant arterial hypertension shows no BP-lowering effect. Therefore, when treating resistant hypertension by catheter-based renal denervation, it seems advisable to try always to perform an effective bilateral procedure.     

Renale Denervierung

Hypertension is a well-known risk factor for major cardiovascular events. Despite advances in medical therapy, sufficient treatment of hypertension remains unsatisfying in a substantial number of patients and is therefore one of the main challenges in modern medicine. In Germany 5–15?% of patients with hypertension suffer from resistant hypertension with elevated blood pressure despite the use of at least three antihypertensive drugs. Additionally patients often suffer from side effects. In patients with resistant hypertension the important role of the sympathetic nervous system with increased sympathetic activity is well known. In the past surgical sympathectomy with extended removal of sympathetic ganglia was performed to reduce blood pressure in patients with malignant hypertension. The positive effect of this highly invasive procedure on blood pressure led to the development of new strategies for the treatment of uncontrolled hypertension. One of the novel procedures includes catheter-based renal sympathetic denervation. The most common system is the radiofrequency ablation catheter (Symplicity?, Medtronic, Minneapolis, USA) which ablates the nerve fibers in the adventitia of the renal arteries by using high-frequency energy. As the results of the Symplicity trials (HTN-1 and HTN-2) showed significant reduction of systolic and diastolic blood pressure after renal denervation there is growing interest in this novel procedure. Moreover, by reducing the sympathetic activity after renal denervation early results indicate a positive impact on glucose metabolism, sleep apnea syndrome, as well as heart and renal failure. These effects led to the development of many different devices for renal denervation; however, trials with a higher number of patients and longer follow-up need to confirm these initially promising results and the value of newer devices. Until then renal denervation should not be regarded as standard therapy for arterial hypertension or an alternative to medical antihypertensive treatment and should be reserved for selected patients with resistant hypertension and specialized medical centres.     

Renal denervation in a patient with prior renal artery stenting

This is a case report of a 69‐year‐old female with treatment‐resistant severe arterial hypertension despite prior successful percutaneous intervention to both renal arteries for significant renal artery stenoses (stenting of the right and balloon angioplasty of the left renal artery). The office blood pressure was 221/108 mm Hg at baseline. Secondary hypertension was ruled out and catheter‐based renal denervation performed (distal to the stent in the right renal artery and in the usual fashion in the left renal artery) without complications. The office blood pressure decreased at 1‐ and 3‐month follow‐up to 185/93 mm Hg and 182/95 mm Hg, respectively. This case illustrates the feasibility and potential efficacy of catheter‐based renal denervation in patients with a renal artery stent, an important finding as persistent hypertension is common in patients despite successful renal artery stenting and currently available trials examining renal denervation have excluded patients with prior renal artery stents. © 2012 Wiley Periodicals, Inc.     

Les sténoses artérielles rénales post-dénervation – une problématique préoccupante ?

Renal denervation, an invasive technique indicated in resistant hypertension patients insufficiently controlled by antihypertensive drugs, has a good safety profile. However, an increasing number of post-denervation renal artery stenosis cases has recently been reported. We describe the case of a 49-year-old woman with resistant hypertension who was referred to our university hypertension center for renal sympathetic denervation. Her daily treatment included six antihypertensive drugs. CT angiography prior to denervation showed no renal artery stenosis or vessel wall lesions. A standard renal denervation procedure using the St Jude protocol was performed. After an initial improvement in blood pressure profile, she presented with a blood pressure impairment at 3 months after renal denervation leading to the diagnosis of a severe right renal artery stenosis.     

Percutaneous Renal Sympathetic Denervation: 2013 and Beyond

Systemic hypertension affects almost a quarter of Canadian adults. Although most can achieve adequate blood pressure control using a combination of medical and lifestyle interventions, many have resistant hypertension and are unable to reach their target. Percutaneous renal sympathetic denervation has been developed to address a crucial mechanism in the pathophysiology of hypertension: renal sympathetic overactivity. In 2009, the first-in-man experience with renal denervation was published. Several studies followed, including the randomized Symplicity HTN-2 trial of 106 patients: 6-month mean blood pressure reduction was 32/12 mm Hg in those who underwent renal denervation, vs a change of +1/0 Hg in those who did not. However, all the evidence to date suffers from the same drawbacks: studies are small, and follow-up is short and largely incomplete. The future of renal denervation will be determined by 3 factors. First, there will be more and better evidence. Symplicity HTN-3 has randomized 530 patients to renal denervation vs a sham procedure; 24-hour ambulatory blood pressure monitoring will be assessed in all participants. Other quality trials will follow, including ones that will assess clinical end points. Second, other indications for this treatment will be investigated. Sympathetic overactivity is implicated in many other conditions, including heart failure and arrhythmia; sympathetic denervation might benefit these patients as well. Third, myriad devices, using different methods to achieve renal denervation, are being developed. The first renal denervation system was approved for clinical use in Canada in March 2012. Until more data are available, patients undergoing this procedure should be carefully screened and, ideally, enrolled in research protocols.     

