Balancing Safety and Access: Renal Denervation in Hypertension With Deepak L. Bhatt, MD, MPH, MBA

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With several years of follow-up data now available, renal denervation is emerging as a safe and viable option for patients with resistant hypertension, easing concerns about issues such as induced renal artery stenosis due to the current energy levels in use and approved, explains Deepak L. Bhatt, MD, MPH, MBA, FACC, FAHA, FESC, MSCAI, director, Mount Sinai Fuster Heart Hospital, and the Dr. Valentin Fuster professor of cardiovascular medicine, Icahn School of Medicine at Mount Sinai.

Like any invasive intervention, however, procedural risks exist, including vascular complications and bleeding, particularly from access through the femoral artery. As the field transitions toward radial artery approaches—mirroring the evolution of coronary stenting—these risks are expected to decline. Other potential complications include arterial dissection or perforation, when wires and catheters are advanced into the renal arteries, although these events remain relatively uncommon, Bhatt notes.

Patient selection also is crucial. The procedure is best suited for individuals whose blood pressure remains uncontrolled despite lifestyle changes, including low-salt diets, and maximal use of available medications. In addition, many patients with resistant hypertension struggle with adherence to multiple therapies, making renal denervation a valuable option to complement treatment.

"Like any invasive procedure, albeit a minimally invasive one, you want to pick the right patients, and so far it seems like patients with out-of-control blood pressure, despite doing the best that you can do with lifestyle and currently available medicines, those are the best patients to target it to," explains Bhatt.

The therapeutic landscape for hypertension continues to expand, with novel drugs such as endothelin receptor antagonists, aldosterone synthase inhibitors, and experimental small-interfering RNA–based therapies in development. How these agents will fit alongside renal denervation is still uncertain, but experts believe the procedure will maintain an important role. Unlike drug therapy, renal denervation carries minimal long-term adverse effects; blood pressure reductions are modest but clinically meaningful, and the risk of excessive hypotension is rare in carefully selected patients.

Barriers to broader adoption remain, particularly around reimbursement. Insurance coverage is currently inconsistent, and hospitals often face financial disincentives to perform the procedure. As reimbursement improves, utilization is expected to increase.

The importance of consultation with noninvasive hypertension experts before recommending the procedure is paramount. With appropriate safeguards and patient selection, renal denervation could become a key tool, used in combination with emerging pharmacologic therapies, to finally achieve blood pressure control in patients who have exhausted conventional options.