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Improved and durable control of hypertension is a global priority for healthcare providers and policymakers. Despite all the efforts, hypertension is still misdiagnosed in half of hypertensive patients and poor drug adherence, reaching half of drug-treated patients, represents the major cause of uncontrolled hypertension. Initial studies on renal denervation (RDN) for the treatment of uncontrolled resistant hypertension produced conflicting results. A new generation of randomized clinical trials has shown promising results with new-generation devices in various hypertensive populations. From uncontrolled-resistant hypertension, the target population for RDN has moved to difficult-to-treat or resistant hypertensive patients. The selection process should take into account not only blood pressure values and the global cardiovascular risk profile, but also drug adherence and tolerability and patient preferences. The following is a state-of-the-art review of current studies and an analysis of the characteristics of hypertensive patients that could benefit from RDN.

Renal denervation (RDN) is a device-based procedure historically studied in the treatment of resistant hypertension. Studies conducted over the years have produced conflicting results and its application in routine antihypertensive treatment is still debated. Recent trials using different devices have shown promising results in the treatment of patients with hypertension at low-moderate cardiovascular risk. Although long-term results are still needed to confirm the efficacy and safety of the procedure, there is reason at the moment to consider an application of RDN in the treatment of selected patients with hypertension, other than the application for resistant hypertension. The following is a state-of-the-art review of current studies and an analysis of the characteristics of hypertensive patients that could benefit from RDN.

Sympathetic overactivity plays a crucial role in the genesis and aggravation of arterial hypertension in patients with Autosomal Dominant Polycystic Kidney Disease (ADPKD). Renal denervation has been shown to be effective and safe in reducing blood pressure (BP) in patients with treatment-resistant hypertension, even with chronic kidney disease (CKD). However, there are no cases in hypertensive patients with ADPKD. We report the exceptional case of a woman with stage 4 CKD secondary to ADPKD and uncontrolled treatment-resistant hypertension. Because of the ineffectiveness of all pharmacological and surgical therapeutic strategies, including the uninephrectomy, renal denervation by radiofrequency ablation of the renal artery was performed. The patient decreased the requirement of antihypertensive medication and the BP showed a remarkable reduction, that resulted stable 12 months after the procedure.

Metaiodobenzylguanidine (MIBG) was developed initially as a tracer for oncological imaging; when labeled with 123 I or 131 I, it may detect APUDomas, such as pheochromocytomas and paragangliomas. In the last years, MIBG has found an important role also in neurology and cardiology, as cardiac innervation tracer. Actually, MIBG cardiac imaging is a universally accepted method to estimate cardiac sympathetic innervations. This review covers the role of MIBG cardiac imaging in Parkinson disease and parkinsonisms, from the pathophysiological premises for cardiac denervation to new emerging data.

Management of Raynaud's phenomenon is essentially "symptomatic". Some hygienic-behavioral rules intended to eliminate all factors (cold, cigarette smoking, drugs, traumata) apt to trigger the phenomenon are essential. A number of drugs have been suggested for treatment: Nifedipine had been found to be effective in reducing frequency and duration of vasospastic attacks thanks to its mainly vasodilatory action, to its ability to influence platelet activity as well as to its antithrombotic effect. Also the most recent generation of calcium-channel blockers (nicardipine felodipine, isradipine, etc.) were found to have therapeutic efficacy comparable to that of nifedipine, with the added advantage of a once daily dosage. Ketanserin, a serotoninergic antagonist, is a valid alternative to calcium-channel blockers for treatment of Raynaud's phenomenon in as much as it can reduce frequency, duration and severity of vasospastic attacks, although not all authors agree upon this point. The use of prostanoids is usually reserved for cases of Raynaud's phenomenon associated with systemic sclerosis accompanied by extensive trophic disorders. Surgery is indicated only in selected cases.

Reference is made to a series of 620 cases of Raynaud's phenomenon observed at the University of Milan between 1951 and 1977. The following parameters are analysed: sex, age, aetiology (where known), incidence of involvement of the four limbs, presence or otherwise of a complete sign, percentage of trophic lesions, arteriographic picture, lab examinations performed. 534 thoracic sympathectomies were performed in 464 patients with Raynaud or Raynaud-like forms. The results are described.

The hemodynamic effects of a synthetic compound of PGF 2 alpha have been studied before and after vagosympathectomy. Synthetic PGF 2 alpha caused a marked hypertension in the pulmonary circulation linked with the vasoconstrictor action of this substance on the small lung vessels. A slight hypotension was observed in the denervated animal where the highest values of pulmonary pressure were reached. The authors conclude that this fact may be due to an inhibition of the vasoconstrictor systemic tone secondary to the pulmonary hypertensive state.

The Authors review 86 cases, aged over 70, needing surgical treatment because of atherosclerotic obstructive disease of the lower limb, stage III-IV. 35 patients underwent thigh amputation with 14% mortality in the early post-operative period (30 days) and 32% in the late post-operative period, considered up to 6 months. For 38 patients who underwent a revascularisation procedure mortality resulted 8% in the 30 post-operative days and 10% at 6 months. Escluding the aorto-iliac reconstructions through a trans-peritoneal approach, the overall mortality is limited to 3,2%. A major amputation was avoided in 76% of patients who underwent a revascularisation. On the base of their results the Authors discuss the indications of direct surgery in treatment of advanced ischemic lesions in elderly patients concluding that a surgical correction should be always considered in the aim of avoiding or limiting the amputation. In these high-risk elderly patients the extra-peritoneal aorto-iliac reconstructive technique must be preferred together with extraanatomical femoro-femoral or axillo-femoral by-passes.

