Renal denervation is a relatively new, minimally invasive intervention for patients with resistant hypertension. FDA-approved in 2023, the procedure is performed by an interventional cardiologist, and patients typically go home the same day.
Renal denervation works by disrupting nerve signals that cause overactive sympathetic nerves, vasoconstriction and sodium retention. By utilizing ablation, the nerves can be treated without damaging the arteries.
“This intervention is long overdue, especially in the management of hypertension,” says interventional cardiologist Kasaiah Makam, MD. “High blood pressure medications have been the same for many years, and until now, have been our only option outside of lifestyle modifications. This is exciting, as it’s the biggest advancement that’s been available for a long time.”
Using radiofrequency energy to ablate the nerves surrounding the renal arteries, a catheter is inserted into the femoral artery in the groin, followed by a spiral catheter into the renal arteries. Once the ablation around the renal arteries is complete, the catheter is removed and final imaging is performed to ensure the arteries remain stable. No implants are left behind, and recovery takes four to five hours.
“When we perform the procedure, we address both kidneys at the same time,” adds Dr. Makam. “It may not be a one-step procedure as we go into all the branches more than three millimeters reaching the kidney. Multiple ablations may be needed to achieve a satisfactory result.”
Patients may experience lower blood pressure, thereby reducing the risk of stroke, kidney disease or heart failure. Being minimally invasive, the procedure allows patients to benefit from a quicker recovery with less pain. To reduce the need for more medication, this low-risk procedure could change the game for some patients.
Hypertension clinic streamlines candidate workup and selection
Before surgery, a thorough secondary hypertension workup is recommended before considering renal denervation. Because this type of workup is often complex and can delay treatment, the hypertension clinic was formed to streamline the process. The team is comprised of an imaging cardiologist, an interventional cardiologist, advanced practitioners, nurses and an endocrinologist.
Patient candidates need to have healthy renal arteries and kidneys, uncontrolled hypertension greater than 140/90 mmHg and be able to tolerate sedation.
“If a patient is on three or more medications and is still not reaching the goal, consider referring them for an evaluation before trying another medication,” says Dr. Makam. “Our hypertension clinic team can perform a formal hypertension workup to find if there are any other secondary causes for their uncontrolled hypertension, before moving forward.”
Patients with certain conditions or on dialysis may be poor candidates as they have not been well-studied for this procedure. This includes patients with:
- Underlying kidney disease.
- Adult polycystic kidney disease.
- Kidney tumors.
- Kidney transplant.
- Renal artery stenosis.
- Fibromuscular dysplasia.
- Renal artery aneurysm.
Patients with artery stenosis would be treated for the condition first, then considered for ablation six months later. Patients with one kidney would be considered on a case-by-case basis.
Outcomes and risks
The data show that the procedure is effective, with consistent reductions in blood pressure and a reduction in medication use (compared with people who did not undergo the procedure). Regardless, each patient responds differently, and because the procedure is relatively new, long-term durability data are still limited.
“We don’t expect that people will completely go off medication once we do the procedure,” adds Dr. Makam. “It can take up to six months to see a real effect on blood pressure, so the effects are not immediate. Sometimes we need to keep a patient on the same medications for a while before we can consider reducing them. Some patients need to stay on some of the medications while others may eventually be able to stop altogether. So far, it seems the sooner we identify a patient as a good candidate, the better they will respond.”
Because the procedure involves the kidney’s blood vessels, minimal risks include bleeding, infection, damage to the renal arteries and other systemic issues. However, the overall risk is estimated to be less than 1%.
Follow-up care and primary care coordination
The renal denervation team works together with primary care physicians to provide comprehensive care. After the procedure, patients are followed closely at one month and three months to:
- Monitor blood pressure over time.
- Perform a renal artery ultrasound at six months.
- Provide ongoing coordination with the patient’s primary care provider to manage blood pressure medications.
After going home, patients should watch for:
- Bleeding from the groin.
- Unusual drop in blood pressure.
- Leaking that causes bruising.
Advancing long-term outcomes in vascular care
Advancements such as renal denervation exemplify the Nebraska Medicine cardiovascular team’s commitment to providing innovative heart and vascular care solutions. For patients who are doing all they can to manage their uncontrolled hypertension, a referral may offer hope of some relief.
“With hypertension being one of the leading causes of cardiac morbidity, we want to work together to try and lower these numbers,” says Dr. Makam. “There are so many patients we see who are on five or six medications for blood pressure management, which gets extremely difficult to manage. I hope once physicians are more aware of this program, we can help more patients than we’ve ever been able to help before.”
Meet the specialist
Dr. Makam is a Board-Certified Interventional Cardiologist passionate about addressing hypertension issues that increase cardiac risk. His goal is to help reduce cardiac-related mortality rates within the next decade by raising awareness about renal denervation. Outside of work, Dr. Makam is a busy family man and enjoys spending time with his children.