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are preferred for early hypertension control, it has been proposed that their benets could extend to renal protection,
decreasing total kidney volume, and decreased incidence left
ventricular hypertrophy, nevertheless, there are some discrepancies between multiple studies and this hypothesis
remains to be conrmed [19, 22, 38, 40].
Tolvaptan, a vasopressin V2 receptor antagonist
showed efficacy in reducing cyst growth, total kidney
volume, and decline in kidney function compared to placebo. A decrease in the number of pain episodes was also
observed in the tolvaptan group. The use of tolvaptan is
included in the ADPKD management recommendation
with a greater benefit in rapidly progressive disease [13,
17, 22, 24, 43].
Local Analgesia
Role ofRenal Innervation asaTherapeutic Target
The kidneys are well supplied by efferent sympathetic
nerves that modulate renal function at various levels. In
the current context, the dense innervation of the kidney
with sensory afferent fibers mediating the perception of
pain is of particular interest. Nerve fibers converge circumferentially around the renal artery and enter the kidney with the renal arteries through the hilum (Fig.13.1)
[19, 26, 44, 45]. The sympathetic innervation of the kidney is predominantly derived from the aorticorenal gan-
glia and splanchnic nerves that converge into the renal
plexus to innervate vascular and smooth muscles. The
signals are finally integrated in the paraventricular
nucleus of the hypothalamus [46].
The sensory nerves are mainly located in the renal pelvic
area, especially in the pelvic wall [46]. Pain signals are
mainly transmitted through unmyelinated C-bers (perception of pain) and a small population A δ bers located in the
adventitia of the renal arteries [14, 46]. These travel through
the intermesenteric and renal plexi, through splanchnic
nerves to the dorsal roots T11-L1 to nally reach the spinothalamic tracts to be integrated in the medial medullary reticular formation. (Fig.13.1) [14, 26, 45–49].
The afferent signals originate predominantly from
stimulation of chemo-receptors in the renal pelvis and
intra-renal tissue which are transmitted through unmyelinated small fibers, [46] and mechano-receptors in the
renal parenchyma that respond to intra-renal pressure
changes. These are transmitted through myelinated large
fibers and their stimulation increases ipsilateral afferent
activity [46]. The visceral pain signal derived from the
kidney is mediated via the splanchnic nerves whereas
signals derived from the sensory fibers of the ureter connect through sympathetic pathways and enter the spinal
cord at T11 and L2, i.e. the dermatomes affected by ureteric pain. The important role of the renal nerves in the
transmission of pain signals renders them an obvious
therapeutic target as discussed in more detail below.
Fig. 13.1 Overview of
kidney innervation. The
kidneys are densely
innervated by both afferent
nociceptive sensory bers and
efferent sympathetic nerve
bers. Their distribution along
the renal artery makes them
accessible to therapeutic
targeting by endoluminal
catheter-based denervation
approaches for kidney-related
pain syndromes. The Green
dotted line represents the
sympathetic component
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L. M. Lugo-Gavidia et al.
Nerve Blockage
As an alternative option to avoid long-term medications,
local anesthetic approaches have been developed.
Bupivacaine or opioid infusion through epidural or intrathecal route can be considered and have shown benet [3, 4,
50]. Multiple studies have examined the infusion of capsa-
icin either local, intra-ureteral, or intra-renal in patients with
LPSH.The technique intends to disrupt the transmission of
sympathetic C bers, due to their capacity to deplete substance P, act as an excitotoxin and ablate nociceptive terminals [2–4, 7, 50–54]. Available data suggest that this provides
a response rate ranging from 25% up to 100%, for a short- to
medium-term of between 2 weeks to 5 months and seems
limited by nerve regeneration [2, 4, 7, 50, 52, 53]. Capsaicin
should be used with caution, as it also affects nephrons, several complications have been associated (renal function deterioration (~29%), extensive chemical inammation leading
to brosis and stricture) [2, 4, 7, 50, 53].
