ISH AHA-1 A CASE OF REFRACTORY HYPERTENSION CONTROLLED BY REPEATED RENAL DENERVATION AND CELIAC PLEXUS BLOCK

Abstract

A 30-year-old woman was referred to our hospital due to high blood pressure, dizziness, headache and blurred vision. She had past history of preeclampsia and gestational hypertension 4 years ago but she had not taken antihypertensive medication in spite of remained hypertension after delivery. She was hospitalized for fever due to urinary tract infection and severe hypertension which was above 210/140 mmHg. Despite maximal medical treatment with telmisartan 80 mg, nifedipine 120 mg, carvedilol 50 mg, doxazocin 8 mg, chlorthalidone 50 mg, spironolactone 50 mg#2, isosorbide dinitrate 80 mg and intermittent intravenous administration of nicardipine and labetalol, her systolic blood pressure remained above 160 mmHg and repeatedly measured above 200 mmHg. Her blood pressure was even refractory to combination of isosorbide dinitrate and sildenafil. Repeated evaluation for secondary cause of hypertension was negative. White coat effect was ruled out by repeated ambulatory blood pressure monitoring. Due to the blood pressure being uncontrolled over the next 3 months, renal denervation was carried out without any significant improvement in her blood pressure. She was referred to another tertiary hospital for a second opinion and suprapubic cystostomy was performed because neurogenic bladder was considered as a possible cause for the refractory hypertension. However, it failed to control the blood pressure. Three months later redo renal denervation was performed but its effect did not last for two days. She was referred to the department of anesthesiology and pain center to determine whether or not celiac plexus block would be effective in reducing the blood pressure. Initially, a temporary celiac plexus block was performed with local anesthetics. Two hours after procedure, blood pressure declined to 110/60 mmHg which was sustained for three days. Based on the efficacy of celiac plexus block, permanent celiac plexus block was perfomed using dehydrated alcohol and ropivacaine. Although her blood pressure was uncontrolled shortly after procedure, systolic blood pressure declined to 110 mmHg after two months and has relatively well controlled for the past three years without antihypertensive medication.