JP2015513437A - 神経調節装置に関するバイオマーカーのサンプリングならびに関連システムおよび方法 - Google Patents
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Abstract
Description
腎臓の神経調節は、腎臓に分布する神経の部分的なもしくは完全な不能化、または他の効果的な妨害(たとえば、神経線維を不活性化する、またあるいは機能の完全なもしくは部分的な低減)である。たとえば、腎臓の神経調節は、腎臓に分布する神経線維(すなわち、遠心性および/または求心性神経線維)に沿った神経伝達を阻害、低減、かつ/または遮断することを含んでもよい。このような不能化は、長期間(たとえば、永続的な期間、もしくは月、年、もしくは数10年といった期間)または短期間(たとえば、数分、数時間、数日、または数週といった期間)であってよい。腎臓の神経調節は、交感神経の活性全体の増大により特徴付けられるいくつかの臨床状態、特に、高血圧、心不全、心筋梗塞、メタボリックシンドローム、インシュリン抵抗性、糖尿病、左室肥大、慢性腎疾患および最終ステージの腎疾患、心不全における不適切な流体保持、心腎症候群、骨粗しょう症、および突然死などの中枢性交感神経の過剰刺激に関連した状態を有効に治療すると予測される。求心性神経シグナルの低減は、概して、交感神経の緊張/駆動の全身的低減に寄与し、腎臓の神経調節は、全身性交感神経の活動亢進または活動過剰に関連するいくつかの状態を治療する際に有益であると予測される。腎臓の神経調節は、交感神経により神経支配される様々な臓器および身体構造にとって潜在的に有益であり得る。
図1は、本技術の実施形態にしたがって構成されたシステム100を例示する部分的概略図である。システム100は、コネクター130(たとえばケーブル)を介してコンソール(たとえばエネルギージェネレータ)132に作動可能に連結した治療装置110(たとえばカテーテル)を含むことができる。図1に示すように、治療装置110は、近位部114、近位部114の近位領域に位置するハンドルアセンブリ112、および近位部114に対して遠位置に延びる遠位部118を有する細長いシャフト116を含むことができる。細長いシャフト116は、遠位部118を治療位置の血管内(たとえば腎動脈内)または別の適切な管腔(たとえば尿管)内に配置するよう構成できる。治療装置110は、細長いシャフト116の遠位部118により運ばれる、または118に取り付けられる神経調節およびサンプリングアセンブリ102をさらに含むことができる。神経調節およびサンプリングアセンブリ102は、治療位置または治療位置の近くの別の適切な位置から生物学的試料を収集するよう構成した1つ以上のサンプリングポート108(図1に概略的に示される)と共に、治療位置または治療位置の近くで神経を調節するよう構成した1つ以上のエネルギー送達構成部104(図1に概略的に示される)(たとえば電極)を含むことができる。本明細書で使用されるように、「生物学的試料」または「試料」は、神経調節により影響を受け得る任意の適切な体液(たとえば血液、血漿、尿など)または組織(たとえば神経調節により影響を受ける1つ以上の標的バイオマーカーを含み得る)を指す。
上述のように、本技術は、神経調節に関連する1つ以上の標的バイオマーカーのレベルまたは活性の変化を検出することにより、神経調節の有効性をモニタリングする方法および工程の多様な実施形態を目的とする。従来の多くの手法とは対照的に、本開示の方法は、リアルタイムのまたはほぼ同時の神経調節有効性のモニタリングが可能となることが予測される。また、神経調節に関連する1つ以上の標的バイオマーカーのレベルまたは活性の変化を検出することにより、非腎臓の神経調節有効性の効力をモニタリングする方法および工程も提供される。以下に記載される方法および技術は、図1〜27Bに準拠して上述したシステムまたは他の適切なシステムのうちの1つを使用して実施してもよい。
実施例1:in vivoでの標的バイオマーカーのスクリーニング(ブタ腎組織)
遺伝子発現の試験を、家畜のブタ由来の腎動脈組織試料で行い、腎臓の脱神経/アブレーションの後の多様な時点での発現レベルの変化を示す候補標的バイオマーカーを同定した。
ヒトの血管細胞および神経細胞のin vitroでのスクリーニングを介して、追加的な候補標的バイオマーカーを評価した。神経細胞および血管細胞に対する熱に基づくストレスを模倣する実験条件に応答して変化する発現および/または分泌レベルに基づいて標的バイオマーカーを同定し、これにより、in vivoでの介入を擬態した。特に、細胞を炎症性の刺激および/または熱に暴露し、in vivoでの動脈のRFアブレーションおよびSNSの脱神経を刺激した。
腎臓の脱神経/アブレーション後の多様な時点で分泌レベルの変化を示す、タンパク質および非タンパク質の候補標的バイオマーカーをスクリーニングするため、腎動脈から収集したブタの血液を使用してプロテオミクス検出試験を行う。
以下の記載は、関連する生体構造および生理学に関するさらなる詳細を提供する。このセクションは、関連する生体構造および生理学に関する前の記載を補足および拡大し、腎臓の神経調節に関連する開示技術および治療上の利点に関する追加的な内容を提供するよう意図される。たとえば、上述するように、腎血管のいくつかの特性が、腎臓の神経調節を達成する治療装置および関連方法を特徴付け、このような装置に特異的な設計の必要条件を決定する。特定の設計の必要条件は、腎動脈、尿管または腎盂に接近することと、治療装置の治療構成部と管腔表面もしくは壁との間の安定した接触を容易にすることと、かつ/または治療上構成部を使用して腎神経を効果的に調節することとを含んでもよい。