Other local analgesia approaches have been used targeting renal nerve activity. Among them, the intercostal nerve,
splanchnic nerve, and celiac plexus nerve blockade have
been used to provide pain relief [2, 4, 7, 55]. This can be
achieved by local administration of relevant local anesthetic
agents such as alcohol or phenol under uoroscopic guidance. The combination with spinal cord stimulation, a neuro-
modulation approach targeting the spinal column by
implanting electrodes in the epidural space, may help to
extend the duration of the effect [4, 13, 19, 26, 29, 30, 56].
The use of neurostimulation has achieved a reduction in pain
and medication in a 6month follow up [56].
Interventional Approaches
Although the above-mentioned treatment options are widely
available it is not uncommon that these are ineffective in
some patients, particularly with longer duration of pain.
Novel interventional approaches may offer a valuable treatment option when other strategies have failed (Fig.13.2).
Minimally Invasive Surgical Approaches
Cyst aspiration is the rst and least invasive option when few
cysts are present, with a pain recurrence rate of 67%.
Sclerotherapy (ethanol, minocycline, or n-butyl cyanoacrylate) can be added for further reduction of cyst size. If the
pain is caused by multiple cysts, a reduction of the capsule
and parenchyma pressure by decortication can be helpful to
relieve pain [16, 19, 30, 57]. In patients with extrarenal cysts,
especially in the liver, cyst fenestration should be considered, in addition to hepatic resections if required [19, 24].
Fig. 13.2 Treatment owchart in pain kidney syndromes. Black color
letters indicate therapies used in both LPSH and ADPKD.Blue color
letters indicate the cautions to be considered and therapies only reported
in ADPKD setting. Red color letters indicate the cautions to be considered in LPSH and therapies only reported in LPSH setting. *data
derived from a case report
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Renal Denervation
Renal denervation (RDN) has been proposed as a potential
treatment option for kidney-related pain syndromes and may
represent a safe option to specically target afferent sensory
nerves to ameliorate pain. While the various renal nerve
ablation approaches deliver the respective energies to all
nerves surrounding the renal artery, the focus for treatment
of kidney-related pain syndromes is on the disruption of the
renal afferent bers [13, 19, 31]. Their location in the adventitial layers surrounding the renal artery makes them accessible to surgical dissection as well as endoluminal
intravascular ablation approaches. Interruption of afferent
signaling by renal denervation is likely to disable the transmission of pain with no progression or worsening of kidney
function [58].
Surgical Renal Denervation
Access for surgical renal denervation can be via thoracoscopic, videothoracic, or laparoscopic approaches. It involves
a thorough wide dissection of the renal artery at the hilum, to
perform a circumferential dissection of the nerves. Of note,
around 28% of the patients present with multiple renal arteries, in which case each artery must be dissected [19, 26].
Catheter-Based Renal Denervation
Percutaneous catheter-based RDN is an endovascular
approach that has the advantage of being minimally invasive.
Although catheter-based RDN can be accompanied by signicant visceral pain due to the sensory innervation of the
kidney adequate analgesia now used routinely for these ablation approaches is usually sufcient to avoid major discomfort during the procedure [14, 59, 60]. The distribution of the
nerves along the renal artery is probably more complex than
previously anticipated and a higher nerve density has been
described in the proximal and middle segment of the renal
artery, along with the most pronounced circumferential distribution in the ventral region compared to dorsal (Fig.13.1)
[44, 61, 62]. Additionally, nerves are located closer to the
intima in the distal artery before the bifurcation and the
branches (Fig.13.1) [44, 58, 61, 62]. Therefore, multiple cir-
cumferential ablations are usually required to achieve effective RDN [44, 61, 62].
Several modalities for device-based RDN have been
tested in clinical trials, all with a favorable safety prole.
