Keeping Endovascularists Busy

Renal denervation may be the next big thing in endovascular intervention, and not just because of the many patients it might help.

Renal denervation is a new procedure for lowering blood pressure that involves placing a radiofrequency catheter inside both of a patient’s renal arteries and zapping the tissue four to eight times on each side, gently enough not to cause trauma but firmly enough to damage the renal nerves and block sympathetic activity and the kidneys’ renin release. It remains investigational in the United States, where a 500-patient pivotal trial recently started, but it’s been available on a routine basis in Europe since 2010, and according to Horst Sievert, a German interventional cardiologist who’s done many denervations since then, it’s been taking off both in terms of the number of endovascular physicians offering it and the number of patients with drug-resistant hypertension being treated.

image courtesy Wikimedia Commons

Though still off the U.S. market, the prospect of FDA approval within the next couple of years was enough to win renal denervation a special session at ISET 2012 last week in Miami Beach. My news article on those talks is here.

An apparently safe, relatively easy, 60-minute procedure that can durably cut systolic blood pressure by about 30 mm Hg in patients who remain hypertensive despite treatment with multiple drugs is certainly very attractive. It may be even more appealing if early evidence pans out and the treatment also helps normalize glycemic control and reduce hyperinsulinemia in at least some patients.

But when vascular medicine specialist Michael Jaff said at the meeting that renal denervation “could arguably be the most exciting advance in interventional vascular medicine,” and that “in the near term I’m incredibly bullish,” it was hard not to imagine that it was more than optimized patient care that made his pulse quicken.

Endovascular medicine became a medical growth industry more than 30 years ago, when it started to become a routine part of cardiology, a way to less-invasively treat stenotic coronary arteries. Since then, it’s become a major part of all vascular medicine, but in recent years the coronary part showed a definite leveling off. Just last year in a talk at ISET, Martin Leon, one of the world’s foremost interventional cardiologists, declared that endovascular coronary interventions appeared to have reached a volume plateau that would not change anytime soon. He said his early recognition of this trend was a motivation for him to turn his attention to transcatheter aortic valve replacement, which has now emerged as a new way for interventional cardiologists to ply their trade.

Renal denervation may be the next step along the same path. If the pivotal trial results and further clinical experience confirm the early findings of safety and efficacy, and especially if the very early findings of a beneficial glycemic effect also pan out, it may well fulfill Dr. Sievert’s prediction that “renal denervation will become as important as percutaneous coronary intervention.”

Important not just for patients, but for practitioners too. Busy hands are happy hands.

—Mitchel Zoler (on Twitter @mitchelzoler)

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1 Comment

Filed under Blognosis, Cardiovascular Medicine, Endocrinology, Diabetes, and Metabolism, IMNG, Internal Medicine, Internal Medicine News, Nephrology, Practice Trends

One response to “Keeping Endovascularists Busy

  1. No one seems to be addressing the obvious question as to why there is sympathetic overdrive in “drug-resistant” hypertension. The vast majority of these patients are obese, a state well-known to be associated with sympathetic stimulation and resistance to antihypertensive drugs. They should not have renal denervation until they are also proven to have lifestyle-resistant hypertension after they have reduced their BMI to less than 25 and or their waist circumference to less than half their heights.

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