US20020016624A1 - Apparatus and method for controlled removal of stenotic material from stents - Google Patents

Abstract

Apparatus and methods for treating in-stent restenosis are described for removing stenotic material from within previously stented regions of a patient's vasculature. The apparatus includes a catheter system having a stenotic material removal mechanism mounted on a distal portion of an elongated inner catheter. A sensing means, such as one or more sensing electrodes, are positioned on an outer surface of the apparatus. In addition, the apparatus optionally includes control means for diametrically expanding the stenotic material removal mechanism for effective recanalization of the stent. A coaxial outer catheter is provided for aspirating stenotic material which is removed from within the stent. In addition, embolic filter apparatus are described for collecting the stenotic material removed from within the stent. The methods comprise operating the stenotic material removal mechanism within a body vessel, typically a coronary artery or other artery, which has become restenosed or otherwise occluded following the initial stent placement, and sensing the proximity or contact between the stenotic material removal mechanism and the stent within the arterial wall so that the stenosis can be effectively recanalized without damaging the stent. The sensing means may be used to indicate an unsafe condition that might lead to stent damage, in response to which, the stenotic material removal mechanism may be manually or automatically deactivated. Alternatively or additionally, the sensing means may be used to indicate an appropriate endpoint for the stenotic material removal process.

Description

CROSS-REFERENCES TO RELATED APPLICATIONS
• This patent application is a division of application Ser. No. 08/857,659, filed May 16, 1997, which is a continuation-in-part of co-owned, copending patent application, Ser. No. 08/798,722, filed Feb. 12, 1997, the entire disclosures of which are incorporated herein by reference.[0001]
BACKGROUND OF THE INVENTION
• 1. Field of the Invention[0002]
• The present invention relates generally to apparatus and methods for removing occluding material from stented regions within blood vessels which have restenosed. More particularly, the present invention relates to apparatus and methods for sensing a stent within the wall of a restenosed blood vessel and removing the occluding material without damaging the stent.[0003]
• Percutaneous transluminal angioplasty (PTA) and percutaneous transluminal coronary angioplasty (PTCA) procedures are widely used for treating stenotic atherosclerotic regions of a patient's vasculature to restore adequate blood flow. Catheters having an expansible distal end, typically in the form of an inflatable balloon, are positioned in an artery, such as a coronary artery, at a stenotic site. The expansible end is then expanded to dilate the artery in order to restore adequate blood flow to regions beyond the stenosis. While PTA and PTCA have gained wide acceptance, these angioplasty procedures suffer from two major problems: abrupt closure and restenosis.[0004]
• Abrupt closure refers to rapid reocclusion of the vessel within hours of the initial treatment, and often occurs in patients who have recently suffered acute myocardial infarction. Abrupt closure often results from either an intimal dissection or from rapid thrombus formation which occurs in response to injury of the vascular wall from the initial angioplasty procedure. Restenosis refers to a re-narrowing of the artery over the weeks or months following an initially apparently successful angioplasty procedure. Restenosis occurs in up to 50% of all angioplasty patients and results at least in part from smooth muscle cell proliferation and migration.[0005]
• Many different strategies have been proposed to ameliorate abrupt closure and reduce the rate of restenosis. Of particular interest to the present invention, the implantation of vascular stents following angioplasty has become widespread. Stents are thin-walled tubular scaffolds which are expanded in the arterial lumen following the angioplasty procedure. Most commonly, the stents are formed from a malleable material, such as stainless steel, and are expanded in situ using a balloon. Alternatively, the stents may be formed from a shape memory alloy or other elastic material, in which case they are allowed to self-expand at the angioplasty treatment site. In either case, the stent acts as a mechanical support for the artery wall, inhibiting abrupt closure and reducing the restenosis rate as compared to PTCA.[0006]
• While stents have been very successful in inhibiting abrupt closure and reasonably successful in inhibiting restenosis, a significant portion of the treated patient population still experiences restenosis over time. Most stent structures comprise an open lattice, typically in a diamond or spiral pattern, and cell proliferation (also referred to as intimal hyperplasia) can intrude through the interstices between the support elements of the lattice. As a result, instead of forming a barrier to hyperplasia and restenosis, the stent can become embedded within an accumulated mass of thrombus and tissue growth, and the treatment site once again becomes occluded.[0007]
• To date, proposed treatments for restenosis within previously stented regions of the coronary and other arteries have included both follow-up balloon angioplasty and directional atherectomy, e.g. using the Simpson directional atherectomy catheter available from Guidant Corporation, Santa Clara, Calif. Neither approach has been wholly successful. Balloon angioplasty can temporarily open the arterial lumen, but rarely provides long-term patency. Directional atherectomy can successfully debulk the lumen within the stent, but typically does not fully restore the stented lumen to its previous diameter because the catheter removes the stenotic material in an asymmetric pattern. Moreover, it has been found that the atherectomy cutting blades can damage the implanted stent. Such adverse effects were reported by Bowerman et al. in Disruption of a coronary stent during atherectomy for restenosis in the December 1991 issue of Catheterization and Cardiovascular Diagnosis and by Meyer et al. in Stent wire cutting during coronary directional atherectomy in the May 1993 issue of Clinical Cardiology. The possibility of such adverse outcomes is likely to limit the application of atherectomy as a treatment for stent restenosis and will probably result in more tentative use of the atherectomy cutter within the stented region when it is applied, leading to less complete removal of the stenosis.[0008]
• For these reasons, it would be desirable to provide improved methods for treating restenosis within regions of the vasculature which have previously been implanted with stents. More particularly, it would be desirable to provide an apparatus for removal of stenotic material from within a stent which includes a sensing means for sensing when the stenosis removal mechanism is approaching or contacting the stent within the arterial wall so that the occluded artery can be effectively recanalized without damaging the stent. The stenosis removal mechanism of the apparatus may advantageously be a directional cutting or debulking device for selectively removing the stenotic material from within a stent or it may be a symmetrical cutting or debulking device for removing the stenotic material uniformly from the entire inner periphery of the stent.[0009]
• 2. Description of the Background Art[0010]
• Post-angioplasty restenosis is discussed in the following publications: Khanolkar (1996) Indian Heart J. 48:281-282; Ghannem et al. (1996) Ann. Cardiol. Angeiol. 45:287-290; Macander et al. (1994) Cathet. Cardiovasc. Diagn. 32:125-131; Strauss et al. (1992) J. Am. Coll. Cardiol. 20:1465-1473; Bowerman et al. (1991) Cathet. Cardiovasc. Diagn. 24:248-251; Moris et al. (1996) Am. Heart. J. 131:834-836; Schomig et al. (1994) J. Am. Coll. Cardiol. 23:1053-1060; Haude et al., “Treatment of In-Stent Restenosis,” in ______,[0011]Chapter 52, pages 357-365; Gordon et al. (1993) J. Am. Coll. Cardiol. 21:1166-1174; and Baim et al. (1993) Am. J. Cardiol. 71:364366. These publications include descriptions of follow-up angioplasty and atherectomy as possible treatments for restenosis.
• Atherectomy catheters having ultrasonic imaging transducers are described in U.S. Pat. Nos. 5,000,185 and 5,100,424. Rotary ablation catheters having selectively expandable burr components are described in U.S. Pat. Nos. 5,217,474 and 5,308,354. A catheter carrying an expandable filter is described in U.S. Pat. No. 4,723,549.[0012]
• Thrombectomy and atherectomy catheters having rotating brush and filament structures are described in U.S. Pat. Nos. 5,578,018; 5,535,756; 5,427,115; 5,370,653; 5,009,659; and 4,850,957; WO 95/29626; DE 39 21 071 C2; and Netherlands 9400027.[0013]
• Representative atherectomy catheters are described in U.S. Pat. Nos. 4,273,128; 4,445,509; 4,653,496; 4,696,667; 4,706,671; 4,728,319; 4,732,154; 4,762,130; 4,790,812; 4,819,634; 4,842,579; 4,857,045; 4,857,046; 4,867,156; 4,883,458; 4,886,061; 4,890,611; 4,894,051; 4,895,560; 4,926,858; 4,966,604; 4,979,939; 4,979,951; 5,011,488; 5,011,489; 5,011,490; 5,041,082; 5,047,040; 5,071,424; 5,078,723; 5,085,662; 5,087,265; 5,116,352; 5,135,483; 5,154,724; 5,158,564; 5,160,342; 5,176,693; 5,192,291; 5,195,954; 5,196,024; 5,209,749; 5,224,945; 5,234,451; 5,269,751; 5,314,438; 5,318,576; 5,320,634; 5,334,211; 5,356,418; 5,360,432; 5,376,100; 5,402,790; 5,443,443; 5,490,859; 5,527,326; 5,540,707; 5,556,405; 5,556,408; and 5,554,163.[0014]
• The disclosures of these patent are incorporated herein by reference in their entirety.[0015]
SUMMARY OF THE INVENTION
• The present invention provides apparatus and methods for removing stenotic material from within previously stented regions of a patient's vasculature. The present invention is particularly intended for treating regions of restenosis within a stent which result from accumulation of cellular, thrombotic, and other material over the weeks and months following an initially successful stent implant. The present invention will also be useful for treating relatively rapid thrombus formation which may sometimes occur during the hours and days following a stent placement procedure.[0016]
• Methods according to the present invention comprise operating a stenotic material removal mechanism within a blood vessel, typically a coronary artery or other artery, which has become restenosed or otherwise occluded following the initial stent placement, and sensing the proximity or contact between the stenotic material removal mechanism and the stent within the arterial wall so that the occluded vessel can be effectively recanalized without damaging the stent. The sensing means for sensing the proximity or contact between the stenotic material removal mechanism and the stent may be used to indicate an unsafe condition that might lead to stent damage, in response to which, the stenotic material removal mechanism may be manually or automatically deactivated. Alternatively or additionally, the sensing means may be used to indicate an appropriate endpoint for the stenotic material removal process.[0017]
• According to this second aspect, the indication of the proximity or contact between the stenotic material removal mechanism and the stent provided by the sensing means may be used as feedback for controlling the stenotic material removal process in the following ways: When used in conjunction with a directional stenotic material removal mechanism, the sensing means may be used to guide the directional stenotic material removal mechanism either to remove stenotic material from selected portions of the interior of the stent or to remove stenotic material uniformly from the entire inner periphery of the stent. When used in conjunction with a controllable-depth stenotic material removal mechanism, the indication from the sensing means may be used as feedback to manually or automatically control the depth of stenotic material removal, preferably to remove stenotic material uniformly from the entire inner periphery of the stent. When used in conjunction with a controllable-width or diameter stenotic material removal mechanism, the indication from the sensing means may be used as feedback to manually or automatically control the width or diameter of the blood flow channel created within the stent. In certain embodiments of the method, the feedback from the sensing means may be used to control a combination of the directionality and the depth or diameter of the stenotic material removal process either to remove stenotic material from selected portions of the interior of the stent or to remove stenotic material uniformly from the entire inner periphery of the stent.[0018]
• In a preferred aspect of the method of the present invention, a catheter carrying the stenotic material removal mechanism is positioned on one side of the restenosed stented region. The stenotic material removal mechanism is advanced from the catheter and positioned across the stenosis within the stent. The stenotic material removal mechanism is then expanded within the stenosis. The expansion may occur passively, as with a resilient stenotic material removal mechanism having one or more resilient members, such as one or more wire-shaped cutting blades, which are released from a tubular sheath and allowed to expand. Otherwise, the expansion may occur actively and controllably, such as with a stenotic material removal mechanism having one or more wire-shaped cutting blades which are actively and controllably extended outward to increase the width or diameter of the stenotic material removal mechanism, or such as a stenotic material removal mechanism having a cutter within a housing and an inflatable balloon located on one side of the housing which is inflated to increase the width or diameter of the stenotic material removal mechanism. The stenotic material removal mechanism is then activated for removing the stenotic material from within the stent. This is typically done by rotating and/or translating the entire stenotic material removal mechanism or a component of it within the stenosis. Medications, chemicals, ionizing radiation or energy, such as electrical, magnetic, ultrasonic, hydraulic, pulsed hydraulic, laser or thermal energy may be applied to assist in removal of the stenotic material and/or for denaturing the remaining tissue to discourage further restenosis at the treatment site. A sensing means which is located on or adjacent to the stenotic material removal mechanism monitors the proximity or contact between the stenotic material removal mechanism and the stent. When the stenotic material removal mechanism has approached close enough to the stent to indicate effective recanalization of the stenosis, the stenotic material removal mechanism is deactivated. In this way, the sensing means provides an interaction between the stenotic material removal mechanism and the stented vessel to achieve effective recanalization of the stenosis without damaging or dislodging the stent within the vessel wall.[0019]