SNSは、腸神経系および副交感神経系と共に自律神経系の一部である。SNSは、基礎レベルで常に活性化しており(交感神経の緊張と呼ばれる)、ストレス時にさらに活性化する。神経系の他の部分のように、交感神経系は、一連の相互接続したニューロンを介して作用する。交感神経ニューロンは、多くが中枢神経系(CNS)内に存在するが、しばしば末梢神経系(PNS)の一部であると考えられている。脊髄の交感神経ニューロン(CNSの一部)は、一連の交感神経節を介して末梢交感神経ニューロンと交信する。神経節内部で、脊髄交感神経ニューロンは、シナプスを介して末梢交感神経ニューロンと接続する。それゆえ、脊髄交感神経ニューロンは、前シナプス(または節前)ニューロンと呼ばれ、末梢交感神経ニューロンは、後シナプス(または節後)ニューロンと呼ばれる。
図78に示すように、SNSは、脳が体と伝達できるような神経のネットワークを提供する。交感神経は脊柱内部で起こり、中間質側柱(または側角)の脊髄の中心に向かい、脊髄の第1胸分節で始まり、第2または第3の腰部まで延びると考えられている。その細胞は脊髄の胸部または腰の領域で始まるため、SNSは胸腰部の流出を有するといわれている。これらの神経の軸索は、前細根/根を介して脊髄を離れる。これらの軸索は、脊髄(知覚)神経節の近くを通過し、脊髄神経の前枝に入る。しかしながら、体細胞の神経支配のようにではなく、それらは脊椎傍(脊柱の近くにある)または脊柱の側面に沿って延びる脊椎前神経節(大動脈分岐)のいずれかに接続する白色の分岐接続部を介してすばやく分離する。
図79に示すように、腎臓の神経系は腎動脈と密接に関連する腎神経叢を含む。腎神経叢は腎動脈を囲む自律神経叢であり、腎動脈の外膜の中に埋め込まれている。腎神経叢は、腎臓の実体に到着するまで腎動脈に沿って延びる。腎神経叢に寄与する線維は、腹腔神経節、上腸間膜神経節、大動脈腎動脈神経節および大動脈神経叢から生じる。腎神経叢はまた腎神経とも呼ばれ、主に交感神経の構成要素からなる。腎臓の副交感系の神経活性は存在しない(または少なくとも非常に小さい)。
メッセージはSNSを介して二方向の流れで移動する。遠心性のメッセージは、同時に体内の異なる部位の変化の引き金となり得る。たとえば、交感神経系は心拍数を加速し、分岐経路を広くし、大腸の動き(移動)を減少させ、血管を収縮させ、食道の蠕動を増大させ、瞳孔の拡張、起毛(鳥肌)および発汗(汗)を引き起こし、ならびに、血圧を上昇させ得る。求心性メッセージは、多様な臓器および他の臓器、特に脳に対する体内の感覚受容器からシグナルを運ぶ。
腎臓に対する交感神経は、血管、傍糸球体装置、および尿細管で終了する。腎臓の交感神経刺激は、レニン放出の増大、ナトリウム(Na+)の再吸収の増大、および腎臓の血流の低減を引き起こす。これらの腎機能の神経調節の構成要素は、増大した交感神経の緊張により特徴付けられる疾患状態において相当程度刺激され、高血圧患者における血圧を上げる明確な原因となる。腎臓の交感神経の遠心性刺激の結果としての腎臓の血流および糸球体濾過比率の低減は、概して、患者の臨床状態および治療で一般的に変動する臨床過程を伴う、慢性心不全の進行性合併症としての腎障害である心腎症候群における腎機能の喪失の要因となりやすい。腎臓の遠心性交感神経の刺激の結果を邪魔する薬理学的戦略としては、中枢性交感神経遮断薬、β遮断薬(レニン放出の低減を意図する)、アンジオテンシン、アンジオテンシン変換酵素阻害薬および受容体遮断薬(レニン放出の結果生じるアンジオテンシンIIおよびアルドステロンの活性を阻害するよう意図する)ならびに利尿剤(腎臓の交感神経媒介型ナトリウムおよび水貯留を妨害するよう意図する)が挙げられる。しかしながら、現在の薬理学的戦略は、限定した効能、服薬率の問題、副作用などを含む著しい限定を有する。
腎臓は、腎臓の感覚求心性神経を介して中枢神経系の複合的な構造と伝達する。いくつかの「腎損傷」の形態は、感覚求心性シグナルの活性化を誘導し得る。たとえば、腎虚血、心拍出量もしくは腎臓の血流の低減、または大量のアデノシンは、求心性神経伝達の活性化の引き金となり得る。図81Aおよび81Bに示すように、求心性伝達は、腎臓から脳であってもよく、1つの腎臓から他の腎臓(中枢神経系を介して)であってもよい。これらの求心性シグナルは、中心で統合され、増大した交感神経の流出をもたらし得る。この交感神経の駆動は、腎臓に向かい、RAASを活性化し、レニン分泌、ナトリウムの保持、流体容量の保持、および血管収縮を誘導する。中枢性交感神経の過度の活性化はまた、心臓および末梢血管構造などの交感神経を有する他の臓器および体内の構造にも影響を与え、交感神経の活性化、血圧をも上昇させる要因となるいくつかの態様といった記載される副作用をもたらす。
上に提供されるように、腎臓の神経調節は、高血圧、メタボリックシンドローム、インシュリン抵抗性、糖尿病、左室肥大、慢性最終ステージ腎疾患、心不全の不適切な水分貯留、心腎症候群、および突然死などの総合的かつ特定の腎臓の交感神経活性化の増大により特徴づけられるいくつかの臨床状態の治療に有効であると考えられる。求心性神経シグナルの低減は、交感神経の緊張/駆動の全身的低減の要因となるため、腎臓の神経調節は、全身性交感神経性の過剰活性に関連する他の状態の治療にも有益である。したがって、腎臓の神経調節は、図78に同定されるものを含む、交感神経を有する他の臓器および体構造にも有益であり得る。
本技術にしたがって、左および/または右の腎動脈と密接に関連する左および/または右の腎神経叢RPの神経調節は、血管内アクセスを介して達成されてもよい。図80Aに示すように、心臓の収縮により移動する血液は、大動脈により心臓の左心室から運ばれる。大動脈は、胸部および分岐部を介して右腎動脈および左腎動脈内へと下る。腎動脈の下で、大動脈は右腸骨動脈および左腸骨動脈として2つに分かれ、左腸骨動脈および右の腸骨動脈はそれぞれ、左右の脚を介して下り、左大腿動脈および右大腿動脈とつながる。
左腎神経叢および/または右腎神経叢の神経調節は、血管内のアクセスを介し本技術にしたがって達成され得るため、腎臓の血管構造の特性および特徴が、このような腎臓の神経調節を達成する装置、システム、および方法の設計に関して制約となる可能性があり、かつ/または設計を特徴づける可能性がある。これらの特性および特徴の一部は、患者の集団で、かつ/または特定の患者における時間、ならびに高血圧、慢性腎疾患、血管疾患、最終ステージ腎疾患、インシュリン抵抗性、糖尿病、メタボリックシンドロームなどの疾患状態に対する応答で変動してもよい。本明細書に記載されるこれらの特性および特徴は、血管内装置の手順および特定の設計の効果に影響してもよい。目的とする特性は、たとえば、物質的/機械的、空間的、流体的、動的/血行力学的、かつ/または熱力学的特性を含んでもよい。
