Renal Sympathetic Denervation by CT-scan-Guided Periarterial Ethanol Injection in Sheep

Pilot testing an ethanol cornual nerve block as a long-term analgesic for calf disbudding

Disbudding prevents horn growth in calves through thermal or chemical cauterization and causes damage that is painful for weeks following the procedure. Current pain management strategies are only effective from 1 to 2 h (local anesthetic) to 1 to 3 d (nonsteroidal anti-inflammatory drugs). A potential practical solution for addressing longer-term pain may be to administer ethanol as a cornual nerve block. When administered at a high concentration, ethanol damages the functionality of peripheral nerves, promoting localized long-lasting analgesia. It is also thought to be painful, thus ethanol may be combined with lidocaine, as a mixed solution or administered beforehand. We tested the use of an ethanol cornual nerve block for anesthesia around the horn bud in 2 pilot studies. We used different concentrations and amounts of ethanol (100% and 70%) in combination with different ratios of lidocaine in our attempt to identify an effective block. In pilot 1, 14 nondisbudded calves were administered 2 to 4 mL of 100% ethanol below the bony ridge on each side of the head to block the cornual nerve at 3 to 10 d of age (n = 28 horn buds) and observed for 5 wk. The duration of loss of sensation was evaluated using pinprick tests 10 min, 1, 3, and 7 d after the block, and then weekly thereafter until 35 d or full sensation had returned. Pinprick tests consisted of lightly pressing a needle in 10 evenly spaced locations around the base of the horn bud (0 responses = no sensation, 1-5 responses = partial sensation, 6-10 responses = full sensation). Pilot 2 looked at the 24 h after the injection and consisted of 9 nondisbudded calves (5 mL of 2:1, 70% ethanol and 2% lidocaine per horn bud) and 6 disbudded individuals (5 mL of 100% ethanol, 70% ethanol, or 2% lidocaine per horn bud). All treatments were administered at the calf level. Anesthesia was checked 10 min after the injection and 4 or 16 h later. In pilot 1, on the day of the ethanol injection (0 d), there was no sensation in 85% of horn buds. Sensation began to return as early as 1 d after blocking, with only 50%, 21%, and 3% of horn buds having no sensation at 1, 7, and 35 d, respectively. Partial sensation was present in 25%, 17%, and 10% of horn buds at these time points. In pilot 2, 27.8% of horn buds in the nondisbudded group had no sensation, whereas 33.3% had partial sensation 10 min after the injection. In the disbudded calves 10 min after the injection, 100% of horn buds from the 100% ethanol group had partial sensation and 100% of horn buds administered 70% ethanol had full sensation. Four or sixteen hours later, 100% of horn buds had full sensation. Together, in these pilot studies, ethanol provided inconsistent anesthesia when used for a cornual nerve block.

Renal Sympathetic Denervation by CT-Guided Ethanol Injection: A Phase II Pilot Trial of a Novel Technique

OBJECTIVES

CT-guided ethanol-mediated renal sympathetic denervation in treatment of therapy-resistant hypertension was performed to assess patient safety and collect preliminary data on treatment efficacy.

MATERIALS AND METHODS

Eleven patients with therapy-resistant hypertension (blood pressure of >160 mmHg despite three different antihypertensive drugs including a diuretic) and following screening for secondary causes were enrolled in a phase II single arm open label pilot trial of CT-guided neurolysis of sympathetic renal innervation. Primary endpoint was safety, and secondary endpoint was a decrease of the mean office as well as 24-h systolic blood pressure in follow-up. Follow-up visits at 4 weeks, 3, and 6 months included 24-h blood pressure assessments, office blood pressure, laboratory values, as well as full clinical and quality of life assessments.

RESULTS

No toxicities ≥3° occurred. Three patients exhibited worsened kidney function in follow-up analyses. When accounting all patients, office systolic blood pressure decreased significantly at all follow-up visits (maximal mean decrease -41.2 mmHg at 3 months). The mean 24-h systolic blood pressure values decreased significantly at 3 months, but not at 6 months (mean: -9.7 and -6.3 mmHg, respectively). Exclusion of five patients who had failed catheter-based endovascular denervation and/or were incompliant for antihypertensive drug intake revealed a more pronounced decrease of 24-h systolic blood pressure (mean: -18.3 and -15.2 mmHg at 3 and 6 months, p = 0.03 and 0.06).

CONCLUSION

CT-guided sympathetic denervation proved to be safe and applicable under various anatomical conditions with more renal arteries and such of small diameter.