• In an alternative aspect of the method of the present invention, the catheter carrying the stenotic material removal mechanism is positioned on one side of the restenosed stented region. The stenotic material removal mechanism is extended from the catheter and advanced part-way into the stenosis within the stent. The stenotic material removal mechanism is then expanded within the stenosis, either passively or actively and controllably as described above, to increase the width or diameter of the stenotic material removal mechanism. The stenotic material removal mechanism is then activated for removing the stenotic material from within a portion of the stent. This may be done by rotating and/or translating the entire stenotic material removal mechanism or a component of it within the stenosis. Medications, chemicals, ionizing radiation or energy, such as electrical, magnetic, ultrasonic, hydraulic, pulsed hydraulic, laser or thermal energy may be applied to assist in removal of the stenotic material and/or for denaturing the remaining tissue to discourage further restenosis at the treatment site. A sensing means which is located on or adjacent to the stenotic material removal mechanism monitors the proximity or contact between the stenotic material removal mechanism and the stent. When the stenotic material removal mechanism has approached close enough to the stent to indicate effective recanalization of that portion of the stenosis, the stenotic material removal mechanism is advanced farther into the stenosis. The stenotic material removal mechanism may be deactivated and advanced step-wise into the stenosis by contracting or compressing the stenotic material removal mechanism, advancing it a short distance and expanding it again in a new portion of the stent. Otherwise, the stenotic material removal mechanism may be advanced continuously, relying on either the resiliency of the stenotic material removal mechanism or active control for adjusting the width or diameter of the stenotic material removal mechanism as it advances. When the sensing means indicates that the new portion of the stent has been effectively recanalized, the stenotic material removal mechanism is advanced again along the stenosis until the entire stented region has been recanalized.[0020]
• Alternatively, the stenotic material removal mechanism may be extended from the catheter and advanced all the way across the stenosis in a contracted or compressed state. The stenotic material removal mechanism is then expanded within the far end of the stenosis or within the vessel beyond the stenosis, either passively or actively and controllably as described above, to increase the width or diameter of the stenotic material removal mechanism. The stenotic material removal mechanism is then activated for removing the stenotic material while withdrawing the stenotic material removal mechanism toward the catheter to advance it through the stenosis in either a step-wise or continuous fashion. Medications, chemicals, ionizing radiation or energy, such as electrical, magnetic, ultrasonic, hydraulic, pulsed hydraulic, laser or thermal energy may be applied to assist in removal of the stenotic material and/or for denaturing the remaining tissue to discourage further restenosis at the treatment site. The sensing means which is used to monitor the proximity or contact between the stenotic material removal mechanism and the stent in order to control the diameter and/or the rate of advancement of the stenotic material removal mechanism for effective recanalization of the stenosis within the stent.[0021]
• The methods of the present invention may include providing a sensing means in the form of one or more open, exposed electrodes which are located on or adjacent to the stenotic material removal mechanism. A direct or alternating current reference voltage is applied to a unipolar electrode or applied between two bipolar electrodes, and the current leakage of the electrode or electrodes is monitored. When one or more of the electrodes contacts the metallic stent, the leakage current increases indicating that the stenotic material has been removed down to the stent support members for effective recanalization of the stenosis within that portion of the stent. Alternatively, the methods of the present invention may include providing a sensing means in the form of two exposed or insulated bipolar electrodes which are located on or adjacent to the stenotic material removal mechanism. An alternating current reference voltage is applied between the bipolar electrodes, and the complex impedance between the electrodes is monitored. As the electrodes approach the metallic stent, the capacitive and inductive characteristics of the electrode circuit change, which can be detected as a change in the complex impedance between the electrodes. When the complex impedance between the electrodes has changed a sufficient amount to indicate effective recanalization of the stenosis within that portion of the stent, the stenotic material removal mechanism may be deactivated or advanced along the stenosis as appropriate. The sensing means can be used to control or guide the stenotic material removal mechanism to remove the stenotic material to within a predetermined thickness of the stent support members or the stenotic material can be removed all the way down to the stent support members without fear of damaging the stent. If exposed electrodes are used in this method, monitoring the complex impedance between the electrodes will indicate when the stenotic material removal mechanism is approaching the metallic stent, then when one or more of the electrodes contacts the metallic stent, it will ground to the stent which can be detected as an extreme change in the complex impedance or as a rise in the leakage current. Thus, the sensing means can be used to separately indicate proximity and contact between the stenotic material removal mechanism and the stent. The sensing means can operate with very low voltage and current that will not create any adverse physiological effects on the vascular wall or the tissues and nerve pathways of the heart.[0022]
• In embodiments where the stenotic material removal mechanism uses direct or alternating current electrical energy to assist in removal of the stenotic material and/or for denaturing the remaining tissue to discourage further restenosis at the treatment site, for example by heating or by radio frequency ablation, the heating or ablation electrodes can serve double duty as the sensing means electrodes for monitoring proximity or contact with the metallic stent.[0023]
• Other types of proximity sensors sensitive to the metallic stent may be used in place of those described. Alternatively, optical or ultrasonic sensors may be used in place of the electronic detectors described for detection of both metallic and nonmetallic stents. For example, a nonimaging, A mode ultrasonic transducer can be used to detect both metallic and nonmetallic stents and to measure their depth within the arterial wall based on echoes caused by the difference in acoustic impedance between the stent material and the arterial tissue or stenosis.[0024]
• The methods of the present invention will optionally further comprise collecting and withdrawing the removed stenotic material from the blood vessel. Collection and withdrawal of the removed stenotic material may be accomplished using the same catheter or catheter assembly which carries the stenotic material removal mechanism, typically by aspiration, entrapment, filtering or some combination thereof. It will be appreciated that various catheter assemblies can be put together using coaxially arranged components which may be introduced through a single vascular access point, such as a femoral or brachial artery. Alternatively, collection and withdrawal can be accomplished using separate collection apparatus, such as a catheter or catheter assembly, which is introduced through a separate access point. In some instances, it may be desirable to partially or totally isolate the stented region from circulation during recanalization. For example, embolic filters or occlusion balloons may be placed upstream and downstream of the treatment site. Alternatively or additionally, the methods of the present invention may optionally further comprise comminution of the removed stenotic material into microscopic particles that will not cause embolization downstream of the treatment site.[0025]
• The methods of the present invention will also optionally comprise the use of introducer means, such as introducer needles, guidewires and/or introducer sheaths for introducing the catheter or catheter system into the vascular system and guide means, such as steerable guidewires and selective and/or subselective guiding or delivery catheters for guiding and advancing the catheter or catheter system through the vasculature to the treatment site and supporting it during the treatment. The selective and subselective guiding or delivery catheters may also serve the functions of aspiration, collection and withdrawal of the removed stenotic material, as well as for infusion of therapeutic substances.[0026]
• Apparatus according to the present invention include catheters, catheter systems, and catheter kits which are specially intended and adapted for performing the methods described above. In particular, the apparatus are designed to afford percutaneous intravascular placement of a catheter carrying a stenotic material removal mechanism for removing stenotic material from within a previously stented region of the vasculature and a sensing means for sensing when the stenotic material removal mechanism is approaching or contacting the stent within the vascular wall. This inventive combination facilitates the effective recanalization of previously placed vascular stents that have become restenosed without risking damaging the stent. To that end, catheter systems according to the present invention may comprise an inner catheter shaft having a proximal end and a distal end. The stenotic material removal mechanism is disposed near the distal end of the inner catheter shaft. The inner catheter shaft will preferably include a guidewire lumen for introduction of the catheter system over a steerable guidewire. The inner catheter shaft may have additional lumens or actuating mechanisms associated with the stenotic material removal mechanism. Various embodiments of the stenotic material removal mechanism will be more fully described below. In embodiments where the stenotic material removal mechanism comprises resilient members which are radially compressible, the catheter system may also include a tubular sheath which serves to maintain the stenotic material removal mechanism in a compressed state as it is maneuvered to, and potentially across, the stenosis. The catheter system will usually further include an outer catheter tube having a proximal end, a distal end and an inner lumen. The outer catheter tube will usually have an aspiration port near its proximal end so that dislodged stenotic material can be aspirated from the vasculature. The outer catheter tube may optionally have selective or subselective curves formed near the distal end of the catheter tube for directing and maneuvering the catheter system through the vasculature to the site of the stenosis. In addition, an outer guiding catheter, for example a coronary guiding catheter, may be used for guiding the catheter system into the desired part of the vasculature and supporting it during the treatment.[0027]
• The stenotic material removal mechanism which is disposed near the distal end of the inner catheter shaft may take one of several possible forms. In a first illustrative embodiment of the apparatus, the stenotic material removal mechanism is in the form of a cutting head having a plurality of longitudinally oriented cutting blades arranged radially about the central axis of the inner catheter. In a second illustrative embodiment of the apparatus, the stenotic material removal mechanism is in the form of a cutting head having a plurality of helically configured cutting blades arranged radially about the central axis of the inner catheter. In these first and second illustrative embodiments, each of the cutting blades is preferably shaped like a flattened wire with one or both lateral edges of the wire sharpened into a cutting edge. The wire-shaped cutting blades are resilient so that they can expand radially outward from the central axis of the inner catheter. Preferably, the wire-shaped cutting blades maintain an approximately parallel orientation to one another as they expand and contract in the radial direction so that the overall configuration of the cutting head is roughly cylindrical. The cutting head can be passively expandable, in which case the resilient wire-shaped cutting blades are treated by coldworking or heat treatment to have an elastic memory that predisposes them to expand outward when they are released from the radial constraint of the tubular sheath. Alternatively, the cutting head can be configured to be actively and controllably expandable. In this case, the resilient wire-shaped cutting blades are attached on their proximal ends to the inner catheter shaft and on their distal ends to an inner actuating member which is coaxially slidably with respect to the inner catheter shaft. When the inner actuating member is moved proximally with respect to the inner catheter shaft, the resilient wire-shaped cutting blades expand radially outward from the central axis of the inner catheter, and when the inner actuating member is moved distally with respect to the inner catheter shaft, the resilient wire-shaped cutting blades contract radially inward toward the central axis of the inner catheter. The resilient wire-shaped cutting blades may be treated by coldworking or heat treatment to have an elastic memory so that they are biased toward the contracted position, the expanded position or an intermediate position, each alternative having various advantages. The inner actuating member may be tubular, such as a polymer tube, a hollow flexible cable or a flexible metallic tube, so that the guidewire lumen can pass coaxially through the inner actuating member. Alternatively, the inner actuating member may be a thin wire which runs parallel to and alongside the guidewire lumen.[0028]