以下の付記項(実施例)は、本技術のいくつかの実施形態を表すものである。
付記項1.患者の腎動脈の神経または腎動脈の近くの神経を調節するよう構成した神経調節構成部と、
前記神経調節構成部が前記神経を調節しながら血管内に配置されるよう構成した第1部分と、前記第1部分に近位で、前記神経調節構成部が前記神経を調節しながら体外に配置されるよう構成した第2部分とを有する細長いシャフトと、
前記第1部分の区分周辺に延びる閉塞部材と、
前記第1部分の区分に遠位的なサンプリングポートと、
前記サンプリングポートから第2の部分に向かって延びるサンプリング管腔と、
前記閉塞部材内の膨張開口部と、
前記膨張開口部から前記第2の部分に向かって延びる膨張管腔と
を含むシステム。
付記項2.前記神経の調節に応答して変化する生物学的パラメータのため、前記患者から生物学的な試料を解析するよう構成したアナライザーをさらに含む、付記項1に記載のシステム。
付記項3.前記アナライザーが、前記第2部分に作動可能に接続され、
前記サンプリング管腔が、前記サンプリングポートから前記シャフトに沿って前記アナライザーへと延びる、
付記項2に記載のシステム。
付記項4.前記第2部分に連結するハンドルをさらに含み、前記アナライザーが前記ハンドルにより運ばれる、
付記項2又は付記項3に記載のシステム。
付記項5.前記アナライザーが、前記生物学的なパラメータの状態、前記生物学的なパラメータに基づく神経調節の状態、またはその両方を示すよう構成したインジケーターを含む、付記項2〜4のいずれか1項に記載のシステム。
付記項6.前記閉塞部材に近位的なかん流吸入口と、
前記閉塞部材に遠位的なかん流排出口と
前記かん流吸入口および前記かん流排出口の間に延びるかん流管腔と、
前記かん流管腔に作動可能に連結した加圧装置と、
前記閉塞部材が、腎動脈を少なくとも部分的に閉塞しながら、前記かん流吸入口を介して前記かん流管腔内に、かつ、かん流排出口を介してかん流管腔から血液を移動するよう構成したポンプと
をさらに含む、付記項2〜5のいずれか1項に記載のシステム。
付記項7.前記シャフト内にガイドワイヤ管腔をさらに含み、前記サンプリング管腔および前記膨張管腔が、前記ガイドワイヤ管腔の反対側に最も近接した前記シャフト内に配置される、付記項1〜6のいずれか1項に記載のシステム。
付記項8.前記閉塞部材が、コンプライアントバルーンである、付記項1〜7のいずれか1項に記載のシステム。
付記項9.前記サンプリング管腔に作動可能に接続した真空ポンプをさらに含む、付記項1〜8のいずれか1項に記載のシステム。
付記項10.前記神経調節構成部が、お互い離れた複数の電極を含み、前記電極が、前記神経にRFエネルギーを同時に送達するよう構成される、付記項1〜9のいずれか1項に記載のシステム。
付記項11.前記神経調節構成部が、送達状態および展開状態を有し、
前記神経調節構成部の少なくとも一部が、前記展開状態でらせん状である、
付記項10に記載のシステム。
付記項12.前記神経調節構成部が、単一の電極を含む、付記項1〜9のいずれか1項に記載のシステム。
付記項13.患者の腎動脈の神経または腎動脈近くの神経を調節するよう構成した神経調節構成部と、
前記神経調節構成部が前記神経を調節しながら血管内に配置されるよう構成した第1部分と、前記第1部分に近位で、前記神経調節構成部が前記神経を調節しながら体外に配置されるよう構成した第2部分とを有する細長いシャフトと、
前記第1部分の区分周辺に延びる閉塞部材と、
前記第1部分の区分に遠位的なサンプリングポートと、
前記サンプリングポートから前記第2部分に向かって延びるサンプリング管腔と、
前記閉塞部材内の膨張開口部と、
前記膨張開口部から前記第2部分に向かって延びる膨張管腔と、
前記神経の調節に応答して変化する生物学的なパラメータのため、前記患者から生物学的なパラメータを解析するよう構成したアナライザーと、
遠位的なサンプリング構成部を有するサンプリングけん引部であって、前記サンプリングけん引部が、前記閉塞部材が前記腎動脈を少なくとも部分的に閉塞しながら、前記シャフトから前記神経調節構成部を越えて前記患者の腎臓の葉間血管に遠位的に延びるように構成されるサンプリングけん引部と
を含み、
前記サンプリングポートが、前記遠位的なサンプリング構成部により運ばれる、
システム。
付記項14.前記第2部分に連結したハンドルをさらに含み、前記アナライザーが前記ハンドルにより運ばれる、付記項13に記載のシステム。
付記項15.前記アナライザーが、前記生物学的パラメータの状態、前記生物学的なパラメータに基づく前記神経調節の状態、またはその両方を示すよう構成したインジケーターを含む、付記項14に記載のシステム。
付記項16.患者の腎動脈の神経または腎動脈近くの神経を調節するよう構成した神経調節構成部と、
前記神経調節構成部が前記神経を調節しながら血管内に配置されるよう構成した第1部分と、前記第1部分に近位で、前記神経調節構成部が前記神経を調節しながら体外に配置されるよう構成した第2部分とを有する第1の細長いシャフトと、
前記第1部分の区分周辺に延びる閉塞部材と、
前記区分に遠位的なサンプリングポートと、
前記サンプリングポートから前記第2部分に向かって延びるサンプリング管腔と、
前記閉塞部材内の膨張開口部と、
前記膨張開口部から前記第2部分に向かって延びる膨張管腔と、
前記神経調節構成部に連結した遠位端部を有する第2の細長いシャフトと、
前記サンプリングポートに遠位的な装置開口部と、
前記装置開口部から前記第2部分に向かって延びる装置管腔と
を含み、前記第2のシャフトが、前記遠位端部が前記装置開口部を介して延びるように、前記装置を介してスライド可能に延びるよう構成した、
システム。
