US20140296708A1 - Systems and Methods for Delivering Drugs to Selected Locations Within the Body - Google Patents
Systems and Methods for Delivering Drugs to Selected Locations Within the Body Download PDFInfo
- Publication number
- US20140296708A1 US20140296708A1 US14/259,529 US201414259529A US2014296708A1 US 20140296708 A1 US20140296708 A1 US 20140296708A1 US 201414259529 A US201414259529 A US 201414259529A US 2014296708 A1 US2014296708 A1 US 2014296708A1
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- US
- United States
- Prior art keywords
- catheter
- drug
- needle
- needles
- tissue region
- Prior art date
- Legal status (The legal status is an assumption and is not a legal conclusion. Google has not performed a legal analysis and makes no representation as to the accuracy of the status listed.)
- Abandoned
Links
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Definitions
- the present invention relates generally to systems and methods for delivering substances into a body, more particularly to systems and methods that use the cardiovascular system as a conduit to deliver drugs, such as therapeutic drugs, genes, growth factors and the like, directly to selected tissue regions within the body, and most particularly to systems and methods that deliver drugs from the venous system transvascularly to selected remote tissue regions.
- drugs such as therapeutic drugs, genes, growth factors and the like
- Such therapies may include delivering substances, such as nitroglycerin, epinepharin, or lydocaine, endocardially or into the pericardial space to treat the coronary system.
- heparin, hirudin, ReoProTM or other anti-thrombotic compounds may be infused into blood vessels associated with the coronary system, such as occluded coronary arteries, or elsewhere in the cardiovascular system.
- gene therapy e.g. introducing genetic material
- growth factor therapy e.g. introducing proteins, cells or vectors including angiogenic growth factors
- one method of delivering such drugs involves percutaneously introducing an infusion catheter into the patient's cardiovascular system.
- a distal portion of the catheter is directed to a desired endovascular location, for example into a coronary artery, and a drug is infused into the artery at a location reachable intraluminally.
- the catheter may include a lumen extending between its proximal and distal ends, the distal end having one or more outlet ports.
- a source of the drug such as a syringe, may be connected to the proximal end and the drug delivered through the lumen and outlet port(s) into the desired location.
- a “bolus,” i.e. a relatively large single dose of a drug, may be delivered using an infusion catheter into an artery, which may be absorbed by the arterial wall, the surrounding tissue, and/or may be carried by blood flow to regions further downstream from the delivery location.
- the drug may be infused continuously or intermittently into the artery for an extended period of time.
- the infusion catheter often includes a porous perfusion balloon on its distal end, the interior of which communicates with the outlet port(s) and lumen in the catheter. Pores or holes in the balloon may be arranged to direct the drug from the balloon towards the arterial wall to improve penetration into the arterial wall and attempt to localize delivery.
- the infusion catheter may be provided with an electrode and/or a heating element on or in the balloon to cause electroporation or to heat the surrounding tissue to further improve localized delivery.
- a first electrode may be provided within a perfusion balloon, and a second electrode provided on an external region of the patient's body near the artery.
- a drug carried by an electrically charged compound may be directed along the path of current flow from the internal electrode towards the external electrode in an attempt to improve penetration of the drug into the arterial wall and surrounding tissue.
- a drug may be embedded in or deposited on a catheter, e.g. in the catheter wall, the wall of a non-porous balloon on the catheter, and/or a coating on the catheter.
- the drug may be delivered into an artery, for example, by ionophoresis similar to that described above or by simply allowing the drug to dissolve within the artery.
- a pair of occlusion balloons disposed along the length of a catheter may be provided on an infusion catheter that may be directed endovascularly to a desired location within an artery.
- the balloons may be inflated to isolate a section of the artery between them, and a drug may be delivered into the isolated section in an attempt to provide sustained delivery to the isolated section.
- the balloons are then deflated, and the catheter removed from the body.
- Drug delivery devices may also be implanted within an artery to provide sustained delivery.
- U.S. Pat. No. 5,628,784 issued to Strecker discloses an expandable annular sleeve that may be deployed within an artery. A small quantity of drugs may be introduced between the sleeve wall and the surrounding arterial wall to directly contact the arterial wall, where they may be absorbed over an extended period of time.
- PCT Publication No. WO 95/01138 discloses a porous ceramic sleeve that may be implanted directly in tissue, such as in bone marrow or a surgically created pouch. The sleeve includes drugs within a cell culture or matrix in the sleeve, which may, for example, be dispersed in the pores of the sleeve or be provided in a cylindrical insert.
- drugs may be injected directly into a desired tissue region, typically by accessing the region through a chest incision.
- a polymer gel or drug-soaked sponge may be attached to the outside of a vessel or to a portion of the endocardium to be absorbed by the contacted region.
- the pericardial space may have substances injected directly into it, for example by accessing the pericardial sac through a chest incision. Such methods may provide either single dose or sustained delivery of drugs to the heart.
- Dilution may substantially reduce the effectiveness of a therapy by preventing sufficient quantities of the drug from reaching a desired region.
- the drug may be diluted as it travels through the arterial wall or may be carried downstream through the artery to other regions within the coronary system and/or elsewhere in the body.
- the volume of drug may be increased to offset dilution concerns, but this may exacerbate concerns about undesired dissemination of the drug.
- certain therapeutic drugs, genetic material and growth factors may have undesired global side effects.
- Releasing a drug into the blood stream may allow it to be carried throughout the coronary system or elsewhere in the body where it may have significant adverse effects. Similar adverse effects may result from pericardial delivery, in which a drug may be absorbed throughout the coronary system, rather than only in a desired local region.
- Occlusion systems such as the dual occlusion balloon catheter, or the implantable sleeves described above, may be able to isolate a region of an artery for some sustained treatments.
- Such occlusion devices may introduce additional risks associated with obstructing flow within the coronary system for extended periods of time.
- substantial damage may occur, for example, ischemia and possibly infarction of tissue downstream from the occluded region.
- infusion catheters may be unable to pass through an occluded region of an artery to treat ischemic tissue downstream of the region.
- it may be hazardous to direct an endovascular device through a stenotic region because of the risk of releasing embolic material from the arterial wall, which may travel downstream and become embedded in other vessels or even travel to vital organs, such as the brain, where they may cause substantial damage or even death.
- More invasive methods such as direct injection of drugs, may provide access to otherwise unattainable regions. Such methods, however, typically involve open-chest or other invasive surgical procedures, and the costs and risks associated with them.
- the present invention is directed to systems and methods for delivering a drug to a tissue region within a patient's body, and in particular to systems and methods that use the venous system as a conduit to deliver a drug directly to a remote tissue region, or to facilitate a catheter-based intervention.
- Drug as defined herein includes any therapeutic drugs, genetic materials, growth factors, cells, e.g. myocites, vectors carrying growth factors, and similar therapeutic agents or substances that may be delivered within a patient's body for any therapeutic, diagnostic or other procedure.
- a transvascular catheter system is provided that generally includes a catheter, a drug delivery element, an orientation element, and possibly a puncturing element and/or an imaging element.
- the catheter has a proximal portion and a distal portion adapted for insertion into a blood vessel, and defines a periphery and a longitudinal axis.
- the puncturing element is deployable from the distal portion in a predetermined relationship with the circumference or periphery of the catheter, and includes a distal tip adapted to penetrate a wall of a blood vessel to access a tissue region beyond the wall of the blood vessel.
- the drug delivery element is provided on the distal portion for delivering a drug to the tissue region, and an orientation element is also provided on the distal portion in a predetermined relationship with the periphery of the catheter and the puncturing element.
- the catheter has a peripheral opening at a predetermined location on the periphery of the distal portion through which the puncturing element may be deployed, and a needle lumen communicating with the peripheral opening for receiving the puncturing element therethrough.
- the needle lumen includes a deflecting element adapted to direct the distal tip substantially transversely with respect to the longitudinal axis when the puncturing element is deployed.
- the system may include an imaging element adjacent the orientation element for detecting the location of the orientation element with respect to the tissue region.
- the imaging element may be an ultrasound transducer which may be received in a lumen extending between the proximal and distal portions of the catheter.
- the puncturing element is a needle and the drug delivery element is a lumen in the needle.
- the needle may include an array of outlet ports for providing a predetermined flow pattern of fluid into the tissue region accessed by the needle.
- at least a portion of the needle may be a conductive material electrically coupled to a proximal end of the puncturing element for coupling the needle to a source of electric current.
- the puncturing element may be a plurality of needles deployable from predetermined locations on the distal portion to provide a selected trajectory pattern into the tissue region.
- the puncturing element includes a guide wire
- the drug delivery element is deployable over the guide wire.
- the drug delivery element may be an infusion catheter, possibly including a perfusion balloon.
- the drug delivery element may include an indwelling catheter which is delivered over the guide wire, either before or after removal of the transvascular catheter.
- the drug delivery element may include a first electrode thereon adapted to be electrically coupled to a second electrode. When direct current is directed between the first and second electrodes, fluid from the drug delivery element may be ionophoretically directed from the drug delivery element towards the second electrode.
- the drug delivery element may be an osmotic surface on the transvascular catheter, the infusion catheter or the indwelling catheter.
- the orientation element preferably has an asymmetric configuration aligned with the puncturing element, for example with the peripheral opening through which the puncturing element may be deployed.
- the orientation element is a “cage” structure that includes a plurality of struts extending axially along the distal portion.
- a first strut is provided at a location in direct axial alignment with the peripheral opening, and a pair of struts are provided opposite the first strut to “point” towards the peripheral opening.
- the orientation element may include a marker that may be imaged using an external imaging system, and preferably a pair of markers disposed opposite one another on the periphery, either instead of or preferably in addition to the “cage” structure.
- a transvascular catheter system in accordance with the present invention may be used to deliver a drug to a tissue region within a patient's body, such as into the myocardium or a coronary artery from the coronary venous system, in a method which may proceed as follows.
- the distal portion of the catheter may be percutaneously introducing into a blood vessel, and directed endovascularly to a vessel location adjacent to the tissue region selected for treatment.
- the puncturing element may be oriented towards the selected tissue region, and deployed to access the tissue region.
- a drug may then be delivered with the drug delivery element to the tissue region.
- the orientation element is imaged, for example with an imaging element adjacent the orientation element.
- the imaging element is preferably operated to obtain an image of the orientation element in relation to the surrounding tissue, thereby identifying the orientation of the puncturing element because of the predetermined relationship between the orientation element and the puncturing element.
- the imaging element is an ultrasound transducer within the catheter that may be used to obtain image slices along a plane substantially normal to the longitudinal axis of the catheter, the images preferably including the orientation element, the selected tissue region and/or other landmarks within the vessel or the surrounding tissue.
- the puncturing element is a drug delivery needle
- the needle may be deployed, penetrating a wall of the blood vessel and entering the tissue region, and the drug may be delivered through a lumen in the needle.
- a drug delivery element may be deployed in combination with the puncturing element.
- an infusion catheter may be advanced over the puncturing element to the tissue region, and the drug infused therethrough, or through a porous balloon on the infusion catheter which may be inflated within the tissue region.
- a “mapping” procedure may be used to ensure that the drug will be delivered as desired into the specific tissue region selected for treatment.
- a radiographic agent may be delivered using the drug delivery element to observe the flow thereof with respect to the selected tissue region. Once it has been confirmed that the radiographic agent flows as desired into the selected tissue region, the drug may then be introduced, thereby possibly avoiding misdelivery of what are often quite expensive drugs.
- a radiographic agent and the like may be mixed with the drug to track the flow of the drug within the body, particularly with respect to the selected tissue region.
- the transvascular catheter system may be used to create a drug reservoir directly in a selected tissue region.
- a tissue ablation device may be provided that is deployable in combination with the puncturing element for creating a cavity in an extravascular tissue region.
- the ablation device may be advanced over the puncturing element into the tissue region, and an ablation element thereon activated to create a cavity or drug reservoir within the tissue region.
- a drug may then be introduced into the drug reservoir, which may be sealed from the vessel, for example by introducing a sealant or matrix into the drug reservoir.
- the drug reservoir may be formed by removing a portion of the tissue region, for example with a cutting instrument or similar mechanical device.
- the transvascular system may be used to facilitate an indwelling catheter-based intervention.
- the catheter may be introduced into a vessel, and then the puncturing element may be oriented and deployed into a tissue region, such as interstitial tissue or another blood vessel.
- a guide wire may be advanced into the tissue region, and the transvascular catheter may then be removed, leaving the guide wire in place, possibly anchored to the tissue region.
- a thin, floppy catheter may be tracked over the guide wire into the tissue region, and left in place within the tissue region, and the wire may be removed.
- the indwelling catheter may be taped, ported or otherwise secured to the patient depending upon the length of time therapy is desired.
- the tissue region may then be accessed via the indwelling catheter to deliver a drug to the tissue region as often as desired.
- an implantable drug reservoir system may be used to provide sustained delivery of a drug within the cardiovascular system of a patient.
- the system includes a reservoir device having an expandable frame and a flexible membrane thereon.
- the frame is adapted to expand between a collapsed condition for insertion into a blood vessel and an enlarged condition for engaging a wall of the blood vessel.
- the frame is preferably biased towards the enlarged condition, and also preferably defines a longitudinal axis and a periphery.
- the flexible membrane is attached to the frame to define a reservoir therein, and includes a porous region, such as a semi-permeable material, that is preferably disposed along the periphery of the frame.
- a drug possibly together with an anti-coagulant, is provided within the reservoir that is adapted to pass through the porous region of the membrane.
- An end region of the membrane may be penetrable, for example by a needle, to facilitate in situ filling of the reservoir.
- a reservoir device similar to that described above may be provided with a septum dividing the reservoir within the membrane into first and second reservoir regions.
- the membrane preferably includes an osmotic region communicating with the first reservoir region, and the porous region of the membrane preferably communicates with the second reservoir region.
- the reservoir device may be introduced along a blood vessel to a location adjacent a selected tissue region, for example within a coronary vein adjacent to an occluded artery or ischemic myocardial tissue.
- the reservoir device may be deployed and expanded, preferably automatically, to its enlarged condition to anchor the reservoir device within the blood vessel.
