US20050070821A1 - System and method for introducing a prosthesis - Google Patents

Abstract

A method and apparatus for introducing a first elongate medical device and short wire guide that are coupled together into a work site and remotely disconnecting them within the work site such that a secondary device comprising a catheter member can be introduced over the wire guide to the work site, and/or a second wire guide can be introduced to the work site via a passageway of the primary access device. A system of indicia, such as radiopaque or viewable markers, permits the operator to monitor the relative alignment of the devices within the work site to determine when uncoupling has occurred. In one example of the method, a wire guide and primary access device (e.g., a sphincterotome) is coupled to the wire guide and introduced via a duodenoscope into the biliary system. After performing a first medical operation, the devices are uncoupled with the wire guide being left within the biliary system such that a secondary access device, such as a balloon, biopsy device, stent delivery catheter, dilator, etc., can be introduced to perform a second medical operation without a traditional over-the-wire exchange being required. In another example of the method, a prosthesis, such as a valve or stent, is placed within the work site coupled to a wire guide which is remotely disconnected within the work site and a secondary device, such as a dilation balloon or second prosthesis, is introduced into the work site after the first delivery system is removed.

Description

CROSS-REFERENCE TO RELATED APPLICATIONS
• This application is a non-provisional application which claims priority of provisional applications Ser. No. 60/491,408, filed Jul. 31, 2003, Ser. No. 60/563,968, filed Apr. 21, 2004, and Ser. No. 60/570,656, filed May 13, 2004.
TECHNICAL FIELD
• This invention relates to medical devices, more particularly catheters and the like that are introduced into the patient over a wire guide.
BACKGROUND OF THE INVENTION
• Minimally invasive medicine, the practice of gaining access into a blood vessel, duct, or organ using a wire guide to facilitate the subsequent introduction or placement of catheters and other medical devices, has been evolving since the Seldinger technique was first popularized during the late 1950s and 1960s. A significant advance was gaining the ability to exchange medical devices over a single indwelling wire guide without requiring displacement of the wire in the process and loss of access to the site. This ‘over the wire’ (OTW) exchange technique requires an extra long guide wire so that control over the wire could be maintained at all times during the procedure. To accomplish this, the portion of the wire extending out of the patient must be at least as long as the device itself so that a proximal portion of the wire could be secured at all times maintain longitudinal positioning, typically by an assistant standing well behind the physician. For example, endoscopic catheters that are used to access the biliary system are typically 200 cm or more in length, requiring a wire guide of more than 400 cm (e.g., 480 cm) to be long enough to remain in the duct during the exchange. To remove the catheter over the wire, the physician and an assistant must carefully make a series of well-coordinated, one to one movements between the exchange wire and device. The assistant pushes the wire the same amount as the physician pulls back on the catheter until the device is completely outside of the patient and the physician gains control over the wire at the port of the scope. The assistant then pulls the device off of the wire such that a second device can be fed back over the wire and into the patient to perform a second operation, requiring the same push-pull technique in reverse. This procedure requires a well-trained assistant, who actually is responsible for the advancement of the wire, instead of the physician. In biliary ERCP, this lack of wire guide control can be a disadvantage when cannulating the ampullary orifice because the techniques used are typically highly dependent on good verbal communication between the physician and assistant, and the experience of the latter.
• Although the ‘long wire’ or OTW technique still remains a commonly used method of exchanging devices in the biliary system, a technique was developed which allowed for a much shorter wire guide and more physician control over the wire. Variously known as the ‘rapid exchange,’ ‘monorail,’ or ‘short-wire’ technique, it differs from the OTW technique in that instead of the device being introduced over the length of the wire guide, the wire guide is coupled for only a portion of the length of the catheter device. The device is fed over the wire guide, which then exits the passageway or a coupling portion of the catheter at a point between the catheter's distal end and the proximal portion via a port or channel formed in the side of the catheter, typically located within the distal portion of the device. This allows the physician to have control of the proximal or external portion of the wire at all times as it exits the patient or scope and reduces the need for coordinating device movements with an assistant. When the coupled portion exits the patient (or endoscope in the case of gastroenterological or other endoscopic procedures), the physician performs a short exchange (instead of the traditional long-wire exchange, which in biliary procedures, requires the assistant to stand well out of the sterile field in order to assist with the exchange). With certain other devices, the catheter is split or torn away to uncouple it from the wire as the catheter exits the patient. To introduce the device, the coupled portion of the catheter is advanced over the proximal end of the wire guide, while the physician is careful to maintain the wire in position so that its distal end is maintained within the work site and access is not lost.
