Tomasz Roleder1, Wojciech Wojakowski2, *Michał Tendera2
Optical coherence tomography imaging of denervated renal arteries
Wewnątrznaczyniowa optyczna tomografia koherentna w ocenie tętnic nerkowych poddanych przezskórnej denerwacji
12nd Department of Cardiology, Medical University of Silesia in Katowice
Head of Department: Professor Zbigniew Gąsior, MD, PhD
23rd Department of Cardiology, Medical School in Katowice, Medical University of Silesia in Katowice
Head of Department: Professor Wojciech Wojakowski, MD, PhD
Streszczenie
Wstęp. Przezskórna denerwacja tętnic nerkowych stanowi alternatywę w leczeniu pacjentów z opornym nadciśnieniem tętniczym.
Cel pracy. W przedstawionym badaniu oceniliśmy możliwości diagnostyczne optycznej tomografii koherentnej w ocenie tętnic nerkowych poddanych przezskórnej denerwacji.
Materiał i metody. Przezskórna denerwacja tętnic nerkowych była przeprowadzona za pomocą systemu Symplicity® (Medtronic, Minneapolis, MN, USA). Wewnątrznaczyniowe obrazowanie za pomocą optycznej tomografii koherentnej (OCT) zostało wykonane za pomocą systemu St. Jude iLumien OPTIS.
Wyniki. Obrazowanie za pomocą OCT było przeprowadzone w 22 tętnicach 18,41 ± 5,83 miesiąca po wykonanym zabiegu denerwacji tętnic nerkowych. Pełny obwód naczynia udało się uwidocznić w 487 mm (80%) z łącznie 608 mm przeanalizowanych segmentów naczyniowych. W segmentach, gdzie nie udało się uwidocznić pełnego obwodu naczynia (20%), mediana 265 (IQR 243, 290) stopni obwodu naczynia była widoczna. Analiza obrazu OCT uwidoczniła, że dwie (9%) tętnice nerkowe posiadały kalcyfikacje. Ponadto udało się uwidocznić 26 ogniskowych zgrubień w błonie wewnętrznej w 14 tętnicach (64%) u 11 (92%) pacjentów.
Wnioski. Optyczna tomografia koherentna jest skutecznym narzędziem w ocenie gojenia się tętnic nerkowych poddanych zabiegowi przezskórnej denerwacji.
Summary
Introduction. The catheter-based radiofrequency renal denervation (RF-RDN) is of a broad interest as a tool to treat patients with resistant hypertension.
Aim. With the following studies we tested whether optical coherence tomography (OCT) may also be feasible to assess the renal arteries healing after RF-RND.
Material and methods. The renal denervation procedure was performed using Symplicity® system (Medtronic, Minneapolis, MN, USA). Intravascular OCT imaging of renal arteries was performed after the angiography using commercially available St. Jude iLumien OPTIS system.
Results. OCT imaging analysis was performed in 22 arteries at 18.41 ± 5.83 months after renal denervation. The full cross-sectional image of renal arteries was successfully visualized in 487 mm (80%) of all analyzed pullbacks (from a total of 608 mm). In segments where full cross-section of the artery was not presented (20%), 265 (IQR 243, 290) degrees of the arterial wall circumference was visible. The OCT analysis showed that 2 (9%) of treated arteries had calcifications. There were 26 areas of focal intimal thickening found in 11 (92%) patients and in 14 (64%) arteries.
Conclusions. OCT is a feasible tool to assess vessel healing post intervention performed within the renal arteries.
Introduction
The catheter-based radiofrequency renal denervation (RF-RDN) is of a broad interest as tool to treat patients with resistant hypertension. It is still under debate whether RF-RND application brings benefit to such patients. The initial enthusiasm derived from the promising results of Simplicity HTN-1 and Simplicity HTN-2 trials was somewhat tempered by poor outcomes of Simplicity HTN-3 trial (1-3). However, main limitations of Simplicity HTN-3 study were a small number of procedures performed per operator and the lack of appropriate monitoring of RF energy application (3).
Data from histology suggested that RF-RND might modify a vessel wall structure but such small edemas and fibrosis within the vessel wall might have been omitted by the relatively low-resolution angio-CT imaging (1, 2, 4). The detection of morphological markers of RF-RND application within the vessel wall in vivo could help to monitor the effectiveness of the procedure, but there was no imaging of renal arteries performed using novel imaging techniques post RND at follow-up.
Intravascular optical coherence tomography (OCT) is an imaging tool that provides high-resolution imaging (10-20 μm), which presents the morphology of the vessel wall with a very high precision (5, 6). It is broadly applied in the coronary imaging to assess the effects of stenting. In the present study we tested whether OCT may be feasible to assess send artery healing after RF RND.
Aim
The aim of the study was to test whether OCT may be feasible to assess renal artery healing after RF RND.
Material and methods
The study was performed at the Upper Silesian Medical Center of the Medical University of Silesia in Katowice. The Ethics Committee of the Medical University of Silesia approved the study. All of the patients gave written informed consent.
Inclusion criteria
Patients with resistant primary hypertension and more then 18 years old were enrolled into the study. Resistant hypertension was diagnosed in patients when office systolic blood pressure (SBP) was ≥ 160 mmHg (or ≥ 150 mmHg in patients with type 2 diabetes) lasted ≥ 5 weeks despite adherenece to at least three antihypertensive drugs. Patients with renal insufficiency (glomerular filtration rate (GFR) < 45 ml/min/1.73 m2 estimated by MDRD formula), significant renal artery stenosis and severe peripheral atherosclerosis leading to the loss of arterial access via femoral arteries were excluded from the study.
Renal denervation procedure
The renal denervation procedure was performed using Symplicity® system (Medtronic, Minneapolis, MN, USA). All patients received unfractionated heparin in doses to achieve activated clotting time (ACT) of > 300 s. Femoral artery closure devices were used in every patient.
OCT imaging
Intravascular OCT imaging of renal arteries was performed after the angiography using commercially available St. Jude iLumien OPTIS system at the follow-up only. Using 6F femoral access, the OCT Dragonfly Duo catheter was introduced into the renal artery through the guiding catheter, and over 0.014” coronary guidewire. The OCT probe (a mid marker at the OCT catheter) was positioned in the distal segment of the renal artery. The OCT imaging was intended to image the entire length of the renal artery. At the time of OCT imaging, the renal artery was flushed by the injection of 30 ml Ultravist contrast with a flow rate 8 ml/s and pressure of 700 psi. This triggered the automated OCT pullback with a speed of 20 mm/s.
OCT image analysis
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Piśmiennictwo
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