Minimally Invasive Therapy for High Blood Pressure: A New Tool to Manage Resistant Hypertension.

About half of U.S. adults—120 million of us—have high blood pressure, also called hypertension. Of these, just under 23% meet the guidelines for “controlled” blood pressure, with regular readings of 130/80 mm HG or lower.

That means about three-quarters of people with hypertension have uncontrolled high blood pressure, despite the many treatment options that are available. 

Why? There are many reasons, including:

• The American lifestyle is sedentary, and our diet is high in sodium

• People forget to—or choose not to—take their blood pressure medication as prescribed

• While it’s often covered by insurance, some families struggle to pay for medication

• Some blood pressure drugs cause side effects such as dizziness or upset stomach

But sometimes, even when a person is doing everything they can, their blood pressure stays high. This is resistant hypertension, in which the blood pressure is consistently 130/80 mm HG or higher despite trying three or more medications and heart-healthy lifestyle changes. 

High blood pressure is a leading cause of heart disease, stroke, and end-stage kidney disease. Controlling it has been shown in multiple randomized controlled trials to decrease these risks. Despite these findings and available resources, people still struggle with hypertension. 

It’s clear that there is a disconnect in how we approach blood pressure management. A new procedure called renal denervation is proving to be one of the missing pieces of this puzzle. 

Renal denervation: A new approach for resistant hypertension.

Renal denervation is a minimally invasive procedure that was approved by the Food and Drug Administration for resistant hypertension in 2023. 

Early data suggests this outpatient procedure could be an effective treatment option for patients whose blood pressure is not controlled with medication and lifestyle changes, including people who are diagnosed with hypertension as teens or young adults.

How it works.

The kidneys are central in hypertension because they receive and send inputs from the nerves inside the kidneys to the blood vessels and the brain. These signals drive part of the blood pressure control mechanism. Eliminating those inputs reduces that drive and can help to modestly lower blood pressure over time.

In this outpatient procedure, we use advanced ultrasound imaging to help us guide a catheter through a small incision in the groin into the renal arteries. These are the main arteries that bring oxygenated blood to the kidneys; the target nerves for the procedure are inside those arteries. 

Through the catheter, we deliver either hot or sound wave energy through the blood vessel wall. This destroys, or ablates, the nerves and eliminates their contribution to increasing blood pressure.

Two systems have been approved for renal denervation to ablate the targeted renal nerves. MedStar Washington Hospital Center uses both the Symplicity Spyral System by Medtronic, which uses radiofrequency heat and the Paradise System by Recor Medical, which uses ultrasound energy with a cooling solution. 

After the procedure, the patient can go home the same day. Side effects are minimal, if any, and can include discomfort at the catheter insertion site, a very small chance of perforating the artery with the catheter, temporary slowing of the heart rate, and temporary arterial spasms. 

Benefits of renal denervation.

There is no permanent device or hardware left in the body after renal denervation, and it does not negatively affect other functions of the kidney. Each patient’s blood pressure will respond differently. Both the radiofrequency and ultrasound systems have been proven safe and effective in clinical studies, with reports of at least a 5-10 mm Hg decrease in blood pressure over two to three months in most patients. 

Some patients may be able to stop one or more of their medications after the procedure. Ongoing research will help us understand who may benefit most and what to expect in terms of effectiveness over the long term. 

Renal denervation isn’t meant to be a one-stop solution for anyone with high blood pressure. Patients still need to follow their doctor’s recommendations for a heart-healthy lifestyle. For people whose blood pressure doesn’t respond to diet and exercise changes—and those who can’t tolerate medication—the procedure can provide an extra layer of support over the long term.

Who is eligible for renal denervation?

Patients who have been diagnosed with resistant hypertension may be eligible for this procedure. These are patients who have not achieved adequate blood pressure control after trying at least three medications and lifestyle changes and undergoing a simple medical evaluation.  

People who also may benefit from renal denervation include those who have:

• Difficulty sticking with diet and exercise modifications over the long term

• Adverse reactions to high blood pressure medications

• Been diagnosed with high blood pressure as a teen or young adult

• Trouble taking or refusal to take medication

• Other chronic health problems such as obesity or Type 2 diabetes

Having chronic kidney disease does not necessarily disqualify you from eligibility for this procedure. Some research has shown that renal denervation may provide cardiovascular and kidney-protective benefits for patients with chronic kidney disease. 

If you are following your hypertension care plan and are not seeing the blood pressure readings you’d like, talk with your doctor about whether renal denervation or trying a different medication makes sense for you.

Related reading: 6 Leading Heart Disease Risks and How to Control Them.

What’s next in blood pressure management?

Two medications that have historically been used for other diseases are showing promise for treating high blood pressure:

• Aprocitentan is a once-daily pill that was FDA-approved in 2024 for hypertension treatment. It has previously been effective to treat pulmonary hypertension, which is high blood pressure in the arteries of the lungs. This medication works by preventing the binding of two neural receptors that cause the blood vessels to narrow and widen; this supports a more neutral blood pressure. 

• Zilebesiran is a medication that is not yet FDA-approved and is currently being studied in clinical trials as an injectable drug. It is thought to work by interfering with the body’s process for creating angiotensinogen, a protein made in the liver—the first step in a hormonal process that helps to regular blood pressure.

Long-term assessment of these medications will help us understand the risk-benefit profile for patients, as well as the cost-effectiveness of these medications for treating resistant hypertension.

While it is encouraging to have new tools to treat high blood pressure, this is a good time for providers and patients alike to get even better at doing what we already know works:

• Getting adequate exercise, which for most adults is at least 150 minutes a week. Brisk walking is enough to get the benefits 

• Eating a heart-healthy diet rich in potassium and low in sodium

• Trying new medications and being patient with the process; it can take time to find the right dosage or combination of drugs

• Monitoring blood pressure at home and watching for increased pressures over time

The body is not programmed to have high blood pressure. In most cases, it is acquired and can be controlled with changes to our daily habits, lifestyles, and environments. Society has allowed resistant hypertension to thrive, and it is up to all of us—doctors and patients—to work together and get the epidemic of high blood pressure back under control. The consequences of not doing so are too high to ignore.