- a drug may be prefilled within the reservoir or an injection device may be advanced to penetrate the membrane of the reservoir device and fill the reservoir in situ with the drug.
- the drug may then permeate, seep, or otherwise pass through the porous region, preferably directly into the wall of the vessel and the surrounding tissue region.
- the reservoir may be refilled in situ using an injection device as the drug is dispersed or otherwise absorbed by the tissue.
- a reservoir device having a septum panel may deliver the drug in the second reservoir region to the tissue region as the first reservoir region osmotically fills, thereby slowly forcing or “pumping” the drug through the porous region.
- a pair of expandable devices similar to the reservoir devices may be used.
- the expandable devices, or endovascular “blockers,” include an expandable frame, and a non-porous membrane covering at least one end of the frame, and preferably extending along at least a portion of the periphery.
- the first blocker is advanced in a collapsed condition along the blood vessel to a location adjacent the selected tissue region.
- the first blocker is then expanded to its enlarged condition, thereby sealing the blood vessel at the location from fluid flow along the blood vessel.
- the second blocker is then advanced in a collapsed condition along the blood vessel to the location, preferably adjacent the first blocker.
- the second blocker is then expanded to its enlarged condition, thereby further sealing the blood vessel at the location from fluid flow along the blood vessel.
- the second blocker is preferably deployed a predetermined distance from the first blocker, thereby defining a substantially sealed drug reservoir within the blood vessel itself between the blockers.
- a drug may be introduced into the blood vessel adjacent the first blocker, either before or after the second blocker is deployed.
- the second blocker may include an end panel only on the end away from the drug reservoir between the blockers, and an injection device may be advanced to penetrate the end panel.
- the drug may then be introduced into the second blocker and consequently into the drug reservoir between the blockers.
- a section of a blood vessel may be isolated and a drug delivered therein to provide sustained and localized delivery of the drug into the selected tissue region surrounding the vessel.
- a principal object of the present invention is to provide a system and method for precisely delivering a drug to a selected tissue location within the body.
- coronary venous system to provide access to a highly remote tissue region of the body, e.g. heart tissue.
- FIG. 1A is a cross-sectional view of a transvascular catheter system in accordance with one aspect of the present invention.
- FIGS. 1B and 1C are side views of a handle on the catheter for the transvascular catheter system of FIG. 1A .
- FIG. 1D is a cross-sectional view of the distal portion of a catheter for the transvascular catheter system of FIG. 1A .
- FIG. 1E is a side view of a needle assembly for the transvascular catheter system of FIG. 1A .
- FIG. 2 is a cross-sectional view of the distal portion of the transvascular catheter system of FIG. 1 , showing the needle assembly deployed into a remote blood vessel.
- FIG. 3A is a cross-sectional view of the transvascular catheter system and surrounding heart tissue of FIG. 2 , taken along line 3 - 3 using an internal imaging element, showing artifacts directing the catheter towards another blood vessel.
- FIG. 3B is a cross-sectional view of the transvascular catheter system and surrounding heart tissue, similar to FIG. 3A , but showing artifacts directing the catheter towards the myocardium of the heart.
- FIG. 4A is a side view detail of a catheter, showing a preferred embodiment of an externally detectable orientation element in accordance with the present invention.
- FIG. 4B is a side view of the catheter of FIG. 4A , rotated 90 degrees from that shown in FIG. 4A .
- FIG. 5A is a side view of an alternative embodiment of the distal portion, including a plurality of needle assemblies.
- FIG. 5B is a side view of another alternative embodiment of the distal portion, including a dual lumen needle assembly.
- FIG. 5C is another alternative embodiment of the distal portion, including a plurality of outlet ports for providing a predetermined flow pattern.
- FIG. 5D is another alternative embodiment of the distal portion, including a feedback sensor on the needle assembly.
- FIG. 6 is a cross-sectional view of another preferred embodiment of a transvascular catheter system in accordance with the present invention, including a guide wire assembly and a drug delivery catheter deployed into a remote tissue region.
- FIG. 7 is a perspective view of an implantable port assembly for use with a transvascular catheter system in accordance with the present invention.
- FIG. 8 is a cross-sectional view of another preferred embodiment of a transvascular catheter system, including a guide wire assembly and an ablation device.
- FIG. 9A is a side view of an implantable endovascular drug reservoir device in accordance with the present invention.
- FIG. 9B is a side view of another embodiment of an implantable endovascular drug reservoir device, including a recrossable end panel.
- FIGS. 9C and 9D are side views of the implantable endovascular drug reservoir device of FIG. 9B , showing an injection device for filling the reservoir.
- FIG. 10 is a cross-sectional side view of the drug reservoir device of FIG. 9A , deployed within a vein adjacent to a stenotic region of an artery.
- FIG. 11 is a side view of an alternative embodiment of an implantable endovascular drug reservoir device in accordance with the present invention.
- FIG. 12 is a side view of another implantable system in accordance with the present invention for creating a drug delivery reservoir, shown within a vein adjacent to a stenotic region of an artery.
- FIG. 13 is a cross-sectional view of a transvascular catheter system in accordance with the present invention delivered downstream of a stenotic region in a blood vessel.
- FIGS. 1A-1E and 2 show a preferred embodiment of a transvascular catheter system 10 in accordance with the present invention for delivering a drug to a selected remote tissue region within a body from a blood vessel near the tissue region.
- the system 10 generally includes a catheter 12 , a puncturing element 14 , an orientation element (e.g. a “cage” structure 16 described below), and an imaging element 18 .
- the catheter 12 may be an elongate member having substantially flexible and/or semi-rigid sections, and defining a circumference or periphery 20 and a longitudinal axis 22 between proximal and distal ends 24 , 26 .
- the catheter 12 includes a proximal portion 28 having a handle 50 and a distal portion 30 having a size and shape to facilitate insertion into a blood vessel.
- An IVUS lumen 32 extends through the catheter 12 from an IVUS entry port 52 in the handle 50 to a tip member 44 on the distal portion 30 for receiving the imaging element 18 .
- a needle lumen 36 also extends from a needle entry port 54 in the handle 50 to a peripheral opening 34 in the distal portion 30 for receiving the puncturing element 14 .
- the needle lumen 36 includes a deflecting element or ramp 48 adjacent the peripheral opening 34 .
- the catheter 12 may include an extruded dual lumen catheter encapsulated within an outer jacket (not shown), and/or may have a proximal portion that is substantially more rigid than a distal portion.
- the catheter 12 includes a proximal portion 12 a , an intermediate portion 12 b , and a distal portion 12 c , each having a dual lumen catheter segment and an outer jacket segment.
- the rigidity or Durometer of the dual lumen catheter and outer jacket segments of the proximal portion 12 a is preferably 63 and 70, while the remaining segments preferably have a Durometer of 40. Additional information on the construction of the catheter 12 , e.g.
- the orientation element is preferably a marker “cage” structure 16 including a plurality of elongate members or struts 38 , 40 on the distal portion 30 located distally of the peripheral opening 34 .
- the struts 38 , 40 preferably extend distally from the distal end 26 substantially parallel to the longitudinal axis 22 to the proximal edge 42 of the tip member 44 , thereby further defining the IVUS lumen 36 .
- the struts 38 , 40 preferably define a peripheral window 46 , which may be covered by a material substantially transparent to the imaging element 18 or may remain open to blood flow.
- the struts 38 , 40 are preferably substantially rigid tubular members, such as hypotubes, which are reflective to the imaging element 18 , i.e. will produce a reflection or artifact when the imaging element 18 is operated, and/or may be substantially opaque to an external imaging apparatus (not shown).
- the struts 38 , 40 have an asymmetrical configuration about the periphery 20 that has a predetermined relationship with the location of the peripheral opening 34 . More preferably, a first strut 38 is located on the periphery 20 directly distally from the location of the peripheral opening 34 . A pair of struts 40 are then positioned opposite the first strut 38 , thereby defining an isosceles triangle or TRI-POINTTM cross-sectional configuration, with the first bar 38 at the top of the triangle.
- the orientation element 16 may “point” circumferentially towards the location of the peripheral opening 34 on the periphery 20 , i.e. towards the location from which the puncturing element 14 may be deployed, as described further below.
- the orientation element may include one or more externally visible markers 116 placed at one or more predetermined locations on the periphery 20 of the catheter 12 .
- the markers 116 define a pattern to facilitate detection of the orientation of the distal portion 30 about the longitudinal axis 22 with the aid of an external imaging apparatus.
- the markers 116 may be formed from a radiopaque material visible using a fluoroscopic imaging system.
- a pair of fluoroscopic markers 116 a , 116 b are provided on the periphery 20 that uniquely indicate the rotational orientation of the peripheral opening 34 , such as the “bulls-eye” arrangement shown. Further discussion of such markers may be found in U.S. Ser. No.
- transvascular catheter system 10 may include both internal and external markers 16 , 116 on the catheter 12 , preferably only one marker or orientation element is necessary to effectively orient the puncturing element 14 .
- the tip member 44 attached to the struts 38 , 40 has an annular shape formed from a substantially flexible material to further define the IVUS lumen 32 .
- the tip member 44 is preferably tapered to facilitate insertion into and direction along the lumen of a blood vessel, and is substantially coaxial with the IVUS lumen 32 in the catheter 12 to facilitate the introduction of a guide wire or other instrument axially therethrough.
- the handle 50 is preferably a substantially rigid member including the IVUS entry port 52 , the needle entry port 54 , and a needle lumen flush port 58 in communication with the needle lumen 36 .
- the ports 52 , 54 and 58 may include one or more seals to prevent backflow, as will be appreciated by those skilled in the art.
- a control and/or locking mechanism 58 is located on the handle 50 that includes a needle thumb slide 68 and an adjustable needle stop 70 that cooperatively slide along a graduated region 60 of the handle 50 .
- the needle thumb slide 68 may be directed axially along the graduated region 60 to deploy the puncturing element 14 , as described more particularly below.
- the adjustable needle stop 70 is slidable on the handle 50 and is securable at a plurality of positions on the graduated region 60 of the handle 50 .
- the adjustable needle stop 70 may be locked at a first position on the graduated region 60 , loosened, directed axially to a second position on the graduated region 60 , and locked at the second position to limit the movement of the needle thumb slide 68 , and consequently the depth of penetration of the puncturing element 14 .
- the puncturing element 14 is preferably a needle assembly 62 including an elongate tubular body 63 having a puncturing distal tip 64 and a proximal safety clip 66 .
- the needle assembly 62 and/or the distal tip 64 are preferably formed from a shape memory alloy, such as Nitinol, that is precurved to enhance transverse deployment of the distal tip 64 .
- the distal tip 64 may be inserted into the needle entry port 54 and directed distally through the needle lumen 36 until the safety clip 66 abuts the needle thumb slide 68 on the handle 50 .
- the needle thumb slide 68 then may be secured to the needle assembly 62 , for example with ball detents that extend radially into the needle lumen 36 from the needle thumb slide 68 (not shown), for controlling axial movement of the needle assembly 62 .
- the needle assembly 62 includes a drug delivery lumen 72 extending from the safety clip 66 to an outlet 74 in the distal tip 64 .
- the outlet 74 may be a single opening for directing fluid distally beyond the distal tip 64 , or may include a plurality of openings having a predetermined outlet pattern.
- the distal tip 64 may include a closed tip 73 and one or more side openings 75 for directing the drug substantially laterally from the distal tip 64 into the tissue region.
- the distal tip 64 also has a sufficiently small gauge diameter such that the passage 123 between the vessel 102 and the tissue region 100 is substantially self-sealing to prevent escape of the drug from the tissue region back into the vessel 102 upon removal of the distal tip 64 .
- the needle assembly 62 may include dual lumens 78 a , 78 b that extend between a multiple line manifold on the proximal end (not shown) to two adjacent outlet ports 74 a , 74 b .
- a dual lumen needle assembly may be useful for delivering a radiographic agent or other compound through one lumen in combination with a drug in the other. More preferably, the dual lumens may allow two drugs to be independently injected, which may then react with one another once within the selected tissue region, as will be appreciated by those skilled in the art.
- the distal tip 64 may also be at least partially conductive, for example, by providing an electrode thereon (not shown) or by forming the distal tip 64 from a conductive material such as platinum, gold, or possibly stainless steel.
- a conductor such as an electrically conductive wire (not shown), may extend proximally from the distal tip 64 through the tubular member 63 to the safety clip 66 of the needle assembly 62 .
- a source of electric current may then be coupled to the conductor to enhance absorption of the drug by the tissue region.
- the distal tip 64 may facilitate electroporation, i.e. energizing the distal tip 64 may create microscopic pores in the surrounding tissue to enhance penetration of the drug therein.
- an intravascular ultrasound (“IVUS”) device 80 is provided.
- a conventional ultrasound transducer 82 is provided on the distal end 84 of the IVUS device 80 that is oriented towards an imaging plane substantially normal to the longitudinal axis 22 .
- the ultrasound transducer 82 or a reflector on the IVUS device 80 may be rotatable about the longitudinal axis 22 to provide ultrasonic image slices along the imaging plane in a conventional manner, or alternatively, a phased array of ultrasound transducers may be provided to allow imaging along a plane substantially normal to the longitudinal axis 22 , as will be appreciated by those skilled in the art.
- the transvascular catheter system 10 may be used to deliver a drug to a selected remote tissue region within a patient's body in the following manner.
- the catheter 12 may be introduced percutaneously into a blood vessel in a conventional manner, while the needle assembly 62 remains retracted within the needle lumen 36 , i.e. while the distal tip 64 is positioned within the needle lumen 36 proximal to the deflecting element 48 .
- the distal portion 30 of the catheter 12 may be directed endovascularly to a vessel location adjacent to a remote tissue region for which treatment is selected.
- the catheter 12 may be directed through the patient's venous system to a coronary vein 102 adjacent to a coronary artery 100 selected for treatment.
- the catheter 12 may be directed to a location within a coronary vein 102 adjacent to a selected ischemic region 220 of the myocardium 112 for delivering a drug therein.
- the catheter 12 may be oriented towards the selected tissue region using ultrasound imaging with the IVUS device 80 , external imaging, such as fluoroscopy, or both.
- the IVUS device 80 is shown being used to orient the system 10 for delivering a drug into a coronary artery 100 from a nearby coronary vein 102 .