• Rapid exchange or short wire techniques have proven particularly desirable in coronary and vascular medicine whereby it is common for a sequence of procedures using multiple catheter-based devices to be performed over a single wire, such as stent placement following angioplasty. Another example of where short wire exchange techniques are often used is in endoscopic procedures performed in the pacreatobiliary system. Typically, an ERCP (endoscopic retrograde cholangiopancreatography) procedure is performed by introducing a catheter device from a duodenoscope through the ampullary orifice (Papilla of Vater) and into the biliary tree, which includes the bile duct, pancreatic duct, and hepatic ducts of the liver. The cannulation device, which typically comprises a sphincterotome/papillotome or ECRP catheter, is introduced into the biliary tree to perform a first operation, which could be diagnostic in nature, such as injecting contrast media, or for therapeutic purposes, such as enlarging the ampullary orifice. When a second medical operation is required, such as to remove a stone, open a stricture, sample tissue, etc., a second or peripheral device, e.g., balloon, basket, snare, biopsy brush, dilator, stent delivery catheter, etc., can be introduced over the original wire guide to perform a secondary therapeutic procedure.
• While OTW techniques have permitted the exchange of devices, the development of short wire techniques has found acceptance by physicians who prefer to maintain greater control of the wire guide at the scope. Well-known examples of this rapid exchange technology are the devices comprising the MICROVASIVE RX BILIARY SYSTEM™ (Boston Scientific Corporation, Natwick, Mass.) in which the catheter portion of the devices include an internal lumen extending between a distal opening and a proximal side opening spaced 5-30 cm therefrom, depending on the device, thereby requiring an exchange of that length as the device is being removed over the 260 cm JAGWIRE® Guidewire guide developed for that system. An example of a sphincterotome of this system (AUTOTOME™ Cannulating Sphincterotome) is depicted inFIG. 1. Extending proximally from the proximal side opening, the lumen forms a ‘C-channel’ (shown inFIG. 2) that holds the wire guide within the catheter as the catheter portion is introduced into the scope, but allows the wire to be laterally pulled out of the channel to gain access of the wire at the biopsy port of the scope as the catheter is being removed from the scope (FIG. 3), so that a second catheter type device (e.g., balloon, basket, stent delivery catheter, etc.) can be subsequently fed over the proximal end of the wire. As the distal portion of the first device is exiting the scope, a short exchange is required (coordinated push-pull movements between the physician and assistant) that is similar in practice to that used in an OTW procedure, until the physician gains control of the wire and the assistant can pull off the first device without risking loss of access. The proximal end of the wire guide is typically secured to the scope during much of the procedure to prevent loss of access, but it must be disengaged from the scope to allow the exchange and removal of the catheter.
• While the Microvasive system has offered modest time savings, more physician control of the wire, and placed less reliance on the skill of the assistant to help perform the exchange, a short exchange procedure is still required in which care must be taken to prevent loss of wire guide access to the duct, particularly since the wire guide cannot be secured to the scope during removal of the catheter. Because the wire guide resides in the channel of the catheter and the coupled devices are constrained together in the accessory channel, uncoupling must take place as the distal portion of the catheter exits the proximal end of the scope. The process is further slowed by the frictional resistance between the wire and catheter, which remains a problem in subsequent exchanges as devices are fed or removed over the wire residing in the catheter lumen or C-channel.
• Having a C-channel extending along the catheter can result in certain clinical disadvantages. For example, the split in the catheter provides an entry point for blood and bile, a known source of viruses and bacteria, to enter the catheter lumen and migrate to the proximal end of the device where they typically leak out onto the floor and clothing of those involved in the procedure. The channel also represents a point of potential air leakage, which can compromise the ability to maintain adequate insufflation within the duodenum during the procedure. Another disadvantage of a C-channel is that it degrades the integrity of the catheter, which can be problematic in a cannulating device (such as a deflecting Sphincterotome) when attempting to push through or ‘lift’ the papilla to straighten the entry pathway into the duct, or when pushing through a stricture.
• The current rapid exchange or short wire system also fails to address some of the shortcomings found in the traditional OTW method. For example, recannulation of the papilla is required when placing multiple plastic drainage stents side by side since the delivery system must be removed to disconnect the wire. Furthermore, existing devices do not offer the ability to place a second wire guide after the first one, such as to place stents in multiple ducts, since the catheter, which could otherwise serve as a conduit, must be removed from the patient and work site before it would have a free lumen for a second wire. Another disadvantage of current systems for exchanging biliary devices is the incompatibility between the two systems. Long wire devices lack the side access port for use with a short exchange wire and the MICROVASIVE RX BILIARY SYSTEM=198 devices with C-channels are poorly configured for long wire exchange since once the C-channel has been breached during the first exchange, it is difficult to introduce a long wire through the proximal wire guide access port (which includes the open channel) and keep it from slipping from the channel as it is being introduced. Further, the C-channel is typically not compatible with smaller-diameter wire guides (less than 0.035″) for the same reason. Incompatibility between systems means that physicians cannot take advantage of all of the choices available when selecting the best device and treatment for a particular patient.
