Percutaneous renal denervation through a false lumen fenestration in aortic dissection type B

Abstract

Aortic dissection is a severe complication of longstanding hypertension increasing morbidity and mortality. Augmented activity of the sympathetic nervous system has been identified as a main contributor to the development and maintenance of resistant hypertension. Renal denervation offers a new treatment approach to reduce sympathetic activity and blood pressure. Recently published data indicate that renal denervation is also effective and safe in patients with moderate to severe chronic kidney disease. A 61-year-old man (height 181 cm, weight 110 kg) presented to our clinic with dyspnea (NYHA II), progressive chest and abdominal pain. Medical history included an aortic dissection type B with perfusion of the left kidney from the false lumen diagnosed in 2009, and chronic kidney disease IV (cystatin C GFR 23.6 ml/min) with nephrosclerosis. The patient was receiving 5 antihypertensive drugs (bisoprolol 5mg 1/2-0-1/2, hydrochlorothiazide 25mg 1-0-0, amlodipine 10mg 0-0-1, urapidil 90mg 1-0-1, moxonidine 0.3mg 1-0-1). Office blood pressure (BP) was 160/95 mmHg. Ambulatory 24-hour BP monitoring confirmed true treatment resistance (mean 141/91 mmHg, non-dipping pattern). Resistant hypertension from secondary causes was excluded. Renal denervation was performed via femoral access. An 8F IMA-guiding catheter (CordisTM) was placed into the true aortic lumen at the level of the left renal artery. After a fenestration maneuver of the intima flap, performed using an IronmanTM PTCA wire, the radiofrequency catheter (SymplicityTM) was introduced and advanced to the distal segment of the renal artery under fluoroscopy. Five treatments of the left artery and six of the right artery, in steps of 5 mm with rotations in order to capture the entire circumference of the vessel, were successfully applied. At 3, 6 and 12-month follow-up, ambulatory 24-hour BP was reduced by 13/10 mmHg, 14/9 mmHg and 13/9 mmHg (mean daytime 130/83 mmHg; mean nighttime 122/79 mmHg), respectively. Six months after treatment BP was controlled to target (office 130/90 mmHg). Renal function remained nearly unchanged after treatment (cystatin C GFR baseline: 23.6 mL/min, 3 months: 21.1 ml/min, 6 months: 26.0 ml/min). Renal denervation did not induce arterial stenosis or aneurysm after 12 months of treatment as assessed by duplex ultrasound. MRA showed no sign of complications at 6-month follow-up. The blood pressure reductions found in our patient are in line with the results from the Symplicity HTN trials. Our first-in-human experience suggests that renal denervation is feasible and effective in patients with aortic dissection type B.