Nationwide Cross-sectional Analysis of Endoscopic Thoracic Sympathectomy to Treat Hyperhidrosis Over 12 years in Brazil: Epidemiology, Costs, and Mortality.

OBJECTIVE: To analyze the number of endoscopic thoracic sympathectomies performed to treat hyperhidrosis in the Universal Public Health System of Brazil, the government reimbursements, and the in-hospital mortality rates. BACKGROUND: Even though endoscopic thoracic sympathectomy has been widely performed for the definitive treatment of hyperhidrosis, no series reported mortality and there are no population-based studies evaluating its costs or its mortality rate. METHODS: Data referring to endoscopic thoracic sympathectomy to treat hyperhidrosis between 2008 and 2019 were extracted from the database of the Brazilian Public Health System, which insures more than 160 million inhabitants. RESULTS: Thirteen thousand two hundred one endoscopic thoracic sympathectomies to treat hyperhidrosis were performed from 2008 to 2019, with a rate of 68.44 procedures per 10 million inhabitants per year. There were 6 in-hospital deaths during the whole period, representing a mortality rate of 0.045%. The total expended throughout the years was U$ 6,767,825.14, with an average of U$ 512.68 per patient. CONCLUSIONS: We observed a rate of 68.44 thoracoscopic sympathectomies for hyperhidrosis' treatment per 10 million inhabitants per year. The inhospital mortality rate was very low, 0.045%, though not nil. To our knowledge, no published series is larger than ours and we are the first authors to formally report deaths after endoscopic thoracic sympathectomies to treat hyperhidrosis. Moreover, there is no other population-based study addressing costs and mortality rates of every endoscopic thoracic sympathectomy for the treatment of any site of hyperhidrosis in a given period.

Assessment of arterial stiffness to predict blood pressure response to renal sympathetic denervation.

BACKGROUND: Recent trials support the efficacy of renal sympathetic denervation (RDN) to reduce blood pressure (BP). Nevertheless, about one third of patients are considered non-responders to RDN. Previous retrospective analyses suggest arterial stiffness could predict BP response to RDN. AIMS: We prospectively assessed the potential of invasive pulse wave velocity (iPWV) to predict BP response to RDN. Additionally, we aimed to establish non-invasive models based on arterial stiffness to predict BP response to RDN. METHODS:  iPWV, magnetic resonance imaging-based markers of arterial stiffness and the carotid-femoral pulse wave velocity were recorded prior to RDN in patients with treatment resistant hypertension. Changes in daytime BP after 3 months were analysed according to the prespecified iPWV cut-off (14.4 m/s). Regression analyses were used to establish models for non-invasive prediction of BP response. Results were compared to iPWV as reference and were then validated in an external patient cohort. RESULTS: Eighty patients underwent stiffness assessment before RDN. After 3 months, systolic 24h and daytime BP were reduced by 13.6±9.8 mmHg and 14.7±10.6 mmHg in patients with low iPWV, versus 6.2±13.3 mmHg and 6.3±12.8 mmHg in those with high iPWV (p<0.001 for both). Upon regression analysis, logarithmic ascending aortic distensibility and systolic baseline BP independently predicted BP change at follow-up. Both were confirmed in the validation cohort. CONCLUSIONS:  iPWV is an independent predictor for BP response after RDN. In addition, BP change prediction following RDN using non-invasive measures is feasible. This could facilitate patient selection for RDN treatment.

Evaluation of Quality of Life: Functional Assessment of Chronic Illness Therapy after Thoracic Sympathectomy for Palmar Hyperhidrosis.