付記項17.前記神経の調節に応答して変化する生物学的なパラメータのため、前記患者から生物学的な試料を解析するよう構成したアナライザーをさらに含む、付記項16に記載のシステム。
付記項18.前記アナライザーが、前記第2部分に作動可能に連結し、
前記サンプリング管腔が、前記サンプリングポートから前記シャフトに沿って、前記アナライザーに延びる、
付記項17に記載のシステム。
付記項19.前記第2部分に連結したハンドルをさらに含み、前記アナライザーが、前記ハンドルにより運ばれる、付記項17または18に記載のシステム。
付記項20.前記アナライザーが、前記生物学的なパラメータの状態、前記生物学的なパラメータに基づく神経調節の状態、またはその両方を示すよう構成したインジケーターを含む、付記項17〜19のいずれか1項に記載のシステム。
付記項21.近位部にハンドルと、遠位部に神経調節およびサンプリングアセンブリと、それらの間に細長いシャフトとを有する血管内カテーテルであって、前記神経調節およびサンプリングアセンブリが、
腎神経を調節するよう構成した神経調節構成部と、
前記神経調節構成部に近位的であり、腎臓の血液試料を収集するよう構成したサンプリング構成部であって、前記サンプリング構成部が、
サンプリングポートと、
前記サンプリングポートから前記シャフトに沿って前記ハンドルに延びるサンプリング管腔と
を有する
サンプリング構成部と、
前記サンプリング構成部に近位的な閉塞構成部であって、前記閉塞構成部が、
バルーンと、
前記バルーン内の膨張開口部と、
前記膨張開口部から前記ハンドルに向かって延びる膨張管腔と
を有する閉塞構成部と
を有するサンプリング構成部と
を含む血管内カテーテルと、
前記ハンドルに作動可能に接続したコンソールであって、前記コンソールが、エネルギーを前記神経調節構成部に供給するよう構成したコンソールと、
前記腎臓の血液試料内のバイオマーカーの濃度を検出するよう構成したアナライザーであって、前記濃度が、前記腎臓の神経の調節度合に対応する、アナライザーと
を含む、システム。
付記項22.患者の腎臓の血管内部または腎臓の血管の近くの治療部位に神経調節構成部を配置することと、
前記神経調節構成部を作動して前記患者の腎神経を調節することと、
前記神経調節構成部を作動した後、前記腎臓の血管内の閉塞部位で閉塞部材を拡大することと、
前記閉塞部材を拡大した後、前記閉塞部位に遠位的な前記腎臓の血管の一部から血液試料を収集することと、
前記神経の調節に応答して変化する生物学的なパラメータのため、前記血液試料を解析することと
を含む、方法。
付記項23.血液試料を収集することが第2の血液試料を収集することを含み、
前記方法が、前記神経調節構成部を作動させる前に、前記腎臓の血管の一部から第1の血液試料を収集することをさらに含み、
血液試料を解析することが、前記第1の血液試料および前記第2の血液試料を解析することを含む、
付記項22に記載の方法。
付記項24.前記血液試料を収集することが、前記腎臓の血管内のサンプリングポートからサンプリング管腔に沿って携帯式コンテナに前記血液試料を輸送することを含み、前記方法が、前記血液試料を解析するよう構成した血液解析ユニットに前記コンテナを移動させることをさらに含む、付記項22に記載の方法。
付記項25.前記閉塞部材を拡大することが、バルーンを膨張させて前記腎臓の血管の腎動脈を完全に閉塞することを含み、
前記血液試料を収集することが、
前記バルーンを膨張した後に、第1の量の血液を収集することと、
前記第1の量の血液を収集した後に、前記バルーンを部分的に収縮することと、
前記バルーンが前記腎動脈を完全に閉塞するように、前記バルーンを部分的に収縮した後に前記バルーンを再膨張することと、
前記バルーンを再膨張した後に、第2の量の血液を収集することと、
前記第1の量および第2の量の血液を組み合わせて前記血液試料を形成することを含む、
付記項22に記載の方法。
付記項26.前記血液試料を解析することが、前記生物学的パラメータの測定値をとることを含み、
前記神経調節構成部を解析することが、第1の時点で起こり、
前記方法が、前記測定値に応答して第2の時点で前記神経調節構成部を作動することをさらに含む、
付記項22に記載の方法。
付記項27.前記第2の時点が、前記第1の時点から約15分未満である、付記項26に記載の方法。
付記項28.ヒトの患者の動脈に腔内に送達するよう構成した遠位部を含む細長いシャフトと、
前記遠位部を介して前記シャフトに接続した神経調節およびサンプリングアセンブリであって、前記アセンブリが、
患者の動脈の最も近くで神経を調節するよう構成したエネルギー送達構成部と、
前記患者から前記治療部位または治療部位の近くで生物学的試料を血管内で得るよう構成したサンプリングポートと
を含む、アセンブリと、
前記シャフトに連結し、ならびに前記生物学的試料の少なくとも一部を受容し、かつ、前記生物学的試料の状態および/または前記生物学的試料に基づく前記神経調節の状態を示すよう構成したアナライザーと
を含む、システム。
付記項29.前記神経調節およびサンプリングアセンブリが、前記サンプリングポートに近位的な前記シャフトの一部周辺に延びる閉塞部材をさらに含む、付記項28に記載のシステム。
付記項30.前記サンプリングポートから前記細長いシャフトの近位部に向かって延びるサンプリング管腔をさらに含む、付記項28または29に記載のシステム。
付記項31.前記サンプリング管腔が、陰圧供給源と作動可能に接続する、付記項30に記載のシステム。
付記項32.前記サンプリング管腔が、1方向弁を含む、付記項30または31に記載のシステム。
付記項33.前記神経調節およびサンプリングアセンブリが、複数のエネルギー送達構成部に点在する複数のサンプリングポートを含む、付記項28〜32のいずれか1項に記載のシステム。
付記項34.ヒト対象の腎神経調節手法の作用をモニタリングする方法であって、前記方法が、
1つ以上の標的バイオマーカーのベースラインのレベルまたは活性を決定することと、
神経調節アセンブリを介して前記対象の腎神経の交感神経活性を少なくとも部分的に阻害することと、