Radiofrequency-mediated RDN uses radiofrequency (RF)
energy to increase the local temperature in a localized area to
achieve nerve ablation. It is now clear that the renal artery
branches and accessory arteries ablations improve the efcacy of the procedure [58]. Ultrasound-based RDN (Paradise
renal denervation system, ReCor) uses ultrasound energy for
a circumferential thermal ablation [58]. Alcohol-mediated
RDN uses a novel delivery system (Peregrine System
Infusion Catheter, Ablative Solutions, Inc.) with 3 retractable
microneedles (220μm) to achieve chemical denervation with
microdoses (0.15–0.6 ml per renal artery) of dehydrated
alcohol as a neurolytic agent [63, 64]. The procedure is associated with intraprocedural pain (43% moderate to severe)
which decreases within 2minutes after the infusion.
Most available clinical trial and registry data, predominantly for hypertension have been obtained with the initial
RF uni-electrode Symplicity-Flex catheter and the subsequent new generation multi-electrode Symplicity Spyral system (Medtronic, Inc) was developed in an effort to increase
the efcacy, reduce the time and the safety of the procedure
[65–68]. The latter consists of four electrodes distributed in
a helical pattern to complete 4 simultaneous, 60-second ablations over four quadrants of the RA and its branches [65, 66].
Recent randomized, sham-controlled clinical studies in
patients on or off concomitant antihypertensive medication
have clearly shown that RDN (RF- and US-based) results in
a clinically relevant BP lowering without major adverse consequences [65, 67, 69–71].
Reassuringly, none of the three described approaches
have been associated with an increased risk of acute kidney
injury, renal deterioration or stenosis, thrombus, dissection,
perforation, brosis, or necrosis [63, 64]. Of note, renal
denervation is usually not recommended in patients with previous renal artery intervention including angioplasty or
endovascular stents (Table13.4). While all the above mentioned interventional ablation approaches have shown efcacy in reducing BP, no randomized controlled studies have
yet been conducted to explore the efcacy of RDN to
improve kidney-related pain syndromes. The apparent safety
of catheter-based RDN paired with its ability to target the
renal afferent nerves however render RDN as an attractive
potential treatment option in this context. Indeed, there is
clinical data from smaller case series and individual case
reports that are encouraging and are summarized below.
Current Evidence
Most of the current evidence comes from individual case
reports and small case series using RDN as the last line of
treatment in patients where other options have failed
(Table 13.4). These cases have reported favorable results
with this approach but are limited by short- to medium-term
follow-up and the absence of control subjects [14, 45,
72–75].
Data from case series and their main ndings are summarized in Table13.4 [13, 18, 48, 49, 55, 76–80] The largest
reports applying surgical RDN in LPSH patients are derived
from surgical RDN cohorts. Andrew etal. reported on 27
surgical RDN procedures which resulted in permanent pain
relief in 4 kidneys. Three additional patients achieved complete pain relief with a second procedure. The remaining
patients experienced a median pain-free interval of
7.5months [76]. In a study conducted by Sheil etal. a higher
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Reported RDN related
complications Reference
Range of reported
Follow-up time
Range of pain
relief duration
[49]
[73]
complications
[14]
vascular injury
[18]
without pathological
implications
[13]
artery spasms
[48]
function (n=1)