• The stenotic material removal mechanism is operated by rotating the cutting head to remove the stenotic material from within the stent by the cutting action of the longitudinally oriented cutting blades. The rotating action of the blades may be accompanied by axially advancing or withdrawing the cutting head through the stenosis and/or by expanding the width or diameter of the cutting head. In accordance with the methods described above, one or more of the longitudinally oriented cutting blades includes a sensing means for sensing the proximity or contact between the cutting blades and the stent. The sensing means may be in the form of one or more electrode wires which are positioned on the cutting blades. When the sensing means detects sufficient proximity or contact between the cutting blades and the stent to indicate effective recanalization of the stenosis, the cutting head is deactivated and withdrawn from the stented vessel.[0029]
• Additionally or alternatively, energy, such as electrical, ultrasonic or thermal energy may be applied through the cutting blades to assist in removal of the stenotic material and/or for denaturing the remaining tissue to discourage further restenosis at the treatment site. In this case, electrodes used for heating or ablation can serve double duty as the sensing means electrodes for monitoring proximity or contact with the stent.[0030]
• In a third illustrative embodiment of the apparatus, the stenotic material removal mechanism is in the form of a blade which is extendible and retractable from within a cavity or lumen located near the distal end of the inner catheter. The blade is actuated to extend radially from the inner catheter by advancing an actuating member which extends through an inner lumen of the catheter to an advancement knob located near the proximal end of the inner catheter. Preferably, the blade maintains an approximately parallel orientation to the inner catheter as it extends and retracts in the radial direction. The stenotic material removal mechanism may operate by cutting action, in which case the blade is preferably shaped like a flattened wire with one or both lateral edges of the wire sharpened into a cutting edge, or it may operate by application of electrical or thermal energy, in which case the blade may be flat, round or any convenient shape.[0031]
• The stenotic material removal mechanism is operated by advancing the actuating member to extend the blade radially from the inner catheter, then rotating the catheter about its longitudinal axis to remove the stenotic material from within the stent. The rotating action of the blades may be accompanied by axially advancing or withdrawing the inner catheter through the stenosis. A sensing means for sensing the proximity or contact between the blade and the stent is positioned on the blade of the catheter. The sensing means may be in the form of one or more electrode wires which are positioned on the cutting blade. If the stenotic material removal mechanism operates by electrical or thermal heating or ablation, the heating or ablation electrodes can also serve as the sensing means electrodes for monitoring proximity or contact with the stent. When the sensing means detects sufficient proximity or contact between the blade and the stent to indicate effective recanalization of the stenosis, the cutting blade is deactivated and withdrawn from the stented vessel.[0032]
• In a fourth illustrative embodiment of the apparatus, the stenotic material removal mechanism has a cutter positioned within a housing. The housing has a side aperture which exposes the cutter and an inflatable balloon located on the back of the housing opposite the side aperture. The balloon can be inflated to increase the width or diameter of the stenotic material removal mechanism and thereby to control the depth of cut and the diameter of the blood flow channel created. The cutter may be a cup-shaped rotating blade, a rotating linear or helical blade, a rotating abrasive burr or a reciprocating or axially movable cutting blade. Additionally or alternatively, medications, chemicals, ionizing radiation or energy, such as electrical, magnetic, ultrasonic, hydraulic, pulsed hydraulic, laser or thermal energy may be applied through the cutter to assist in removal of the stenotic material and/or for denaturing the remaining tissue to discourage further restenosis at the treatment site.[0033]
• The stenotic material removal mechanism is positioned by advancing the inner catheter so that the side aperture of the housing is situated across the stenosis within the stent and inflating the balloon to press the side aperture against the stenotic material. Then, the cutter is actuated by rotating and/or by axially advancing the cutter within the housing to remove stenotic material from within the stent. A sensing means for sensing the proximity or contact between the stenotic material removal mechanism and the stent is positioned on the cutter and/or the housing of the catheter. Again, the sensing means may be in the form of one or more electrode wires which are positioned on the cutter and/or the housing. If the stenotic material removal mechanism operates by electrical or thermal heating or ablation, the heating or ablation electrodes can also serve as the sensing means electrodes for monitoring proximity or contact with the stent. When the sensing means detects sufficient proximity or contact between the cutter and the stent to indicate the desired depth of cut, the cutter is deactivated and withdrawn or directed to another part of the stenosis within the stented portion of the vessel.[0034]
• In a fifth illustrative embodiment of the apparatus, the stenotic material removal mechanism has a rotating cutting head attached to a hollow drive cable which is coaxially and rotatably positioned over a guidewire. The rotating cutting head is typically spherical or ovoid in shape and has cutting blades, teeth or abrasive particles on its exterior surface. Optionally, the inner catheter or guidewire may have a bend or a steering mechanism close to its distal end for directing the cutting head against the stenotic material within the stent. Alternatively or additionally, the cutting head may also have control means for adjusting the outer diameter of the cutting head. A sensing means for sensing the proximity or contact between the cutting head and the stent is positioned on the cutting head. The sensing means may be in the form of one or more electrodes which are positioned on the cutting head.[0035]
• The stenotic material removal mechanism is operated by advancing the inner catheter so that the cutting head is positioned within the stenosis, then rotating the drive cable and the cutting head to remove stenotic material from within the stent. The rotating action of the cutting head may be accompanied by axially advancing or withdrawing the cutting head through the stenosis. The cutting blades, teeth or abrasive particles on the exterior surface of the cutting head comminute or pulverize the stenotic material into fine particles that will not cause embolization downstream of the treatment site. The optional bend or steering mechanism of the inner catheter or guidewire may be used for directing the cutting head against the stenotic material within the stent. Alternatively, the control means may be used for adjusting the diameter of the cutting head to achieve effective recanalization of the stented artery. When the sensing means indicates sufficient proximity or contact between the cutting head and the stent, the cutting head is deactivated and withdrawn or directed to another part of the stenosis within the stented portion of the vessel.[0036]
• Each embodiment of the apparatus of the present invention will also include a monitoring means which couples to the sensor means of the catheter system through a connection fitting at the proximal end of the inner catheter. In one preferred embodiment, the monitoring means includes a voltage source that generates a direct or alternating current reference voltage which is applied to a unipolar electrode or applied between two bipolar electrodes positioned on the stenotic material removal mechanism, and an electrical monitor for monitoring the electrical conditions at the sensor electrode or electrodes. The electrical monitor may monitor the current leakage at the unipolar or bipolar sensor electrode to detect contact between the sensor electrode and a metallic stent and/or monitor the complex impedance across bipolar electrodes to detect proximity between the sensor electrodes and a metallic stent. The monitoring means may optionally include control means for deactivating the stenotic material removal mechanism when an unsafe condition that might lead to stent damage is detected or when the sensing means indicates an appropriate endpoint for the stenotic material removal process has been reached.[0037]
• In an alternative embodiment, the monitoring means may be an optical sensor that includes an optical fiber which transmits a reference beam to a distal end of the catheter and directs it at the inner surface of the vessel close to the stenotic material removal mechanism. A photodetector detects the intensity and/or the wavelength of the light reflected back from the inner surface of the vessel through the optical fiber. A difference in reflectivity between the tissue of the vessel wall and the stent material allows the photodetector to detect proximity and/or contact between the stenotic material removal mechanism and the stent. In another alternative embodiment, the monitoring means may be a nonimaging, A mode ultrasonic scanner which generates a pulsed ultrasonic signal in a transducer mounted on or near the stenotic material removal mechanism. Differences in the acoustic impedance between the stent material and the arterial tissue or stenosis will cause echoes of the ultrasonic signal back to the transducer. The A mode ultrasonic scanner analyzes the amplitude and timing of the echoes detected by the ultrasonic transducer to measure the depth of the stent within the vessel wall. These two alternative embodiments of the monitoring means are useful for detection of both metallic and nonmetallic stents.[0038]
• Preferably, each embodiment of the apparatus of the present invention will also include a motor drive unit which attaches at the proximal end of the catheter system. The motor drive unit houses a drive motor which is mechanically coupled to the inner catheter or the drive cable of the various embodiments to rotate and/or axially translate the stenotic material removal mechanism. For use with the first four embodiments of the apparatus described above, the drive motor is preferably a motor or gear motor which operates at relatively low speed for rotating the various cutters at a speed from 500 to 2000 rpm. For use with the fifth embodiment of the apparatus described above, the drive motor is preferably a high speed motor which rotates the cutting head at a speed from 2000 to 150000 rpm for effective comminution of the stenotic material. Alternatively, the stenotic material removal mechanism may be operated by hand.[0039]
• Optionally, the apparatus of the present invention may further comprise means for collecting and withdrawing the removed stenotic material from the blood vessel. The means for collection and withdrawal of the removed stenotic material may include an irrigation and/or aspiration apparatus attached respectively to the inner and outer catheters of the catheter assembly. Additionally, embolic filters or occlusion balloons may be included in the catheter system for placement upstream and/or downstream of the treatment site. An embolic filters and other stenotic material capture means are described for use in conjunction and/or in a combined apparatus with the stenotic material removal mechanism.[0040]
BRIEF DESCRIPTION OF THE DRAWINGS
• FIG. 1 is a generalized schematic diagram of the apparatus of the present invention showing the different components of the catheter system.[0041]
• FIG. 2 is a side view of the distal portion of a first embodiment of the apparatus of the present invention having a stenotic material removal mechanism having with a plurality of longitudinally oriented cutting blades shown in the contracted position.[0042]
• FIG. 3 is a side view of the apparatus of FIG. 2 showing the stenotic material removal mechanism in the expanded position.[0043]
• FIG. 4 is a distal end view of the apparatus of FIG. 2 with the stenotic material removal mechanism in the expanded position.[0044]
• FIG. 5 is a magnified cutaway view of a cutting blade of the apparatus of FIG. 2 showing the sensor electrodes.[0045]
• FIG. 6 is a cross section of the cutting blade of FIG. 5.[0046]
• FIG. 7 is a side view of the distal portion of a second embodiment of the apparatus of the present invention having a stenotic material removal mechanism having with a plurality of helically configured cutting blades shown in the expanded position.[0047]
• FIG. 8 is an enlarged distal end view of the apparatus of FIG. 7 with the stenotic material removal mechanism in the expanded position.[0048]
• FIG. 9 is a magnified cutaway view of a cutting blade of the apparatus of FIG. 7 showing the sensor electrodes.[0049]
• FIG. 10 is a cross section of the cutting blade of FIG. 9.[0050]
• FIG. 11 is a side view of the distal portion and the proximal portion of a third embodiment of the apparatus of the present invention having a stenotic material removal mechanism with an extendible and retractable blade shown in the retracted position.[0051]
• FIG. 12 is a side view of the apparatus of FIG. 11 showing the stenotic material removal mechanism in the extended position.[0052]
• FIG. 13 is a magnified cross section of the cutting blade of the apparatus of FIG. 11 showing the sensor electrodes.[0053]
• FIG. 14 is a side view of the distal portion of a fourth embodiment of the apparatus of the present invention showing a directional stenotic material removal mechanism with the balloon in the inflated position.[0054]
• FIG. 15 is a top view of the apparatus of FIG. 14.[0055]
• FIG. 16 is a side view of the distal portion and the proximal portion of a fifth embodiment of the apparatus of the present invention having an abrasive cutting head.[0056]
• FIG. 17 is a magnified view of the cutting head of the apparatus of FIG. 16 showing the sensor electrodes.[0057]
• FIGS. 18, 19,[0058]20 and21 are a series of drawings illustrating the method of the present invention using the apparatus of FIG. 2.
• FIGS. 22, 23,[0059]24 and25 are a series of drawings illustrating an alternate method of the present invention using the apparatus of FIG. 2.
• FIGS. 26, 27,[0060]28 and29 are a series of drawings illustrating another alternate method of the present invention using the apparatus of FIG. 2.
• FIGS. 30, 31 and[0061]32 are a series of drawings illustrating the operation of an optional embolic filter apparatus which may be used in conjunction with the method of the present invention.
• FIGS. 33, 34,[0062]35 and36 are a series of drawings illustrating the operation of a combined stenotic material removal mechanism and stenotic material capture mechanism according to the present invention.