前記標的バイオマーカーの神経調節後のレベルまたは活性を決定することと、
前記ベースラインのレベルまたは活性と前記神経後調節後のレベルまたは活性を比較することと
を含み、
前記神経調節手法が、前記神経調節後のレベルまたは活性が、前記ベースラインのレベルまたは活性と顕著に異なる場合成功と分類される、
方法。
付記項35.前記対象の腎神経の交感神経活性を少なくとも部分的に阻害することが、前記神経調節アセンブリを介して前記腎神経にエネルギーを送達して前記腎神経を調節することを含む、付記項34に記載の方法。
付記項36.前記エネルギーが無線周波数(RF)エネルギーである、付記項35に記載の方法。
付記項37.前記エネルギーが、RFエネルギー、マイクロ波エネルギー、レーザー光エネルギー、光エネルギー、超音波エネルギー、高密度焦点式超音波エネルギー、磁性エネルギー、直接的な熱エネルギー、および凍結療法用エネルギーからなる群から選択される、付記項35に記載の方法。
付記項38.前記対象の腎神経の交感神経の活性を少なくとも部分的に阻害することが、前記神経調節アセンブリを介して前記腎神経に化学物質を送達して前記腎神経を調節することを含む、付記項34〜37のいずれか1項に記載の方法。
付記項39.前記神経調節アセンブリが、前記腎神経に最も近くに配置したエネルギー送達構成部を運ぶ、血管内に配置したカテーテルを含む、付記項34〜38のいずれか1項に記載の方法。
付記項40.前記対象の腎神経の交感神経の活性を少なくとも部分的に阻害することが、前記対象の腎臓の血管内から前記神経調節アセンブリを介して前記腎神経を熱的に調節することを含む、付記項34〜39のいずれか1項に記載の方法。
付記項41.前記対象の腎神経の交感神経の活性を少なくとも部分的に阻害することが、交感神経活性を調節する方法で、腎臓の血管の治療位置で組織に化学剤を送達することを含む、付記項34に記載の方法。
付記項42.前記1つ以上の標的バイオマーカーが、ADRA2b、ATP1A1、BDNF、BMP7、BNP、BTG2、CALCB、CD40L、CDKN1B、CDKN2B/p15、CLU、DNAJA4、DNAJB1、EDN3、ETB、FASLG、FOS、HMOX−1、HSPA5、HSPA14、HSPB1、HSPD1、HSPH1、IL−10、ITGAM、KLKB1、LIF、MC2R、NTF3、P2RY12、SELE、SLC2A5/GLUT5、SOD2、TLR3、TLR4、TLR7、およびTNFRSF1Bからなる群から選択される、付記項34〜41のいずれか1項に記載の方法。
付記項43.前記1つ以上の標的バイオマーカーが、CASP10、CCL13、CCND1、CD70、CRYAB、CPS1、DNAJB1、DNAJB11、HSPA1A、HSPA1B、HSPB6、IL−10、KIT、LTA、MYLK3、NODAL、NPY1R、POU1F1、およびTCP1からなる群から選択される、付記項34〜41のいずれか1項に記載の方法。
付記項44.前記1つ以上の標的バイオマーカーが、ACTA2、CACY/2A9、CFL1、CTAG1A1/CTAG21、LDHA、MGC141/TMEM141、NAA20/NAT5、NM23B、PAHX/PHYH1、PFDN1、PLK−2、TUBA1B、およびVIMからなる群から選択される、付記項34〜41のいずれか1項に記載の方法。
付記項45.前記1つ以上の標的バイオマーカーが、SNCA、BDNF、CNTF、FGF2、GDNF、NGF2、NTF3、PF4、EDN2、ACE2、IFN−γ、ARTN、LIF、CBLN1、NRG1、NRG2、NRG4、PSPN、NTF4、およびTGFAからなる群から選択される、付記項34〜41のいずれか1項に記載の方法。
付記項46.前記1つ以上の標的バイオマーカーが、NE、CFL1、NPY、DBN、Ca2+、レニン、DBH、エンドセリン1、2、および3、NTS、ならびにAPPからなる群から選択される、付記項34〜41のいずれか1項に記載の方法。
付記項47.前記標的バイオマーカーの神経調節後のレベルまたは活性が、脱神経してから10分、24時間または7日後に決定される、付記項34〜46のいずれか1項に記載の方法。
付記項48.ヒトの患者の腎神経手法を実施する方法であって、前記方法が、
神経調節アセンブリを前記患者の腎神経に近接して血管内に配置することと、
前記神経調節アセンブリを配置する前または後に、1つ以上の標的バイオマーカーのベースラインのレベルまたは活性を決定することと、
前記神経調節アセンブリを介して前記腎神経にエネルギーを適用することにより、前記腎神経の機能を部分的に妨害することと、
前記標的バイオマーカーの神経調節後のレベルまたは活性を決定することと、
前記ベースラインのレベルまたは活性と、前記神経調節後のレベルまたは活性を比較することと
を含み、
前記神経調節手法が、前記神経調節後のレベルまたは活性が、前記ベースラインのレベルまたは活性と顕著に異なる場合成功と分類される、
方法。
付記項49.前記腎神経の機能を部分的に妨害することが、前記患者の腎神経の過形成を低減することを含む、付記項48に記載の方法。
付記項50.前記腎神経の機能を部分的に妨害することが、正常圧の患者から発現したレベルまたはレベル近くまで、患者の機能する腎神経の総数を低減することを含む、付記項48または49に記載の方法。
付記項51.前記1つ以上の標的バイオマーカーが、ADRA2b、ATP1A1、BDNF、BMP7、BNP、BTG2、CALCB、CD40L、CDKN1B、CDKN2B/p15、CLU、DNAJA4、DNAJB1、EDN3、ETB、FASLG、FOS、HMOX−1、HSPA5、HSPA14、HSPB1、HSPD1、HSPH1、IL−10、ITGAM、KLKB1、LIF、MC2R、NTF3、P2RY12、SELE、SLC2A5/GLUT5、SOD2、TLR3、TLR4、TLR7、およびTNFRSF1Bからなる群から選択される、付記項48〜50に記載の方法。