BACKGROUND: Primary hyperhidrosis is a condition that significantly decreases the quality of life (QOL). Thoracic sympathectomy is safe and efficient method of treatment in palmar hyperhidrosis. OBJECTIVE: The aim of the study was to evaluate the change in QOL in patients with palmar hyperhidrosis who underwent thoracic sympathectomy. METHODS: The study includes 149 patients (37 men and 112 women) who were treated with bilateral thoracoscopic sympathectomy for primary palmar hyperhidrosis. Subjective and objective evaluation of hyperhidrosis were performed prior to the surgery, 3 and 12 months after the treatment. Control group consists of 305 healthy volunteers (118 men and 187 women). The QOL was measured using Functional Assessment of Chronic Illness Therapy (FACIT) scale. RESULTS: The average level of palmar hyperhidrosis in the study group prior to surgery was 224.69 ± 179.20 mg/min/m2. General QOL (FACIT total) before the surgery was significantly lower in the study group when compared with the control group (66.57 ± 16.33 vs. 91.29 ± 11.13; p < 0.05). Three months after surgery level of hyperhidrosis decreased significantly and remained at similar level 12 months after the procedure (13.55 ± 15.41 mg/min/m2 p < 0.05 and 14.41 ± 18.19 mg/min/m2 p < 0.05, respectively). After thoracoscopic sympathectomy, the QOL increased and did not differ when compared with the control group 3 and 12 months after the surgery (90.28 ± 11.13 vs. 91.29 ± 11.13; p = 0.55 and 89.59 ± 11.34 vs. 91.29 ± 11.13; p = 0.84, respectively). The highest increase was observed in functional well-being domain (32.25%); however, it was also noticeable in other domains. CONCLUSION: Thoracic sympathectomy is an efficient method of treatment in palmar hyperhidrosis which significantly increases patients' QOL especially in a functional domain.

Cardiac magnetic resonance assessment of central and peripheral vascular function in patients undergoing renal sympathetic denervation as predictor for blood pressure response.

BACKGROUND: Most trials regarding catheter-based renal sympathetic denervation (RDN) describe a proportion of patients without blood pressure response. Recently, we were able to show arterial stiffness, measured by invasive pulse wave velocity (IPWV), seems to be an excellent predictor for blood pressure response. However, given the invasiveness, IPWV is less suitable as a selection criterion for patients undergoing RDN. Consequently, we aimed to investigate the value of cardiac magnetic resonance (CMR) based measures of arterial stiffness in predicting the outcome of RDN compared to IPWV as reference. METHODS: Patients underwent CMR prior to RDN to assess ascending aortic distensibility (AAD), total arterial compliance (TAC), and systemic vascular resistance (SVR). In a second step, central aortic blood pressure was estimated from ascending aortic area change and flow sequences and used to re-calculate total arterial compliance (cTAC). Additionally, IPWV was acquired. RESULTS: Thirty-two patients (24 responders and 8 non-responders) were available for analysis. AAD, TAC and cTAC were higher in responders, IPWV was higher in non-responders. SVR was not different between the groups. Patients with AAD, cTAC or TAC above median and IPWV below median had significantly better BP response. Receiver operating characteristic (ROC) curves predicting blood pressure response for IPWV, AAD, cTAC and TAC revealed areas under the curve of 0.849, 0.828, 0.776 and 0.753 (p = 0.004, 0.006, 0.021 and 0.035). CONCLUSIONS: Beyond IPWV, AAD, cTAC and TAC appear as useful outcome predictors for RDN in patients with hypertension. CMR-derived markers of arterial stiffness might serve as non-invasive selection criteria for RDN.

Retroperitoneoscopic lumbar sympathectomy for plantar hyperhidrosis.

OBJECTIVE: The objective of this study was to assess the reduction in quality of life (QoL) caused by the persistence of primary plantar hyperhidrosis (PPH) symptoms and the level of satisfaction in PPH patients after retroperitoneoscopic lumbar sympathectomy (RLS). The efficacy, safety, and procedure of bilateral RLS in both sexes are also described in this study. METHODS: This is a longitudinal study of consecutive patients who sought specific treatment from a private practitioner for severe PPH as classified on the Hyperhidrosis Disease Severity Scale (HDSS) from October 2005 to October 2014. The patients were asked to report the symptoms of PPH experienced in the immediate preoperative period and to complete a standardized QoL questionnaire developed by de Campos at least 12 months after RLS. Disease outcomes, recurrence of symptoms, and any adverse effects of surgery were evaluated after 30 days and at least 12 months after RLS. RESULTS: Lumbar sympathectomy was performed 116 times in 58 patients; 30 days after surgery, PPH was resolved in all patients. Three patients (5.2%) reported transient thigh neuralgia, and 19 (32.7%) reported transient paresthesia in the lower limbs. There were no reports of retrograde ejaculation. At a minimum of 12 months after RLS, 49 of the 58 patients had fully and correctly answered the follow-up questionnaire and noted a mild (HDSS 2) to moderate (HDSS 3) increase in pre-existing compensatory sweating. One patient had a PPH relapse within 6 months. Improvement in QoL due to the resolution of PPH was reported in 98% of the 49 patients. None of the operations necessitated a change in the laparotomy approach, and none of the patients died. CONCLUSIONS: RLS is safe and effective for the treatment of severe PPH in both sexes. There were no reports of retrograde ejaculation after resection of L3 and L4 ganglia. There was a mild to moderate increase in compensatory sweating in about half of the patients, but without any regret or dissatisfaction for having undergone the surgery because of a significant improvement in QoL.