- the distal portion 30 of the catheter 12 is directed endovascularly through the venous system, for example over a guidewire 86 , until it is within the coronary vein 102 and adjacent the selected coronary artery 100 .
- the ultrasound transducer 82 may then be operated to provide a cross-sectional image of the region, shown illustratively in FIG. 3A .
- the resulting image aids the user in orienting the catheter 12 with respect to the tissue surrounding the vein 102 , for example to identify landmarks such as the pericardium 109 , the endocardium 111 , the epicardium 113 , and/or the heart chamber 110 .
- the struts 38 , 40 are opaque to the ultrasound transducer 82 (not shown in FIG. 3A ), they produce artifacts 104 , 106 on the image, thereby providing the orientation of the distal portion 30 of the catheter 12 with respect to the surrounding myocardium 112 and the selected coronary artery 100 .
- the catheter 12 may be torqued about its longitudinal axis 22 to rotate the distal portion 30 , as observed by the artifacts 104 , 106 , until it can be seen that the distal tip 64 of the needle assembly 62 , i.e. the artifact 104 , is directed towards the selected the coronary artery 100 .
- the resulting ultrasound image may also be scalable, allowing the user to measure the distance to the selected target region from the catheter 12 , and thereby determine the precise distance that the distal tip 64 of the needle assembly 62 will need to be directed to reach the selected tissue region.
- the needle stop 70 on the handle 50 may then be loosened, adjusted along the graduated region 60 , and then locked at a predetermined position corresponding to the precise distance.
- the distal tip 64 of the needle assembly 62 may be deployed from the catheter 12 to penetrate the wall 103 of the vessel location 102 and enter the selected tissue region 100 .
- the needle thumb slide 68 is directed distally by the user, thereby directing the distal tip 64 against the deflecting element 48 and causing the distal tip 64 to deflect radially outward as it exits the peripheral opening 34 .
- the needle thumb slide 68 may be quickly advanced distally until it abuts the needle stop 70 , thereby puncturing the wall 103 of the vein 102 and delivering the distal tip 64 the precise distance, i.e. precisely within the selected target region of the artery 100 .
- a drug may then be introduced into the selected tissue region, for example by connecting a source of the drug such as a syringe (not shown), to the proximal end (not shown) of the needle assembly 62 , and injecting the drug through the lumen 72 and the outlet 74 in the distal tip 64 .
- the distal tip 64 may then be withdrawn back into the needle lumen 36 and the catheter 12 withdrawn from the patient in a conventional manner.
- a “mapping” procedure may be used to ensure that the drug will be delivered as desired into the specific tissue region selected for treatment.
- a radiographic agent may be delivered through the outlet 74 in the distal tip 64 .
- the flow of the radiographic agent may be observed with respect to the selected tissue region, for example using fluoroscopy.
- the drug may then be introduced, thereby possibly avoiding misdelivery of what are often quite expensive drugs.
- a radiographic agent and the like may be mixed with the drug to track the flow of the drug within the body, particularly with respect to the selected tissue region.
- FIG. 6 another preferred embodiment of a transvascular catheter system 10 for delivering a drug to a remote tissue region 220 within the myocardium 112 is shown.
- the system 10 of this embodiment includes a drug delivery element, namely a drug delivery catheter 214 , that may be deployed from the distal portion 30 of the catheter 12 , preferably in combination with the puncturing element 14 .
- the puncturing element 14 preferably includes a solid needle or guide wire assembly 162 , without a lumen but otherwise similar to the needle assembly 62 previously described, over which the drug delivery catheter 214 may be deployed.
- the guide wire assembly 162 may include an anchoring tip (not shown) for fixing the distal tip 164 of the guide wire assembly 162 in the tissue region 220 and/or to facilitate introduction of instruments, such as the drug delivery catheter 214 , to the tissue region 220 .
- the drug delivery catheter 214 may include a porous balloon 218 for infusing the drug in a predetermined pattern within the tissue region 220 , and generally includes a plurality of lumens extending between its proximal portion (not shown), and a distal portion 222 .
- the drug delivery catheter 214 preferably has a guide wire lumen 224 such that the drug delivery catheter 214 may be delivered to the tissue region 220 over the guide wire assembly 162 , and also has a drug delivery lumen (not shown) communicating with a portion, e.g. the interior, of the porous balloon 218 .
- the porous balloon 218 includes a porous region, such as a plurality of holes 226 , a permeable membrane and the like, preferably arranged to provide a predetermined flow pattern through the balloon 218 into the tissue region 220 .
- the catheter 12 may be introduced percutaneously into a blood vessel 102 , and oriented with respect to the selected tissue region 220 (see FIG. 3B ).
- the guide wire assembly 162 may then be deployed transvascularly to access the selected tissue region 220 , similar to the process previously described.
- the drug delivery catheter 214 may then be advanced over the guide wire assembly 162 until it enters the tissue region 220 .
- the balloon 218 may then be inflated, expanding it from a collapsed condition around the drug delivery catheter 214 to an enlarged condition contacting the surrounding tissue 220 .
- the balloon 218 may be inflated simply by introducing a drug through the drug delivery lumen, which may then seep through the porous region 226 and pass into the tissue region 220 .
- the catheter 214 may include a separate inflation lumen (not shown) through which an inflation media such as saline may be introduced into a non-porous region within the balloon isolated from the porous region, as will be appreciated by those skilled in the art.
- the drug delivery element may be a flexible, thin, floppy catheter which may be left behind to serve as an “indwelling” transcutaneous access catheter, as described more particularly below.
- the drug delivery catheter 214 and/or the guide wire assembly 162 may include an electrode or other element (not shown) to enhance penetration of the delivered drug into the tissue region.
- an internal heating element (not shown) may be provided within the balloon 218 to heat the fluid therein and/or the surrounding tissue 220 , which may enhance absorption of the drug delivered into the tissue.
- an electrode (not shown) may be provided on or within the balloon 218 which may be coupled to an external electrode (not shown). Direct current may then be applied between the electrodes to ionophoretically direct drugs from the drug delivery catheter 214 deep into the surrounding tissue 220 .
- the distal tip 164 of the guide wire assembly 162 may be formed from an electrically conductive material such as gold or platinum, or may include an electrode on a portion thereof (not shown), which may be coupled to an external source of electric current via a conductor (not shown) extending proximally through the guide wire assembly 162 .
- a transvascular catheter system 10 in accordance with the present invention may be used to deliver a single dose or bolus of a drug directly and precisely into a selected remote tissue region.
- the system may be used for sustained delivery by keeping the distal portion 30 of the catheter 12 and/or the distal tip 64 of the needle assembly 62 within the blood vessel and/or selected tissue region for an extended period of time.
- the needle assembly 62 or infusion catheter 214 may be used to inject a matrix material into a tissue region which may slowly diffuse a drug into the tissue region.
- a stent or similar structure may be delivered into the tissue region, the structure including a drug therein that may be released over time.
- an indwelling catheter may be left behind within the selected tissue region.
- the transvascular catheter system 10 may be introduced into a blood vessel, and the puncturing element 14 , e.g. the needle assembly 62 or the guide wire assembly 162 , may be oriented and deployed within a selected tissue region, such as an interstitial tissue region or another blood vessel.
- a guide wire may be advanced into the tissue region, and possibly anchored in place.
- the transvascular catheter 12 may be withdrawn from the blood vessel, leaving the guide wire, and a thin, floppy catheter (not shown), which may be an infusion catheter similar to that previously described or simply a single delivery port device, may be tracked over the guide wire into the tissue region and left there.
- the guide wire may then be removed, and the proximal end (not shown) of the thin, floppy catheter may be secured to the patient, for example taped or ported (such as using a port assembly such as that described below) depending upon the length of time therapy is desired.
- the distal end of the indwelling catheter may then remain in place within the tissue region, possibly for extended periods of time, to provide access whenever needed.
- the transvascular catheter system 10 may include an implantable port assembly 350 .
- the port assembly 350 includes a body 352 which may be implantable on or beneath the skin of the patient, and one or more seals 354 .
- the body includes a hollow hub 356 the interior of which communicates with the seal 354 which may be attached to the transvascular catheter system 10 , such as the proximal end 24 of the catheter 12 or preferably to an indwelling catheter (not shown).
- the catheter 12 shown in FIG. 1 may be percutaneously introduced into a patient's cardiovascular system, and the distal portion 30 may be advanced into a selected vessel, whereupon the distal tip 64 of the needle assembly 62 (not shown in FIG. 7 ) may be advanced into a selected remote tissue region, similar to the methods previously described.
- the handle 50 (not shown in FIG. 7 ) may then be removed from the proximal end 24 and replaced with the port assembly 350 such that the hub 356 may communicate with the needle lumen 36 , the IVUS lumen 32 , and/or a drug delivery lumen in the indwelling catheter.
- the port assembly 350 may then be stitched or otherwise implanted onto an accessible region of the patient's body (not shown).
- an instrument such as a needle, an infusion device, a sensor and the like (not shown) may be directed through the seal 354 to communicate with the drug delivery element extending to the selected tissue region.
- an instrument such as a needle, an infusion device, a sensor and the like (not shown) may be directed through the seal 354 to communicate with the drug delivery element extending to the selected tissue region.
- compounds such as angiogenic growth factors, for extensive periods of time.
- the implantable system of the present invention facilitates such sustained treatment by allowing the tissue region to be accessed as often as necessary to maintain a desired level of growth factor at the selected tissue region.
- FIG. 8 another preferred embodiment of a transvascular catheter system 10 in accordance with the present invention is shown, which may be used to create a drug reservoir 224 within a selected tissue region 220 itself to provide sustained delivery.
- a catheter 12 similar to that previously described, may be introduced endovascularly into a blood vessel 102 until the distal portion 30 is adjacent the tissue region 220 .
- the distal tip 64 of the needle assembly 62 may be oriented and deployed to puncture the wall 103 of the vessel 102 and enter the tissue region 220 , using methods similar to those described above.
- An ablation device 230 such as a radio frequency (RF) device, a laser device, and the like, may be advanced over the needle assembly 62 into the tissue region 220 .
- One or more electrodes 232 or similar elements on the ablation device 230 may be activated to create a cavity 224 within the tissue region 220 in a manner known to those skilled in the art.
- the ablation device 230 may then be removed, and a drug may be introduced into the cavity 224 to create a drug reservoir in continuous contact with the surrounding tissue 220 , thereby providing sustained delivery as the drug is slowly absorbed by the surrounding tissue 220 .
- a non-porous balloon catheter (not shown) may be advanced over the needle assembly 62 into the tissue region 220 .
- the balloon may be inflated to its enlarged condition to contact and push aside the surrounding tissue 220 , and create a cavity 224 .
- No additional treatment of the tissue 220 may be needed to create the cavity 224 , particularly in ischemic tissue which is substantially non-resilient as compared to healthy tissue and unlikely to expand back to fill the cavity 224 .
- other devices such as cutting, coring or other mechanical instruments, may also be used to remove tissue to create the cavity 224 by being advanced over the needle assembly 62 into the tissue region 220 , as will be appreciated by those skilled in the art.
- a sealant or matrix material such as collagen or a filament structure (e.g. drug-impregnated suture material)
- a sealant or matrix material such as collagen or a filament structure (e.g. drug-impregnated suture material)
- the distal tip 64 may be sufficiently small so as to create a self-sealing passage 223
- advancement of instruments such as the drug delivery catheter 214 of FIG. 6 , may dilate the passage 223 , which may result in the drug leaking through the passage 23 back into the blood vessel 102 from the cavity 224 .
- a sealant, matrix material, or filament may be injected into the cavity 224 itself, or into the passage 223 , for example through a lumen in the drug delivery element 214 or the needle assembly 62 before or while it is being withdrawn from the cavity 224 .
- the transvascular catheter system 10 may include a plurality of needle assemblies 62 , similar to the individual needle assembly described above, to be deployed in a predetermined arrangement along the periphery 20 of the catheter 12 .
- the needle assemblies 62 are arranged axially in a row, aligned with the strut of the “cage” structure orientation element (not shown in FIG. 5A ).
- it may desirable to access an extended remote tissue region, for example extending substantially parallel to a vessel, especially within the myocardium.
- a single device may be delivered into a vessel and oriented.
- the array of needles may be sequentially or simultaneously deployed to inject one or more drugs into the extended tissue region, thereby providing a selected trajectory pattern.
- a catheter having a drug delivery element, an orientation element and possibly an imaging element may be provided similar to those described above.
- the distal portion of the catheter may include an osmotic surface on a portion of the circumference or periphery and extending axially along the distal portion (not shown).
- the osmotic surface preferably has a predetermined relationship to the orientation element, such that the osmotic surface may be directed circumferentially towards a selected tissue region, e.g. a specific portion of a vessel wall and/or a tissue region beyond the vessel wall.
- the catheter may include a balloon or other expandable structure which may push the osmotic surface into direct contact with the vessel wall to further facilitate delivery.
- a drug possibly embedded within the osmotic surface itself or in a chamber beneath the osmotic surface, may then be delivered with or without ionophoresis or other assisted delivery mechanism.
- the systems and methods of the present invention may also be used to provide access downstream of an occluded or stenotic region of a blood vessel, for example to treat a coronary artery or ischemic tissue region of the myocardium downstream of an occluded coronary artery.
- a location downstream of an occluded section 404 of a coronary artery 400 may be selected for treatment, and a transvascular catheter device (not shown) percutaneously introduced into the venous system and advanced until it reaches a coronary vein 402 adjacent the selected artery 400 .
- An interstitial passage 406 may be created between the coronary vein 402 and the coronary artery 400 , and a guide wire 410 may be advanced through the interstitial passage 406 into the coronary artery 400 .
- the guide wire 410 may be substantially anchored within the coronary artery 400 , for example by embedding the distal end of the guide wire 410 into the wall of the coronary artery 400 (not shown). Further details on the systems and methods for performing interstitial or transvascular procedures between the venous and arterial systems may be found in co-pending application Ser. Nos. 08/730,327 and 08/730,496, both filed Oct. 11, 1996, the disclosures of which are expressly incorporated herein by reference.