• What is needed is an improved short-wire system and technique for efficiently and reliably exchanging devices within a work site which is compatible with long wire exchange method and which addresses the other deficiencies described above.
SUMMARY OF THE INVENTION
• The foregoing problems are solved and a technical advance is achieved in an illustrative system and method for introducing and exchanging multiple elongate medical devices, e.g., tubular members such as catheters and the like, over an indwelling guiding member, such as a wire guide, within a patient by remotely uncoupling the first device (primary access device) from the guiding member within the work site (defined as a lumen, duct, organ, vessel, other bodily passage or cavity, or the pathway leading thereto in which wire guide/guiding member access is maintained throughout a particular procedure or series of procedures), thereby facilitating the removal of the device and simplifying introduction of a secondary access device over the indwelling wire without an exchange of devices taking place outside of the patient. While the primary focus of this application is the exchange of devices within the pancreatobiliary system or elsewhere in the gastrointestinal tract, the system and method of remote uncoupling of devices within a work site can be adapted for any part of the body to perform any suitable procedure where the exchange of devices takes place over an indwelling guiding member. Examples include, but are not limited to the introduction and placement of balloons, stents, grafts, occluders, filters, distal protection devices, catheters for ablation, phototherapy, brachytherapy etc., prosthetic valves, or other instrumentation or devices into the vascular system, including the coronary arteries, peripheral arterial system (e.g., carotid or renal arteries), or venous system (e.g., the deep veins of the legs). Other exemplary sites include the genito-urinary system (e.g., bladder, ureters, kidneys, fallopian tubes, etc.), and the bronchial system. Additionally, the present system and method can be used for exchanging devices within body cavities, e.g., the peritoneum, pleural space, pseudocysts, or true cystic structures, via percutaneous placement and exchange through a needle, trocar, or sheath.
• The basic system of devices for remote uncoupling comprises a guiding member, typically a wire guide. It should be understood that hereafter, the term ‘wire guide’ is used in the specification in a generic sense to include any device (e.g., small-diameter catheter, laser fiber, string, plastic beading, stylet, needle etc.) configured to perform the same function, although such a device technically may not be considered a wire guide (or ‘guidewire’) as the term is most commonly used in the medical arts. Remote uncoupling permits a shorter guiding member/wire guide to be used than for other short wire methods (e.g., rapid exchange), and thus hereafter, the methods described in this specification are referred to collectively as the ‘ultra-short wire’ technique, or depending on the work site, ‘intraductal exchange’ (IDE), ‘intravascular exchange’ (IVE), etc. The reason that the wire guide can be of a shorter length than traditional rapid exchange wire guides is that there is no exchange outside the patient. In fact, remote uncoupling allows for the exchange wire guide to be shorter than the devices being introduced since the devices are not removed over the wire. For example, the wire guide of the present inventive system of biliary devices (for use in a 145 cm channel duodenoscope) is typically 185 cm (minimum functional length of about 180 cm), as opposed to the 260 cm wire guide typically used for the Microvasive ‘rapid exchange’ procedures in which a 5 to 30 cm external exchange must be performed each time, depending on the device used. The shorter wire is easier to manipulate by a single operator and helps prevent it from contacting non-sterile surfaces, such as the floor, patient bed, instrument table, imaging unit, etc. The 185 cm length still permits most external changes to be performed, if necessary. To accommodate a longer wire for exchanging a device otherwise not compatible with the system, an optional coupling mechanism on the proximal end of the wire can be included to engage a wire guide extender portion to lengthen the wire (e.g., to 260 or 480 cm) and permit a traditional exchange to take place.
• Coupled to the guiding member/wire guide is a first elongate medical device (the primary access device), typically a tubular member or catheter device, which includes a coupling region, such as a passageway or lumen, external channel, outer ring, or other interface area, located about the distal portion and which is configured to receive a portion of the wire guide such that both devices can comprise a releasably coupled pair while operating within a work site. The coupling region may be an integral part of the elongate medical device or may located about a separate element disposed therewith (e.g., an elongate engagment member), which for purposes of this application is considered part of the elongate medical device. A separate elongate engagement member can provide a primary or secondary means of releasably securing the wire guide and catheter device until they are to be repositioned or uncoupled. The elongate engagement member, typically but not necessarily disposed within the passageway of the tubular member, can further comprise the coupling region as well. Preferably, the primary access devices used with this system have a closed or self-sealing passageway extending to the proximal (external) portion of the device (instead of an open or split channel) such that the system can be readily converted to introduce a long wire if a long wire-compatible device is selected. Further, the devices of this invention are configured for traditional short wire exchange back over the wire, if so desired, or when remote uncoupling becomes problematic (e.g., due to unexpected anatomical constraints).