Poor movility 48–72hrs
post procedure
L. M. Lugo-Gavidia et al.
Subsequent
Procedures (n
patients)
Successful pain
resolution (n
procedures)
Type of
procedure
a
Number of
initial
procedures
a
Number of
patients
21 27 (6 bilateral) Surgical 4/27 9/18 28-111months 28–140months NA [76]
b
LPHS/
ADPKD
LPHS
5 Percutaneous 3/5 1/2 NA 12-19months Intraprocedure renal
c
LPHS 20 24 (4 bilateral) Surgical 8/18 4/12 7.8-9years 6–9.9years Mild wound infections [55]
ADPKD 1 2 Laparoscopic 2/2 0 NA NA NA [45]
ADPKD 1 1 Laparoscopic 1/1 0 2years 2years NA [75]
LPHS 24 25 (1 bilateral) Surgical 7/25 7/18 0–120months 1–168months NA [77]
ADPKD 4 5 (1 bilateral) Laparoscopic 5/5 NA 6–16months 6–16months Urinary leakage (n=1) [79]
ADPKD 12 16 (4 bilateral) Laparoscopic 9/12 NA 18-41month 18–41month Urinary leakage (n=1) [80]
LPHS 9 11 (2 bilateral) Laparoscopic 4/9 1/5 NA 12-93months None signicant
PKD 1 2 (1 bilateral) Percutaneous 2/2 0 12months 12months Small hematoma without
LPSH 1 1 Percutaneous 1/1 0 6months 6months Artery parietal changes
ADPKD 5
11 13 (2 bilateral) Percutaneous NA NA NA 12months Mild reduction of renal
d
LPHS 4 8 (4 bilateral) Percutaneous 4/8 NA NA 6months NA [78]
LPHS/
ADPKD
LPHS 12 24 (12 bilateral) Percutaneous NA 6/12 NA 6months Pain in the puncture site
Authors
(Year)
Andrews
etal. (1997)
Sheil etal.
Table 13.4 Summary of current case series and reports of interventional approaches [37]
(1998)
Valente etal.
(2001)
Chapuis
etal. (2004)
Greenwell
etal. (2004)
Resnick et at.
(2006)
Casale etal.
(2008)
Kadi etal.
(2013)
Shetty etal.
(2013)
Gambaro
etal. (2013)
Casteleijn
etal. (2017)
Prasad etal.
(2017)
De Jager
etal. (2017)
Prasad etal.
(2018)
NA not available
3 patients had other cause of renal pain
6 LPHS and 5 ADPKD
Number of patients included in the nal analysis
Patients underwent previous celiac block, the ones who failed were referred to RDN
a
b
c
d
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pain-free rate was reported (36%) with a mean follow-up of
8years [55]. Furthermore, Greenwell et al. reported on 24
patients undergoing a total of 33 interventions (25 initial procedures and 8 subsequent RDN) and a median follow up time
of 39.5months, in whom the relapse of symptomatology and
the subsequent appearance of contralateral pain was frequent
(14%) yet complete pain remission was achieved in 9
(27.2%) kidneys [77].
In 2001 laparoscopic RDN was described to treat
ADPKD-related pain. The patient reported a decrease in pain
with no changes in renal function or blood pressure. It was
the rst case report in ADPKD, however, no follow-up information is available [45]. Similar results were observed in a
47-year-woman with ADPKD with intractable pain. The
patient achieved a total relief of pain that persisted at a 2-year
follow-up [75].
Other small scale investigations on laparoscopic RDN
reported different success pain resolution rates (44% to
100%) with a pain relief duration up to 41months [49, 79,
80].
The initial reports on percutaneous RDN for LPHS and
kidney-related pain were derived from case reports. Shetty
etal. reported a successful percutaneous RDN for the treatment of kidney pain syndrome with complete remission of
pain after 12months follow-up [73]. Gambaro etal. used the
same approach in a 40-year old patient with LPHS and
hypertensive crisis. The patient experienced immediate pain
relief after the procedure and the absence of any hypertensive crises during the 6months follow-up [14].
Consistent results were reported in larger series including
LPSH and ADPKD patients, where a decrease in pain perception (evaluated by the Visual Analogue Scale score),
number and daily intake of pain medications, was observed
over 12months [13]. A single-arm study evaluating the efcacy of RDN with bilateral endovascular RDN in 12 patients
with LPSH reported a substantial reduction in self-reported
pain (McGill pain questionnaire) from baseline at both 3 and
6-months follow up (38.5, 7.5, and 2.0 respectively).
Additional improvements in disability, mood, and quality of
life were reported [48].