- a transvascular catheter system 10 may then be advanced over the guide wire 410 along the venous system, through the interstitial passage 406 and into the coronary artery 400 downstream of the occluded region 404 , thus without disturbing plaque or otherwise affecting flow through the arterial system. It will be appreciated by those skilled in the art that the transvascular catheter system 10 used to deliver the drug may also be used to create the interstitial passage 406 .
- the artery 400 itself may then be treated, for example, using the needle assembly 62 of FIG. 1 or the drug delivery catheter 214 of FIG. 6 .
- a drug may be delivered into the lumen 408 of the artery 400 , into the vessel wall 412 and/or the surrounding tissue 414 .
- one or more drug reservoirs may be created within the surrounding tissue 414 , most preferably within myocardial tissue adjacent to a coronary artery, for receiving a drug that may be absorbed by the surrounding tissue 414 over an extended period of time.
- the catheter 12 may include one or more stabilizing balloons (not shown) on the distal portion 30 , for example proximal to the peripheral opening 34 .
- An inflation lumen may be provided in the catheter 12 to allow an inflation medium, e.g. saline, to be introduced into the stabilizing balloon to substantially anchor the catheter 12 at a desired location within the blood vessel, i.e. to prevent the catheter 12 from moving axially within the vessel once the distal portion 30 is adjacent to a remote tissue region selected for treatment.
- an inflation medium e.g. saline
- one or more of the elements of the system may include a sensor for measuring information relevant to the treatment of the selected tissue region.
- a pressure sensor may be provided on the catheter 12 , the needle assembly 62 and/or the drug delivery element.
- a lumen may extend proximally through the respective element, thereby allowing the user to continuously monitor pressure at or near the delivery site.
- the drug delivery element may also include a flow measurement sensor, allowing the amount of drug being delivered to the selected tissue region to be precisely measured.
- thermocouple or other temperature sensor may be provided on systems including ionophoresis electrodes or ablation devices to monitor the amount of heating being experienced by tissue during a procedure.
- the needle assembly 62 or other component may include a feedback element 79 for measuring a physiological condition.
- an EKG lead may be included on the distal tip or otherwise delivered within the selected tissue region, thereby allowing electrical events within the heart to be monitored during drug delivery.
- a drug may be delivered into a tissue region until a desired condition is met, such as until the tissue becomes non-tachycardic, or until tachycardia is induced.
- An important aspect of the transvascular catheter system of the present invention is the ability to precisely deliver a drug to a selected remote location within a reference frame, preferably including a circumferential or peripheral component and a radial component.
- the orientation element provides the peripheral component because of its predetermined relationship with the periphery of the catheter and the drug delivery element.
- the imaging element preferably provides the radial component by detecting the relationship of the orientation element to the selected remote location (e.g. the distance between them), or landmarks in a known relationship with the selected remote location. Once the location of the selected remote location is known within the reference frame, the drug delivery element may be directed towards the selected remote location for precise delivery of a drug.
- FIGS. 9A-9D and 10 show a preferred embodiment of an implantable reservoir device 400 that may be used to provide sustained delivery of a drug to tissue surrounding a blood vessel, preferably within a coronary vein 102 adjacent to ischemic myocardial tissue 112 .
- the reservoir device 400 includes a substantially cylindrical frame 402 adapted to expand between a collapsed condition for insertion into a blood vessel and an enlarged condition for engaging a wall 103 of the blood vessel 102 , and defining a longitudinal axis 404 .
- the frame 402 is sufficiently flexible to expand between the collapsed and enlarged conditions during use without substantial risk of failing or fatiguing, yet sufficiently rigid to anchor the reservoir device 400 within the blood vessel 102 .
- the frame 402 is resiliently biased towards the enlarged condition to prevent substantial movement of the frame 402 axially within the blood vessel 102 .
- the frame 402 may be formed from a woven mesh of wire of, for example, a shape memory alloy such as Nitinol, stainless steel, platinum, polymers or other plastics and the like.
- the frame 402 may be woven into a criss-cross structure, a sinusoidal structure, or may include a pair of expandable rings connected by spacers to retain the rings apart axially.
- a flexible membrane 408 is attached to the frame 402 , preferably to the exterior of frame 402 such that the membrane 408 may enhance a fluid-tight seal when pressed against the wall 103 of the vessel 102 by the frame 402 after deployment.
- the membrane 408 includes a periphery 412 and end panels 414 , 416 , which together define a sealed reservoir 410 within the membrane 408 and the frame 402 .
- the membrane 408 should be substantially flexible, and may be elastic if tension over the frame is preferred, or plastic if a small initial diameter is preferred.
- Preferred materials include dacron and PTFE, which may also be silicone dipped.
- the membrane 408 includes a porous region 418 , which is preferably disposed along at least a portion of the periphery 412 of the membrane 408 .
- the porous region 418 may be a permeable or semi-permeable material bonded or otherwise attached to non-permeable segment(s) of the membrane 408 .
- the entire membrane 408 may be formed from a non-permeable material with holes formed through discrete areas to define the porous region 418 .
- At least one of the end panels 416 may be recrossable, i.e., may be penetrable by a needle 432 , but automatically resealable, to facilitate in situ filling or refilling of the reservoir 410 , preferably having a concave shape to facilitate penetration by the needle 432 .
- the reservoir 410 may be prefilled with a drug, possibly together with an anti-coagulant or other compound, prior to delivery into the blood vessel 422 .
- the drug and the pore size of the porous region 418 may have a predetermined relationship such that the drug permeates or flows through the porous region 418 into the surrounding tissue at a predetermined flow rate.
- the reservoir device 400 is percutaneously delivered into a blood vessel in its collapsed condition using a delivery device, for example within a lumen of a delivery catheter or sheath adapted to receive the reservoir device 400 .
- the frame 402 may include a control hub on one end (not shown), which may be gripped and compressed radially inward to collapse the frame 402 .
- the reservoir device 400 is deployed from the delivery device, for example using a plunger within the delivery catheter lumen (not shown).
- the frame 402 automatically expands to its enlarged condition, thereby substantially anchoring the device 400 in position within the vessel 102 .
- the frame 402 may also create a substantially fluid-tight seal with the wall 103 of the vessel 102 , to prevent substantial leakage of fluid delivered through the periphery 412 downstream within the vessel 102 .
- a drug delivery element may be introduced into the vessel 102 to fill the reservoir 410 .
- an injection device 430 including a sheath 434 covering a hollow needle 432 may be delivered endovascularly, or the delivery catheter used to deliver the reservoir device 400 may include an additional drug delivery needle lumen.
- the needle 432 may be deployed to penetrate the recrossable end region 416 , whereupon the reservoir 410 may be filled by introducing the drug through the needle 432 .
- the reservoir device 400 may remain in the vessel 102 for a substantial period of time, possibly hours or days, allowing the drug to slowly absorb into the wall of the vessel and preferably the surrounding tissue.
- the drug delivery element e.g. the sheath-covered hollow needle
- the reservoir device 400 may include an electrode (not shown) to enable ionophoresis or other enhanced delivery.
- a catheter including a conductor may be introduced into the vessel 102 , coupled to the electrode, and then energized by an external source of electric current (not shown) for this purpose.
- the reservoir device 400 may provide an endovascular “pump” for time-release delivery of a drug.
- the reservoir device 400 includes a septum panel 420 dividing the reservoir 410 into first and second regions 410 a , 410 b .
- the first end panel 414 of the membrane 408 is an osmotic membrane and the first reservoir 410 a is filled with a fluid absorbing compound.
- the porous region 418 of the membrane 408 communicates only with the second reservoir 410 b , which is filled with a drug in situ or before deployment.
- the compound in the first reservoir 410 a begins to slowly draw fluid osmotically from within the lumen of the vessel.
- the septum panel 420 is forced to expand towards the second end panel 416 , thereby applying a force within the second reservoir 410 b , which “pumps” or otherwise encourages the drug to flow out the porous region 418 , and preferably into the wall of the vessel.
- a cylindrical septum may be provided, creating an internal first reservoir and an annular second reservoir surrounding the first reservoir (not shown).
- the area of one or both end panels in contact with the internal first reservoir may be provided from an osmotic material, thereby creating a similar flow out of a porous region on the periphery of the membrane in communication with the annular second reservoir.
- reservoir device 400 may also be provided that may be deployed and substantially anchored adjacent a selected tissue region.
- a drug reservoir device similar to those described may be delivered directly into tissue, for example, using one of the transvascular catheter systems previously described, as will be appreciated by those skilled in the art.
- an implantable system including a pair of endovascular blocker devices 500 may be used to create a drug reservoir 508 a within a blood vessel 102 itself, i.e. between the blockers 500 and the wall 103 a of the vessel 102 between them.
- the blockers 500 preferably include an expandable frame 502 and a flexible membrane 504 attached to the frame 502 , similar to that described above.
- the membrane 504 is preferably non-permeable, although alternatively a permeable periphery (not shown) may be provided to increase the surface area through which the drug may be directed towards the vessel wall 103 .
- the first blocker 500 a is deployed within a vessel 102 adjacent a selected tissue region, such as a stenotic region 105 within an artery 102 , using a method similar to that described above for the reservoir device 400 .
- a drug is introduced into the vessel lumen 108 a
- a second blocker 500 b is deployed within the vessel 102 , thereby encapsulating the drug in the lumen 108 a between the blockers 500 a , 500 b.
- the drug may be delivered into the reservoir 508 a after both blockers 500 are deployed and in secured within the vessel 102 .
- the second blocker 500 b may include a recrossable end panel 514 on one end, and an open interior that may communicate directly with the reservoir 108 a .
- an injection needle device (not shown) may be used to inject the drug through the recrossable end panel 514 and into the reservoir 508 a in situ.
- an implantable reservoir system in accordance with the present invention may be used to create a reservoir within a coronary vein without interfering substantially with the flow of return blood from the myocardium. A drug within the reservoir may then be absorbed by the vessel wall and surrounding tissue to treat selected tissue regions adjacent the reservoir site.
- the reservoir devices in accordance with the present invention may be deployed in one or more regions within the coronary venous system without substantial risk of adversely affecting coronary blood flow or damaging the tissues of the coronary system.
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Abstract
Description
- This application is a continuation of U.S. patent application Ser. No. 14/032,351 filed Sep. 20, 2013, which is a continuation of U.S. patent application Ser. No. 13/338,106 filed Dec. 27, 2011 and now issued as U.S. Pat. No. 8,540,694 which is a continuation of U.S. patent application Ser. No. 12/715,252 filed Mar. 1, 2010 and issued on Dec. 27, 2011 as U.S. Pat. No. 8,083,708, which is a continuation of U.S. patent application Ser. No. 11/646,644 filed on Aug. 15, 2006 and issued on Mar. 2, 2010, as U.S. Pat. No. 7,670,868, which is a continuation of U.S. patent application Ser. No. 10/738,226 filed Dec. 16, 2003 and issued on Aug. 22, 2006, as U.S. Pat. No. 7,094,230, which is a continuation of U.S. patent application Ser. No. 09/826,049 filed Apr. 3, 2001 and issued as U.S. Pat. No. 6,685,648, which is a Division of U.S. patent application Ser. No. 09/048,147 filed on Mar. 25, 1998 and issued as U.S. Pat. No. 6,283,951. This application does not claim priority prior to Mar. 25, 1998.
- The present invention relates generally to systems and methods for delivering substances into a body, more particularly to systems and methods that use the cardiovascular system as a conduit to deliver drugs, such as therapeutic drugs, genes, growth factors and the like, directly to selected tissue regions within the body, and most particularly to systems and methods that deliver drugs from the venous system transvascularly to selected remote tissue regions.
- It is often desirable to deliver drugs into a patient's body to treat medical conditions. In particular, a variety of drug therapies are available for treating the coronary system, either alone or in combination with more invasive procedures. Such therapies may include delivering substances, such as nitroglycerin, epinepharin, or lydocaine, endocardially or into the pericardial space to treat the coronary system. In addition, heparin, hirudin, ReoPro™ or other anti-thrombotic compounds may be infused into blood vessels associated with the coronary system, such as occluded coronary arteries, or elsewhere in the cardiovascular system. More recently, gene therapy, e.g. introducing genetic material, and growth factor therapy, e.g. introducing proteins, cells or vectors including angiogenic growth factors, have been demonstrated to provide potential benefits in treating ischemic heart tissue and other regions of the coronary system, for example, by stimulating growth of neovascular conduits, which may evolve into new blood vessels.
- In current medical therapy, one method of delivering such drugs involves percutaneously introducing an infusion catheter into the patient's cardiovascular system. A distal portion of the catheter is directed to a desired endovascular location, for example into a coronary artery, and a drug is infused into the artery at a location reachable intraluminally. The catheter may include a lumen extending between its proximal and distal ends, the distal end having one or more outlet ports. A source of the drug, such as a syringe, may be connected to the proximal end and the drug delivered through the lumen and outlet port(s) into the desired location.
- For example, a “bolus,” i.e. a relatively large single dose of a drug, may be delivered using an infusion catheter into an artery, which may be absorbed by the arterial wall, the surrounding tissue, and/or may be carried by blood flow to regions further downstream from the delivery location. Alternatively, the drug may be infused continuously or intermittently into the artery for an extended period of time.
- The infusion catheter often includes a porous perfusion balloon on its distal end, the interior of which communicates with the outlet port(s) and lumen in the catheter. Pores or holes in the balloon may be arranged to direct the drug from the balloon towards the arterial wall to improve penetration into the arterial wall and attempt to localize delivery. In addition, the infusion catheter may be provided with an electrode and/or a heating element on or in the balloon to cause electroporation or to heat the surrounding tissue to further improve localized delivery.
- Some devices try to enhance localized delivery of drugs using ionophoresis. A first electrode may be provided within a perfusion balloon, and a second electrode provided on an external region of the patient's body near the artery. When direct current is applied between the electrodes, a drug carried by an electrically charged compound may be directed along the path of current flow from the internal electrode towards the external electrode in an attempt to improve penetration of the drug into the arterial wall and surrounding tissue.