• In a first aspect of the invention, the system further includes an alignment indicator system, such as a system of indicia (e.g., radiopaque markers, external markings, endoscopic markings, etc.) located about the wire guide and/or first elongate medical device that can be utilized by the operator in locating the position of the distal end or distal portion of the wire guide relative to the proximal end of the coupling region, such as at a side access port or aperture (e.g., scive) through which the wire exits. The alignment indication system advantageously allows the physician to control when the two devices are coupled or uncoupled within the work site and helps provide confirmation that uncoupling has occurred. Without the ability to receive such confirmation, it would be extremely difficult for the physician to attempt, with any confidence, the uncoupling of the catheter from the wire guide (e.g., under fluoroscopic guidance) without knowing when uncoupling has occurred or is about to occur. Depending on the location or work site within the body and the device being delivered, an attempt to ‘blindly’ uncouple devices can lead to loss of wire guide access, especially if the device is prematurely withdrawn with the wire guide still engaged. Furthermore, the amount of relative movement between the device and the wire guide required to ensure that uncoupling had occurred would generally be much greater than if indicia were utilized, thus increasing risks such as the wire guide being withdrawn too far and access lost or encountering situations where there is insufficient space within the work site left for uncoupling to take place. Typical rapid exchange devices are not configured with the necessary radiographic or other appropriate indicia since the exchange procedure is intended to take place outside of the patient. The external exchange is a slower process and dictates removal of the first catheter before another catheter or wire guide can be advanced to the work site over an existing device (which always must be a wire guide or guiding device in traditional rapid exchange).
• A first series of embodiments of the system of indicia includes radiographic or ultrasonically reflective markings located about one or more of the devices which are used by the operator under an appropriate external guidance system (fluoroscopy, MRI, CT scan, x-ray, ultrasound, etc.) to determine the state of alignment and engagement between the primary or secondary access device and guiding device. A first example comprises radiopaque or high-density bands, markings, etc., located on the distal portions of the wire guide and first elongate medical device. In particular, the distal tip of the wire guide includes a radiopaque portion that typically comprises at least the length of the coupling region of the first elongate medical device, which itself includes a radiopaque marker, such as a band comprising iridium, platinum, or other suitable material, located about the proximal end of the coupling region (e.g., at, or just distal to the side access port), thus allowing the operator to know when the distal tip of the wire is nearing or has exited the point of the catheter at which the devices become uncoupled or separate within the work site. Additionally, other radiopaque markers may be present that are generally not used to assist in remote uncoupling, such as at the distal end of the catheter or indicia used for stent or balloon placement.
• A second series of embodiments of the system indicia comprises directly viewable indicia located about the proximal portions of the wire guide and the tubular member to which it is coupled during the procedure. In one example, the wire guide comprises a visually distinctive alignment point, such as a single mark (e.g., colored band) or a transition point between different colored and/or patterned regions of the wire guide outer coating, which when aligned with a specified first marking on the proximal portion of the elongate medical device, indicates that the distal ends of the wire guide and tubular member are in alignment with respect to one another. The catheter further includes a second mark that represents the disengagement point, that when aligned with the designated alignment marking of the wire guide, is indicative that the two devices are about to or have uncoupled or disengaged with the distal tip of the wire guide having exited the coupling region. Preferably, the first (distal) and second (proximal) markings on the proximal portion of the catheter are located within a region that remains external of the patient or scope during a procedure and are spaced apart by the same distance as the length of the coupling region. For very short coupling regions (e.g., rings), a single mark on the catheter may be preferable to indicate disengagement, if proximal indicia are to be used.
• A third series of embodiments of the system of indicia include markings that are configured to be viewable by a fiberoptic endoscope or videoendoscope (e.g., duodenoscope, gastroscope, bronchoscope, ureteroscope, etc.). In devices configured for accessing the pancreatobiliary system, the indicia comprise a marking located on both the wire guide and elongate medical device disposed within an intermediate portion of each, which is typically located distal to the viewing lens or video chip of the scope, but proximal to the ampullary orifice during a typical procedure, such that they can be aligned by using the video monitor (or viewing port) to ascertain that uncoupling within the duct has occurred. The device may include other endoscopic indicia useful during the remote uncoupling procedure. For example, a biliary catheter may include a depth marking at a designated distance from the catheter tip (e.g., 10 cm) which when buried within the papilla, indicates that IDE can be performed safely within the duct without risking loss of wire guide access. Furthermore, the distal portion of the wire guide can be distinctive in appearance (e.g., black) as a visual cue to warn the physician if the tip is in danger of pulling completely out of the duct, which would require recannulation of the papilla. The second and third system of indicia do not require external imaging, thus the physician can advantageously limit the time that the patient is exposed to fluoroscopy. For example, fluoroscopy can be used only at selected, critical times during the procedure with at least one of the other types or indicia being used elsewhere for alignment guidance.