RDN seems to achieve a consistent improvement in pain
perception and a reduction in pain medication intake, which
directly impacts the quality of life of these patients [13, 18,
48, 78]. There were no major safety concerns reported in this
subset of patients, only minor complications mainly related
to vascular access similar to what has been reported in the
literature from previous renal denervation studies for the
indication of uncontrolled hypertension. [14, 18, 55, 73, 79,
80] As the procedures in the presented case reports were
indicated mainly for pain control, only three studies reported
the effect on the blood pressure after RDN with a consistent
reduction in BP where reported [13, 18, 73]. It is perhaps of
interest to note that one case report from a patient with com-
bined severe hypertension and kidney-related pain syndrome
not only demonstrated signicant pain relief but also a substantial BP reduction from 170/108 to 126/74mmHg [73].
RDN may therefore be particularly helpful in patients in
whom both conditions are evident such as ADPKD. It is
important to outline that regardless of the outcome of the rst
procedure, some patients can develop contralateral pain or a
recurrence, requiring subsequent denervation or in more
severe cases autotransplantation [49, 77].
Although the success rates mentioned above might be
related to the characteristics of the technique per se (e.g. less
invasive, more selective, lower rates of complications), the
number of procedures, duration of pain relief, the recurrence
of pain, and most importantly time of follow up, need to be
taken into account when interpreting the results provided
[13, 18, 48, 49, 55, 72, 76–80].
Renal Autotransplantation andNephrectomy
LPSH: Renal autotransplantation is an alternative treatment
strayegy. It requires the complete removal of the kidney and
upper ureter and complete excision from the hilum of renal
nerves and lymphatic tissue ex-situ (an additional capsulotomy can be performed), followed by the re-implantation of
the kidney into the ipsilateral iliac fossa to the iliac vessels.
It has been shown to be associated with longer-term pain
relief and is associated with lower rates of pain recurrence
due to nerve regeneration. However, hematuria often persists
[2, 7, 55]. This procedure can be considered as the last
resource if other approaches have failed.
ADPKD: In patients with ESRD and in whom other
options have failed, unilateral or bilateral nephrectomy followed by dialysis or renal transplantation could be considered. In patients with ESRD who are not a candidate to
nephrectomy, transcatheter arterial embolization of the renal
artery’s distal branches is used to decrease the renal volume
and relieve the symptoms related to the increased pressure
[13, 19].
Perspectives andFuture Directions
The currently available evidence is quite limited and mostly
derived from clinical experience and small case series rather
than randomized trials. Given the absence of RCT data and
current uncertainties regarding success rates and the rates of
pain recurrence RDN is currently not widely performed for
kidney-related pain syndromes and usually only considered
as an option on a case-by-case basis in centers familiar with
catheter-based renal denervation approaches, where they are
predominantly applied for BP lowering. While the available
data from case reports and small case series indicate that
catheter-based RDN may have a role to play in the complex
management of kidney-related pain syndromes, larger-scale
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L. M. Lugo-Gavidia et al.
properly designed clinical trials will be required to provide
sufcient evidence for wider use of this approach. Multiple
efforts have been made to design randomized trials to assess
the effect of RDN on pain especially in the setting of
ADPKD.Unfortunately, one of the studies (The Safety and
Efcacy of Catheter-based Renal Denervation Using the
Vessix™ Renal Denervation System in Autosomal Dominant
Polycystic Kidney Disease Patients With Severe Debilitating
Pain; NCT02746419) was withdrawn due to the removal of
the catheter-based RDN device from the market. The results
of the RAFALE study (The Radiofrequency Ablation for
ADPKD Blood Pressure and Disease Progression Control;
NCT01932450), an open-label single-center study to compare the efcacy of catheter-based RDN vs antihypertensive
drugs alone for the control of blood pressure in patients with
ADPKD with 12 months of follow up have not been
published.