- As an alternative to perfusion balloons and/or infusion catheters, a drug may be embedded in or deposited on a catheter, e.g. in the catheter wall, the wall of a non-porous balloon on the catheter, and/or a coating on the catheter. After the distal end is directed to a desired location, the drug may be delivered into an artery, for example, by ionophoresis similar to that described above or by simply allowing the drug to dissolve within the artery.
- In an alternative to delivering a bolus of drugs, it is often desirable to provide sustained delivery of a drug within the cardiovascular system. For example, a pair of occlusion balloons disposed along the length of a catheter may be provided on an infusion catheter that may be directed endovascularly to a desired location within an artery. The balloons may be inflated to isolate a section of the artery between them, and a drug may be delivered into the isolated section in an attempt to provide sustained delivery to the isolated section. The balloons are then deflated, and the catheter removed from the body.
- Drug delivery devices may also be implanted within an artery to provide sustained delivery. For example, U.S. Pat. No. 5,628,784 issued to Strecker discloses an expandable annular sleeve that may be deployed within an artery. A small quantity of drugs may be introduced between the sleeve wall and the surrounding arterial wall to directly contact the arterial wall, where they may be absorbed over an extended period of time. PCT Publication No. WO 95/01138 discloses a porous ceramic sleeve that may be implanted directly in tissue, such as in bone marrow or a surgically created pouch. The sleeve includes drugs within a cell culture or matrix in the sleeve, which may, for example, be dispersed in the pores of the sleeve or be provided in a cylindrical insert.
- In addition, a number of extravascular methods have also been suggested. For example, drugs may be injected directly into a desired tissue region, typically by accessing the region through a chest incision. Alternatively, a polymer gel or drug-soaked sponge may be attached to the outside of a vessel or to a portion of the endocardium to be absorbed by the contacted region. In addition, the pericardial space may have substances injected directly into it, for example by accessing the pericardial sac through a chest incision. Such methods may provide either single dose or sustained delivery of drugs to the heart.
- One of the problems often associated with existing methods is dilution or “wash-out” of the drug during delivery. Dilution may substantially reduce the effectiveness of a therapy by preventing sufficient quantities of the drug from reaching a desired region. For example, during endovascular delivery using an infusion catheter, the drug may be diluted as it travels through the arterial wall or may be carried downstream through the artery to other regions within the coronary system and/or elsewhere in the body.
- The volume of drug may be increased to offset dilution concerns, but this may exacerbate concerns about undesired dissemination of the drug. For example, certain therapeutic drugs, genetic material and growth factors may have undesired global side effects. Releasing a drug into the blood stream may allow it to be carried throughout the coronary system or elsewhere in the body where it may have significant adverse effects. Similar adverse effects may result from pericardial delivery, in which a drug may be absorbed throughout the coronary system, rather than only in a desired local region.
- Further, many conventional methods are unable to provide effective sustained delivery, which may be important to the success of certain treatments, such as gene or growth factor therapy, where it may be desirable to maintain a drug in a desired region for hours, days or even longer. Occlusion systems, such as the dual occlusion balloon catheter, or the implantable sleeves described above, may be able to isolate a region of an artery for some sustained treatments.
- Such occlusion devices, however, may introduce additional risks associated with obstructing flow within the coronary system for extended periods of time. In particular, if the arterial system is occluded for more than short periods of time during treatment, substantial damage may occur, for example, ischemia and possibly infarction of tissue downstream from the occluded region.
- Conventional endovascular systems may also be inadequate to access certain tissues in need of treatment. For example, infusion catheters may be unable to pass through an occluded region of an artery to treat ischemic tissue downstream of the region. Further, it may be hazardous to direct an endovascular device through a stenotic region because of the risk of releasing embolic material from the arterial wall, which may travel downstream and become embedded in other vessels or even travel to vital organs, such as the brain, where they may cause substantial damage or even death.
- More invasive methods, such as direct injection of drugs, may provide access to otherwise unattainable regions. Such methods, however, typically involve open-chest or other invasive surgical procedures, and the costs and risks associated with them.
- Accordingly, there is a need for improved systems and methods of delivering drugs to desired locations within the body with greater precision, reduce global side-effects, and/or that substantially reduce the problems of the previous systems and methods.
- The present invention is directed to systems and methods for delivering a drug to a tissue region within a patient's body, and in particular to systems and methods that use the venous system as a conduit to deliver a drug directly to a remote tissue region, or to facilitate a catheter-based intervention. “Drug” as defined herein includes any therapeutic drugs, genetic materials, growth factors, cells, e.g. myocites, vectors carrying growth factors, and similar therapeutic agents or substances that may be delivered within a patient's body for any therapeutic, diagnostic or other procedure. In one aspect of the present invention, a transvascular catheter system is provided that generally includes a catheter, a drug delivery element, an orientation element, and possibly a puncturing element and/or an imaging element. The catheter has a proximal portion and a distal portion adapted for insertion into a blood vessel, and defines a periphery and a longitudinal axis. The puncturing element is deployable from the distal portion in a predetermined relationship with the circumference or periphery of the catheter, and includes a distal tip adapted to penetrate a wall of a blood vessel to access a tissue region beyond the wall of the blood vessel. The drug delivery element is provided on the distal portion for delivering a drug to the tissue region, and an orientation element is also provided on the distal portion in a predetermined relationship with the periphery of the catheter and the puncturing element.
- Preferably, the catheter has a peripheral opening at a predetermined location on the periphery of the distal portion through which the puncturing element may be deployed, and a needle lumen communicating with the peripheral opening for receiving the puncturing element therethrough. The needle lumen includes a deflecting element adapted to direct the distal tip substantially transversely with respect to the longitudinal axis when the puncturing element is deployed.
- The system may include an imaging element adjacent the orientation element for detecting the location of the orientation element with respect to the tissue region. For example, the imaging element may be an ultrasound transducer which may be received in a lumen extending between the proximal and distal portions of the catheter.
- In a first preferred embodiment, the puncturing element is a needle and the drug delivery element is a lumen in the needle. The needle may include an array of outlet ports for providing a predetermined flow pattern of fluid into the tissue region accessed by the needle. In addition, at least a portion of the needle may be a conductive material electrically coupled to a proximal end of the puncturing element for coupling the needle to a source of electric current. Alternatively, the puncturing element may be a plurality of needles deployable from predetermined locations on the distal portion to provide a selected trajectory pattern into the tissue region.
- In a second preferred embodiment, the puncturing element includes a guide wire, and the drug delivery element is deployable over the guide wire. For example, the drug delivery element may be an infusion catheter, possibly including a perfusion balloon. Alternatively, the drug delivery element may include an indwelling catheter which is delivered over the guide wire, either before or after removal of the transvascular catheter. The drug delivery element may include a first electrode thereon adapted to be electrically coupled to a second electrode. When direct current is directed between the first and second electrodes, fluid from the drug delivery element may be ionophoretically directed from the drug delivery element towards the second electrode. Alternatively, the drug delivery element may be an osmotic surface on the transvascular catheter, the infusion catheter or the indwelling catheter.
- To assist in orienting the system during use, the orientation element preferably has an asymmetric configuration aligned with the puncturing element, for example with the peripheral opening through which the puncturing element may be deployed. In a first preferred embodiment, the orientation element is a “cage” structure that includes a plurality of struts extending axially along the distal portion. Preferably, a first strut is provided at a location in direct axial alignment with the peripheral opening, and a pair of struts are provided opposite the first strut to “point” towards the peripheral opening. Alternatively, the orientation element may include a marker that may be imaged using an external imaging system, and preferably a pair of markers disposed opposite one another on the periphery, either instead of or preferably in addition to the “cage” structure.
- A transvascular catheter system in accordance with the present invention may be used to deliver a drug to a tissue region within a patient's body, such as into the myocardium or a coronary artery from the coronary venous system, in a method which may proceed as follows. The distal portion of the catheter may be percutaneously introducing into a blood vessel, and directed endovascularly to a vessel location adjacent to the tissue region selected for treatment. The puncturing element may be oriented towards the selected tissue region, and deployed to access the tissue region. A drug may then be delivered with the drug delivery element to the tissue region.
- Preferably, when the puncturing element is being oriented, the orientation element is imaged, for example with an imaging element adjacent the orientation element. The imaging element is preferably operated to obtain an image of the orientation element in relation to the surrounding tissue, thereby identifying the orientation of the puncturing element because of the predetermined relationship between the orientation element and the puncturing element. Preferably, the imaging element is an ultrasound transducer within the catheter that may be used to obtain image slices along a plane substantially normal to the longitudinal axis of the catheter, the images preferably including the orientation element, the selected tissue region and/or other landmarks within the vessel or the surrounding tissue.
- Where the puncturing element is a drug delivery needle, the needle may be deployed, penetrating a wall of the blood vessel and entering the tissue region, and the drug may be delivered through a lumen in the needle. Alternatively, a drug delivery element may be deployed in combination with the puncturing element. For example, an infusion catheter may be advanced over the puncturing element to the tissue region, and the drug infused therethrough, or through a porous balloon on the infusion catheter which may be inflated within the tissue region.
- Prior to delivering the drug, a “mapping” procedure may be used to ensure that the drug will be delivered as desired into the specific tissue region selected for treatment. For example, a radiographic agent may be delivered using the drug delivery element to observe the flow thereof with respect to the selected tissue region. Once it has been confirmed that the radiographic agent flows as desired into the selected tissue region, the drug may then be introduced, thereby possibly avoiding misdelivery of what are often quite expensive drugs. Alternatively, a radiographic agent and the like may be mixed with the drug to track the flow of the drug within the body, particularly with respect to the selected tissue region.
- In another preferred method, the transvascular catheter system may be used to create a drug reservoir directly in a selected tissue region. For example, a tissue ablation device may be provided that is deployable in combination with the puncturing element for creating a cavity in an extravascular tissue region. The ablation device may be advanced over the puncturing element into the tissue region, and an ablation element thereon activated to create a cavity or drug reservoir within the tissue region. A drug may then be introduced into the drug reservoir, which may be sealed from the vessel, for example by introducing a sealant or matrix into the drug reservoir. Alternatively, the drug reservoir may be formed by removing a portion of the tissue region, for example with a cutting instrument or similar mechanical device.
- In a further alternative, the transvascular system may be used to facilitate an indwelling catheter-based intervention. The catheter may be introduced into a vessel, and then the puncturing element may be oriented and deployed into a tissue region, such as interstitial tissue or another blood vessel. A guide wire may be advanced into the tissue region, and the transvascular catheter may then be removed, leaving the guide wire in place, possibly anchored to the tissue region. A thin, floppy catheter may be tracked over the guide wire into the tissue region, and left in place within the tissue region, and the wire may be removed. The indwelling catheter may be taped, ported or otherwise secured to the patient depending upon the length of time therapy is desired. The tissue region may then be accessed via the indwelling catheter to deliver a drug to the tissue region as often as desired.
- In another aspect of the present invention, an implantable drug reservoir system may be used to provide sustained delivery of a drug within the cardiovascular system of a patient. Generally, the system includes a reservoir device having an expandable frame and a flexible membrane thereon. The frame is adapted to expand between a collapsed condition for insertion into a blood vessel and an enlarged condition for engaging a wall of the blood vessel. The frame is preferably biased towards the enlarged condition, and also preferably defines a longitudinal axis and a periphery.
- The flexible membrane is attached to the frame to define a reservoir therein, and includes a porous region, such as a semi-permeable material, that is preferably disposed along the periphery of the frame. A drug, possibly together with an anti-coagulant, is provided within the reservoir that is adapted to pass through the porous region of the membrane. An end region of the membrane may be penetrable, for example by a needle, to facilitate in situ filling of the reservoir.
- In an alternative embodiment of the implantable drug reservoir system, a reservoir device similar to that described above may be provided with a septum dividing the reservoir within the membrane into first and second reservoir regions. The membrane preferably includes an osmotic region communicating with the first reservoir region, and the porous region of the membrane preferably communicates with the second reservoir region.
- During use, the reservoir device may be introduced along a blood vessel to a location adjacent a selected tissue region, for example within a coronary vein adjacent to an occluded artery or ischemic myocardial tissue. The reservoir device may be deployed and expanded, preferably automatically, to its enlarged condition to anchor the reservoir device within the blood vessel. A drug may be prefilled within the reservoir or an injection device may be advanced to penetrate the membrane of the reservoir device and fill the reservoir in situ with the drug.
- The drug may then permeate, seep, or otherwise pass through the porous region, preferably directly into the wall of the vessel and the surrounding tissue region. If desired, the reservoir may be refilled in situ using an injection device as the drug is dispersed or otherwise absorbed by the tissue. Similarly, a reservoir device having a septum panel may deliver the drug in the second reservoir region to the tissue region as the first reservoir region osmotically fills, thereby slowly forcing or “pumping” the drug through the porous region.
- In another preferred embodiment of an implantable drug reservoir system, a pair of expandable devices, similar to the reservoir devices may be used. The expandable devices, or endovascular “blockers,” include an expandable frame, and a non-porous membrane covering at least one end of the frame, and preferably extending along at least a portion of the periphery.
- The first blocker is advanced in a collapsed condition along the blood vessel to a location adjacent the selected tissue region. The first blocker is then expanded to its enlarged condition, thereby sealing the blood vessel at the location from fluid flow along the blood vessel. The second blocker is then advanced in a collapsed condition along the blood vessel to the location, preferably adjacent the first blocker. The second blocker is then expanded to its enlarged condition, thereby further sealing the blood vessel at the location from fluid flow along the blood vessel. The second blocker is preferably deployed a predetermined distance from the first blocker, thereby defining a substantially sealed drug reservoir within the blood vessel itself between the blockers.
- A drug may be introduced into the blood vessel adjacent the first blocker, either before or after the second blocker is deployed. For example, the second blocker may include an end panel only on the end away from the drug reservoir between the blockers, and an injection device may be advanced to penetrate the end panel. The drug may then be introduced into the second blocker and consequently into the drug reservoir between the blockers. Thus, a section of a blood vessel may be isolated and a drug delivered therein to provide sustained and localized delivery of the drug into the selected tissue region surrounding the vessel.
- Accordingly, a principal object of the present invention is to provide a system and method for precisely delivering a drug to a selected tissue location within the body.
- It is also an object to provide a system and method for providing sustained delivery of a drug to a desired location within the body over an extended period of time.