付記項52.前記1つ以上の標的バイオマーカーが、CASP10、CCL13、CCND1、CD70、CRYAB、CPS1、DNAJB1、DNAJB11、HSPA1A、HSPA1B、HSPB6、IL−10、KIT、LTA、MYLK3、NODAL、NPY1R、POU1F1、およびTCP1からなる群から選択される、付記項48〜50のいずれか1項に記載の方法。
付記項53.前記1つ以上の標的バイオマーカーが、ACTA2、CACY/2A9、CFL1、CTAG1A1/CTAG21、LDHA、MGC141/TMEM141、NAA20/NAT5、NM23B、PAHX/PHYH1、PFDN1、PLK−2、TUBA1B、およびVIMからなる群から選択される、付記項48〜50のいずれか1項に記載の方法。
付記項54.前記1つ以上の標的バイオマーカーが、SNCA、BDNF、CNTF、FGF2、GDNF、NGF2、NTF3、PF4、EDN2、ACE2、IFN−γ、ARTN、LIF、CBLN1、NRG1、NRG2、NRG4、PSPN、NTF4、およびTGFAからなる群から選択される、付記項48〜50のいずれか1項に記載の方法。
付記項55.前記1つ以上の標的バイオマーカーが、NE、CFL1、NPY、DBN、Ca2+、レニン、DBH、AGT、エンドセリン1、2、および3、NTS、ならびにAPPからなる群から選択される、付記項48〜50のいずれか1項に記載の方法。
付記項56.ヒトの患者のバイオマーカーの活性を決定する方法であって、前記方法が、
前記患者の標的血管内、かつ標的神経線維に隣接して、カテーテルのエネルギー送達構成部を経腔的に配置することと、
前記エネルギー送達構成部を介して前記標的神経線維を少なくとも部分的にアブレーションすることと、
前記カテーテルの捕捉区画に少なくとも1種のバイオマーカーを部分的に捕捉することであって、前記バイオマーカーが、前記アブレーションの結果として分泌されることと、
前記捕捉区画に前記少なくとも1種のバイオマーカーを隔離して前記バイオマーカーを濃縮することと、
前記捕捉区画の内面に配置した少なくとも1つの固定化した捕捉剤に前記バイオマーカーを結合することと、
前記バイオマーカーの濃度を検出することであって、前記濃度が、前記標的神経線維のアブレーションの度合いと少なくとも部分的に対応することと
を含む、方法。
付記項57.前記カテーテルが、前記捕捉区画の遠位端に遠位フィルターをさらに含み、前記カテーテルの捕捉区画内の複数のうち少なくとも1種のバイオマーカーを捕捉することが、前記遠位フィルターを介して前記捕捉区画内への他の生体分子の通過を防止しながら、前記遠位フィルターを介して前記捕捉区画内への前記バイオマーカーの通過を可能にすることを含む、付記項56に記載の方法。
付記項58.前記カテーテルが、前記捕捉区画の近位端に近位フィルターをさらに含み、前記カテーテルの捕捉区画に複数のうち少なくとも1種のバイオマーカーを捕捉することが、前記近位フィルターを介して前記捕捉区画から血液が流出させながら、前記捕捉区画から、前記近位フィルターを介した前記バイオマーカーの通過を防止することを含む、付記項56または57に記載の方法。
付記項59.前記カテーテルの捕捉区画が、前記バイオマーカーを捕捉しながら前記患者内部に配置される、付記項56〜58のいずれか1項に記載の方法。
付記項60.前記カテーテルの捕捉区画が、前記バイオマーカーを捕捉しながら前記患者の外に配置される、付記項56〜58のいずれか1項に記載の方法。
付記項61.ヒトの対象の腎臓の神経調節手法の有効性をモニタリングする方法であって、
1つ以上の標的バイオマーカーのベースラインのレベルまたは活性を決定することと
神経調節アセンブリを介して前記対象の腎神経の交感神経活性を少なくとも部分的に阻害することと、
1つ以上の標的バイオマーカーの神経調節後のレベルまたは活性を決定することと、
所定の閾値のレベルまたは活性と、前記1つ以上の標的バイオマーカーの神経調節後のレベルまたは活性を比較することであって、前記神経調節手法が、前記神経調節後のレベルまたは活性が、前記所定の閾値のレベルまたは活性を超える場合成功と分類されることと
を含む、方法。
付記項62.付記項34、48、56、または61のいずれかに記載される方法を実行する装置。
付記項63.ヒトの患者の動脈へと腔内送達するよう構成した遠位部を含む細長いシャフトと、
前記遠位部を介して前記シャフトに接続した神経調節およびサンプリングアセンブリであって、前記アセンブリが、
患者の動脈の最も近くの神経を調節するよう構成したエネルギー送達構成部と、
前記治療部位または前記治療部位の近くで、前記患者から生物学的試料を血管内から得るよう構成したサンプリングポートと、
前記サンプリングポートに近位した閉塞部材であって、前記閉塞部材が、1つ以上の圧力センサーを含む、閉塞部材と
を含む、神経調節およびサンプリングアセンブリと、
前記1つ以上の圧力センサーに作動可能に連結したコントローラであって、前記コントローラが、メモリおよび処理回路を含み、前記メモリが、前記処理回路を使用して前記コントローラにより実施した際に、
前記1つ以上の圧力センサーを介して閉塞部材の圧力測定値をコントローラが獲得し、
前記閉塞部材の圧力測定値に基づき前記閉塞部材が容量を拡大する
命令を記憶する、
コントローラと
を含む、システム。
本技術の上述の実施形態の詳細な説明は、例示のみを目的とし、上述した正確な形態に対する本技術の徹底、または限定を意図するものではない。これに相当する様々な変形は、本技術の範囲内にある可能性があり、関連する当業者はこれを認識しているものとする。たとえば、ステップが所定の順番で表され得るが、代替的な実施形態では、異なる順番でステップを実施してもよい。本明細書に記載される多様な実施形態およびそれらの構成部を組み合わせてさらなる実施形態を提供してもよい。いくつかの場合、よく知られている構造および機構は、本技術の実施形態の記載を不必要に妨害することを避けるために、詳細を示さず、記載しなかった。
Claims (34)
- 患者の腎動脈または腎動脈の近くの神経を調節するよう構成した神経調節構成部と、