Account for Clinical Heterogeneity in Assessment of Catheter-based Renal Denervation among Resistant Hypertension Patients: Subgroup Meta-analysis.

BACKGROUND: Catheter-based renal denervation (RDN) is a novel treatment for resistant hypertension (RH). A recent meta-analysis reported that RDN did not significantly reduce blood pressure (BP) based on the pooled effects with mild to severe heterogeneity. The aim of the present study was to identify and reduce clinical sources of heterogeneity and reassess the safety and efficacy of RDN within the identified homogeneous subpopulations. METHODS: This was a meta-analysis of 9 randomized clinical trials (RCTs) among patients with RH up to June 2016. Sensitivity analyses and subgroup analyses were extensively conducted by baseline systolic blood pressure (SBP) level, antihypertensive medication change rates, and coronary heart disease (CHD). RESULTS: In all patients with RH, no statistical differences were found in mortality, severe cardiovascular events rate, and changes in 24-h SBP and office SBP at 6 and 12 months. However, subgroup analyses showed significant differences between the RDN and control groups. In the subpopulations with baseline 24-h SBP ≥155 mmHg (1 mmHg = 0.133 kPa) and the infrequently changed medication, the use of RDN resulted in a significant reduction in 24-h SBP level at 6 months (P = 0.100 and P= 0.009, respectively). Subgrouping RCTs with a higher prevalent CHD in control showed that the control treatment was significantly better than RDN in office SBP reduction at 6 months (P < 0.001). CONCLUSIONS: In all patients with RH, the catheter-based RDN is not more effective in lowering ambulatory or office BP than an optimized antihypertensive drug treatment at 6 and 12 months. However, among RH patients with higher baseline SBP, RDN might be more effective in reducing SBP.

Renal artery and parenchymal changes after renal denervation: assessment by magnetic resonance angiography.

OBJECTIVES: Relatively little is known about the incidence of long-term renal damage after renal denervation (RDN), a potential new treatment for hypertension. In this study the incidence of renal artery and parenchymal changes, assessed with contrast-enhanced magnetic resonance angiography (MRA) after RDN, is investigated. METHODS: This study is an initiative of ENCOReD, a collaboration of hypertension expert centres. Patients in whom an MRA was performed before and after RDN were included. Scans were evaluated by two independent, blinded radiologists. Primary outcome was the change in renal artery morphology and parenchyma. RESULTS: MRAs from 96 patients were analysed. Before RDN, 41 renal anomalies were observed, of which 29 mostly mild renal artery stenoses. After a median time of 366 days post RDN, MRA showed a new stenosis (25-49% lumen reduction) in two patients and progression of pre-existing lumen reduction in a single patient. No other renal changes were observed and renal function remained stable. CONCLUSIONS: We observed new or progressed renal artery stenosis in three out of 96 patients, after a median time of 12 months post RDN (3.1%). Procedural angiographies showed that ablations were applied near the observed stenosis in only one of the three patients. KEY POINTS: • The incidence of vascular changes 12 months post RDN was 3.1%. • No renal vascular or parenchymal changes other than stenoses were observed. • Ablations were applied near the stenosis in only one of three patients.

Assessment of hypertension control and clinical course of patients excluded from the SYMPLICITY HTN-3 trial.