- It is also an object to provide a system and method for creating a reservoir within the body for receiving a drug to provide sustained delivery to a desired tissue region within the body.
- It is also an object to provide a system and method that use the cardiovascular system as a conduit to deliver a drug to a selected remote tissue region within the body with substantial precision.
- It is also an object to provide a system and method for delivering a drug transvascularly using the venous system as a conduit to access a selected remote tissue region.
- More particularly, it is specifically an object of the present invention to use the coronary venous system to provide access to a highly remote tissue region of the body, e.g. heart tissue.
- Other objects and features of the present invention will become apparent from consideration of the following description taken in conjunction with the accompanying drawings.
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FIG. 1A is a cross-sectional view of a transvascular catheter system in accordance with one aspect of the present invention. -
FIGS. 1B and 1C are side views of a handle on the catheter for the transvascular catheter system ofFIG. 1A . -
FIG. 1D is a cross-sectional view of the distal portion of a catheter for the transvascular catheter system ofFIG. 1A . -
FIG. 1E is a side view of a needle assembly for the transvascular catheter system ofFIG. 1A . -
FIG. 2 is a cross-sectional view of the distal portion of the transvascular catheter system ofFIG. 1 , showing the needle assembly deployed into a remote blood vessel. -
FIG. 3A is a cross-sectional view of the transvascular catheter system and surrounding heart tissue ofFIG. 2 , taken along line 3-3 using an internal imaging element, showing artifacts directing the catheter towards another blood vessel. -
FIG. 3B is a cross-sectional view of the transvascular catheter system and surrounding heart tissue, similar toFIG. 3A , but showing artifacts directing the catheter towards the myocardium of the heart. -
FIG. 4A is a side view detail of a catheter, showing a preferred embodiment of an externally detectable orientation element in accordance with the present invention. -
FIG. 4B is a side view of the catheter ofFIG. 4A , rotated 90 degrees from that shown inFIG. 4A . -
FIG. 5A is a side view of an alternative embodiment of the distal portion, including a plurality of needle assemblies. -
FIG. 5B is a side view of another alternative embodiment of the distal portion, including a dual lumen needle assembly. -
FIG. 5C is another alternative embodiment of the distal portion, including a plurality of outlet ports for providing a predetermined flow pattern. -
FIG. 5D is another alternative embodiment of the distal portion, including a feedback sensor on the needle assembly. -
FIG. 6 is a cross-sectional view of another preferred embodiment of a transvascular catheter system in accordance with the present invention, including a guide wire assembly and a drug delivery catheter deployed into a remote tissue region. -
FIG. 7 is a perspective view of an implantable port assembly for use with a transvascular catheter system in accordance with the present invention. -
FIG. 8 is a cross-sectional view of another preferred embodiment of a transvascular catheter system, including a guide wire assembly and an ablation device. -
FIG. 9A is a side view of an implantable endovascular drug reservoir device in accordance with the present invention. -
FIG. 9B is a side view of another embodiment of an implantable endovascular drug reservoir device, including a recrossable end panel. -
FIGS. 9C and 9D are side views of the implantable endovascular drug reservoir device ofFIG. 9B , showing an injection device for filling the reservoir. -
FIG. 10 is a cross-sectional side view of the drug reservoir device ofFIG. 9A , deployed within a vein adjacent to a stenotic region of an artery. -
FIG. 11 is a side view of an alternative embodiment of an implantable endovascular drug reservoir device in accordance with the present invention. -
FIG. 12 is a side view of another implantable system in accordance with the present invention for creating a drug delivery reservoir, shown within a vein adjacent to a stenotic region of an artery. -
FIG. 13 is a cross-sectional view of a transvascular catheter system in accordance with the present invention delivered downstream of a stenotic region in a blood vessel. - Turning now to the drawings,
FIGS. 1A-1E and 2 show a preferred embodiment of atransvascular catheter system 10 in accordance with the present invention for delivering a drug to a selected remote tissue region within a body from a blood vessel near the tissue region. Thesystem 10 generally includes acatheter 12, a puncturingelement 14, an orientation element (e.g. a “cage”structure 16 described below), and animaging element 18. - The
catheter 12 may be an elongate member having substantially flexible and/or semi-rigid sections, and defining a circumference orperiphery 20 and alongitudinal axis 22 between proximal and distal ends 24, 26. Thecatheter 12 includes a proximal portion 28 having ahandle 50 and adistal portion 30 having a size and shape to facilitate insertion into a blood vessel. - An
IVUS lumen 32 extends through thecatheter 12 from an IVUS entry port 52 in thehandle 50 to atip member 44 on thedistal portion 30 for receiving theimaging element 18. Aneedle lumen 36 also extends from a needle entry port 54 in thehandle 50 to aperipheral opening 34 in thedistal portion 30 for receiving the puncturingelement 14. Theneedle lumen 36 includes a deflecting element or ramp 48 adjacent theperipheral opening 34. - The
catheter 12 may include an extruded dual lumen catheter encapsulated within an outer jacket (not shown), and/or may have a proximal portion that is substantially more rigid than a distal portion. For example, in the preferred embodiment shown inFIG. 1A , thecatheter 12 includes a proximal portion 12 a, an intermediate portion 12 b, and adistal portion 12 c, each having a dual lumen catheter segment and an outer jacket segment. The rigidity or Durometer of the dual lumen catheter and outer jacket segments of the proximal portion 12 a is preferably 63 and 70, while the remaining segments preferably have a Durometer of 40. Additional information on the construction of thecatheter 12, e.g. its material composition, its size and shape, may be found in co-pending application Ser. Nos. 08/730,327 and 08/730,496, both filed on Oct. 11, 1996, and in PCT Application No. PCT/US97/01459, filed on Jan. 31, 1997, the disclosures of which are expressly incorporated herein by reference. - The orientation element is preferably a marker “cage”
structure 16 including a plurality of elongate members or struts 38, 40 on thedistal portion 30 located distally of theperipheral opening 34. Thestruts distal end 26 substantially parallel to thelongitudinal axis 22 to theproximal edge 42 of thetip member 44, thereby further defining theIVUS lumen 36. Thestruts peripheral window 46, which may be covered by a material substantially transparent to theimaging element 18 or may remain open to blood flow. Thestruts imaging element 18, i.e. will produce a reflection or artifact when theimaging element 18 is operated, and/or may be substantially opaque to an external imaging apparatus (not shown). - Preferably, the
struts periphery 20 that has a predetermined relationship with the location of theperipheral opening 34. More preferably, afirst strut 38 is located on theperiphery 20 directly distally from the location of theperipheral opening 34. A pair ofstruts 40 are then positioned opposite thefirst strut 38, thereby defining an isosceles triangle or TRI-POINT™ cross-sectional configuration, with thefirst bar 38 at the top of the triangle. Thus, theorientation element 16 may “point” circumferentially towards the location of theperipheral opening 34 on theperiphery 20, i.e. towards the location from which thepuncturing element 14 may be deployed, as described further below. - In an alternative embodiment shown in
FIGS. 4A and 4B , the orientation element may include one or more externally visible markers 116 placed at one or more predetermined locations on theperiphery 20 of thecatheter 12. The markers 116 define a pattern to facilitate detection of the orientation of thedistal portion 30 about thelongitudinal axis 22 with the aid of an external imaging apparatus. For example, the markers 116 may be formed from a radiopaque material visible using a fluoroscopic imaging system. Preferably, a pair offluoroscopic markers 116 a, 116 b are provided on theperiphery 20 that uniquely indicate the rotational orientation of theperipheral opening 34, such as the “bulls-eye” arrangement shown. Further discussion of such markers may be found in U.S. Ser. No. 08/730,327 filed Oct. 11, 1996, the disclosure of which is expressly incorporated herein by reference. Although thetransvascular catheter system 10 may include both internal andexternal markers 16, 116 on thecatheter 12, preferably only one marker or orientation element is necessary to effectively orient the puncturingelement 14. - Returning to
FIGS. 1A-1E and 2, thetip member 44 attached to thestruts IVUS lumen 32. Thetip member 44 is preferably tapered to facilitate insertion into and direction along the lumen of a blood vessel, and is substantially coaxial with theIVUS lumen 32 in thecatheter 12 to facilitate the introduction of a guide wire or other instrument axially therethrough. - With particular reference to
FIGS. 1A-1C , thehandle 50 is preferably a substantially rigid member including the IVUS entry port 52, the needle entry port 54, and a needle lumenflush port 58 in communication with theneedle lumen 36. Theports 52, 54 and 58 may include one or more seals to prevent backflow, as will be appreciated by those skilled in the art. A control and/orlocking mechanism 58 is located on thehandle 50 that includes aneedle thumb slide 68 and an adjustable needle stop 70 that cooperatively slide along a graduatedregion 60 of thehandle 50. - The
needle thumb slide 68 may be directed axially along the graduatedregion 60 to deploy the puncturingelement 14, as described more particularly below. Theadjustable needle stop 70 is slidable on thehandle 50 and is securable at a plurality of positions on the graduatedregion 60 of thehandle 50. Thus, theadjustable needle stop 70 may be locked at a first position on the graduatedregion 60, loosened, directed axially to a second position on the graduatedregion 60, and locked at the second position to limit the movement of theneedle thumb slide 68, and consequently the depth of penetration of the puncturingelement 14. - Turning to
FIGS. 1A-1E , the puncturingelement 14 is preferably aneedle assembly 62 including an elongate tubular body 63 having a puncturingdistal tip 64 and aproximal safety clip 66. Theneedle assembly 62 and/or thedistal tip 64 are preferably formed from a shape memory alloy, such as Nitinol, that is precurved to enhance transverse deployment of thedistal tip 64. Thedistal tip 64 may be inserted into the needle entry port 54 and directed distally through theneedle lumen 36 until thesafety clip 66 abuts theneedle thumb slide 68 on thehandle 50. Theneedle thumb slide 68 then may be secured to theneedle assembly 62, for example with ball detents that extend radially into theneedle lumen 36 from the needle thumb slide 68 (not shown), for controlling axial movement of theneedle assembly 62. - Preferably, the
needle assembly 62 includes adrug delivery lumen 72 extending from thesafety clip 66 to anoutlet 74 in thedistal tip 64. Theoutlet 74 may be a single opening for directing fluid distally beyond thedistal tip 64, or may include a plurality of openings having a predetermined outlet pattern. For example, as shown inFIG. 5C , thedistal tip 64 may include aclosed tip 73 and one ormore side openings 75 for directing the drug substantially laterally from thedistal tip 64 into the tissue region. Preferably, thedistal tip 64 also has a sufficiently small gauge diameter such that thepassage 123 between thevessel 102 and thetissue region 100 is substantially self-sealing to prevent escape of the drug from the tissue region back into thevessel 102 upon removal of thedistal tip 64. - Alternatively, as shown in
FIG. 5B , theneedle assembly 62 may include dual lumens 78 a, 78 b that extend between a multiple line manifold on the proximal end (not shown) to two adjacent outlet ports 74 a, 74 b. A dual lumen needle assembly may be useful for delivering a radiographic agent or other compound through one lumen in combination with a drug in the other. More preferably, the dual lumens may allow two drugs to be independently injected, which may then react with one another once within the selected tissue region, as will be appreciated by those skilled in the art. - The
distal tip 64 may also be at least partially conductive, for example, by providing an electrode thereon (not shown) or by forming thedistal tip 64 from a conductive material such as platinum, gold, or possibly stainless steel. A conductor, such as an electrically conductive wire (not shown), may extend proximally from thedistal tip 64 through the tubular member 63 to thesafety clip 66 of theneedle assembly 62. A source of electric current may then be coupled to the conductor to enhance absorption of the drug by the tissue region. For example, thedistal tip 64 may facilitate electroporation, i.e. energizing thedistal tip 64 may create microscopic pores in the surrounding tissue to enhance penetration of the drug therein. - With respect to the
imaging element 18, in a first preferred embodiment best seen inFIG. 2 , an intravascular ultrasound (“IVUS”)device 80 is provided. Aconventional ultrasound transducer 82 is provided on thedistal end 84 of theIVUS device 80 that is oriented towards an imaging plane substantially normal to thelongitudinal axis 22. Theultrasound transducer 82 or a reflector on the IVUS device 80 (not shown) may be rotatable about thelongitudinal axis 22 to provide ultrasonic image slices along the imaging plane in a conventional manner, or alternatively, a phased array of ultrasound transducers may be provided to allow imaging along a plane substantially normal to thelongitudinal axis 22, as will be appreciated by those skilled in the art. Further information on the use of an IVUS device for imaging tissue and other surrounding landmarks from within a blood vessel may be found in “Transvenous Coronary Ultrasound Imaging—A Novel Approach to Visualization of the Coronary Arteries” by Sudhir et al., the disclosure of which is expressly incorporated herein by reference. - During use, the
transvascular catheter system 10 may be used to deliver a drug to a selected remote tissue region within a patient's body in the following manner. Thecatheter 12 may be introduced percutaneously into a blood vessel in a conventional manner, while theneedle assembly 62 remains retracted within theneedle lumen 36, i.e. while thedistal tip 64 is positioned within theneedle lumen 36 proximal to the deflectingelement 48. Thedistal portion 30 of thecatheter 12 may be directed endovascularly to a vessel location adjacent to a remote tissue region for which treatment is selected. - For example, in one preferred method shown in
FIGS. 2 and 3A , thecatheter 12 may be directed through the patient's venous system to acoronary vein 102 adjacent to acoronary artery 100 selected for treatment. In another preferred method shown inFIGS. 6 and 3B thecatheter 12 may be directed to a location within acoronary vein 102 adjacent to a selectedischemic region 220 of themyocardium 112 for delivering a drug therein. Once the desired endovascular location is reached, thecatheter 12 may be oriented towards the selected tissue region using ultrasound imaging with theIVUS device 80, external imaging, such as fluoroscopy, or both. - Turning to
FIGS. 2 and 3A , theIVUS device 80 is shown being used to orient thesystem 10 for delivering a drug into acoronary artery 100 from a nearbycoronary vein 102. Thedistal portion 30 of thecatheter 12 is directed endovascularly through the venous system, for example over a guidewire 86, until it is within thecoronary vein 102 and adjacent the selectedcoronary artery 100. Theultrasound transducer 82 may then be operated to provide a cross-sectional image of the region, shown illustratively inFIG. 3A . The resulting image aids the user in orienting thecatheter 12 with respect to the tissue surrounding thevein 102, for example to identify landmarks such as thepericardium 109, theendocardium 111, theepicardium 113, and/or theheart chamber 110. Further, because thestruts FIG. 3A ), they produceartifacts distal portion 30 of thecatheter 12 with respect to the surroundingmyocardium 112 and the selectedcoronary artery 100. - More particularly, because of the triangular arrangement of the
