Introduction
Renal Denervation
Mechanism of Action
Current Evidence
Future Directions
Baroreflex Activation Therapy
Mechanism of Action
Current Evidence
Future Directions
Carotid Body Ablation
Mechanism of Action
Current Evidence
Future Directions
Central Iliac Arterio-Venous Anastomosis
Mechanism of Action
Current Evidence
Future Directions
Deep Brain Stimulation
Mechanism of Action
Current Evidence
Future Directions
Median Nerve Stimulator
Mechanism of Action
Current Evidence
Future Directions
Vagal Nerve Stimulation
Mechanism of Action
Current Evidence
Future Directions
Can Focused Patient Selection Improve Outcomes When Using Device Therapies of Hypertension?
Conclusions
Strength of evidence | Sham trial | Verifiable technical success | Reversible | Current estimated cost | Patient selection | Specific advantage | Potential adverse events | |
---|---|---|---|---|---|---|---|---|
Renal denervation | Large sham-controlled RCT, no clear effect but potential confounders. Supportive registry data. | Yes | No | No | ∼ €5–6000 | Younger patients, non-African Americans, preserved renal function | Multiple approaches to achieve denervation | Diffuse arterial injury (from endovascular approach) with thermal energy |
Baroreflex activation therapy | Large RCT for first-generation device completed. Ongoing large RCT (optimal medical therapy as control) for new-generation device. | Not yet | Yes | Yes. All electrical neuromodulation is reversible by switching off | ∼€24,000 per device and ∼€15,000 for replacement battery every three years | Not enough experience | Potentially titratable activation with future iterations of device. | Potential nerve damage, although risk thought to be reduced with smaller, single-lead next-generation device. Battery replacement needed at 3–5-year intervals, generator failure possible. Open loop system—cannot titrate therapy to ambient BP levels |
Carotid body ablation | Ongoing observational feasibility study | Not yet | Yes (surgical resection) | No | Not enough experience | Patients with high carotid body tone, although difficult to measure | Verifiable surgical resection | Not enough experience |
Central iliac arterio-venous anastamosis | Small RCT (standard medical care as control) completed. Ongoing global registry study | Not easily achieved | Yes | Yes | ∼ €4,000 for coupler (not including cost of procedure) | Nearly all patients respond but may best suit older patients with arterial stiffness/isolated systolic hypertension | Verifiable procedural success with immediate BP reduction. Targets mechanical aspects of the circulation rather than sympathetic drive | 30 % incidence of ipsilateral venous stenosis, increased cardiac output |
Deep brain stimulation | No registered trials, only observational data from non-blood pressure indications available | Not yet | Yes | Yes. All electrical neuromodulation is reversible by switching off | ∼€40,000 per device (based on epilepsy therapy), uncertain costs for replacement battery | Not enough experience | Not enough experience | Not enough experience. Generator failure possible and battery replacement needed every 3–5 years. Open loop system - cannot titrate therapy to ambient BP levels |
Median nerve stimulation | Ongoing sham-controlled RCT | In progress | Not enough experience | Yes. All electrical neuromodulation is reversible by switching off | Proposed to be low (<€2000) | Not enough experience | Minimally invasive procedure, inexpensive. Potentially titratable activation with future iterations of device. | Not enough experience. Battery replacement needed every 3–5 years. Open loop system—cannot titrate therapy to ambient BP levels |
Vagal nerve stimulation | Animal model data and human case report available | Not yet | Not enough experience | Yes. All electrical neuromodulation is reversible by switching off | ∼€20,000 (based on epilepsy therapy), uncertain for replacement battery | Not enough experience | Acts on parasympathetic system. Frequency- and current-dependent—facilitates titratable stimulation with future devices. | Battery replacement needed every 3–5 years. Open loop system—cannot titrate therapy to ambient BP levels |