前記神経調節構成部が前記神経を調節しながら血管内に配置されるよう構成した第1部分と、前記神経調節構成部が前記神経を調節しながら、体外に配置されるように構成された前記第1部分の近位の第2部分とを有する、細長いシャフトと、
前記第1部分の区分周辺を延びる閉塞部材と、
前記第1部分の区分の遠位側のサンプリングポートと、
前記サンプリングポートから前記第2部分に向かって延びるサンプリング管腔と、
前記閉塞部材内の膨張開口部と、
前記膨張開口部から前記第2部分に向かって延びる膨張管腔と、を備えている、
ことを特徴とするシステム。 - 前記神経の調節に応答して変化する生物学的パラメータのため、前記患者から生物学的試料を解析するよう構成されたアナライザーをさらに含む、
請求項1に記載のシステム。 - 前記アナライザーが、前記第2部分に作動可能に連結され、
前記サンプリング管腔が、前記サンプリングポートから前記シャフトに沿って前記アナライザーに延びる、
請求項2に記載のシステム。 - 前記第2部分に連結するハンドルをさらに含み、前記アナライザーが前記ハンドルに指示されている、
請求項2に記載のシステム。 - 前記アナライザーが、前記生物学的パラメータの状態、前記生物学的パラメータに基づく神経調節の状態、またはその両方を示すよう構成されたインジケーターを備えている、
請求項2に記載のシステム。 - 前記閉塞部材の近位側のかん流吸入口と、
前記閉塞部材の遠位側のかん流排出口と、
前記かん流吸入口および前記かん流排出口の間を延びるかん流管腔と、
前記かん流管腔に作動可能に連結された加圧装置と、
前記閉塞部材が腎動脈を少なくとも部分的に閉塞しながら、前記かん流吸入口を介して前記かん流管腔に、かつ、前記かん流排出口を介してかん流管腔から、血液を移動させるよう構成されたポンプと、をさらに備えている、
請求項2に記載のシステム。 - 前記シャフト内にガイドワイヤ管腔をさらに含み、前記サンプリング管腔および膨張管腔が、前記ガイドワイヤ管腔の反対側に最も近いシャフト内に配置される、
請求項1に記載のシステム。 - 前記閉塞部材が、コンプライアントバルーンである、
請求項1に記載のシステム。 - 前記サンプリング管腔に作動可能に連結された真空ポンプをさらに含む、
請求項1に記載のシステム。 - 前記神経調節構成部が、お互い離れた複数の電極を備え、前記電極が、RFエネルギーを前記神経に同時に送達するよう構成された、
請求項1に記載のシステム。 - 前記神経調節構成部が、送達状態および展開状態を有し、
前記神経調節構成部の少なくとも一部が、前記展開状態でらせん状である、
請求項10に記載のシステム。 - 前記神経調節構成部が、単一の電極を備えている、
請求項1に記載のシステム。 - 患者の腎動脈または腎動脈の近くで神経を調節するよう構成された神経調節構成部と、
前記神経調節構成部が前記神経を調節しながら血管内に配置される第1部分と、前記神経調節構成部が前記神経を調節しながら体外に配置されるよう構成された前記第1部分の近位の第2部分と、を有する細長いシャフトと、
前記第1部分の区分周辺に延びる閉塞部材と、
前記第1部分の区分に遠位的なサンプリングポートと、
前記サンプリングポートから前記第2部分に向かって延びるサンプリング管腔と、
前記閉塞部材内の膨張開口部と、
前記膨張開口部から前記第2部分に向かって延びる膨張管腔と、
前記神経の調節に応答して変化する生物学的なパラメータのため、前記患者からの生物学的試料を解析するよう構成されたアナライザーと、
遠位的サンプリング構成部を有するサンプリングけん引部であって、
前記閉塞部材が腎動脈を少なくとも部分的に閉塞しながら、前記サンプリングけん引部が前記シャフトから前記神経調節構成部を越えて前記患者の腎臓の葉間血管に遠位的に延びるよう構成されている、
サンプリングけん引部と、備え、
前記サンプリングポートが、前記遠位的サンプリング構成部に支持されている、
ことを特徴とするシステム。 - 前記第2部分に連結するハンドルをさらに含み、前記アナライザーが、前記ハンドルに支持されている、
請求項13に記載のシステム。 - 前記アナライザーが、前記生物学的パラメータの状態、前記生物学的パラメータに基づく前記神経調節の状態、またはその両方を示すよう構成されたインジケーターを備えている、
請求項13に記載のシステム。 - 患者の腎動脈または腎動脈近くの神経を調節するよう構成された神経調節構成部と、
前記神経調節構成部が前記神経を調節しながら血管内に配置されるよう構成された第1部分と、前記神経調節構成部が前記神経を調節しながら体外に配置するよう構成された前記第1部分の近位の第2部分と、を有する第1の細長いシャフトと、
前記第1部分の区分周辺に延びる閉塞部材と、
前記区分の遠位側のサンプリングポートと、
前記サンプリングポートから前記第2部分に向かって延びるサンプリング管腔と、
前記閉塞部材内の膨張開口部と、
前記膨張開口部から前記第2部分に向かって延びる膨張管腔と、
前記神経調節構成部に連結した遠位端部を有する第2の細長いシャフトと、
前記サンプリングポートの遠位側の装置開口部と、
前記装置開口部から前記第2部分に向かって延びる装置管腔と
を含むシステムであって、
前記第2のシャフトが、前記遠位端部が前記装置開口部を介して延びるように、前記装置管腔を介してスライド可能に延びるよう構成される、
ことを特徴とするシステム。 - 前記神経の調節に応答して変化する生物学的なパラメータのため、前記患者から生物学的試料を解析するよう構成されたアナライザーをさらに備えている、
請求項16に記載のシステム。 - 前記アナライザーが、前記第2部分に作動可能に連結し、
前記サンプリング管腔が、前記サンプリングポートから前記シャフトに沿って前記アナライザーに延びる、
請求項17に記載のシステム。 - 前記第2部分に連結するハンドルをさらに備え、前記アナライザーが前記ハンドルにより運ばれる、
請求項17に記載のシステム。 - 前記アナライザーが、前記生物学的パラメータの状態、前記生物学的パラメータに基づく前記神経の調節の状態、またはその両方を示すよう構成されたインジケーターを備えている、
