Renal Artery Denervation: Evidence, Guidelines, and Major Trials

Renal artery denervation (RDN) has emerged as a promising treatment for resistant hypertension, characterized by high blood pressure (BP) unresponsive to three or more antihypertensive medications. This chapter reviews current evidence, guidelines, and major trials related to RDN. RDN targets the sympathetic nervous system in the renal arteries to reduce BP through radiofrequency ablation of sympathetic nerves. Key mechanisms include sympathetic nerve ablation, modulation of the renin-angiotensin system (RAS), and enhancement of baroreflex sensitivity. Clinical trials such as SYMPLICITY HTN-1 and HTN-2 demonstrated significant BP reductions, sustained for up to 36 months. However, SYMPLICITY HTN-3 found no significant difference between RDN and sham procedures, highlighting issues like incomplete nerve ablation. Subsequent SPYRAL HTN and RADIANCE-HTN trials addressed these limitations, showing consistent BP reductions and supporting RDN’s efficacy as both a standalone and adjunctive therapy. Guidelines from the European Society of Hypertension (ESH) 2023 recommend RDN for select patients with resistant hypertension, emphasizing optimal pharmacological treatment and lifestyle adherence. The American Heart Association (AHA) suggests RDN cautiously for patients failing multiple medications. In conclusion, RDN offers a novel approach to BP management in resistant hypertension. Continued research is essential to refine patient selection, procedural techniques, and long-term outcomes, enhancing the therapeutic potential of RDN in clinical practice.