• FIGS. 37, 38 and[0063]39 are a series of drawings illustrating the operation of an alternate combined stenotic material removal mechanism and stenotic material capture mechanism according to the present invention.
• FIG. 40 illustrates a kit including a catheter, a package and instructions for use according to the present invention.[0064]
DESCRIPTION OF THE SPECIFIC EMBODIMENTS
• FIG. 1 is a generalized schematic diagram of the apparatus of the present invention. The apparatus comprises a catheter system designed to facilitate percutaneous removal of stenotic material from within a previously stented region of the vasculature without damaging or disrupting the implanted stent. In particular, the catheter system includes an[0065]inner catheter shaft50 having a proximal end and a distal end, with a stenoticmaterial removal mechanism52 mounted near the distal end of theinner catheter shaft50 and a sensing means54 for sensing when the stenoticmaterial removal mechanism52 is approaching or contacting the stent within the vascular wall. Theinner catheter shaft50 will preferably include a guidewire lumen for introduction of the catheter system over asteerable guidewire56. Theinner catheter shaft50 may have additional lumens or actuating mechanisms associated with the stenoticmaterial removal mechanism52. Various embodiments of the stenoticmaterial removal mechanism52 will be more fully described below. In embodiments where the stenoticmaterial removal mechanism52 comprises resilient members which are radially compressible, the catheter system may also include an optionaltubular sheath58 which serves to maintain the stenoticmaterial removal mechanism52 in a compressed state as it is maneuvered to, and potentially across, the stenosis. Thetubular sheath58 may be split or scored along its length so that is can be easily removed from around theinner catheter shaft50 and discarded after the stenoticmaterial removal mechanism52 has been maneuvered into place. The catheter system will usually further include anouter catheter tube60 having a proximal end, a distal end and an inner lumen. The outer catheter tube will usually have ahemostasis valve62 and anaspiration port64 near its proximal end so that dislodged stenotic material can be aspirated from the vasculature. Theouter catheter tube60 may optionally have selective or subselective curves formed near the distal end of theouter catheter tube60 for directing and maneuvering the catheter system through the vasculature to the site of the stenosis. In addition, anouter guiding catheter66, for example a coronary guiding catheter, may be used for guiding the catheter system into the desired part of the vasculature and supporting it during the treatment. The guidingcatheter66 will have a Y-fitting with ahemostasis valve68 connected at its proximal end.
• Typically, the[0066]outer catheter60 will have an overall length of approximately 60 cm to 120 cm, depending on the location of the vessel to be treated in the patient's body and the point of entry into the vasculature. For application in peripheral vessels or for application in the coronary arteries via a brachial artery insertion, theouter catheter60 will typically have an overall length of approximately 60 cm to 90 cm. For application in the coronary arteries via a percutaneous femoral artery insertion, theouter catheter60 will typically have an overall length of approximately 90 cm to 120 cm. Theinner catheter50 should have an overall length somewhat longer than theouter catheter60 so that the stenoticmaterial removal mechanism52 can be extended out from the distal end of theouter catheter60. Theinner catheter50 should therefore have an overall length of approximately 80 cm to 150 cm so that it can be extended 20 cm to 30 cm beyond the distal end of theouter catheter60.
• In a preferred embodiment, the catheter system includes a[0067]motor drive unit70 which attaches at the proximal end of theinner catheter shaft50. Themotor drive unit70 houses a drive motor72 which is mechanically coupled to theinner catheter shaft50 to rotate and/or axially translate the stenoticmaterial removal mechanism52 for removing stenotic material from within the stented vessel. The drive motor72 may be a low speed motor or gear motor which operates at a speed from 500 to 2000 rpm or a high speed motor or a turbine which operates at a speed from 2000 to 150000 rpm. The operating speed of the drive motor72 will be chosen according to the particular needs of the stenoticmaterial removal mechanism52, as will be discussed in more detail below. In alternative embodiments, the stenoticmaterial removal mechanism52 may be operated by hand.
• The catheter system will also include a monitoring means[0068]80 which couples to the sensor means54 of the catheter system through a connection fitting82 on the proximal end of theinner catheter shaft50. Typically, the connection fitting82 will electrically couple to the monitoring means80 through acommutator84 which is part of themotor drive unit70. Alternatively, the monitoring means80 may be miniaturized and incorporated as an integral part of themotor drive unit70. The monitoring means80 may include anaudible alarm85 and avisual alarm86 to indicate contact between the stenoticmaterial removal mechanism52 and the stent and/or avisual gauge88 of the proximity of the stenoticmaterial removal mechanism52 to the stent. The structure and function of the sensor means54 and the monitoring means80 will be discussed in further detail below.
• Optionally, the catheter system may further include an[0069]embolic filter90 which may be coaxially deployed over thesame guidewire56 as the rest of the catheter system. Alternatively, embolic filters and/or occlusion balloons may be deployed on separate catheters for placement upstream and/or downstream of the treatment site.
• The stenotic material removal mechanism which is disposed near the distal end of the inner catheter shaft may take one of several possible forms. The distal portion of a first illustrative embodiment of an inner catheter according to the apparatus of the present invention is depicted in FIGS.[0070]2-6. In this embodiment, the stenotic material removal mechanism is in the form of a cuttinghead100 having a plurality of longitudinally oriented cuttingblades102 arranged radially about the central axis of theinner catheter shaft104. The cuttinghead100 is shown in a contracted position in FIG. 2 with thecutting blades102 compressed closely around the central axis of theinner catheter shaft104. FIG. 3 shows the cuttinghead100 in an expanded position with thecutting blades102 extending radially outward from the central axis of theinner catheter shaft104. FIG. 4 shows a distal end view of the cuttinghead100 in the expanded position. In variations of this embodiment, there may be two, three, four or more longitudinally oriented cuttingblades102. Each of thecutting blades102 is preferably shaped like a flattened wire with one or bothlateral edges110,112 of the wire sharpened into a cutting edge, as shown in the cross section of FIG. 6. The wire-shapedcutting blades102 are resilient so that they can expand radially outward from the central axis of theinner catheter shaft104. Preferably, the wire-shapedcutting blades102 maintain an approximately parallel orientation to one another as they expand and contract in the radial direction so that the overall configuration of the cuttinghead100 is roughly cylindrical. Thecutting blades102 are preferably made of a strong and resilient biocompatible material capable of holding a sharp cutting edge. Suitable materials for thecutting blades102 include metals, such as stainless steel, titanium and nickel/titanium alloys, and cobalt alloys like Elgiloy and MP35. Composite constructions are also possible for thecutting blades102.
• The cutting[0071]head100 can be passively expandable, in which case the resilient wire-shapedcutting blades102 are treated by coldworking or heat treatment to have an elastic memory that predisposes them to expand outward when they are released from the radial constraint of thetubular sheath58 which was shown in FIG. 1. Alternatively, the cuttinghead100 can be configured to be actively and controllably expandable. In this case, the resilient wire-shapedcutting blades102 are attached on their proximal ends to theinner catheter shaft104 and on their distal ends to aninner actuating member106 which is coaxially slidably with respect to theinner catheter shaft104. When theinner actuating member106 is moved proximally with respect to theinner catheter shaft104, thecutting blades102 expand radially outward from the central axis of theinner catheter shaft104, and when theinner actuating member106 is moved distally with respect to theinner catheter shaft104, thecutting blades102 contract radially inward toward the central axis of theinner catheter shaft104. Thecutting blades102 may be treated by coldworking or heat treatment to have an elastic memory so that they are biased toward the contracted position so that the cuttinghead100 will contract easily for advancing it across tight stenotic lesions, or toward a fully expanded position so that the cuttinghead100 will be easy to deploy. Alternatively, the resilient wire-shapedcutting blades102 may be treated so that they are biased toward an intermediate position which corresponds with a nominal expanded diameter. Theinner actuating member106 may be tubular, such as a polymer tube, a hollow flexible cable or a flexible metallic tube, so that alumen108 for aguidewire56 can pass coaxially through theinner actuating member106. Alternatively, the inner actuating member may be a thin wire which runs parallel to and alongside the guidewire lumen.
• The[0072]inner catheter shaft104 is a tubular structure with aninner lumen114 for passing theguidewire56 and, in some embodiments, theinner actuating member106 through. Theinner catheter shaft104 may be a polymer tube, a braid reinforced polymer tube, a hollow flexible cable, such as a multifilar wound cable, or a flexible metallic tube. Theinner catheter shaft104 acts as a flexible drive shaft for transmitting rotation and torque from the drive motor72 (FIG. 1) to the cuttinghead100. The stenotic material removal mechanism is operated by rotating the cuttinghead100 to remove the stenotic material from within the stent by the cutting action of the longitudinally oriented cuttingblades102. The rotating action of theblades102 may be accompanied by axially advancing or withdrawing the cuttinghead100 through the stenosis and/or by expanding the width or diameter of the cuttinghead100. The cuttinghead100 should be expandable over a range of approximately 2 mm to 5 mm for use in stented coronary arteries or as high as 6 mm for use in stented vein grafts and even larger for use in stented peripheral vessels and other stented body structures. The cuttinghead100 should contract to as small a diameter as possible for passing through tightly stenotic lesions, preferably to a diameter smaller than 2 mm, more preferably to a diameter smaller than 1 mm. The effective cutting length of the cuttinghead100 is preferably within the range of approximately 10 mm to 40 mm for use in stented coronary arteries and can be longer for use in stented peripheral vessels.
• One or more, or all, of the longitudinally oriented cutting[0073]blades102 includes a sensing means for sensing the proximity or contact between the cuttingblades102 and the stent. In this illustrative embodiment, the sensing means are provided in the form of one ormore electrode wires116,118 which are positioned on the cutting blades, as best seen in FIGS. 5 and 6. Thesensing electrodes116,118 may extend the full length of thecutting blades102 or only a portion of it, or thesensing electrodes116,118 may be arranged to provide a plurality of sensing locations along the length of thecutting blades102. In a first implementation of this embodiment, one or more open, exposedelectrodes116,118 are located on the surface of thecutting blades102. Alternatively, thecutting blades102 themselves may serve as the sensor electrodes. A direct or alternating current reference voltage is applied to a unipolar electrode or applied between two bipolar electrodes, and the current leakage of the electrode or electrodes is monitored. When one or more of theelectrodes116,118 contacts the metallic stent, the leakage current increases indicating that the stenotic material has been removed down to the stent support members for effective recanalization of the stenosis within that portion of the stent. A second implementation of this embodiment involves two capacitively coupledbipolar electrodes116,118 which are located on the surface of thecutting blades102. An alternating current reference voltage is applied between thebipolar electrodes116,118, and the complex impedance between the electrodes is monitored. As theelectrodes116,118 approach the metallic stent, the capacitive and inductive characteristics of the electrode circuit change, which can be detected as a change in the complex impedance between the electrodes. When the complex impedance between the electrodes has changed a sufficient amount to indicate effective recanalization of the stenosis within that portion of the stent, the stenotic material removal mechanism may be deactivated or advanced along the stenosis as appropriate. These two implementations can be combined by applying an alternating current reference voltage between two exposedbipolar electrodes116,118, and monitoring the complex impedance between the electrodes to indicate when the stenotic material removal mechanism is approaching the metallic stent, then when one or more of the electrodes contacts the metallic stent, it will ground to the stent which can be detected as an extreme change in the complex impedance or as a rise in the leakage current. Thus, the sensing means can be used to separately indicate proximity and contact between the cuttingblades102 and the stent. The sensing means can operate with very low voltage and current that will not create any adverse physiological effects on the vascular wall or the tissues and nerve pathways of the heart.
• The distal portion of a second illustrative embodiment of an inner catheter according to the apparatus of the present invention is depicted in FIGS.[0074]7-10. In this embodiment, the stenotic material removal mechanism is in the form of a cuttinghead120 having a plurality of helically configured cuttingblades122 arranged radially about the central axis of theinner catheter shaft124, as shown in FIG. 7. FIG. 8 shows an enlarged distal end view of the cuttinghead120 in the expanded position. In variations of this embodiment, there may be two, three, four or more helically configured cuttingblades122. Preferably, each of thecutting blades122 is shaped like a flattened wire with one or bothlateral edges130,132 of the wire sharpened into a cutting edge, as shown in the cross section of FIG. 10. Preferably, the helically configured cuttingblades122 maintain an approximately parallel orientation to one another as they expand and contract in the radial direction so that the overall configuration of the cuttinghead120 is roughly cylindrical. Thecutting blades122 are made of a strong and resilient biocompatible material capable of holding a sharp cutting edge, such as stainless steel, titanium and nickel/titanium alloys, and cobalt alloys like Elgiloy and MP35, or a composite construction.