• In addition to the use of visual indicia to confirm whether the wire guide and first elongate medical device (and subsequent devices) are engaged or uncoupled, the present invention includes other types of alignment indication systems, such as a tactile system that includes one or more protuberances and/or indentations along one or more of the devices or the endoscope accessory channel port to allow the physician to ‘feel’ or sense the point where disengagement has occurred or is imminent due to the discrete point(s) of increased resistance between the device as they move relative to one another. Magnets can be a part of a tactile system as well. Other embodiments of the alignment indicator system include sensor-based systems in which a sensor located within the system, such as along the catheter or endoscope channel/port, detects a calibrated location elsewhere in the system (e.g., the wire guide or catheter) and emits or provides a signal or cue (e.g., electrical signal) that is relayed to the operator in the form of an audio or visual alert that warns the operator that the devices have or are about to become uncoupled. The alignment system can comprise a single system or means for alignment, or any combination of visual and non-visual indicators.
• In a second aspect of the invention, a method is provided for uncoupling the first elongate medical device from the wire guide while both are still dwelling within the work site (i.e., the basic ultra-short wire technique). Both devices are introduced into the work site, using a standard introduction method and introducer member such as an endoscope, introducer sheath, etc., with the wire guide engaged through the coupling region of the medical device being introduced. In one embodiment for use in the pancreatobiliary system, the coupling region comprises a passageway within the distal portion of the catheter, such as the distal 6 cm thereof, with the wire guide exiting at that point through a side access port (e.g., scive) such that the wire guide coextends along the outside of the proximal portion of the catheter as both reside side by side along the introduction pathway, which in the biliary embodiment comprises the channel of the duodenoscope. For example, a wire guide or primary access device, such as a sphincterotome, needle knife, ERCP catheter, etc., may be introduced first to cannulate the duct, with the primary access device being subsequently advanced over the wire to perform a first medical operation that is diagnostic and/or therapeutic in nature. During this time, the wire guide is preferably secured in place by attaching the proximal portion to the endoscope via a locking device, clip, other means located about wire guide entry port (biopsy port), thus fixing its position longitudinally to assist with maintaining access to the work site. Once the first device has performed its intended operation (inject contrast media, ablate the sphincter, etc.), the operator preferably uses the radiographic, endoscopic, and/or proximal system of indica to provide visual guidance during repositioning of the devices to permit disengagement. One technique (referred to herein as ‘device IDE’) includes advancing the primary access device over the stationary wire guide until uncoupling has occurred. A second technique (referred to herein as ‘wire guide IDE’ includes withdrawing the wire guide while maintaining the primary access device in a stationary position until the alignment indicia indicates that uncoupling has occurred. A third technique would involve a combination of the device and wire guide IDE. Also, there typically is a characteristic ‘whipping’ action of the radiopaque wire guide tip portion upon exit from the passageway that is viewable under fluoroscopy which also provides a visually distinctive indicator of uncoupling.
• When the physician, using at least one component of the alignment indicator system, has determined that the tip of the wire guide has disengaged from the coupling region of the primary access device, the first device can be easily removed by merely pulling it back out of the endoscope accessory channel (or introducer sheath in the case of vascular or certain other non-endoscopic applications). Removal is greatly facilitated by the elimination of friction which would have otherwise existed between the wire guide and catheter if the wire resided within the channel or lumen. Although some of the aforementioned MICROVASIVE RX™ biliary devices (e.g., the AUTOTOME™ sphincterotome) include a side port within the distal portion, all of the devices lack the combination of indicia that make a remote or intraductal exchange clinically practical or even possible. Furthermore, those devices that include an open channel extending proximally of the side access port cannot be uncoupled within the duct or work site regardless of the lack of indicia since the proximal portion of the wire guide tends to ‘seek’ and reenter the channel when both devices are residing within the accessory channel of the scope. Thus, remote disconnection is rendered impossible without some means to releasably disengage the wire from the channel.
• After the catheter and wire guide are uncoupled, the proximal end of the wire is available for a third elongate medical device (e.g., a secondary access device or a second device that is the same as the first) to be advanced thereover to the work site. In one example of the method, the proximal end of the indwelling wire is fed through the distal opening and out of the side access port of the secondary device, which is then advanced to the work site. If after the second medical operation using the secondary device, another secondary device is required for another operation, the first secondary device (third medical device) is removed from the wire guide and the patient, and the wire guide is available to provide access for a fourth device in the same manner as the first two.