struts artifacts periphery 20 corresponding to the location of theperipheral opening 34, and consequently in the direction towards which thedistal tip 64 of theneedle assembly 62 will be deployed from thecatheter 12. Thecatheter 12 may be torqued about itslongitudinal axis 22 to rotate thedistal portion 30, as observed by theartifacts distal tip 64 of theneedle assembly 62, i.e. theartifact 104, is directed towards the selected thecoronary artery 100. - The resulting ultrasound image may also be scalable, allowing the user to measure the distance to the selected target region from the
catheter 12, and thereby determine the precise distance that thedistal tip 64 of theneedle assembly 62 will need to be directed to reach the selected tissue region. Theneedle stop 70 on thehandle 50 may then be loosened, adjusted along the graduatedregion 60, and then locked at a predetermined position corresponding to the precise distance. - Once the
catheter 12 is properly oriented and theneedle stop 70 is locked at the predetermined position, thedistal tip 64 of theneedle assembly 62 may be deployed from thecatheter 12 to penetrate thewall 103 of thevessel location 102 and enter the selectedtissue region 100. Preferably, theneedle thumb slide 68 is directed distally by the user, thereby directing thedistal tip 64 against the deflectingelement 48 and causing thedistal tip 64 to deflect radially outward as it exits theperipheral opening 34. - Because of the secured position of the needle stop 70 on the
handle 50, theneedle thumb slide 68 may be quickly advanced distally until it abuts theneedle stop 70, thereby puncturing thewall 103 of thevein 102 and delivering thedistal tip 64 the precise distance, i.e. precisely within the selected target region of theartery 100. Alternatively, it may be desirable to overshoot, i.e. pass a predetermined distance through and beyond the selected target region, and then slowly withdraw thedistal tip 64 until it reaches the selected tissue region. - A drug may then be introduced into the selected tissue region, for example by connecting a source of the drug such as a syringe (not shown), to the proximal end (not shown) of the
needle assembly 62, and injecting the drug through thelumen 72 and theoutlet 74 in thedistal tip 64. Thedistal tip 64 may then be withdrawn back into theneedle lumen 36 and thecatheter 12 withdrawn from the patient in a conventional manner. - Prior to delivering the drug, a “mapping” procedure may be used to ensure that the drug will be delivered as desired into the specific tissue region selected for treatment. For example, a radiographic agent may be delivered through the
outlet 74 in thedistal tip 64. The flow of the radiographic agent may be observed with respect to the selected tissue region, for example using fluoroscopy. Once it has been confirmed that the radiographic agent flows as desired into the selected tissue region, the drug may then be introduced, thereby possibly avoiding misdelivery of what are often quite expensive drugs. Alternatively, a radiographic agent and the like may be mixed with the drug to track the flow of the drug within the body, particularly with respect to the selected tissue region. - Turning now to
FIG. 6 , another preferred embodiment of atransvascular catheter system 10 for delivering a drug to aremote tissue region 220 within themyocardium 112 is shown. Several of the elements are similar to those previously described and consequently have the same reference numbers and will not be described further. Thesystem 10 of this embodiment includes a drug delivery element, namely adrug delivery catheter 214, that may be deployed from thedistal portion 30 of thecatheter 12, preferably in combination with the puncturingelement 14. - The puncturing
element 14 preferably includes a solid needle or guidewire assembly 162, without a lumen but otherwise similar to theneedle assembly 62 previously described, over which thedrug delivery catheter 214 may be deployed. Theguide wire assembly 162 may include an anchoring tip (not shown) for fixing thedistal tip 164 of theguide wire assembly 162 in thetissue region 220 and/or to facilitate introduction of instruments, such as thedrug delivery catheter 214, to thetissue region 220. - The
drug delivery catheter 214 may include aporous balloon 218 for infusing the drug in a predetermined pattern within thetissue region 220, and generally includes a plurality of lumens extending between its proximal portion (not shown), and a distal portion 222. Thedrug delivery catheter 214 preferably has aguide wire lumen 224 such that thedrug delivery catheter 214 may be delivered to thetissue region 220 over theguide wire assembly 162, and also has a drug delivery lumen (not shown) communicating with a portion, e.g. the interior, of theporous balloon 218. Theporous balloon 218 includes a porous region, such as a plurality ofholes 226, a permeable membrane and the like, preferably arranged to provide a predetermined flow pattern through theballoon 218 into thetissue region 220. - During use, the
catheter 12 may be introduced percutaneously into ablood vessel 102, and oriented with respect to the selected tissue region 220 (seeFIG. 3B ). Theguide wire assembly 162 may then be deployed transvascularly to access the selectedtissue region 220, similar to the process previously described. Thedrug delivery catheter 214 may then be advanced over theguide wire assembly 162 until it enters thetissue region 220. Theballoon 218 may then be inflated, expanding it from a collapsed condition around thedrug delivery catheter 214 to an enlarged condition contacting the surroundingtissue 220. Theballoon 218 may be inflated simply by introducing a drug through the drug delivery lumen, which may then seep through theporous region 226 and pass into thetissue region 220. Alternatively, thecatheter 214 may include a separate inflation lumen (not shown) through which an inflation media such as saline may be introduced into a non-porous region within the balloon isolated from the porous region, as will be appreciated by those skilled in the art. In a further alternative, the drug delivery element may be a flexible, thin, floppy catheter which may be left behind to serve as an “indwelling” transcutaneous access catheter, as described more particularly below. - In further alternatives, the
drug delivery catheter 214 and/or theguide wire assembly 162 may include an electrode or other element (not shown) to enhance penetration of the delivered drug into the tissue region. For example, an internal heating element (not shown) may be provided within theballoon 218 to heat the fluid therein and/or thesurrounding tissue 220, which may enhance absorption of the drug delivered into the tissue. Alternatively, an electrode (not shown) may be provided on or within theballoon 218 which may be coupled to an external electrode (not shown). Direct current may then be applied between the electrodes to ionophoretically direct drugs from thedrug delivery catheter 214 deep into the surroundingtissue 220. In a further alternative, thedistal tip 164 of theguide wire assembly 162 may be formed from an electrically conductive material such as gold or platinum, or may include an electrode on a portion thereof (not shown), which may be coupled to an external source of electric current via a conductor (not shown) extending proximally through theguide wire assembly 162. - Thus, a
transvascular catheter system 10 in accordance with the present invention may be used to deliver a single dose or bolus of a drug directly and precisely into a selected remote tissue region. Alternatively, the system may be used for sustained delivery by keeping thedistal portion 30 of thecatheter 12 and/or thedistal tip 64 of theneedle assembly 62 within the blood vessel and/or selected tissue region for an extended period of time. - For example, the
needle assembly 62 orinfusion catheter 214 may be used to inject a matrix material into a tissue region which may slowly diffuse a drug into the tissue region. Alternatively, a stent or similar structure may be delivered into the tissue region, the structure including a drug therein that may be released over time. - In addition, to provide sustained delivery and/or a series of treatments of a drug, an indwelling catheter (not shown) may be left behind within the selected tissue region. For example, the
transvascular catheter system 10 may be introduced into a blood vessel, and the puncturingelement 14, e.g. theneedle assembly 62 or theguide wire assembly 162, may be oriented and deployed within a selected tissue region, such as an interstitial tissue region or another blood vessel. - A guide wire (not shown) may be advanced into the tissue region, and possibly anchored in place. The
transvascular catheter 12 may be withdrawn from the blood vessel, leaving the guide wire, and a thin, floppy catheter (not shown), which may be an infusion catheter similar to that previously described or simply a single delivery port device, may be tracked over the guide wire into the tissue region and left there. The guide wire may then be removed, and the proximal end (not shown) of the thin, floppy catheter may be secured to the patient, for example taped or ported (such as using a port assembly such as that described below) depending upon the length of time therapy is desired. The distal end of the indwelling catheter may then remain in place within the tissue region, possibly for extended periods of time, to provide access whenever needed. - Alternatively, turning to
FIG. 7 , thetransvascular catheter system 10 may include animplantable port assembly 350. Theport assembly 350 includes abody 352 which may be implantable on or beneath the skin of the patient, and one ormore seals 354. The body includes ahollow hub 356 the interior of which communicates with theseal 354 which may be attached to thetransvascular catheter system 10, such as the proximal end 24 of thecatheter 12 or preferably to an indwelling catheter (not shown). - For example, the
catheter 12 shown inFIG. 1 may be percutaneously introduced into a patient's cardiovascular system, and thedistal portion 30 may be advanced into a selected vessel, whereupon thedistal tip 64 of the needle assembly 62 (not shown inFIG. 7 ) may be advanced into a selected remote tissue region, similar to the methods previously described. The handle 50 (not shown inFIG. 7 ) may then be removed from the proximal end 24 and replaced with theport assembly 350 such that thehub 356 may communicate with theneedle lumen 36, theIVUS lumen 32, and/or a drug delivery lumen in the indwelling catheter. Theport assembly 350 may then be stitched or otherwise implanted onto an accessible region of the patient's body (not shown). - Whenever it is desired to access the tissue region, an instrument such as a needle, an infusion device, a sensor and the like (not shown) may be directed through the
seal 354 to communicate with the drug delivery element extending to the selected tissue region. For example, during gene or growth factor therapy, it is often desired to subject the selected tissue region to compounds, such as angiogenic growth factors, for extensive periods of time. The implantable system of the present invention facilitates such sustained treatment by allowing the tissue region to be accessed as often as necessary to maintain a desired level of growth factor at the selected tissue region. - Turning now to
FIG. 8 , another preferred embodiment of atransvascular catheter system 10 in accordance with the present invention is shown, which may be used to create adrug reservoir 224 within a selectedtissue region 220 itself to provide sustained delivery. Acatheter 12, similar to that previously described, may be introduced endovascularly into ablood vessel 102 until thedistal portion 30 is adjacent thetissue region 220. Thedistal tip 64 of theneedle assembly 62 may be oriented and deployed to puncture thewall 103 of thevessel 102 and enter thetissue region 220, using methods similar to those described above. - An
ablation device 230, such as a radio frequency (RF) device, a laser device, and the like, may be advanced over theneedle assembly 62 into thetissue region 220. One ormore electrodes 232 or similar elements on theablation device 230 may be activated to create acavity 224 within thetissue region 220 in a manner known to those skilled in the art. Theablation device 230 may then be removed, and a drug may be introduced into thecavity 224 to create a drug reservoir in continuous contact with the surroundingtissue 220, thereby providing sustained delivery as the drug is slowly absorbed by the surroundingtissue 220. - As an alternative to ablation of tissue, a non-porous balloon catheter (not shown) may be advanced over the
needle assembly 62 into thetissue region 220. The balloon may be inflated to its enlarged condition to contact and push aside the surroundingtissue 220, and create acavity 224. No additional treatment of thetissue 220 may be needed to create thecavity 224, particularly in ischemic tissue which is substantially non-resilient as compared to healthy tissue and unlikely to expand back to fill thecavity 224. It is also within the spirit of the present invention that other devices, such as cutting, coring or other mechanical instruments, may also be used to remove tissue to create thecavity 224 by being advanced over theneedle assembly 62 into thetissue region 220, as will be appreciated by those skilled in the art. - In addition, it may be desirable to inject a sealant or matrix material, such as collagen or a filament structure (e.g. drug-impregnated suture material), into the
cavity 224 or into thepassage 223 extending between theblood vessel 102 and thecavity 224. Although thedistal tip 64 may be sufficiently small so as to create a self-sealingpassage 223, advancement of instruments, such as thedrug delivery catheter 214 ofFIG. 6 , may dilate thepassage 223, which may result in the drug leaking through the passage 23 back into theblood vessel 102 from thecavity 224. To substantially reduce the risk of this occurring, a sealant, matrix material, or filament (not shown) may be injected into thecavity 224 itself, or into thepassage 223, for example through a lumen in thedrug delivery element 214 or theneedle assembly 62 before or while it is being withdrawn from thecavity 224. - In a further alternative shown in
FIG. 5A , thetransvascular catheter system 10 may include a plurality ofneedle assemblies 62, similar to the individual needle assembly described above, to be deployed in a predetermined arrangement along theperiphery 20 of thecatheter 12. Preferably, theneedle assemblies 62 are arranged axially in a row, aligned with the strut of the “cage” structure orientation element (not shown inFIG. 5A ). In particular, it may desirable to access an extended remote tissue region, for example extending substantially parallel to a vessel, especially within the myocardium. With a multiple needle transvascular catheter system, a single device may be delivered into a vessel and oriented. The array of needles may be sequentially or simultaneously deployed to inject one or more drugs into the extended tissue region, thereby providing a selected trajectory pattern. - Other directional drug delivery elements may also be provided within the present invention. For example, a catheter having a drug delivery element, an orientation element and possibly an imaging element may be provided similar to those described above. Instead of a needle or guide wire assembly, the distal portion of the catheter may include an osmotic surface on a portion of the circumference or periphery and extending axially along the distal portion (not shown).
- The osmotic surface preferably has a predetermined relationship to the orientation element, such that the osmotic surface may be directed circumferentially towards a selected tissue region, e.g. a specific portion of a vessel wall and/or a tissue region beyond the vessel wall. The catheter may include a balloon or other expandable structure which may push the osmotic surface into direct contact with the vessel wall to further facilitate delivery. A drug, possibly embedded within the osmotic surface itself or in a chamber beneath the osmotic surface, may then be delivered with or without ionophoresis or other assisted delivery mechanism.