• As with the first embodiment, the cutting[0075]head120 can be passively expandable or actively and controllably expandable. In the latter case, the helically configured cuttingblades122 are attached on their proximal ends to theinner catheter shaft124 and on their distal ends to aninner actuating member126 which slides proximally and distally with respect to theinner catheter shaft124 to expand and contract diameter of the cuttinghead120, respectively. Thecutting blades122 may be treated by coldworking or heat treatment to have an elastic memory so that they are biased toward the contracted position, the expanded position or an intermediate position. Theinner actuating member126 may be tubular, such as a polymer tube, a hollow flexible cable or a flexible metallic tube, so that alumen128 for aguidewire56 can pass coaxially through theinner actuating member126. Alternatively, the inner actuating member may be a thin wire which runs parallel to and alongside the guidewire lumen.
• The[0076]inner catheter shaft124 is a tubular structure with aninner lumen134 for passing theguidewire56 and, in some cases, theinner actuating member126 through. Theinner catheter shaft124 may be a polymer tube, a braid reinforced polymer tube, a hollow flexible cable, such as a multifilar wound cable, or a flexible metallic tube that serves as a flexible drive shaft for transmitting rotation and torque from the drive motor72 (FIG. 1) to the cuttinghead120. The stenotic material removal mechanism is operated by rotating the cuttinghead120 to remove the stenotic material from within the stent by the cutting action of the helically configured cuttingblades122. The rotating action of theblades122 may be accompanied by axially advancing or withdrawing the cuttinghead120 through the stenosis and/or by expanding the width or diameter of the cuttinghead120. The cuttinghead120 should be expandable over a range of approximately 2 mm to 5 mm for use in stented coronary arteries or as high as 6 mm for use in stented vein grafts and even larger for use in stented peripheral vessels and other stented body structures. The cuttinghead120 should contract to as small a diameter as possible for passing through tightly stenotic lesions, preferably to a diameter smaller than 2 mm, more preferably to a diameter smaller than 1 mm. The effective cutting length of the cuttinghead120 is preferably within the range of approximately 10 mm to 40 mm for use in stented coronary arteries and can be longer for use in stented peripheral vessels.
• One or more, or all, of the helically configured cutting[0077]blades122 includes a sensing means for sensing the proximity or contact between the cuttingblades122 and the stent. As shown in FIGS. 9 and 10, the sensing means may be in the form of one ormore electrode wires136,138 which are positioned on the surface of thecutting blades122. Thesensing electrodes136,138 may extend the full length of thecutting blades122 or only a portion of it, or thesensing electrodes136,138 may be arranged to provide a plurality of sensing locations along the length of thecutting blades122. As in the first embodiment described above, theelectrodes136,138 may be exposed or insulated and unipolar or bipolar. Alternatively, thecutting blades122 themselves may serve as the sensor electrodes. Contact and/or proximity between the cuttingblades122 and the stent can be monitored by sensing the leakage current and/or the complex impedance of the sensor electrode circuit. When the sensing means detects sufficient proximity or contact between the cuttingblades122 and the stent to indicate effective recanalization of the stenosis within that portion of the stent, the cuttinghead120 may be deactivated or advanced along the stenosis as appropriate.
• The distal portion and the proximal portion of a third illustrative embodiment of an inner catheter according to the apparatus of the present invention is depicted in FIGS.[0078]11-13. In this embodiment, the stenotic material removal mechanism is in the form of ablade140 which is extendible and retractable from within acavity142 located near the distal end of theinner catheter shaft144. Theblade140 is actuated to extend radially from theinner catheter shaft144 by advancing an actuatingmember146 which extends through aninner lumen148 of the catheter to anadvancement knob152 which is located on ahandle assembly150 near the proximal end of theinner catheter shaft144. FIG. 11 is a side view of the inner catheter with theblade140 on the distal portion of theinner catheter shaft144 and theadvancement knob152 on theproximal handle assembly150 in the retracted position. FIG. 12 is a side view of the inner catheter with theblade140 and theadvancement knob152 in the extended position. Preferably, theblade140 maintains an approximately parallel orientation to theinner catheter shaft144 as it extends and retracts in the radial direction. Theblade140 may be treated by coldworking or heat treatment to have an elastic memory so that it is biased toward the retracted position, in which case theblade140 will be extended by a compression force applied to the actuatingmember146 by theadvancement knob152 on thehandle assembly150. Alternatively, theblade140 may be treated to be biased toward the extended position, in which case theblade140 will be self-extending and will be retracted by a tensile force applied to the actuatingmember146 by theadvancement knob152. Accordingly, the actuatingmember146 may be a thin wire, a flexible cable, or a thin tensile filament.
• The[0079]inner catheter shaft144 is a tubular structure with aninner lumen162 which extends to the distal end for passing aguidewire56 through for directing the catheter into and across a stented region in an artery. Theinner catheter shaft144 may be a polymer tube, a braid reinforced polymer tube, a hollow flexible cable, such as a multifilar wound cable, or a flexible metallic tube. Preferably, theinner catheter shaft144 has sufficient torsional rigidity to serve as a flexible drive shaft for transmitting rotation and torque from theproximal handle assembly150 to theblade140 on the distal end of theinner catheter shaft144. The torque may be applied to theproximal handle assembly150 manually by the operator or theproximal handle assembly150 may include a drive motor72, as in FIG. 1.
• The stenotic material removal mechanism is operated by advancing the actuating[0080]member146 to extend theblade140 radially from theinner catheter shaft144, then rotating thecatheter shaft144 about its longitudinal axis to remove the stenotic material from within the stent. The rotating action of theblade140 may be accompanied by axially advancing or withdrawing the inner catheter through the stenosis. In one preferred embodiment, the stenotic material removal mechanism of the inner catheter operates by cutting action, in which case theblade140 is preferably shaped like a flattened wire with one or bothlateral edges154,156 of the wire sharpened into a cutting edge, as shown in the magnified cross section of the cutting blade in FIG. 13. Thecutting blade140 is made of a strong and resilient biocompatible material capable of holding a sharp cutting edge, such as stainless steel, titanium and nickel/titanium alloys, and cobalt alloys like Elgiloy and MP35, or a composite construction. Thecutting blade140 includes a sensing means for sensing the proximity or contact between thecutting blade140 and the stent. As shown in FIG. 13, the sensing means may be in the form of one ormore electrode wires158,160 which are positioned on the surface of thecutting blade140. Theelectrodes158,160 may be exposed or insulated and unipolar or bipolar. Alternatively, thecutting blade140 itself may serve as a unipolar sensor electrode. Contact and/or proximity between thecutting blade140 and the stent can be monitored by sensing the leakage current and/or the complex impedance of the sensor electrode circuit. When the sensing means detects sufficient proximity or contact between thecutting blade140 and the stent to indicate effective recanalization of the stenosis within that portion of the stent, the cuttinghead120 may be deactivated or advanced along the stenosis as appropriate.
• Additionally or alternatively, energy, such as electrical, ultrasonic or thermal energy may be applied through the[0081]blade140 to assist in removal of the stenotic material and/or for denaturing the remaining tissue to discourage further restenosis at the treatment site. In this case, electrodes used for heating or ablation can also serve as the sensing means electrodes for monitoring proximity or contact with the stent. If the device relies principally on ablation as the stenotic material removal technique, theblade140 need not be sharpened as shown, but may instead be flat, round or any convenient shape.
• The distal portion of a fourth illustrative embodiment of an inner catheter according to the apparatus of the present invention is depicted in FIGS.[0082]14-15. In this embodiment, the stenoticmaterial removal mechanism170 has acutter172 positioned within ahousing174. Thehousing174 has aside aperture176 which exposes thecutter172 and aninflatable balloon180 located on the back of thehousing174 opposite theside aperture176. Theballoon180 can be inflated with fluid injected through aballoon lumen182 to increase the width or diameter of the stenoticmaterial removal mechanism170 and thereby to control the depth of cut and the diameter of the blood flow channel created. Theballoon180 may be made of polyethylene, polyester, nylon or other polymeric materials. Thecutter172 may be a cup-shaped rotating blade, a rotating linear or helical blade, a rotating abrasive burr or an axially movable cutting blade, which is rotated and/or translated by adrive shaft178 that extends proximally through alumen186 within thecatheter shaft184. Additionally or alternatively, medications, chemicals, ionizing radiation or energy, such as electrical, magnetic, ultrasonic, hydraulic, pulsed hydraulic, laser or thermal energy may be applied through thecutter172 to assist in removal of the stenotic material and/or for denaturing the remaining tissue to discourage further restenosis at the treatment site.
• The[0083]catheter shaft184 is a tubular structure which includes theballoon lumen182 and thedrive shaft lumen186. Thecatheter shaft184 may be a polymer tube, a braid reinforced polymer tube, a hollow flexible cable, such as a multifilar wound cable, or a flexible metallic tube. Preferably, thecatheter shaft184 has sufficient torsional rigidity to rotate thehousing174 on the distal end of the catheter by rotating the proximal end of thecatheter shaft184. Thedrive shaft178 may be a hollow tube with aguidewire lumen190 which extends to the distal end for passing aguidewire56 through for directing the catheter into and across a stented region in an artery. Thedrive shaft178 may be a polymer tube, a braid reinforced polymer tube, a hollow flexible cable, such as a multifilar wound cable, or a flexible metallic tube. Alternatively, thedrive shaft178 may be a solid wire, in which case theguidewire lumen190 could be a separate lumen within thecatheter shaft184.
• In operation, the stenotic[0084]material removal mechanism170 is positioned by advancing and rotating the inner catheter so that theside aperture176 of thehousing174 is situated across the stenosis within the stent and inflating theballoon180 to press theside aperture176 against the stenotic material. Then, thecutter172 is actuated by rotating and/or by axially advancing thecutter172 within thehousing174 to remove stenotic material from within the stent. A sensing means188,188′ for sensing the proximity or contact between the stenoticmaterial removal mechanism170 and the stent is positioned on thecutter172 and/or thehousing174 of the catheter. Again, the sensing means188,188′ may be in the form of one or more electrode wires which are positioned on thecutter172 and/or thehousing174. If the stenoticmaterial removal mechanism170 operates by electrical or thermal heating or ablation, the heating or ablation electrodes can also serve as the sensing means electrodes for monitoring proximity or contact with the stent. When the sensing means detects sufficient proximity or contact between thecutter172 and the stent to indicate the desired depth of cut, thecutter172 is deactivated and withdrawn or directed to another part of the stenosis within the stented portion of the vessel.
• The distal portion of a fifth illustrative embodiment of an inner catheter according to the apparatus of the present invention is depicted in FIGS.[0085]16-17. In this embodiment, the stenotic material removal mechanism is rotatably and slidably received within aninner lumen212 of theinner catheter shaft210. The stenotic material removal mechanism has arotating cutting head200 attached to ahollow drive cable202 which is coaxially and rotatably positioned over aguidewire204. Therotating cutting head200 is typically spherical or ovoid in shape and has cutting blades, teeth orabrasive particles206 on its exterior surface. In one preferred embodiment, the cuttinghead200 has minute diamondabrasive particles206 embedded on its exterior surface. Thehollow drive cable202 is preferably a multifilar wound cable, but alternatively may be a polymer tube, a braid reinforced polymer tube, a hollow flexible cable or a flexible metallic tube. Optionally, theinner catheter shaft210 and/or theguidewire204 may have abend214,216 or other steering mechanism close to its distal end for directing the cuttinghead200 against the stenotic material within the stent. Alternatively or additionally, the cuttinghead200 may also have control means for adjusting the outer diameter of the cuttinghead200. Suitable cutting head diameter control means are described in U.S. Pat. Nos. 5,217,474 and 5,308,354, the specifications of which are hereby incorporated by reference in their entirety.
• A sensing means for sensing the proximity or contact between the cutting[0086]head200 and the stent is positioned on the cuttinghead200. The sensing means may be in the form of one ormore electrodes218,220 which are positioned on the cuttinghead200. One or moreelectrode lead wires222,224 may be incorporated into the multifilarhollow drive cable202. Theelectrodes218,220 may be exposed or insulated and unipolar or bipolar. Alternatively, the cuttinghead200 itself may serve as a unipolar sensor electrode and the multifilarhollow drive cable202 may serve as a single electrode lead wire.