Personal surgical experience with 14 cases of total occlusion of the abdominal aorta is presented. In 11 cases the revascularization has been performed with thrombectomy from below and bifurcated aortic prothesis. In 5 cases of infrarenal aortic occlusion the thrombectomy has been accomplished with only temporary digital suprarenal compression. The postoperative mortality has been nil. No temporary or definitive renal complications.

The Authors present the results got regarding operations of sympathectomy together with operations of distal by-pass at the Institute of Surgical Pathology of the University of Verona from 1979 to 1983. Among the 106 cases, in 58 (55%) sympathectomy was performed with a aorto-bifemoral or iliac-femoral by-pass at the same time, in 48 (45%) pas performed with more distal by-pass. At follow-up in the 72% of the cases a clinical improvement as been noticed, in the 14.5% of the cases a steady result as been found, and in the 12.6% of the cases an aggravation of the situation. Furthermore the clinical stage of the disease (according to Fountain) as been compared with the operation. The Authors concluded that the sympathectomy carried out together with other vascular surgical operations is still a good procedure if the patients are within 70 years of age, no diabetics and pith a sufficient perfusion pressure of the ankle. Moreover, paradoxically, the sympathectomy is much more useful on stage II or III than on stage IV.

The effects on pattern of breathing, on compliance and respiratory resistances of PGF 22 were investigated in anaesthetized pigs before and after vagosympathectomy. A marked increase in respiratory resistance and a decrease in lung compliance simultaneously with a pulmonary congestion were observed. The respiratory changes were considered secondary both to a vagal reflex and to the hemodynamic impairment.

A brief historical account of the nosological and pathogenetic classification of rheumatic polymyalgia (RPM) is followed by an indication of the importance of vasculitis during its course. Elective involvement of the temporal artery is not always observed, though there may also, or exclusively, be involvement of other arterial districts, such as those of the subaxillary and subclavicular, that of the thoracic and abdominal aorta, and of the large branches of the lower limbs. Two clinical cases are presented in support of these assertions. It is also shown that arteritis may appear several months after the onset of RPM, and that its progress may be quite separate from that of the latter. Doppler examination is now of assistance in the diagnosis of these forms, since it permits exploration of the various districts and the detection of subclinical lesions. It is also useful in the monitoring of arteritis and its response to treatment.

Here is a presentation of the role played by neurolesive procedures in the management of cancer pain. The authors suggest that these procedures should be considered secondary to the analgesic drugs and should be used only in a very limited number of situations (20/25%) due to the changes in neurophysiology of nerve transmission, caused by these interventions. Open neurolesive surgical treatments have a restricted indication because they are very traumatizing and the risk-benefit ratio is scarcely positive. Generally the chemical and thermal neurolesive procedures which are more widely used are represented by: sacral subarachnoidal block, alcholization of celiac ganglion, thermorhyzotomy of Gasser's and percutaneous chordotomy. The limits and benefits of these procedures are discussed. The authors maintain that a single technique can never completely solve the problem of pain; it can give pauses from pain, which have to be integrated sooner or later by analgesic drugs, within a continuing care program.

Stress is laid on the important role that lumbar gangliectomy has acquired among treatments of chronic arteriopathies of the lower extremities. For patients at Leriche 2nd stage and suffering from obstructions confined to the superficial femoral, no other treatment would appear to boast such high success percentages over time. General surgeons are invited to make use of this comparatively simple and certainly effective intervention, in consideration of the fact, among others, that the few vascular surgery centres in existence are not in a position to meet the flow of requests from the arteriopathics who apply to them.

Reference is made to personal experience (421 lumbar sympathectomies in 1640 vascular operations carried out over the last ten years) and the results of an enquiry addressed to more than 200 Italian surgeons are cited for the proposition that the indications for this operation are still the subject of disagreement, while its results occasionally appear to be contradictory. It is felt that the procedure is best reserved for cases in the second initial or intermediate stage, and should only be employed in advanced 2nd-stage, and 3rd and 4th stage patients whose poor general condition is a contraindication to reconstruction (indication of necessity). Other parameters to be taken into consideration include: age, site and type of the obliterating disease, ineffectiveness of drug management, and concomitant diseases (if any). Sympathectomy plus reconstructive surgery should only be used in cases where the run-off seems unsatisfactory.

The Authors report their experience concerning 120 patients with Raynaud's Disease (50 pats.) or Syndrome (70 pats.). All patients were studied before and after treatment, by clinical, thermometric, oscillographic and photoplethysmographic observation and by the Doppler examination, in order to evaluate the functional and organic component of the disease. Surgical treatment was reserved to 45 patients with secondary or primitive Raynaud's phenomenon refractory to medical therapy. The treatment of choice was thoracic sympathectomy. The result was excellent in 64% of cases, fair in 26%, and nil in 8%. 75 patients were treated with various drugs for a period of 6 months or 1 year. In 54% of cases the result was excellent, fair in 29%, and nil in 16%. The Authors conclude that diagnosis of Raynaud's Syndrome is above all clinical, that a leading part is played by photoplethysmography and the Doppler examination, and that medical therapy is indicated in the first instance, since it is capable of preventing the rise of those distal trophic disorders that constitute one of the main indications of surgical treatment.

After a brief foreword on the indication of open surgery in the treatment of neoplastic pain those procedures are detailed which are more effective and widely used: Posterior Rhizotomy, Cordotomy, Mediolongitudinal Mielotomy and Bulbar trigeminal tractotomy. Of each procedure main technical features, indications and complications are detailed. It is concluded that these techniques are still very useful in management of severe cancer pain.