請求項17に記載のシステム。 - 近位部にハンドルと、遠位部に神経調節およびサンプリングアセンブリと、それらの間に細長いシャフトとを有する血管内カテーテルであって、前記神経調節およびサンプリングアセンブリが、
腎臓の神経を調節するよう構成された神経調節構成部と、
神経調節構成部に近位的であり、腎臓血液試料を収集するよう構成されたサンプリング構成部であって、前記サンプリング構成部が、
サンプリングポートと、
前記サンプリングポートから前記シャフトに沿って前記ハンドルに延びるサンプリング管腔と、を有するサンプリング構成部と、
前記サンプリング構成部の近位側の閉塞構成部であって、前記閉塞構成部が、
バルーンと、
前記バルーン内の膨張開口部と、
前記膨張開口部から前記ハンドルに向かって延びる膨張管腔と
を有する、血管内カテーテルと、
前記ハンドルに作動可能に連結したコンソールであって、前記神経調節構成部にエネルギーを供給するよう構成された、コンソールと、
前記腎臓の血液の試料内のバイオマーカーの濃度を検出するよう構成されたアナライザーであって、前記濃度が、前記腎神経の調節の度合いに対応するアナライザーと、
を備えている、
ことを特徴とするシステム。 - 患者の腎臓血管内または血管の近くの治療部位に神経調節構成部を配置することと、
前記神経調節構成部を作動して前記患者の腎神経を調節することと、
前記神経調節構成部を作動した後に、前記腎臓の血管内の閉塞部位で閉塞部材を拡大することと、
前記閉塞部材を拡大した後に、前記閉塞部位に遠位的な前記腎臓の血管の一部から血液試料を収集することと、
前記神経の調節に応答して変化する生物学的なパラメータのため、前記血液試料を解析することと、を含む、
ことを特徴とする方法。 - 血液試料を収集することが、第2の血液試料を収集することを含み、
前記方法が、前記神経調節構成部を作動する前に、前記腎臓の血管の一部からの第1の血液試料を収集することをさらに含み、
前記血液試料を解析することが、前記第1の血液試料および前記第2の血液試料を解析することを含む、
請求項22に記載の方法。 - 血液試料を収集することが、前記血液試料を腎臓の血管内サンプリングポートからサンプリング管腔に沿って携帯式コンテナに輸送することを含み、前記方法が、前記血液試料を解析するよう構成された血液解析ユニットに前記コンテナを移動させることをさらに含む、
請求項22に記載の方法。 - 前記閉塞部材を拡大することが、バルーンを膨張して前記腎臓の血管の腎動脈を完全に閉塞することと、
前記血液試料を収集することが、
前記バルーンを膨張した後に第1の量の血液を収集することと、
第1の量を収集した後に前記バルーンを部分的に収縮することと、
前記バルーンが前記腎動脈を完全に閉塞するように前記バルーンを部分的に収縮した後に前記バルーンを再膨張することと、
前記バルーンを再膨張した後に第2の量の血液を収集することと、
前記第1および第2の量の血液を組み合わせて前記血液試料を形成することと、を備えている、
請求項22に記載の方法。 - 前記血液の試料を解析することが、前記生物学的なパラメータの測定値をとることを含み、
前記神経調節構成部を作動することが、第1の時点で起こり、
前記方法が、前記測定値に応答して第2の時点で前記神経調節構成部を作動することをさらに備えている、
請求項22に記載の方法。 - 前記第2の時点が、前記第1の時点から約15分未満である、
請求項26に記載の方法。 - ヒト患者の動脈への管腔内送達のために構成された遠位部を含む細長いシャフトと、
前記遠位部を介して前記シャフトに接続する神経調節およびサンプリングアセンブリであって、
患者の動脈の最も近くで神経を調節するよう構成されたエネルギー送達構成部と、
前記患者から前記治療部位または治療部位の近くで生物学的試料を血管内で得るよう構成されたサンプリングポートと、を有するアセンブリと、
前記シャフトに作動可能に連結し、前記生物学的な試料の少なくとも一部を受容し、前記生物学的試料の状態、および/または前記生物学的試料に基づく前記神経の調節の状態を示すよう構成されたアナライザーと、を備えている、
ことを特徴とするシステム。 - 前記神経調節およびサンプリングアセンブリが、前記サンプリングポートに近位的な前記シャフトの一部周辺に延びる閉塞部材をさらに備えている、
請求項28に記載のシステム。 - 前記サンプリングポートから前記細長いシャフトの近位部に向かって延びるサンプリング管腔をさらに含む、
請求項28に記載のシステム。 - 前記サンプリング管腔が、陰圧供給源と作動可能に連結される、
請求項30に記載のシステム。 - 前記サンプリング管腔が、1方向弁を備えている、
請求項31に記載のシステム。 - 前記神経調節およびサンプリングアセンブリが、複数のエネルギー送達構成部に点在する複数のサンプリングポートを備えている、
請求項31に記載のシステム。 - ヒトの患者の動脈への管腔内送達のために構成された遠位部を含む細長いシャフトと、
前記遠位部を介して前記シャフトに連結する神経調節およびサンプリングアセンブリであって、
患者の動脈の最も近くで神経を調節するよう構成されたエネルギー送達構成部と、
前記患者から前記治療部位または前記治療部位の近くで生物学的試料を血管内で得るように構成されたサンプリングポートと、
前記サンプリングポートに近位的な閉塞部材であって、1つ以上の圧力センサーを有する閉塞部材と、を有するアセンブリと、
前記1つ以上の圧力センサーに作動可能に接続するコントローラであって、メモリおよび処理回路を含み、前記メモリが、前記処理回路を使用して前記コントローラにより実行される際、
前記コントローラが前記1つ以上の圧力センサーを介して閉塞部材の圧力測定値を獲得し、かつ
前記閉塞部材が前記閉塞部材の圧力測定値に基づきある容積まで拡大する命令を記憶する、コントローラと、を備えている、
ことを特徴とするシステム。
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AU2013229776A1 (en) | 2014-09-18 |
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