The Mayo Clinic conducted a prospective study to evaluate the impact of thoracoscopic RDN on pain control, opioid
use, quality of life, and renal blood ow (measured by MRI),
and renal function. The Autosomal Dominant Polycystic
Kidney Disease (ADPKD) Pain Study (NCT NCT00571909)
enrolled 18 patients into a 2-year follow-up. Only preliminary results have been published, nevertheless, the results are
promising, as all the patients (10 reported) described a
decrease in the intensity of the pain immediately after the
procedure. The nal results of this study will provide a better
overview of the long-term use of RDN [19, 30].
At this stage, the encouraging clinical evidence provided
by these reports suggests that catheter-based RDN can be
considered as a potential treatment option for kidney-related
pain syndromes on a case-by-case basis when other more
established therapies have failed. It should be carried out in
an experienced centre at catheter-based renal denervation.
Most importantly, it seems now the right time to explore the
utility of catheter-based RDN in his context in properly
designed clinical trials with sufcient long-term follow up to
provide an acceptable scientic evidence base for this promising approach.
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Part III
https://t.me/medicina_free
Renal Denervation Devices
Symplicity SPYRAL™: Device
https://t.me/medicina_free
andProcedural Tips andTricks
JoachimWeil
14
Introduction totheSPYRAL™ Catheter
System
When using renal denervation (RDN) more widely in the
future [1], more complex cases will be seen in the catheterization laboratory. The Symplicity SPYRAL™ multi-electrode renal denervation catheter [2] is designed to be used
with a radio frequency (RF) generator (Symplicity G3™).
The catheter connects to the generator using the integrated
cable attached to the catheter handle. The catheter requires
the use of a 0.36-mm (0.014-in) guidewire for delivery,
preferably without hydrophilic coating. Generally, the
softer wires are safer and easier to advance into tortuous
branches, whereas stiffer wires give better torque control.
The maximum prole is 0.052 inch.
A standard dispersive electrode (grounding pad) must be
placed on the patient’s thigh area and connected to the generator for the therapy to be delivered. The catheter has an
effective length of 117cm, is compatible with a 6-Fr guide
catheter (55cm length), and is designed for treating vessels
with diameters ranging from 3 to 8mm. Therefore, currently,
it cannot be used via radial access.
The catheter features 4 gold radiopaque electrodes at the
helical distal end (Fig.14.1a). In the straight conguration,
the distance between the electrodes is 6.5 mm. The elec-
trodes are deployed into a spiral shape by partially retracting
the guidewire proximally. The treatment length (the distance
between electrodes 1 and 4) of the catheter changes with the
vessel diameter (Table 14.1). A radiopaque tip marker is
located 1mm proximal to the catheter tip and assists in the
positioning of the catheter using uoroscopic guidance. The
catheter also features a straightening tool that facilitates safe
insertion of the guidewire into the catheter (Fig.14.1b). This
tool is located near the handle and slides along the catheter
shaft to straighten the distal end. However, insertion of the
guidewire also can be done as in every coronary procedure
using rapid-exchange balloons.
The generator is shown in Fig.14.2a, b. The front touch
screen displays information such as impedance, temperature,
ablation time, and error messages. The front panel also features an RF activation button. Electrode identiers on the
generator screen correspond to each electrode on the catheter. The generator touch screen and remote control allow the
user to navigate different options, such as the selection/deselection of single electrodes. The generator uses an automated
algorithm to control the power and time settings.
The accessories needed for the procedure include a 6-Fr
introducer sheath, stopcock sidearm, Tuohy-Borst adapter,
as well as any other standard items used to aid percutaneous
transluminal catheterization in renal arteries.
J. Weil (*)
Lübeck Medical School and Chief Cardiology, SanaCardioMed
Heart Center, Lübeck, Germany
e-mail: joachim.weil@sana.de
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
R. R. Heuser et al. (eds.), Renal Denervation, https://doi.org/10.1007/978-3-031-38934-4_14
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