• The stenotic material removal mechanism is operated by advancing the inner catheter so that the cutting[0087]head200 is positioned within the stenosis, then rotating thedrive cable202 and the cuttinghead200 to remove stenotic material from within the stent. Preferably, the cuttinghead200 is rotated with a high speed motor or turbine which rotates the cutting head at a speed from 2000 to 150000 rpm. The rotating action of the cuttinghead200 may be accompanied by axially advancing or withdrawing the cuttinghead200 through the stenosis. The cutting blades, teeth orabrasive particles206 on the exterior surface of the cuttinghead200 comminute, or pulverize, the stenotic material into fine particles that will not cause embolization downstream of the treatment site. Theoptional bend214,216 or steering mechanism of theinner catheter210 orguidewire204 may be used for directing the cuttinghead200 against the stenotic material within the stent. Alternatively, the control means may be used for adjusting the diameter of the cuttinghead200 to achieve effective recanalization of the stented artery. When the sensing means indicates sufficient proximity or contact between the cuttinghead200 and the stent, the cuttinghead200 is deactivated and withdrawn or advanced and directed to another part of the stenosis within the stented portion of the vessel.
• The function of the monitoring means[0088]80 of the catheter system, shown generically in FIG. 1, will be more fully appreciated in light of the foregoing descriptions of the various embodiments of the stenotic material removal mechanism and their related sensing means. In one preferred embodiment, the monitoring means includes a voltage source that generates a direct or alternating current reference voltage which is applied to a unipolar electrode or applied between two bipolar electrodes positioned on the stenotic material removal mechanism, and an electrical monitor for monitoring the electrical conditions at the sensor electrode or electrodes. The electrical monitor may monitor the current leakage at the unipolar or bipolar sensor electrode to detect contact between the sensor electrode and a metallic stent and/or monitor the complex impedance across bipolar electrodes to detect proximity between the sensor electrodes and a metallic stent. The monitoring means may optionally include control means for deactivating the stenotic material removal mechanism when an unsafe condition that might lead to stent damage is detected or when the sensing means indicates that an appropriate endpoint for the stenotic material removal process has been reached.
• In cases where the sensing means provides separate sensing electrodes on the different blades of the stenotic material removal mechanism or where a plurality of sensing locations are provided along the length of the stenotic material removal mechanism, the monitoring means[0089]80 can be designed to monitor each of the multiple electrodes or sensing locations simultaneously, or it can be designed to have an appropriate sampling rate for alternately monitoring each of the electrodes or sensing locations in sequence.
• In an alternative embodiment, the monitoring means may be an optical sensor that includes an optical fiber which transmits a reference beam to a distal end of the catheter and directs it at the inner surface of the vessel close to the stenotic material removal mechanism. A photodetector detects the intensity and/or the wavelength of the light reflected back from the inner surface of the vessel through the optical fiber. A difference in reflectivity between the tissue of the vessel wall and the stent material allows the photodetector to detect proximity and/or contact between the stenotic material removal mechanism and the stent.[0090]
• In another alternative embodiment, the monitoring means may be a nonimaging, A mode ultrasonic scanner which generates a pulsed ultrasonic signal in a transducer mounted on or near the stenotic material removal mechanism. Differences in the acoustic impedance between the stent material and the arterial tissue or stenosis will cause echoes of the ultrasonic signal back to the transducer. The A mode ultrasonic scanner analyzes the amplitude and timing of the echoes detected by the ultrasonic transducer to measure the depth of the stent within the vessel wall. These two alternative embodiments of the monitoring means are useful for detection of both metallic and nonmetallic stents. A nonimaging, A mode ultrasonic scanner of this type is much more economical than the imaging ultrasonic scanners which have been described in combination with various atherectomy devices. The high echogenicity of the stent material will give a reliable measure of the depth of the stent within the vessel wall without the need for expensive imaging equipment.[0091]
• FIGS. 18, 19,[0092]20 and21 are a series of drawings illustrating the method of the present invention. The method is illustrated and described using the apparatus of FIG. 1 with the stenotic material removal mechanism of FIGS.2-6 by way of example. This method may be applied using any of the various apparatus described above with minor modifications to the procedure. The catheter system of FIG. 1 is introduced into the patient's vascular system through a peripheral arterial access using the known techniques of an arterial cutdown, the Seldinger technique and/or an introducer sheath. The catheter system is maneuvered to the vicinity of a restenosed region within a previously stented region of the vasculature, for example within a coronary artery, using manipulations of the optional guidingcatheter66 and theouter catheter60 of the catheter system. Theinner catheter50 carrying the stenoticmaterial removal mechanism52 is positioned on one side of the restenosed stented region and thesteerable guidewire56 is maneuvered across the stenosis.
• Referring now to FIG. 18, the cutting[0093]head100 of the stenotic material removal mechanism is advanced from the inner catheter in the contracted position and positioned across the stenosis S within the stent T. The cuttinghead100 is then expanded within the stenosis S, as shown in FIG. 19. The expansion may occur passively, by withdrawing the optional tubular sheath58 (shown in FIG. 1) and allowing theresilient cutting blades102 of the cuttinghead100 to expand outward. Alternatively, the expansion may occur actively and controllably, by withdrawing theinner actuating member106 to expand thecutting blades102 outward and increase the width or diameter of the cuttinghead100. The stenotic material removal mechanism is then activated by rotating the cuttinghead100 to remove the stenotic material M from within the stenosis S. The cuttinghead100 may be manually rotated by the operator or by a drive motor72 within amotor drive unit70, as shown in FIG. 1. Medications, chemicals, ionizing radiation or energy, such as electrical, magnetic, ultrasonic, hydraulic, pulsed hydraulic, laser or thermal energy may be applied to assist in removal of the stenotic material M and/or for denaturing the remaining tissue to discourage further restenosis at the treatment site. The stenotic material M that is removed may be aspirated out through theaspiration port64 of the outer catheter60 (shown in FIG. 1). Theelectrodes116,118 of the sensing means located on thecutting blades102 monitor the proximity or contact between the cuttinghead100 and the stent T. When thecutting blades102 have approached close enough to the stent T to indicate effective recanalization of the stenosis S, as shown in FIG. 20, the stenotic material removal mechanism is deactivated. The catheter system is then withdrawn, leaving the stented region recanalized and open to renewed blood flow, as shown in FIG. 21.
• FIGS. 22, 23,[0094]24 and25 are a series of drawings illustrating an alternate method of the present invention. As above, the method is illustrated and described using the stenotic material removal mechanism of FIGS.2-6, but the method may be applied using most of the various apparatus described above with minor modifications to the procedure. In this alternative method, the catheter carrying the stenotic material removal mechanism is positioned on one side of the restenosed stented region. The cuttinghead100 of the stenotic material removal mechanism is extended from the catheter and advanced part-way into the stent T and thecutting blades102 are expanded outward, as shown in FIG. 22. Theelectrodes116,118 of the sensing means located on thecutting blades102 monitor the proximity or contact between the cuttinghead100 and the stent T so that the diameter of the cuttinghead100 can be accommodated to the internal diameter of the stent T. If the stenosis S does not extend all of the way to the end of the stent T, the expansion step can be performed while the cuttinghead100 is stationary. However, if necessary, the stenotic material removal mechanism can be activated by rotating the cuttinghead100 as thecutting blades102 expand outward to begin removing the stenotic material M while adjusting the diameter of the cuttinghead100 to the size of the stent T.
• The stenotic material M is removed from within the stent T by rotating the cutting[0095]head100 and advancing it through the stenosis S, as shown in FIGS. 23 and 24. The diameter of the cuttinghead100 can be held constant as it is advanced through the stenosis S or it can be adjusted continuously based on feedback from the sensing means. Medications, chemicals, ionizing radiation or energy, such as electrical, magnetic, ultrasonic, hydraulic, pulsed hydraulic, laser or thermal energy may be applied to assist in removal of the stenotic material M and/or for denaturing the remaining tissue to discourage further restenosis at the treatment site. The stenotic material M that is removed may be aspirated out through theaspiration port64 of the outer catheter60 (shown in FIG. 1). When the cuttinghead100 has passed all the way through the stenosis S, the stenotic material removal mechanism is deactivated and the catheter system is withdrawn, leaving the stented region recanalized and open to renewed blood flow, as shown in FIG. 25.
• This method can be effectively performed in the reverse direction, by advancing the cutting[0096]head100 all the way across the stenosis in a contracted or compressed state. The cuttinghead100 is then expanded within the far end of the stenosis S or within the vessel beyond the stenosis, using the sensing means to adjust the diameter of the cuttinghead100 to the size of the stent T. The cuttinghead100 is then rotated while withdrawing it toward the catheter to advance it through the stenosis S.
• FIGS. 26, 27,[0097]28 and29 are a series of drawings illustrating another alternate method of the present invention. Once again, the method is illustrated and described using the stenotic material removal mechanism of FIGS.2-6, but the method may be applied using most of the various apparatus described above with minor modifications to the procedure. In this alternative method, the catheter carrying the stenotic material removal mechanism is positioned on one side of the restenosed stented region. The cuttinghead100 of the stenotic material removal mechanism is extended from the catheter and advanced part-way into the stenosis S within the stent T, as shown in FIG. 26. Thecutting blades102 are then expanded outward within the stenosis S, either passively or actively and controllably as described above, to increase the width or diameter of the cuttinghead100. The stenotic material removal mechanism is then activated by rotating the cuttinghead100 to begin removing the stenotic material M from within the stenosis S, as shown in FIG. 27. Medications, chemicals, ionizing radiation or energy, such as electrical, magnetic, ultrasonic, hydraulic, pulsed hydraulic, laser or thermal energy may be applied to assist in removal of the stenotic material M and/or for denaturing the remaining tissue to discourage further restenosis at the treatment site. The stenotic material M that is removed may be aspirated out through theaspiration port64 of the outer catheter60 (shown in FIG. 1). Theelectrodes116,118 of the sensing means located on thecutting blades102 monitor the proximity or contact between the cuttinghead100 and the stent T. When thecutting blades102 have approached close enough to the stent T to indicate effective recanalization of that portion of the stenosis S, the cuttinghead100 is advanced farther into the stenosis S, as shown in FIG. 28. The stenotic material removal mechanism may be deactivated and advanced step-wise into the stenosis S by contracting or compressing the cuttinghead100, advancing it a short distance and expanding it again in a new portion of the stent T. Otherwise, the cuttinghead100 may be advanced continuously, relying on either the resiliency of thecutting blades102 or active control for adjusting the width or diameter of the cuttinghead100 as it advances. When the sensing means indicates that the new portion of the stent T has been effectively recanalized, the cuttinghead100 is advanced again along the stenosis S until the entire stented region has been recanalized, as shown in FIG. 29.
• This method can be effectively performed in the reverse direction, by advancing the cutting[0098]head100 all the way across the stenosis in a contracted or compressed state. The cuttinghead100 is then expanded within the far end of the stenosis S or within the vessel beyond the stenosis, either passively or actively and controllably as described above, to increase the width or diameter of the cuttinghead100. The cuttinghead100 is then rotated while withdrawing it toward the catheter to advance it through the stenosis in either a step-wise or continuous fashion. Medications, chemicals, ionizing radiation or energy, such as electrical, magnetic, ultrasonic, hydraulic, pulsed hydraulic, laser or thermal energy may be applied to assist in removal of the stenotic material and/or for denaturing the remaining tissue to discourage further restenosis at the treatment site. The sensing means is used to monitor the proximity or contact between the cuttinghead100 and the stent T in order to control the diameter and/or the rate of advancement of the cuttinghead100 for effective recanalization of the stenosis S within the stent T.
• The methods of the present invention will optionally further comprise collecting and withdrawing the removed stenotic material from the blood vessel. FIGS. 30, 31 and[0099]32 are a series of drawings illustrating the operation of an optionalembolic filter apparatus90 which may be used in conjunction with the method of the present invention. Theembolic filter apparatus90 may be arranged coaxially as part of the catheter system as shown in FIG. 1 and introduced through a single vascular access point and positioned distally to the treatment site. Alternatively,embolic filter apparatus90 may be arranged on a separate catheter which is introduced through a different vascular access point and positioned proximally or distally to the treatment site.
