The role of intravascular imaging in optimizing renal denervation outcomes

The 2023 ESH Guidelines recommend renal denervation (RDN) for patients with uncontrolled blood pressure (BP) and preserved kidney function despite optimal antihypertensive therapy, or intolerance to such therapy. Early trials (Symplicity HTN-1 and HTN-2) showed substantial BP reductions without serious complications, indicating a promising safety profile. However, subsequent trials revealed inconsistent results regarding BP reductions, highlighting the need for further investigation into RDN efficacy and patient selection criteria. RDN works by ablating sympathetic nerves in the renal artery adventitia, leading to thrombus formation, endothelial edema, vasospasm, and dissections. Intravascular imaging techniques like optical coherence tomography have advanced the understanding of these lesions. The previous discrepancies in clinical studies on RDN may stem not only from differences in procedural techniques, patient selection and study designs, but also by lack of standardized procedural outcomes, identified by intravascular imaging. The routine use of optical coherence tomography during RDN is still under debate and currently there is no clear correlation between focal vascular lesions and long-term BP reduction. However, recent data suggest that the use of intravascular imaging might potentially improve procedural outcomes by identifying the (desired) vascular changes directly after RDN. Here, the pathophysiology and imaging methods of RDN-induced vascular lesions are summarized, the association between vascular lesions and clinical effects of RDN, as well as current guidelines for peri- and postoperative pharmacotherapy after RDN.