The screening of patients referred for the Symplicity Renal-Denervation Catheter Therapy on Resistant Hypertension (SYMPLICITY HTN-3) trial was rigorous, with many found not eligible to participate. We investigate patients who were not included in the trial and evaluate their current hypertensive (HTN) therapy, control and clinical status. A retrospective review and telephone interview was performed 8-10 months postscreening on 45 patients and their referring providers who were ultimately not included. Patients were grouped into 4 categories: (1) noninterest; (2) excluded (not meeting inclusion criteria); (3) screen failure (excluded during screening visits due to adequate blood pressure control guided by HTN specialist); or (4) referred after enrollment closure. Primary outcomes evaluated included current anti-HTN management and clinical outcomes. This population consisted of 42% males, mean age 65 ± 5 years, 78% African American, 64% diabetic, and 21% chronic kidney disease. Primary referral basis included cardiology (44%), nephrology (30%), and primary care (26%). At time of follow-up, 20% had continued resistant HTN while most of the patients had controlled HTN (60%); with highest success rates among the screen failure group (88%) who also had the lowest average systolic blood pressure (137 ± 11 mm of Hg) when compared to other groups (P = .04). Average number of medications was lowest in the screen failure group (2.8 ± 1.6, P = .07). Resistant and/or uncontrolled HTN was most prevalent in the noninterest or excluded groups, as were hospitalization for cardiovascular and HTN urgency/emergency. This study highlights the disparity of HTN control and treatment in daily practice compared with clinical trials, and confirms a need for vigilant screening of those considered candidates for renal denervation.

Multimodality Intra-Arterial Imaging Assessment of the Vascular Trauma Induced by Balloon-Based and Nonballoon-Based Renal Denervation Systems.

BACKGROUND: Renal denervation is a new treatment considered for several possible indications. As new systems are introduced, the incidence of acute renal artery wall injury with relation to the denervation method is unknown. We investigated the acute repercussion of renal denervation on the renal arteries of patients treated with balloon-based and nonballoon-based denervation systems by quantitative angiography, intravascular ultrasound, and optical coherence tomography (OCT). METHODS AND RESULTS: Twenty-five patients (50 renal arteries) underwent bilateral renal denervation with 5 different systems, 3 of which balloon-based (Paradise [n=5], Oneshot [n=6], and Vessix V2 [n=5)]) and 2 nonballoon-based (Symplicity [n=6] and EnligHTN [n=3]). Analysis included quantitative angiography and morphometric intravascular ultrasound measurements pre and post procedure and assessment of vascular trauma (dissection, edema, or thrombus) by OCT after denervation. A significant reduction in lumen size by quantitative angiography and intravascular ultrasound was observed in nonballoon denervation but not in balloon denervation. By postdenervation OCT, dissection was seen in 14 arteries (32.6%). The percentage of frames with dissection was higher in balloon-based denervation catheters. Thrombus and edema were detected in 35 (81.4%) and 32 (74.4%) arteries, respectively. In arteries treated with balloon-based denervation that had dissection by OCT, the balloon/artery ratio was higher (1.24 [1.17-1.32] versus 1.10 [1.04-1.18]; P<0.01). CONCLUSIONS: A varying extent of vascular injury was observed after renal denervation in all systems; however, different patterns were identified in balloon-based and in nonballoon-based denervation systems. In balloon denervation, the presence of dissections by OCT was associated with a higher balloon/artery ratio.

Denervación simpática renal mediante ablación endovascular por radiofrecuencia para hipertensión arterial refractaria / Endovascular radiofrequency denervation of the renal sympathetic nerve in refractory arterial hypertension / Denervação simpática renal através de ablação endovascular por radiofrequência para tratamento da hipertensão arterial refratária