• In a variation of the present method, the primary access device may be left in place at the work site after disengagement with the wire guide to serve as an introduction pathway or conduit for a second wire guide, such as for a procedure where two branches of a duct or vessel are to be cannulated. An example of such a procedure is when a stent must be placed in two different ducts draining separate lobes of the liver. The second wire guide is typically introduced through a proximal wire guide port or hub of the first device, typically disposed about the handle portion, the port communicating with the passageway. This technique typically requires a long-wire exchange of the catheter. A second option is to introduce the wire through a proximal side access port (e.g., a scive) formed through the wall of the tubular member so that full control of the wire is maintained. In this embodiment, the catheter walls are configured to be splittable between the proximal and side access ports, or include an open or self-sealing channel through which the wire guide can be stripped out toward the distal portion of the device such that a long exchange is not required. Removing or stripping the wire guide laterally from the passageway can be done by any well-known means, such as scoring or structurally weakening a wall of the catheter, using a splittable, isotropically oriented catheter wall material (e.g., PTFE), incorporating a sealable or locking seam therealong, or by thinning the wall and/or using a material that allows the wire guide to split the wall and form its own exit pathway when sufficient force is supplied. Alternatively, a wire guide that includes a coupling region, such as an attached sleeve, can be used to couple to a standard wire guide that is already indwelling, or both wires can be coupled together and advanced through the passageway of the elongate tubular member.
• After gaining access to the passageway by one of the aforementioned routes, the wire guide is guided under external imaging, such as fluoroscopy, into the desired location. Optionally, if the first device is a sphincterotome or other type of deflectable catheter, the operator can manipulate the shape and orientation of the catheter tip portion to help guide the tip of the second wire guide into the opposite (or side) branch of the duct or vessel. Orientation within the work site can be facilitated with a rotatable handle to direct the tip. Furthermore, it has been demonstrated that certain shorter wire guides, such as the illustrative 185 cm biliary wire guide of the present invention, are sufficiently torqueable such that an operator can simply rotate the wire with his or her fingers to achieve similar results in most instances.
• In another aspect of the invention, primary access devices further include an elongate engagement member configured to releasably engage with the wire guide within or about the coupling region (e.g., the distal passageway of the tubular member). Embodiments include using a flexible wire stop (e.g., a nylon stylet) configured to wedge the wire guide within the passageway when in the fully advanced position, and a thread-like member (e.g., suture) that ensnares the wire guide and provides tension to maintain it in a longitudinally secure position relative to the tubular member. When an elongate engagement member is not used during introduction, such as when secondary access devices are being introduced over the already indwelling wire guide, a stiffening stylet may be optionally maintained in the passageway of the tubular member to add rigidity to the device during introduction and/or for advantageously traversing scives in the tubular member, such as the side access port, to prevent kinking thereabout.
• In still another aspect of the invention, the system of devices adapted for remote uncoupling or ultra-short wire techniques includes a delivery catheter for plastic tubular drainage stents and a technique for deployment that allows for placing multiple stents side by side within the bile duct using a single cannulation procedure. By placing the side access port on the inner carrying member (over which the stent is mounted) at a point distal to the stent, the wire guide can be uncoupled within the duct and the stent deployed without having to withdraw the entire system, including the wire, in the process. The junction between the inner carrying member and wire guide can be advantageously used to ‘catch’ the stent when the inner member is pulled back, thus allowing the entire delivery system, including the stent, to be pulled back within the duct. This feature, which is not present in other stent delivery systems, is especially important to address situations when the stent is advanced too far into the duct and needs to be repositioned. After the stent is in the correct position for deployment, the inner carrying member is advanced and/or the wire guide withdrawn to uncouple the two, allowing the inner carrying member to be withdrawn through the stent and from the duct while the wire guide remains behind for a second stent delivery catheter (and additional stents) to be advanced into the duct and placed along side the first stent. Pigtail stents and others that include shaped distal portions for anchoring can be temporarily straightened during delivery by the wire guide which traverses the coupling region.
