Percutaneous transluminal renal sympathetic denervation for resistant hypertension

Evidence-based recommendations on percutaneous transluminal renal sympathetic denervation for resistant hypertension. This involves inserting a device through the skin (percutaneous) into an artery in the thigh and then into the renal arteries (transluminal). It sends radio or sound waves to destroy the nerves in the renal arteries (sympathetic denervation). The aim is to lower blood pressure.

# Recommendations
Percutaneous transluminal renal sympathetic denervation for resistant hypertension should only be used with special arrangements for clinical governance, consent, and audit or research. Find out what special arrangements mean on the NICE interventional procedures guidance page.
Clinicians wanting to do percutaneous transluminal renal sympathetic denervation for resistant hypertension should:
Inform the clinical governance leads in their healthcare organisation.
Ensure that people (and their families and carers as appropriate) understand the procedure's safety and efficacy, and any uncertainties about these.
Take account of NICE's guidance on shared decision making, and NICE's information for the public.
Audit and review clinical outcomes of everyone having the procedure. The main efficacy and safety outcomes identified in this guidance can be entered into NICE's interventional procedure outcomes audit tool (for use at local discretion).
Discuss the outcomes of the procedure during their annual appraisal to reflect, learn and improve.
Healthcare organisations should:
Ensure systems are in place that support clinicians to collect and report data on outcomes and safety for everyone having this procedure.
Regularly review data on outcomes and safety for this procedure.
Further research should include randomised controlled trials or analysis of registry data. It should report details of patient selection, technique used and long-term outcomes.
Patient selection should be done by a multidisciplinary team including experts in managing hypertension and potential complications, and clinicians with specific training in this procedure.
Why the committee made these recommendations
Evidence from a Cochrane review, a meta-analysis and clinical trials, supplemented by observational studies (registries) was reviewed by the committee.
The evidence suggests that there are no major safety concerns in the short term, and complications are well recognised such as renal artery damage. The evidence shows that it reduces blood pressure in the short and medium term. Overall, there are uncertainties about how well it works in the long term and whether there are long-term complications. So, it should only be used with special arrangements.
Hypertension can be a lifelong condition, so further evidence generation to establish the long-term outcomes of this procedure is particularly important.# The condition, current treatments and procedure

# The condition
Hypertension is a major risk factor for cardiovascular disease and chronic kidney disease. Hypertension can be primary or secondary. Primary hypertension does not have a single known cause, whereas secondary hypertension develops because of an underlying medical condition or disease. Hypertension is considered resistant if it is not controlled after treatment with at least 3 antihypertensive medications from different classes.

# Current treatments
NICE's guideline on hypertension in adults describes diagnosing and managing hypertension, including resistant hypertension. Current treatments for hypertension include lifestyle modifications and antihypertensive medications. Blood pressure and treatment are regularly monitored, and treatment is adjusted as needed. For resistant hypertension, additional medications and device-based antihypertensive therapies (for example renal denervation and carotid baroreceptor stimulation) can be considered.

# The procedure
This procedure is usually done using local anaesthesia, with sedation and anticoagulation. A catheter is introduced through the femoral artery and advanced into each renal artery under fluoroscopic guidance. The catheter is connected to a generator which delivers radiofrequency or ultrasound energy (depending on the type of system used) from the distal to proximal end of each renal artery. This ablates the renal nerves leading to the kidney, with the aim of disrupting neurogenic reflexes involved in blood pressure control. There are different systems with different technologies in use for renal sympathetic denervation.