• In FIG. 30, the[0100]embolic filter90 is shown in its compacted position within atubular sheath92 as it is first introduced into the vasculature and advanced to or across the stenosis. In coaxial arrangements, thetubular sheath92 may be the same as thetubular sheath58 or theinner catheter50 of the catheter system of FIG. 1. Theembolic filter90 may be delivered coaxially over aseparate guidewire56, or it may be built integrally with aguidewire56 constructed especially for the purpose. Once theembolic filter90 is in position, thetubular sheath92 is withdrawn and theembolic filter90 is allowed to expand to the full diameter of the vessel, as shown in FIG. 31. The expansion can occur passively, or anactuation member94 may be used to actively expand theembolic filter90. Theembolic filter90 should be expandable over a range of approximately 2 mm to 5 mm for use in stented coronary arteries or as high as 6 mm for use in stented vein grafts and even larger for use in stented peripheral vessels and other stented body structures. Theembolic filter90 should contract to as small a diameter as possible for passing through tightly stenotic lesions, preferably to a diameter smaller than 2 mm, more preferably to a diameter smaller than 1 mm. Theembolic filter90 has a plurality ofstructural members96, which enclose and support a nonthrombogenicexpandable filter medium98. Thestructural members96 can be made of a metallic or polymeric material, and may be biased radially outward to assist in expansion of theembolic filter90. The expandable filter medium98 may be a porous foam material or it may be a fibrous filter medium such as polyester fiber, which, in its expanded state, has a pore size appropriate for capturing significant emboli which may be dislodged during the stenotic material removal process. The pore size of the expandable filter medium98 may advantageously be in the range of 0.01 to 0.2 mm to capture potential emboli. Once the stenotic material removal procedure has been completed, theembolic filter90 is compressed slightly, by passive or active means, and withdrawn into anouter catheter99, to capture the emboli without releasing them, as shown in FIG. 32. In coaxial arrangements, theouter catheter99 may be theinner catheter50 orouter catheter60 of the catheter system of FIG. 1. Theouter catheter99 and theembolic filter90 are then withdrawn from the patient's vasculature. In other alternative methods, embolic filters and/or occlusion balloons may be placed upstream and downstream of the treatment site to isolate or capture potential emboli.
• FIGS. 33, 34,[0101]35 and36 are a series of drawings illustrating a method and an apparatus according to the present invention that combine a stenotic material removal mechanism with an embolic filter for capturing stenotic material M which is removed from within the stent T. The apparatus has a cuttinghead300 which is mounted on the distal end of aninner catheter shaft302. The cuttinghead300 has a cuttingportion304 and a filtering ormaterial capturing portion306. In this illustrative embodiment, the cuttingportion304 is centrally located on the cuttinghead300 and thematerial capturing portion306 is located distal to it. The cuttinghead300 should be expandable over a range of approximately 2 mm to 5 mm for use in stented coronary arteries or as high as 6 mm for use in stented vein grafts and even larger for use in stented peripheral vessels and other stented body structures. The cuttinghead300 should contract to as small a diameter as possible for passing through tightly stenotic lesions, preferably to a diameter smaller than 2 mm, more preferably to a diameter smaller than 1 mm. The effective cutting length of the cuttingportion304 is preferably within the range of approximately 10 mm to 40 mm for use in stented coronary arteries and can be longer for use in stented peripheral vessels. Additionally or alternatively, the cuttinghead300 may also include a secondmaterial capturing portion306′ located proximally to the cuttingportion304. Alternatively, thematerial capturing portion306 may occupy the entire length of the cuttinghead300. The cuttingportion304 of the cuttinghead300 may take any one of the different forms described herein in connection with the various embodiments of the invention. For illustrative purposes, the cuttingportion304 is shown having a plurality of longitudinally oriented cuttingblades308, similar to those shown in FIGS.2-6. Alternatively, the cutting blades may be laterally or circumferentially oriented or helically configured, similar to those shown in FIGS.7-10, or any convenient geometry. Thecutting blades308 of the cuttinghead300 may be either passively or actively expandable, as described above.
• The[0102]material capturing portion306 preferably contains a nonthrombogenicexpandable filter medium310. The expandable filter medium310 may be a porous foam material or it may be a fibrous filter medium such as polyester fiber, which, in its expanded state, has a pore size appropriate for capturing significant emboli which may be dislodged during the stenotic material removal process. The pore size of the expandable filter medium310 may advantageously be in the range of 0.01 to 0.2 mm to capture potential emboli. Theexpandable filter medium310 is enclosed and supported by thecutting blades308 of the cuttinghead300. Additionally or alternatively, the expandable filter medium310 may include a membranous filter material that is attached to and suspended between the cuttingblades308 of the cuttinghead300. Suitable membranous filter materials include flexible woven, nonwoven or knitted filtration fabrics. Theexpandable filter medium310 occupies adistal portion306 and/or aproximal portion306′ of the cuttinghead300. Alternatively, the expandable filter medium310 may occupy the entire length of the cuttinghead300.
• In use, the catheter carrying the stenotic material removal mechanism is positioned on one side of the restenosed stented region. The cutting[0103]head300 is extended from the catheter and advanced across the stenosis S in the contracted position, as shown in FIG. 33. Theexpandable filter medium310 is compressed within the cuttinghead300. The cuttinghead300 is then expanded within the stenosis S, as shown in FIG. 34. The expansion may occur passively, by withdrawing a surrounding tubular sheath58 (shown in FIG. 1) and allowing theresilient cutting blades308 of the cuttinghead300 to expand outward. Alternatively, the expansion may occur actively and controllably, by operating an actuating mechanism to expand thecutting blades308 outward and increase the width or diameter of the cuttinghead300, as described above in connection with FIGS.2-6. Preferably, thefilter medium310 within thematerial capturing portion306 of the cuttinghead300 expands to a diameter at least as large or larger than the expanded diameter of the cuttingportion304 of the cuttinghead300. The stenotic material removal mechanism is then activated by rotating the cuttinghead300 to remove the stenotic material M from within the stenosis S. The cuttinghead300 may be rotated manually by the operator or by a drive motor72 within a -motor drive unit70, as shown in FIG. 1. Medications, chemicals, ionizing radiation or energy, such as electrical, magnetic, ultrasonic, hydraulic, pulsed hydraulic, laser or thermal energy may be applied to assist in removal of the stenotic material M and/or for denaturing the remaining tissue to discourage further restenosis at the treatment site. The stenotic material M that is removed is captured by thefilter medium310 within thematerial capturing portion306 of the cuttinghead300, as shown in FIG. 35.
• Preferably, the cutting[0104]head300 includes a sensing means, such as thesensor electrodes116,118 described above in connection with FIGS. 5 and 6, for sensing the proximity or contact between the cuttingblades308 of the cuttinghead300 and the stent T. When thecutting blades308 have approached close enough to the stent T to indicate effective recanalization of the stenosis S, as shown in FIG. 35, the stenotic material removal mechanism is deactivated. The cuttinghead300 and all of the stenotic material M captured by thefilter medium310 within thematerial capturing portion306 of the cuttinghead300 are then withdrawn into theouter catheter60, as shown in FIG. 36. The catheter system is then withdrawn from the patient, leaving the stented region recanalized and open to renewed blood flow.
• Alternatively, this cutting[0105]head300 with a combined stenotic material removal mechanism and stenotic material capture mechanism may be operated as a simple shearing body without a sensing means. In this alternative method, the cuttinghead300 may be rotated and/or translated within the stenosis S to dislodge stenotic material M from within an interface envelope defined by the stent T embedded within the vessel wall, as shown in FIG. 34. The cuttinghead300 may be expanded passively or actively to remove all of the stenotic material M from within the stent T. The stenotic material M that is removed is captured by thefilter medium310 within thematerial capturing portion306 of the cuttinghead300, as shown in FIG. 35. The cuttinghead300 and all of the stenotic material M captured by thefilter medium310 within thematerial capturing portion306 of the cuttinghead300 are then withdrawn into theouter catheter60, as shown in FIG. 36.
• FIGS. 37, 38 and[0106]39 are a series of drawings illustrating an alternate method and apparatus according to the present invention that also combine a stenotic material removal mechanism with a means for capturing the stenotic material M that is removed from within the stent T. The apparatus has ahead350 which is mounted on the distal end of aninner catheter shaft352. Thehead350 is a cage-like structure of counterwound or interwovenhelical elements356. Thehelical elements356 may comprise round filaments, ribbon filaments, or the like, made of a metallic or polymeric material. Thehelical elements356 are attached to adistal ring358 and to aproximal ring360 which is free to slide over theinner catheter shaft352. Thehelical elements356 may be treated by coldworking or heat treatment to have an elastic memory so that they are biased toward the expanded position, allowing thehead350 to be passively expanded. Alternatively, theproximal ring360 may optionally be attached to a rod, sleeve, orother means362 for axially translating theproximal ring360 to actively and controllably adjust the radius of thehead350. The cage-like structure of counterwound or interwovenhelical elements356 serves to capture dislodged stenotic material M that passes through the interstices between thehelical elements356.
• In use, the[0107]catheter60 carrying the stenotic material removal mechanism is positioned on one side of the restenosed stented region. Thehead350 is extended from the catheter and advanced across the stenosis S in a contracted position, as shown in FIG. 37. Thehead350 is then expanded within the stenosis S, either passively or actively and controllably as described above. The stenotic material removal mechanism is then activated by rotating and/or translating thehead350 within the stenosis S to remove stenotic material M from within the stent T, as shown in FIG. 38. Thehead350 may be rotated manually by the operator or by a drive motor72 within amotor drive unit70, as shown in FIG. 1. Thehead350 may operate by cutting action, abrasive action or shearing action. Alternatively or additionally, medications, chemicals, ionizing radiation or energy, such as electrical, magnetic, ultrasonic, hydraulic, pulsed hydraulic, laser or thermal energy may be applied to assist in removal of the stenotic material M and/or for denaturing the remaining tissue to discourage further restenosis at the treatment site. The stenotic material M that is dislodged passes through the interstices between thehelical elements356 and is captured within the cage-like structure of thehead350.
• Preferably, the[0108]head350 includes a sensing means for sensing the proximity or contact between thehelical elements356 of thehead350 and the stent T. As shown in FIG. 38, the sensing means may take the form of one or moresensor electrode wires366,368 interwoven among thehelical elements356 of thehead350. Alternatively, thehelical elements356 of thehead350 may serve as sensor electrodes themselves. When thehelical elements356 of thehead350 have approached close enough to the stent T to indicate effective recanalization of the stenosis S, as shown in FIG. 38, the stenotic material removal mechanism is deactivated. Thehead350 and all of the stenotic material M captured within the cage-like structure of thehelical elements356 are then withdrawn into theouter catheter60, as shown in FIG. 39. The interstices between thehelical elements356 of thehead350 contract as thehead350 is drawn into thecatheter60, helping to assure that the particles of dislodged stenotic material M remain captured within the catheter. The catheter system is then withdrawn from the patient, leaving the stented region recanalized and open to renewed blood flow.
• Alternatively, the[0109]head350 of this apparatus may be operated as a simple shearing body without a sensing means. In this alternative method, thehead350 may be rotated and/or translated within the stenosis S to dislodge stenotic material M from within an interface envelope defined by the stent T embedded within the vessel wall, as shown in FIG. 38. Thehead350 may be expanded passively or actively to remove all of the stenotic material M from within the stent T. The stenotic material M that is dislodged passes through the interstices between thehelical elements356 and is captured within the cage-like structure of thehead350. Thehead350 and all of the stenotic material M captured within it are then withdrawn into theouter catheter60, as shown in FIG. 39.
• Referring now to FIG. 40, a catheter kit according to the present invention comprises a catheter or[0110]catheter system370, often mounted on a board or in atray372, instructions for use (IFU)374, and apouch376 or other conventional package. A motor drive unit70 (FIG. 1) may be packaged together with the catheter kit or separately. The instructions for use (IFU)374 are typically part of a separate sheet or booklet which together with thecatheter370, is packaged within thepouch376 or other packaging material. The packaging and its contents will preferably be sterile or sterilizable. The instructions for use (IFU)374 will set forth method steps comprising the method(s) as described above.
• Although the method of the present invention has been described using the example of revascularizing restenosed coronary arteries, it should be noted that the methods and apparatus disclosed may be used for reopening any previously stented body passage which has been subject to restenosis or reclosure. Other body passages where these methods and apparatus may apply include the peripheral blood vessels, the urinary tract, the digestive tract and the respiratory tract.[0111]