• In still another aspect of the invention, the wire guide can be placed through the mouth by dragging or carrying the wire down using a endoscope and guide wire carrying mechanism that either resides in the channel of the scope and engages the wire guide about the scope tip, or attaches to (or co-extends with) the scope and engages the wire guide alongside. The treatment site, such as the gastroesophageal (GE) junction, is visualized and the distance to the mouth is measured using scale indicia located on the proximal portion of the scope. The wire guide, still coupled to the wire guide carrying mechanism, is then advanced a known distance (e.g., 10 cm) past the treatment site and into the stomach where uncoupling takes place following treatment. The wire guide includes a reference marking (e.g., at 10 cm) which lies at a known reference point relevant to treatment, such as the GE junction. The proximal portion of the wire guide preferably includes scale indicia, such as different colored bands or interverals (e.g., 5 cm) having different numbers or types of markings that reference a particular distance (typically using non-numerical indicia) to the reference mark at the GE junction. With the wire guide in position, the operator advances a primary access device, such as a dilator, PDT balloon, achalasia balloon etc., using corresponding indicia on the proximal portion thereof that align with that of the wire guide to guide placement of the device to the desired treatment site, such as the GE junction. If a secondary access device is required, such as a larger dilator, the first device is advanced into the stomach over the wire and uncoupled so that the wire becomes available for the next device to be fed thereover. Carrying the wire outside of the scope to a treatment site, which may also include the jejunum or other portions of the gastrointestinal tract, adventageously provides a means for placing devices larger than scope accessory channel, while still retaining the benefit of endoscopic navigation within the patient.
BRIEF DESCRIPTION OF THE DRAWING
• Embodiments of the present invention will now be described by way of example with reference to the accompanying drawings, in which:
• FIG. 1 depicts a perspective view of a prior art sphincterotome adapted for short-wire exchange;
• FIG. 2 depicts a cross-sectional view taken along line2-2 ofFIG. 1;
• FIG. 3 depicts the device ofFIG. 1 being used with an endoscope;
• FIG. 4 depicts a side view of an illustrative catheter configured for use in the illustrative system and method;
• FIG. 5 depicts a cross-sectional view of the distal portion of the embodiment ofFIG. 4 and illustrative wire guide coupled thereto;
• FIG. 6 depicts a side view of an embodiment of the present invention wherein the coupling region comprises an external channel;
• FIG. 7 depicts a side view of a wire guide in which the proximal portion is oriented at an angle relative to the distal and intermediate portions;
• FIG. 8 depicts a side view of an embodiment of proximal system of indicia located on the first elongate medical device and wire guide;
• FIGS. 9a-fdepict the steps of an example of the present method in which multiple catheter devices are exchanged over a guide wire within the common bile duct;
• FIG. 10 depicts a side view of an embodiment of the present invention wherein the first elongate medical device comprises a balloon catheter;
• FIG. 11 depicts a view in situ of a sphincterotome of the present invention being used to introduce a second wire guide into a branch of a passageway;
• FIG. 12 depicts a perspective view of an illustrative wire guide holding device of the present system and method;
• FIG. 13 depicts a side view of a wire guide having a coupling mechanism for attaching a second wire guide to the proximal end thereof;
• FIG. 14 depicts a side view of a retrieval basket of the present invention that includes a coupling ring to engage the wire guide;
• FIGS. 15-16 depict cross-sectional views of sphincterotome catheters comprising a splittable wire guide passageway;
• FIG. 17 depicts a side view of a biliary stent and delivery catheter of the present invention;
• FIG. 18 depicts a side view of an embodiment of the present invention comprising a splittable region in the tubular member;
• FIG. 19 depicts a side view of a dilation balloon of the present invention;
• FIG. 20 depicts a side view of an extraction balloon of the present invention;
• FIG. 21 depicts a side view of a biopsy device of the present invention;
• FIG. 22 depicts a side view of a self-expanding prosthesis delivery apparatus of the present invention;
• FIG. 23 depicts a partially sectioned side view of a first embodiment of an elongate engagement member (distal portion) comprising a wire stop member;
• FIG. 24 depicts a side view of the proximal portion of the embodiment ofFIG. 23;
• FIG. 25 depicts a partially sectioned side view of a second embodiment of the elongate engagement member comprising a thread-like member;
• FIGS. 26a-bdepict a third system of indicia located on the intermediate, viewable portion of the coupled devices of the present invention;
• FIG. 27 depicts a cross-sectional view of a stent and pusher apparatus of the present invention;
• FIG. 28 depicts a cross-sectional view of radioactive seed delivery apparatus of the present invention;
• FIGS. 29a-edepict a method of delivering multiple stents within the common bile duct using the system embodied inFIG. 17.
• FIG. 30 depicts a partially sectioned view of a wire-guided wire of the present invention;
• FIGS. 31-32 depict partially sectioned views of embodiment of the present invention in which the coupling region is located on a separate member;
• FIG. 33 depicts a side view of an embodiment of the present invention have two distal side access ports;
• FIG. 34 depicts perspective view of an embodiment of the present invention in which the wire guide hooks into the side access port;
• FIGS. 35a-bdepicts side views of a hooked wire guide before and after uncoupling;
• FIG. 36 depicts a side view of an embodiment of the present invention comprising a pair of slotted coaxial members.
