肾动脉去神经术治疗难治性高血压的疗效观察及术式改良

Therapeutic effect and surgical improvement of renal denervation for resistant hypertension

目的探讨肾动脉去神经术(RDN)治疗难治性高血压(RHTN)的适应证选择、临床疗效及安全性,并对RDN术式进行探索和改良。方法纳入2016年9月至2019年1月经福建医科大学附属第一医院心血管内科确诊的RHTN患者27例(其中顽固性高血压17例),均行RDN治疗,其中13例采用肾动脉三维重建下单极消融,近期12例使用改良新型GL-6W导管消融,1例行单侧消融治疗,1例行混合术式消融,进行为期3～24个月的随访,记录手术前后血压、肾功能、降压药物种类、计算降压药物强度指数、日均降压药费用,及手术方式、术中消融参数、手术操作相关并发症。结果术后家庭自测收缩压和舒张压随访均有明显下降,其中术后3个月家庭自测收缩压和舒张压分别下降(26.1±15.8)和(11.0±14.8)mm Hg。术后药物数量逐渐减少,降压药物强度指数、日均降压费用较术前下降。术后3个月,慢性肾脏病3～5期患者家庭自测血压较术前明显下降(均P<0.05)。不同术式的比较:肾动脉三维重建下单极消融组出现4例血管创伤性并发症,使用新型肾动脉消融导管GL-6W未出现任何相关并发症,两者降压效果差异无统计学意义。结论 RHTN患者RDN术后血压平稳下降,降压药物减少,手术对肾功能无恶化趋势,相对安全。使用GL-6W消融导管进行RDN更加安全。

Objective To investigate the indication, clinical efficacy and safety of renal denervation(RDN) in the treatment of resistant hypertension(RHTN), and to explore and improve the RDN procedure. Methods From September 2016 to January 2019, 27 patients with RHTN(including 17 subjects with refractory hypertension), diagnosed in Cardiovascular Department of the First Affiliated Hospital of Fujian Medical University, were treated with RDN. Among them, 13 patients underwent renal unipolar ablation under three-dimensional reconstruction of renal artery. The recent 12 cases were treated with modified new GL-6 W ablation catheter, 1 case underwent unilateral ablation, while 1 case combined ablation. A follow-up period of 3-24 months was conducted. Blood pressure, renal function, kinds of antihypertensive drugs, intensity index of antihypertensive drug, daily average cost of antihypertensive drug, and surgical methods, ablation parameters and complications were recorded before and after peration. Results The postoperative home systolic blood pressure and diastolic blood pressure were significantly decreased, which decreased by(26.1±15.8) mm Hg and by(11.0±14.8)mm Hg respectively 3 months after operation. After operation, the number of drugs gradually decreased, the intensity index of antihypertensive drug and daily average cost decreased compared with preoperative. At 3 months after surgery, the family self-test blood pressure of patients with chronic kidney disease(CKD) at stage 3-5 was significantly lower than that before surgery(all P<0.05). Comparison of different surgical methods: there were 4 cases of vascular traumatic complications in the unipolar ablation group under three-dimensional reconstruction of the renal artery. Whereas no complications were founds in ablation subjects with the new catheter GL-6 W. There was no significant difference in the antihypertensive effect between the two groups. Conclusion After RDN, blood pressure decreased steadily,the use of antihypertensive drugs reduced, and renal function did not deteriorate, which was relatively safe. Additionally, it was safer to use GL-6 W catheter for RDN.