- Turning to
FIG. 13 , the systems and methods of the present invention may also be used to provide access downstream of an occluded or stenotic region of a blood vessel, for example to treat a coronary artery or ischemic tissue region of the myocardium downstream of an occluded coronary artery. First, a location downstream of anoccluded section 404 of acoronary artery 400 may be selected for treatment, and a transvascular catheter device (not shown) percutaneously introduced into the venous system and advanced until it reaches acoronary vein 402 adjacent the selectedartery 400. Aninterstitial passage 406 may be created between thecoronary vein 402 and thecoronary artery 400, and aguide wire 410 may be advanced through theinterstitial passage 406 into thecoronary artery 400. Theguide wire 410 may be substantially anchored within thecoronary artery 400, for example by embedding the distal end of theguide wire 410 into the wall of the coronary artery 400 (not shown). Further details on the systems and methods for performing interstitial or transvascular procedures between the venous and arterial systems may be found in co-pending application Ser. Nos. 08/730,327 and 08/730,496, both filed Oct. 11, 1996, the disclosures of which are expressly incorporated herein by reference. - A
transvascular catheter system 10, similar to those previously described, may then be advanced over theguide wire 410 along the venous system, through theinterstitial passage 406 and into thecoronary artery 400 downstream of theoccluded region 404, thus without disturbing plaque or otherwise affecting flow through the arterial system. It will be appreciated by those skilled in the art that thetransvascular catheter system 10 used to deliver the drug may also be used to create theinterstitial passage 406. - The
artery 400 itself may then be treated, for example, using theneedle assembly 62 ofFIG. 1 or thedrug delivery catheter 214 ofFIG. 6 . A drug may be delivered into thelumen 408 of theartery 400, into thevessel wall 412 and/or thesurrounding tissue 414. In addition, one or more drug reservoirs (not shown) may be created within the surroundingtissue 414, most preferably within myocardial tissue adjacent to a coronary artery, for receiving a drug that may be absorbed by the surroundingtissue 414 over an extended period of time. - Other useful features may also be included in any of the embodiments of the
transvascular catheter system 10 in accordance with the present invention. For example, thecatheter 12 may include one or more stabilizing balloons (not shown) on thedistal portion 30, for example proximal to theperipheral opening 34. An inflation lumen may be provided in thecatheter 12 to allow an inflation medium, e.g. saline, to be introduced into the stabilizing balloon to substantially anchor thecatheter 12 at a desired location within the blood vessel, i.e. to prevent thecatheter 12 from moving axially within the vessel once thedistal portion 30 is adjacent to a remote tissue region selected for treatment. - In addition, one or more of the elements of the system may include a sensor for measuring information relevant to the treatment of the selected tissue region. For example, a pressure sensor may be provided on the
catheter 12, theneedle assembly 62 and/or the drug delivery element. A lumen may extend proximally through the respective element, thereby allowing the user to continuously monitor pressure at or near the delivery site. The drug delivery element may also include a flow measurement sensor, allowing the amount of drug being delivered to the selected tissue region to be precisely measured. - Other feedback elements may also be provided, for example, a thermocouple or other temperature sensor may be provided on systems including ionophoresis electrodes or ablation devices to monitor the amount of heating being experienced by tissue during a procedure. Alternatively as shown in
FIG. 5D , theneedle assembly 62 or other component may include a feedback element 79 for measuring a physiological condition. For example, an EKG lead may be included on the distal tip or otherwise delivered within the selected tissue region, thereby allowing electrical events within the heart to be monitored during drug delivery. During treatment, for example, a drug may be delivered into a tissue region until a desired condition is met, such as until the tissue becomes non-tachycardic, or until tachycardia is induced. - An important aspect of the transvascular catheter system of the present invention is the ability to precisely deliver a drug to a selected remote location within a reference frame, preferably including a circumferential or peripheral component and a radial component. The orientation element provides the peripheral component because of its predetermined relationship with the periphery of the catheter and the drug delivery element. The imaging element preferably provides the radial component by detecting the relationship of the orientation element to the selected remote location (e.g. the distance between them), or landmarks in a known relationship with the selected remote location. Once the location of the selected remote location is known within the reference frame, the drug delivery element may be directed towards the selected remote location for precise delivery of a drug.
- In another aspect of the present invention,
FIGS. 9A-9D and 10 show a preferred embodiment of animplantable reservoir device 400 that may be used to provide sustained delivery of a drug to tissue surrounding a blood vessel, preferably within acoronary vein 102 adjacent to ischemicmyocardial tissue 112. Thereservoir device 400 includes a substantiallycylindrical frame 402 adapted to expand between a collapsed condition for insertion into a blood vessel and an enlarged condition for engaging awall 103 of theblood vessel 102, and defining alongitudinal axis 404. - The
frame 402 is sufficiently flexible to expand between the collapsed and enlarged conditions during use without substantial risk of failing or fatiguing, yet sufficiently rigid to anchor thereservoir device 400 within theblood vessel 102. Preferably, theframe 402 is resiliently biased towards the enlarged condition to prevent substantial movement of theframe 402 axially within theblood vessel 102. Theframe 402 may be formed from a woven mesh of wire of, for example, a shape memory alloy such as Nitinol, stainless steel, platinum, polymers or other plastics and the like. Theframe 402 may be woven into a criss-cross structure, a sinusoidal structure, or may include a pair of expandable rings connected by spacers to retain the rings apart axially. - A
flexible membrane 408 is attached to theframe 402, preferably to the exterior offrame 402 such that themembrane 408 may enhance a fluid-tight seal when pressed against thewall 103 of thevessel 102 by theframe 402 after deployment. Themembrane 408 includes aperiphery 412 and endpanels reservoir 410 within themembrane 408 and theframe 402. Themembrane 408 should be substantially flexible, and may be elastic if tension over the frame is preferred, or plastic if a small initial diameter is preferred. Preferred materials include dacron and PTFE, which may also be silicone dipped. - The
membrane 408 includes aporous region 418, which is preferably disposed along at least a portion of theperiphery 412 of themembrane 408. Theporous region 418 may be a permeable or semi-permeable material bonded or otherwise attached to non-permeable segment(s) of themembrane 408. Alternatively, theentire membrane 408 may be formed from a non-permeable material with holes formed through discrete areas to define theporous region 418. - In addition, as shown in
FIGS. 9B and 9C , at least one of theend panels 416 may be recrossable, i.e., may be penetrable by aneedle 432, but automatically resealable, to facilitate in situ filling or refilling of thereservoir 410, preferably having a concave shape to facilitate penetration by theneedle 432. Alternatively, thereservoir 410 may be prefilled with a drug, possibly together with an anti-coagulant or other compound, prior to delivery into the blood vessel 422. In addition, the drug and the pore size of theporous region 418 may have a predetermined relationship such that the drug permeates or flows through theporous region 418 into the surrounding tissue at a predetermined flow rate. - During use, the
reservoir device 400 is percutaneously delivered into a blood vessel in its collapsed condition using a delivery device, for example within a lumen of a delivery catheter or sheath adapted to receive thereservoir device 400. Alternatively, theframe 402 may include a control hub on one end (not shown), which may be gripped and compressed radially inward to collapse theframe 402. - Once the
reservoir device 400 is in a blood vessel adjacent the target region, such as thecoronary vein 102 adjacent to the selectedtissue region 112, thereservoir device 400 is deployed from the delivery device, for example using a plunger within the delivery catheter lumen (not shown). Preferably, theframe 402 automatically expands to its enlarged condition, thereby substantially anchoring thedevice 400 in position within thevessel 102. Theframe 402 may also create a substantially fluid-tight seal with thewall 103 of thevessel 102, to prevent substantial leakage of fluid delivered through theperiphery 412 downstream within thevessel 102. - If the
reservoir 410 is empty during deployment, for example, to prevent rupture of themembrane 408 when theframe 402 is collapsed, a drug delivery element may be introduced into thevessel 102 to fill thereservoir 410. For example, as shown inFIGS. 9C and 9D , aninjection device 430 including asheath 434 covering ahollow needle 432 may be delivered endovascularly, or the delivery catheter used to deliver thereservoir device 400 may include an additional drug delivery needle lumen. Theneedle 432 may be deployed to penetrate therecrossable end region 416, whereupon thereservoir 410 may be filled by introducing the drug through theneedle 432. - The
reservoir device 400 may remain in thevessel 102 for a substantial period of time, possibly hours or days, allowing the drug to slowly absorb into the wall of the vessel and preferably the surrounding tissue. In addition, the drug delivery element, e.g. the sheath-covered hollow needle, may be reintroduced into the vessel 423 to refill thereservoir 410, for example using an implantable port assembly similar to that shown inFIG. 7 . Alternatively, thereservoir device 400 may include an electrode (not shown) to enable ionophoresis or other enhanced delivery. A catheter including a conductor (not shown) may be introduced into thevessel 102, coupled to the electrode, and then energized by an external source of electric current (not shown) for this purpose. - In an alternative embodiment, shown in
FIG. 11 , thereservoir device 400 may provide an endovascular “pump” for time-release delivery of a drug. In this embodiment, thereservoir device 400 includes aseptum panel 420 dividing thereservoir 410 into first and second regions 410 a, 410 b. Thefirst end panel 414 of themembrane 408 is an osmotic membrane and the first reservoir 410 a is filled with a fluid absorbing compound. Theporous region 418 of themembrane 408 communicates only with the second reservoir 410 b, which is filled with a drug in situ or before deployment. - When the
reservoir device 400 is deployed within a vessel (not shown), using a procedure similar to that just described, the compound in the first reservoir 410 a begins to slowly draw fluid osmotically from within the lumen of the vessel. As this occurs, theseptum panel 420 is forced to expand towards thesecond end panel 416, thereby applying a force within the second reservoir 410 b, which “pumps” or otherwise encourages the drug to flow out theporous region 418, and preferably into the wall of the vessel. - In other arrangements, instead of the
septum panel 420, a cylindrical septum may be provided, creating an internal first reservoir and an annular second reservoir surrounding the first reservoir (not shown). The area of one or both end panels in contact with the internal first reservoir may be provided from an osmotic material, thereby creating a similar flow out of a porous region on the periphery of the membrane in communication with the annular second reservoir. - Other shapes and configurations of the
reservoir device 400 may also be provided that may be deployed and substantially anchored adjacent a selected tissue region. In addition, a drug reservoir device similar to those described may be delivered directly into tissue, for example, using one of the transvascular catheter systems previously described, as will be appreciated by those skilled in the art. - In another preferred embodiment shown in
FIG. 12 , an implantable system including a pair of endovascular blocker devices 500 may be used to create a drug reservoir 508 a within ablood vessel 102 itself, i.e. between the blockers 500 and the wall 103 a of thevessel 102 between them. The blockers 500 preferably include anexpandable frame 502 and aflexible membrane 504 attached to theframe 502, similar to that described above. Themembrane 504, however, is preferably non-permeable, although alternatively a permeable periphery (not shown) may be provided to increase the surface area through which the drug may be directed towards thevessel wall 103. - To create the reservoir 508 a, the first blocker 500 a is deployed within a
vessel 102 adjacent a selected tissue region, such as astenotic region 105 within anartery 102, using a method similar to that described above for thereservoir device 400. A drug is introduced into the vessel lumen 108 a, and a second blocker 500 b is deployed within thevessel 102, thereby encapsulating the drug in the lumen 108 a between the blockers 500 a, 500 b. - Alternatively, the drug may be delivered into the reservoir 508 a after both blockers 500 are deployed and in secured within the
vessel 102. For example, the second blocker 500 b may include a recrossable end panel 514 on one end, and an open interior that may communicate directly with the reservoir 108 a. Thus, an injection needle device (not shown) may be used to inject the drug through the recrossable end panel 514 and into the reservoir 508 a in situ. - It has been determined clinically that one or more segments of the venous system, even within the coronary system, may be occluded for extensive periods of time without adversely affecting the performance of the coronary system. Accordingly, an implantable reservoir system in accordance with the present invention may be used to create a reservoir within a coronary vein without interfering substantially with the flow of return blood from the myocardium. A drug within the reservoir may then be absorbed by the vessel wall and surrounding tissue to treat selected tissue regions adjacent the reservoir site.
- Of further note, it has been clinically determined that complete occlusion and shutdown of the coronary venous system may not impair normal operation of the heart. The endocardial veins may take over at least a portion of the additional venous return. Furthermore, within thirty minutes of complete occlusion, the Thebesian system, which includes capillaries, venals and porous tissue that makes up the myocardium itself, may replace the venous system and return one hundred percent of the return blood from the myocardium. Thus, the reservoir devices in accordance with the present invention may be deployed in one or more regions within the coronary venous system without substantial risk of adversely affecting coronary blood flow or damaging the tissues of the coronary system.
- While the invention is susceptible to various modifications, and alternative forms, specific examples thereof have been shown in the drawings and are herein described in detail. It should be understood, however, that the invention is not to be limited to the particular forms or methods disclosed, but to the contrary, the invention is to cover all modifications, equivalents and alternatives falling within the spirit and scope of the appended claims.
Claims (14)
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US11/646,644 US7670868B2 (en) | 2005-12-30 | 2006-12-27 | Complementary metal oxide silicon image sensor and method of fabricating the same |
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Also Published As
Publication number | Publication date |
---|---|
EP1066070A4 (en) | 2009-08-05 |
US7094230B2 (en) | 2006-08-22 |
US6685648B2 (en) | 2004-02-03 |
US8083708B2 (en) | 2011-12-27 |
US7670329B2 (en) | 2010-03-02 |
US20070021730A1 (en) | 2007-01-25 |
US20020002349A1 (en) | 2002-01-03 |
WO1999048545A1 (en) | 1999-09-30 |
AU2905499A (en) | 1999-10-18 |
US8540694B2 (en) | 2013-09-24 |
EP1066070A1 (en) | 2001-01-10 |
JP2002507458A (en) | 2002-03-12 |
CA2325032A1 (en) | 1999-09-30 |
US20100324471A1 (en) | 2010-12-23 |
AU749417B2 (en) | 2002-06-27 |
US20140249507A1 (en) | 2014-09-04 |
US6283951B1 (en) | 2001-09-04 |
IL138298A0 (en) | 2001-10-31 |
US20120172838A1 (en) | 2012-07-05 |
US20040133154A1 (en) | 2004-07-08 |
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