Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3772_Библиотеки_им_академика_М_И_Перельмана

Arterial hypertension is recognized as a silent killer and a major contributor to global premature cardiovascular (CV) morbidity and mortality. Hypertension is largely preventable by maintaining healthy lifestyle habits and initiation of anti­hypertensive treatment as the next step to lower blood pres­sure (BP) and CV risk. Despite clinical and research advances in hypertension prevention and management, the number of people with elevated BP remains high. According to a global prevalence analysis of 1201 population studies of trends in hypertension prevalence, detection, treatment, and control, the number of adults aged 30–79years with hypertension has doubled from 650 million to 1.28 billion between the years 1990 and 2019 [1]. An estimated 46% of adults with elevated BP are unaware of their condition and BP control is only achieved in half of those treated for hypertension. Achievement of BP control is the most cost-effective way of reducing the associated hypertension-mediated organ dam­age and high risk for death from stroke, ischemic heart dis­ease, other vascular diseases, and chronic kidney disease. In light of these adverse outcomes, one of the global targets for non-communicable diseases is to reduce the prevalence of hypertension by one-third by 2030. The importance of aggressive BP targets in high-risk hypertensive patients has been found in the Systolic Blood Pressure Intervention Trial [2]. While targeting a systolic BP of less than 120mm Hg was associated with lower rates of fatal and nonfatal major

While growing evidence from numerous experimental and clinical studies supports the strong rationale for renal nerve ablation for hypertension therapy, not all renal arteries can be treated with currently available RDN devices. A sub­stantial proportion of patients with resistant hypertension do not meet the anatomic eligibility criteria for the arterial RDN approach due to small inaccessible accessory renal arteries or inadequate diameter and length of renal arteries to accom­modate catheters for effective procedures. Importantly, no useful intra-procedural markers of success for arterial RDN have been identied. Factors such as insufcient destruction of renal efferent and afferent nerves, renal artery wall thick­ening associated with underlying atherosclerosis, and inter­stitial fat surrounding the renal arteries can all contribute to the variable BP response to arterial RDN.The BP lowering effects achieved with RDN may be delayed and noticed over the long-term observation [31–33]. Notably, RF energy delivered by most catheters reaches ~3.5 up to 4mm into the perivascular tissue which should be effective in the distal branches of the renal artery as sympathetic nerve bers move into proximity to the artery walls. Ultrasound energy pro­vides circumferential thermal ablation with a penetration depth of up to 6mm which is the expected location of sym­pathetic bers in the central parts of the renal arteries where this energy is usually applied. This circumferential ablation at 1–6mm in depth seems to target ~80% of nerves. However, a recent study on microdissection of the human renal ner­vous system documented that not all renal innervation goes through the main renal artery and a signicant portion of the renal nerves (late arriving nerves) frequently reached the kid­ney (73% of the right kidney and 53% of the left kidney) bypassing the main renal artery, which can explain incom­plete or suboptimal RDN [34]. Furthermore, these nerves are essentially sympathetic efferent bers which account for