Claims (70)

What is claimed is:

1. An apparatus for removing stenotic material from within a stent located within a body vessel, said apparatus comprising:

a stenotic material removal mechanism for removing stenotic material from within the stent,

sensor means associated with said stenotic material removal mechanism for sensing proximity or contact between said stenotic material removal mechanism and the stent,

whereby said sensor means is used to determine an unsafe condition or an appropriate endpoint for removal of stenotic material from within the stent based on the sensed proximity or contact between said stenotic material removal mechanism and the stent for effective recanalization of the body vessel.

2. The apparatus ofclaim 1 further comprising a control means for controlling a depth to which said stenotic material removal mechanism removes the stenotic material from within the stent.

3. The apparatus ofclaim 2 wherein said control means comprises a mechanism for diametrically expanding said stenotic material removal mechanism.

4. The apparatus ofclaim 1 further comprising a means for directing said stenotic material removal mechanism to remove stenotic material from a selected area within the stent.

5. The apparatus ofclaim 1 further comprising a means for diametrically expanding said stenotic material removal mechanism.

6. The apparatus ofclaim 1 wherein said stenotic material removal mechanism comprises at least one longitudinally oriented blade.

7. The apparatus ofclaim 1 wherein said stenotic material removal mechanism comprises a plurality of longitudinally oriented blades.

8. The apparatus ofclaim 7 wherein said longitudinally oriented blades are resiliently biased to expand radially outward from a central axis of said stenotic material removal mechanism.

9. The apparatus ofclaim 1 wherein said stenotic material removal mechanism comprises a plurality of helically configured blades.

10. The apparatus ofclaim 9 wherein said helically configured blades are resiliently biased to expand radially outward from a central axis of said stenotic material removal mechanism.

11. The apparatus ofclaim 1 wherein said stenotic material removal mechanism comprises a rotating blade.

12. The apparatus ofclaim 1 wherein said stenotic material removal mechanism comprises a rotating abrasive tool.

13. The apparatus ofclaim 1 wherein said stenotic material removal mechanism comprises a cage-like network of filaments.

14. The apparatus ofclaim 1 further comprising a monitoring means associated with said sensor means for monitoring the proximity or contact between said stenotic material removal mechanism and the stent.

15. The apparatus ofclaim 14 wherein said sensor means comprises at least one electrical conductor on an exterior of said apparatus and said monitoring means comprises a leakage current detector for detecting a leakage current when said at least one electrical conductor contacts said stent.

16. The apparatus ofclaim 14 wherein said sensor means comprises a first electrical conductor and a second electrical conductor on an exterior of said apparatus and said monitoring means comprises a leakage current detector for detecting a leakage current when said first electrical conductor and said second electrical conductor contacts said stent.

17. The apparatus ofclaim 14 wherein said sensor means comprises at least one electrical conductor within said apparatus and said monitoring means comprises a means for detecting a change in electrical impedance when said at least one electrical conductor approaches said stent.

18. The apparatus ofclaim 14 wherein said sensor means comprises a first electrical conductor and a second electrical conductor within said apparatus and said monitoring means comprises a means for detecting a change in electrical impedance when said first electrical conductor and said second electrical conductor approach said stent.

19. The apparatus ofclaim 14 wherein said monitoring means produces a signal indicative of the proximity or contact between said stenotic material removal mechanism and the stent.

20. The apparatus ofclaim 14 wherein said monitoring means includes means for deactivating said stenotic material removal mechanism when a predetermined level of proximity or contact between said stenotic material removal mechanism and the stent is detected.

21. The apparatus ofclaim 1 wherein said stenotic material removal mechanism is positioned at a distal portion of a first elongated catheter shaft.

22. The apparatus ofclaim 21 wherein said first elongated catheter shaft includes a lumen for passage of a guidewire therethrough.

23. The apparatus ofclaim 21 further comprising a second elongated catheter shaft positioned coaxially around said first elongated catheter shaft.

24. The apparatus ofclaim 23 wherein said second elongated catheter shaft includes an internal lumen for aspiration of stenotic material removed from within the stent.

25. The apparatus ofclaim 1 further comprising a stenotic material collection mechanism for collecting stenotic material removed from within the stent.

26. The apparatus ofclaim 25 wherein said stenotic material collection mechanism comprises an embolic filter positioned in operative association with said stenotic material removal mechanism.

27. The apparatus ofclaim 26 wherein said embolic filter is positioned coaxially with said stenotic material removal mechanism.

28. The apparatus ofclaim 25 wherein said stenotic material collection mechanism is positioned internally to said stenotic material removal mechanism.

29. An apparatus for removing stenotic material from within a stent located within a body vessel, said apparatus comprising:

a catheter shaft having a proximal end and a distal end,

a stenotic material removal mechanism, and

means coupled to the stenotic material removal mechanism for increasing a depth to which the stenotic material removal mechanism removes the stenotic material from within the stent, wherein said means is limited to prevent further increase in depth when or before the stenotic material removal mechanism engages the stent.

30. The apparatus ofclaim 29 wherein said means deactivates said stenotic material removal mechanism when or before the stenotic material removal mechanism engages the stent.

31. The apparatus ofclaim 29 wherein said means includes a sensor for sensing contact between said stenotic material removal mechanism and the stent.

32. The apparatus ofclaim 29 wherein said means includes a sensor for sensing proximity between said stenotic material removal mechanism and the stent.

33. The apparatus ofclaim 29 wherein said means includes sensor means for sensing contact and proximity between said stenotic material removal mechanism and the stent.

34. The apparatus ofclaim 29 wherein said means includes a mechanism for diametrically expanding said stenotic material removal mechanism.

35. The apparatus ofclaim 29 further comprising a means for directing said stenotic material removal mechanism to remove stenotic material from a selected area within the stent.

36. The apparatus ofclaim 29 wherein said stenotic material removal mechanism comprises at least one longitudinally oriented blade.

37. The apparatus ofclaim 29 wherein said stenotic material removal mechanism comprises a plurality of longitudinally oriented blades.

38. The apparatus ofclaim 29 wherein said stenotic material removal mechanism comprises a plurality of helically configured blades.

39. The apparatus ofclaim 29 wherein said stenotic material removal mechanism comprises a rotating blade.

40. The apparatus ofclaim 29 wherein said stenotic material removal mechanism comprises a rotating abrasive tool.

41. The apparatus ofclaim 29 wherein said stenotic material removal mechanism comprises a cage-like network of filaments.

42. An apparatus for removing stenotic material from within a body vessel, said apparatus comprising:

a stenotic material removal mechanism for removing stenotic material from within the body vessel, said stenotic material removal mechanism having a plurality of elongated blades, and

a stenotic material collection mechanism for collecting stenotic material removed from within the body vessel, said stenotic material collection mechanism including an expandable filter medium enclosed and supported by said plurality of elongated blades.

43. The apparatus ofclaim 42 further comprising a means for diametrically expanding said stenotic material removal mechanism.

44. The apparatus ofclaim 42 wherein said elongated blades are resiliently biased to expand radially outward from a central axis of said stenotic material removal mechanism.

45. A method for removing stenotic material from within a stent located within a body vessel, said method comprising:

operating a stenotic material removal mechanism to remove stenotic material from within the stent;

sensing proximity or contact between said stenotic material removal mechanism and the stent; and

determining an appropriate endpoint for removal of stenotic material from within the stent based on the sensed proximity or contact between said stenotic material removal mechanism and the stent for effective recanalization of the body vessel.

46. The method ofclaim 45 further comprising controlling a depth to which said stenotic material removal mechanism removes the stenotic material from within the stent.

47. The method ofclaim 45 comprising diametrically expanding said stenotic material removal mechanism.

48. The method ofclaim 45 comprising directing said stenotic material removal mechanism to remove stenotic material from a selected area within the stent.

49. The method ofclaim 45 further comprising producing a signal indicative of the proximity or contact between said stenotic material removal mechanism and the stent.

50. The method ofclaim 45 further comprising deactivating said stenotic material removal mechanism when a predetermined level of proximity or contact between said stenotic material removal mechanism and the stent is detected.

51. The method ofclaim 45 further comprising monitoring the proximity or contact between said stenotic material removal mechanism and the stent.

52. The method ofclaim 51 wherein said sensor means comprises at least one electrical conductor on an exterior of said stenotic material removal mechanism and wherein the step of monitoring comprises detecting a leakage current when said at least one electrical conductor contacts the stent.

53. The method ofclaim 51 wherein said sensor means comprises a first electrical conductor and a second electrical conductor on an exterior of said stenotic material removal mechanism and wherein the step of monitoring comprises detecting a leakage current when said first electrical conductor and said second electrical conductor contacts the stent.

54. The method ofclaim 51 wherein said sensor means comprises at least one electrical conductor positioned on said stenotic material removal mechanism and wherein the step of monitoring comprises detecting a change in electrical impedance when said at least one electrical conductor approaches the stent.

55. The method ofclaim 51 wherein said sensor means comprises a first electrical conductor and a second electrical conductor positioned on said stenotic material removal mechanism and wherein the step of monitoring comprises detecting a change in electrical impedance when said first electrical conductor and said second electrical conductor approach the stent.

56. The method ofclaim 45 further comprising aspirating stenotic material removed from within the stent.

57. The method ofclaim 45 further comprising collecting stenotic material removed from within the stent.

58. The method ofclaim 45 further comprising inserting said stenotic material removal mechanism into the body vessel on an elongated catheter.

59. The method ofclaim 58 further comprising introducing said stenotic material removal mechanism on said elongated catheter into the body vessel through a percutaneous puncture.

60. A method for removing stenotic material from within a stent located within a body vessel, said method comprising:

engaging a stenotic material removal mechanism to remove a portion of stenotic material from within the stent;

expanding the stenotic material removal mechanism to remove additional portions of the stenotic material; and

limiting the expansion of the stenotic material removal mechanism when or before the stenotic material removal mechanism engages the stent.

61. The method ofclaim 60 comprising diametrically expanding said stenotic material removal mechanism.

62. The method ofclaim 60 further comprising deactivating said stenotic material removal mechanism when or before the stenotic material removal mechanism engages the stent.

63. The method ofclaim 60 further comprising directing said stenotic material removal mechanism to remove stenotic material from a selected area within the stent.

64. The method ofclaim 60 further comprising sensing proximity or contact between said stenotic material removal mechanism and the stent.

65. The method ofclaim 64 further comprising deactivating said stenotic material removal mechanism when a predetermined level of proximity or contact between said stenotic material removal mechanism and the stent is detected.

66. The method ofclaim 60 further comprising aspirating stenotic material removed from within the stent.

67. The method ofclaim 60 further comprising collecting stenotic material removed from within the stent.

68. The method ofclaim 60 further comprising inserting said stenotic material removal mechanism into the body vessel on an elongated catheter.

69. The method ofclaim 68 further comprising introducing said stenotic material removal mechanism on said elongated catheter into the body vessel through a percutaneous puncture.

70. A catheter kit comprising:

(a) a catheter including:

a catheter shaft having a proximal end and a distal end,

a stenotic material removal mechanism, wherein said removal mechanism is expandable, and

(b) instructions for use setting forth the following steps:

percutaneously introducing the stenotic material removal mechanism into a restenosed stent in a blood vessel;

engaging the stenotic material removal mechanism to remove a portion of stenotic material from within the restenosed stent;

expanding the stenotic material removal mechanism to remove additional portions of the stenotic material; and

limiting the expansion of the stenotic material removal mechanism when or before the stenotic material removal mechanism engages the stent; and

(c) a package holding the catheter and the instructions for use.

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