INTRODUCCIÓN: La Hipertensión Arterial (HTA) tiene una carga global calculada en mil millones de casos en todo el mundo, provocando anualmente 7,5 millones de muertes (12,8% del total de muertes). En Argentina la prevalencia es del 34,8% en mayores de 18 años. Se define como HTA refractaria (HTAR) al fracaso en el control de la tensión arterial (TA) tras la administración de al menos 3 fármacos con diferentes mecanismos de acción, incluyendo un diurético, estimándose que corresponde al 10% de la población de hipertensos. Para este grupo de pacientes se postula que la denervación simpática de la arteria renal mediante ablación endovascular por radiofrecuencia (DRAR) puede mejorar el control de la TA al reducir la hiperactividad adrenérgica. TECNOLOGÍA: El rol de la hiperactividad simpática es central en el inicio, progresión y persistencia de la HTA. La DRAR es una intervención mínimamente invasiva, que consiste en la introducción de un electrodo mediante un catéter percutáneo endovascular hasta las arterias renales y el uso subsecuente de corriente alterna de alta frecuencia para provocar necrosis coagulativa del tejido neural. OBJETIVO: Evaluar la evidencia disponible acerca de la eficacia, seguridad y aspectos relacionados a las políticas de cobertura de la denervación simpática de la arterial renal mediante ablación endovascular por radiofrecuencia para la hipertensión arterial refractaria. MÉTODOS: Se realizó una búsqueda en las principales bases de datos bibliográficas DARE, NHS EED en buscadores genéricos de Internet, agencias de evaluación de tecnologías sanitarias y financiadores de salud. Se priorizó la inclusión de revisiones sistemáticas (RS), ensayos clínicos controlados aleatorizados (ECAs), evaluaciones de tecnologías sanitarias y económicas (ETS), evaluaciones económicas, guías de práctica clínica (GCP) y políticas de cobertura de otros sistemas de salud. RESULTADOS: En el siguiente reporte se incluyeron una RS, dos ECAs junto con una serie de casos publicados posteriormente, seis GPC, seis ETS y una política de cobertura de financiadores de salud. CONCLUSIONES: La evidencia encontrada fue de moderada calidad metodológica, existiendo inconsistencia sobre la eficacia de la DRAR en el tratamiento de la HTAR. Los estudios más recientes y de mejor calidad metodológica reportan una ausencia de efecto significativo a seis meses de la DRAR sobre los valores de TA en sujetos con HTAR comparada al tratamiento médico. Las GPC y ETS relevadas basan sus recomendaciones en la evidencia previa y no se encuentran actualizadas.

INTRODUCTION: Arterial Hypertension (AHT) has an overall burden of a thousand million cases around the world, resulting in 7.5 million deaths per year (12.8% of total deaths). In Argentina, its prevalence is 34.8% in individuals over 18 years old. Refractory AHT (RAHT) is defined as failure to control blood pressure (BP) in spite of administering three drugs with different mechanisms of action, including one diuretic, estimating that it corresponds to 10% of the hypertense population. For this group of patients, it is stated that Endovascular Radiofrequency Denervation of the Renal Sympathetic Nerve (RDN) may improve BP control by reducing adrenergic hyperactivity. TECHNOLOGY: The role of sympathetic hyperactivity is key to the beginning, progression and persistence of AHT. RDN is a minimally invasive intervention that consists in introducing an electrode through an endovascular percutaneous catheter up to the renal arteries and subsequent use of high-frequency alternate current to obtain a coagulative necrosis of the neural tissue. PURPOSE: To assess the available evidence on the efficacy, safety and coverage policy related aspects regarding the use of radiofrequency renal sympathetic denervation in refractory arterial hypertension. METHODS: A bibliographic search was carried out on the main databases: DARE, NHS EED, on Internet general search engines, in health technology evaluation agencies and health sponsors. Priority was given to the inclusion of systematic reviews (SRs); controlled, randomized clinical trials (RCTs); health technology assessments (HTAs), economic evaluations (EEs), clinical practice guidelines (CPGs) and coverage policies of other health systems. RESULTS: The following report includes one SR, two RCTs along with a case series published at a later date, six CPGs, six EEs and one coverage policy from health sponsors. CONCLUSIONS: The evidence found was of moderate methodological quality. There is inconsistency on the efficacy of RDN for the treatment of RAHT. Most recent studies with better methodological quality report the lack of significant effect of RDN on BP values at six months in subjects with RAHT when compared with medical treatment. The GCPs and the HTAs assessed, based their recommendations on the previous evidence and they are not updated.

