Can renal denervation be performed in patients with renal stenosis?

Renal Denervation in Patients with Renal Stenosis

Renal denervation should not be performed in patients with renal artery stenosis due to the risk of worsening renal function and potential complications. 1

Rationale and Evidence

The European Society of Cardiology (ESC) 2024 guidelines provide clear recommendations regarding the management of renovascular hypertension, but do not support renal denervation in patients with renal artery stenosis 1. Instead, the guidelines recommend:

• For fibromuscular dysplasia: Renal artery angioplasty without stenting
• For atherosclerotic renal artery stenosis: Renal artery angioplasty with stenting may be considered in specific cases

The presence of renal artery stenosis is actually a reason to consider revascularization procedures rather than denervation, particularly when the stenosis is hemodynamically significant (>70% stenosis or 50-69% with post-stenotic dilatation) 1.

Risks and Concerns

Several important concerns exist regarding renal denervation in patients with renal stenosis:

1. Risk of worsening stenosis: Case reports have documented the development of renal artery stenosis following denervation procedures 2

2. Compromised renal blood flow: Denervation in an already stenotic vessel could further compromise blood flow and worsen renal function

3. Technical challenges: Stenotic vessels present technical difficulties for proper catheter placement and effective denervation

4. Limited evidence: No major trials have specifically evaluated the safety of renal denervation in patients with pre-existing renal artery stenosis

Alternative Management Approaches

For patients with renal artery stenosis and hypertension, the following approaches are recommended:

For Fibromuscular Dysplasia

• Renal artery angioplasty without stenting should be considered (Class IIa recommendation) 1
• Medical therapy with careful monitoring of renal function

For Atherosclerotic Renal Artery Stenosis

• Renal artery angioplasty and stenting may be considered in specific scenarios (Class IIb recommendation) 1:
  • Recurrent heart failure or flash pulmonary edema
  • Resistant hypertension
  • Hypertension with unexplained unilaterally small kidney or CKD
  • Bilateral renal artery stenosis or unilateral stenosis in a solitary viable kidney

Medical Management

• Optimize antihypertensive therapy with a three-drug combination (ACE inhibitor/ARB, calcium channel blocker, and thiazide-like diuretic) 3
• Careful monitoring is required when using RAS blockers (ACE inhibitors/ARBs) in patients with renal artery stenosis, as they can cause acute renal failure in those with tight bilateral stenoses or stenosis in a solitary functioning kidney 1

Monitoring and Follow-up

For patients with renal artery stenosis:

• Regular monitoring of renal function is essential, especially when using ACE inhibitors or ARBs
• Blood pressure monitoring using ambulatory or home measurements
• Periodic imaging to assess for progression of stenosis

Conclusion

Renal denervation is not recommended in patients with renal artery stenosis. Instead, the focus should be on appropriate medical management and consideration of revascularization procedures when indicated based on the specific clinical scenario and the nature of the stenosis (fibromuscular dysplasia vs. atherosclerotic).