Renal Denervation in a Hypertensive Patient With End‐Stage Renal Disease and Small Arteries: A Direction for Future Research

J Clin Hypertens (Greenwich). 2012;14:799–801. ©2012 Wiley Periodicals, Inc. Sympathetic overactivity plays a crucial pathogenetic role in the maintenance and aggravation of arterial hypertension in patients with end‐stage renal disease (ESRD). Renal denervation has been shown to be effective and safe in reducing blood pressure (BP) in patients with treatment‐resistant hypertension; however, there are only case reports in hypertensive patients with ESRD and data are lacking about possibility of renal denervation in small renal arteries. A woman with uncontrolled treatment‐resistant hypertension on chronic hemodialysis underwent bilateral native kidney, catheter‐based renal denervation. Both native renal arteries were <4 mm. After 6 months without any change of antihypertensive medication or hemodialysis parameters, the authors observed a remarkable BP reduction of 38/30 mm Hg (from baseline 172/100 mm Hg to 134/70 mm Hg) as evaluated by 24‐hour ambulatory BP monitoring. The authors report that renal denervation seems to be effective in controlling hypertension in patients with ESRD, even in cases of small renal arteries.     

Resistant hypertension: is renal denervation the current treatment of choice?

Background: Resistant hypertension is simply defined as failure to control blood pressure <140/90?mmHg in an adherent non-diabetic patient with normal kidney function despite the use of optimal doses of three antihypertensive agents, including a diuretic. Also, control of blood pressure in any adherent patient with more than four antihypertensive agents defines resistant hypertension. In a patient with diabetes or chronic kidney disease, the goal blood pressure is <130/80?mmHg. One of the most important pathophysiological mechanisms of resistant hypertension is overactivity of the sympathetic nervous system (SNS). In selected patients with resistant hypertension, renal denervation has been shown to control blood pressure by suppressing SNS overactivity. Summary: This review summarizes the results of the studies of renal denervation for resistant hypertension and suggests the use of this procedure in several other conditions that are associated with SNS overactivity. Key message: Renal denervation seems to control blood pressure in patients with resistant hypertension.     

经皮肾交感神经射频消融术治疗难治性高血压:附2例报告

目的初步观察和探索经皮肾交感神经射频消融术治疗难治性高血压的疗效及操作方法。方法对2例难治性高血压患者实施经皮肾交感神经射频消融术并随访半年至一年,观察其血压及用药水平的变化。结果术后患者的血压较术前明显下降,降压药物种类及剂量亦减少。随访结果显示2例患者的高血压药物使用剂量和种类均有减少,其中1例患者血压控制在目标水平,1例未达到目标水平。结论难治性高血压患者通过经皮肾交感神经射频消融术使血压持续下降,用药剂量和种类减少。     

Renal hemodynamics and renal function after catheter-based renal sympathetic denervation in patients with resistant hypertension

Increased renal resistive index and urinary albumin excretion are markers of hypertensive end-organ damage and renal vasoconstriction involving increased sympathetic activity. Catheter-based sympathetic renal denervation (RD) offers a new approach to reduce renal sympathetic activity and blood pressure in resistant hypertension. The influence of RD on renal hemodynamics, renal function, and urinary albumin excretion has not been studied. One hundred consecutive patients with resistant hypertension were included in the study; 88 underwent interventional RD and 12 served as controls. Systolic, diastolic, and pulse pressure, as well renal resistive index in interlobar arteries, renal function, and urinary albumin excretion, were measured before and at 3 and 6 months of follow-up. RD reduced systolic, diastolic, and pulse pressure at 3 and 6 months by 22.7/26.6 mm Hg, 7.7/9.7 mm Hg, and 15.1/17.5 mm Hg (P for all <0.001), respectively, without significant changes in the control group. SBP reduction after 6 months correlated with SBP baseline values (r=-0.46; P<0.001). There were no renal artery stenoses, dissections, or aneurysms during 6 months of follow-up. Renal resistive index decreased from 0.691±0.01 at baseline to 0.674±0.01 and 0.670±0.01 (P=0.037/0.017) at 3- and 6-month follow-up. Mean cystatin C glomerular filtration rate and urinary albumin excretion remained unchanged after RD; however, the number of patients with microalbuminuria or macroalbuminuria decreased. RD reduced blood pressure, renal resistive index, and incidence of albuminuria without adversely affecting glomerular filtration rate or renal artery structure within 6 months and appears to be a safe and effective therapeutic approach to lower blood pressure in patients with resistant hypertension.