INTRODUÇÃO: A Hipertensão Arterial (HTA) tem uma carga global calculada em milhões de casos em todo o mundo; provocando anualmente 7,5 milhões de mortes (12,8% do total de mortes). Na Argentina a prevalência é de 34,8% nos maiores de 18 anos. Se define como HTA refratária (HTAR) ao fracasso no controle da pressão artéria (PA) depois da administração de ao menos 3 fármacos com diferentes mecanismos de ação, incluindo um diurético; estima-se que a HTAR atinge cerca de 10% da população de hipertensos. Para esse grupo de pacientes postula-se que a denervação simpática da artéria renal através da ablação endovascular por radiofrequência (DRAR) pode melhorar o controle da PA ao reduzir a hiperatividade adrenérgica. TECNOLOGIA: O papel da hiperatividade simpática é central no início, progressão e persistência da HTA. A DRAR é uma intervenção minimamente invasiva que consiste na introdução de um eletrodo, através de um cateter percutâneo endovascular, até as artérias renais pelos quais se administra corrente alternada de alta frequência para provocar necrose do tecido neural por coagulação. OBJETIVO: Avaliar a evidência disponível sobre a eficácia, segurança e aspectos relacionados às políticas de cobertura da denervação simpática renal através de ablação endovascular por radiofrequência para tratamento da hipertensão arterial refratária. MÉTODOS: Realizou-se uma busca nas principais bases de dados bibliográficos DARE, NHS EED, em buscadores genéricos de Internet, agências de avaliação de tecnologias sanitárias e financiadores de saúde. Priorizou-se a inclusão de revisões sistemáticas (RS), ensaios clínicos controlados aleatorizados (ECAs), avaliações de tecnologias sanitárias e econômicas (ETS/EE), guias de práticas clínica (GPC) e políticas de cobertura de outros sistemas de saúde. RESULTADOS: No presente informe incluíram-se uma RS, dois ECAS junto com uma série de casos publicados a posteriori, seis GPC, seis ETS e uma política de cobertura de financiadores de saúde. CONCLUSÕES: A evidência encontrada é de moderada qualidade metodológica, existindo inconsistência sobre a eficácia da DRAR no tratamento da HTAR. Os estudos mais recentes e de melhor qualidade metodológica reportam ausência de efeito significativo aos seis meses da DRAR sobre os valores de PA em sujeitos com HTAR comparada ao tratamento médico. As GPC e ATS relevadas baseiam suas recomendações na evidência prévia e não se encontram atualizadas.

The effect of renal denervation added to standard pharmacologic treatment versus standard pharmacologic treatment alone in patients with resistant hypertension: rationale and design of the SYMPATHY trial.

The first studies on renal denervation (RDN) suggest that this treatment is feasible, effective, and safe in the short term. Presently available data are promising, but important uncertainties exist; therefore, SYMPATHY has been initiated. SYMPATHY is a multicenter, randomized, controlled trial in patients randomized to RDN in addition to usual care (intervention group) or to continued usual care (control group). Randomization will take place in a ratio of 2 to 1. At least 300 participants will be included to answer the primary objective. Sample size may be extended to a maximum of 570 to address key secondary objectives. The primary objective is to assess whether RDN added to usual care compared with usual care alone reduces blood pressure (BP) (ambulatory daytime systolic BP) in subjects with an average daytime systolic BP ≥135, despite use of ≥3 BP-lowering agents, 6 months after RDN. Key secondary objectives are evaluated at 6 months and at regular intervals during continued follow-up and include the effect of RDN on the use of BP-lowering agents, in different subgroups (across strata of estimated glomerular filtration rate and of baseline BP), on office BP, quality of life, and cost-effectiveness.

Similarities and differences between renal sympathetic denervation and carotid baroreceptor stimulation.

The two novel approaches recently introduced for the treatment of resistant hypertension, i.e. carotid baroreceptor stimulation and renal denervation, share a number of similarities but are also characterized by important differences. The similarities include the evidence that both interventions have as common pathophysiological background the state of sympathetic overdrive characterizing essential hypertension. In addition both procedures 1) are invasive, 2) exert in the short-term period clearcut blood pressure lowering effects and 3) still face a number of open questions, particularly related to the long-term blood pressure lowering effects, impact on end-organ damage and on cardiovascular events. The differences include the fact that two procedures act on distinct targets that trigger sympathetic activation and consequently blood pressure increase. In addition, only in the case of carotid baroreceptor stimulation the blood pressure effects can be easily assessed immediately following the implantation. Finally, the economic costs, metabolic effects and impact on vagal modulation of heart rate are different between the two interventions. This paper will provide a comparison of the background, effects and outcome of renal denervation and carotid baroreceptor stimulation, stressing whenever possible the clinical implications of the main features of the two interventions.

Renal denervation - a clinical update and future directions.

The aim of this review is to give a contemporary update on renal denervation therapy focusing particularly on the scientific background and present literature as well as on different technical approaches and potential future directions.

Morphological assessment of renal arteries after radiofrequency catheter-based sympathetic denervation in a porcine model.

OBJECTIVES: Catheter-based renal artery denervation has been successfully introduced as alternative treatment for patients suffering from drug-resistant essential hypertension. However, the local morphological changes within the vessel wall accompanying this technique remain elusive and we sought to characterize these by utilizing the simplicity radiofrequency catheter approach. METHODS: Following treatment of seven pigs, renal arteries were assigned to either the acute (n  =  6), subacute (10-day follow-up, n  =  6) or control (untreated, n  =  2) group. At follow-up blood analysis, final angiography and optical coherence tomography (OCT)-imaging of the treated arteries were performed and renal arteries and kidneys were processed for histopathology and immunohistochemistry. RESULTS: Radiofrequency-derived energy application to the vessel wall induced transmural tissue coagulation and loss of endothelium resulting in local thrombus formation also detectable by OCT. At 10 days, the luminal surface was almost completely re-endothelialized. Mural wall damage was replaced by fibrotic tissue and the adventitial layer showed strong inflammatory infiltration including vasculogenesis. Remnant autonomic nerve fascicles within the lesion segments of the subacute group displayed enhanced vacuolic degeneration and an impaired neurofilament protein immunostaining pattern. Examination of the kidneys revealed no abnormalities and blood parameters remained within the physiological range. CONCLUSION: Catheter-based application of radiofrequency energy resulted in circumscribed transmural injury within the arterial wall affecting autonomic nerve fascicles delayed to treatment. Acute loss of endothelialization resulted in thrombus formation leaving kidney perfusion apparently unimpaired.

[Comparative assessment of methods used for predicting efficiency of lumbar sympathectomy in patients with lower-limb critical ischaemia].

The article deals with the findings of examination and treatment of patients presenting with lesions of the distal-bed arteries and critical lower-limb ischaemia who were subjected to lumbar sympathectomy (LSE). The methods aimed at predicting efficacy of LSE in seventy-five patiens included Doppler ultrasonography with the nitroglycerine test and with the epidural blockade. Of these forty-five patients were subjected to laser Doppler flowmetry (LDF) and measurement of the transcutaneous oxygen tension in tissues before and after the epidural blockade. Presented herein are remote results of LPE obtained at terms up to 36 months for sixty-nine patients (92%) and analyzed depending on the parameters of the functional tests. Our findings suggest that the most statistically significant methods of study for predicting the outcome of lumbar sympathectomy turned out to be LDF and Doppler ultrasonography performed before and after the epidural blockade.

An assessment of plantar hyperhidrosis after endoscopic thoracic sympathicolysis.

BACKGROUND: Endoscopic bilateral thoracic sympathicolysis (EBTS) is an effective and minimally invasive procedure used for patients with primary hyperhidrosis. The purpose of this study was to examine plantar hyperhidrosis before and after EBTS. METHODS: A total of 198 patients with primary hyperhidrosis underwent 396 thoracoscopic sympathicolysis of ganglia T2-T3 in a prospective study. All completed a preoperative questionnaire, followed by a second questionnaire 12 months after the operation. The questionnaires evaluated sweating in the different body areas. Only the zones of anhydrosis were considered in delimiting the cutaneous expression of sympathetic ganglia T2-T3. RESULTS: Redistribution of perspiration as reported by the patients comprised significant reductions in palmar and axillary hyperhidrosis, and an increase in the zone of the trunk and popliteal region. The incidence of plantar anhydrosis and plantar hypohidrosis was 30.3% and 20.7%, respectively (p < 0.001). CONCLUSIONS: EBTS is followed by redistribution of body perspiration, with, and important, plantar anhydrosis and hypohidrosis. Although EBTS is the standard treatment for palmar primary hyperhidrosis, we must continue studying baseline sympathetic activity in patients affected by primary hyperhidrosis and the neuroanatomy of the sympathetic system to understand the redistribution of sweating and decrease of hyperhidrosis in the zones regulated by mental or emotional stimuli.