• FIG. 37 depicts a cross-sectional view of the embodiment ofFIG. 36 taken along line37-37;
• FIG. 38 depicts a partially sectioned view of an introducer member of the present invention;
• FIG. 39 depicts a partially sectioned view of a delivery catheter of the present invention;
• FIG. 40 depicts a side view of and embodiment of the present invention comprising a tactile alignment indication system;
• FIG. 41 depicts a side view of a pigtail drainage catheter of the present invention in its deployed configuration;
• FIG. 42 depicts a partially sectioned view of the embodiment ofFIG. 41 coupled to a wire guide;
• FIG. 43 depicts a side view of an alternate embodiment of a drainage catheter having anchoring flaps;
• FIG. 44 depicts a side view of a dilator catheter of the present invention;
• FIG. 45 depicts a side view of a wire guide of the present invention adapted for being carried by an endoscope to a work site;
• FIG. 46 depicts a side view of device attached to an endoscope which for carrying the wire guide ofFIG. 45;
• FIG. 47 depicts an end view of the embodiment ofFIG. 46;
• FIG. 48 depicts a side view of a wire guide carrying mechanism of the present invention;
• FIG. 49 depicts a cross-sectional view of the distal portion of embodiment ofFIG. 48 engaging a loop tip wire guide;
• FIG. 50 depicts a side view of the loop tip wire guide ofFIG. 49;
• FIG. 51 depicts a side view of a photodynamic therapy balloon of the present invention;
• FIG. 52 depicts a plan view of a the devices ofFIG. 50 and51 being introduced through a bite block/wire guide holder of the present invention;
• FIG. 53 depicts a side view of an achalasia balloon of the present balloon;
• FIG. 54 depicts a partially sectioned view of a naso-enteric tube of the present invention including a stiffening stylet;
• FIG. 55a-fdepicts steps of esophageal dilation using the present method;
• FIG. 56 depicts a side view of an dilator having a reduced diameter portion proximal to the side access port; and
• FIG. 57 depicts a wire guide of the present invention that includes a lubricious intermediate portion.
DETAILED DESCRIPTION
• An illustrative system and method for introducing a series of medical devices over a wire guide into a patient by remotely uncoupling the first device from the wire guide inside of the patient without utilizing a long wire or standard short wire exchange procedure is embodied inFIGS. 4-57. A first exemplary embodiment of the system is depicted inFIGS. 4-5, which comprises a first elongatemedical device10, such as theillustrative tubular member77 or catheter that includes features similar to the GLO-TIP II® E.R.C.P. Catheter (Wilson-Cook Medical, Inc.), the catheter further including acoupling region14 having a first, distal end75 (oriented toward the distal end of the device), a second,proximal end76, and an interconnectingpassageway31 sized and configured to receive a standard-diameter exchange wire guide11 (e.g., METRO® Wire Guide; Wilson-Cook Medical, Inc.) or other guiding device suitable for coupling to the first elongatemedical device10. Thecoupling region14, generally located about thedistal portion13 of the tubular member77 (first elongate medical device10), may be coincident with the distal portion of the main passageway27 (as depicted) or separate therefrom. Thedistal portions13,60 of the fist elongatemedical device10 and thewire guide11, to which the former is coupled via thecoupling region14, are generally defined as the portion of each that are disposed within the work site during the medical operation and the subsequent uncoupling of the two devices. For purposes of this disclosure, the work site is defined as the lumen, duct, organ, vessel, other bodily passage/cavity, or the pathway leading thereto, in which wire guide access is maintained to perform a particular medical procedure/operation or series of procedures. For example, in a procedure involving the biliary system, the work site is considered the common bile duct, including the pancreatic duct and the ducts extending into the lobes of the liver.
• The coupling region is configured to permit the first elongatemedical device10 to be co-introduced over the wire guide (either sequentially or together) into the work site in a coupled state (e.g., with thewire guide11 traversing thepassageway27 of the first device10) such that theproximal portion59 of the wire guide exits the passageway and is external to thetubular member77 as thewire guide11 and tubular member exit the patient or scope. Like traditional forms of short wire or rapid exchange, this gives the physician more control over the wire at that point. In theillustrative coupling region14 ofFIGS. 4-5, thefirst end75 thereof comprises adistal opening19 in thetubular member77, and thesecond end76 comprises aside access port15 or scive traversing the side wall of thetubular member77 and located approximately6 cm from thedistal end12 of the tubular member. Theillustrative coupling region14 is located within thedistal portion13 of the first elongatemedical device10 with thecoupling region passageway31 comprising the distal portion of the mainwire guide passageway27. The range of lengths of thecoupling region14 or the distance of the side access port15 (or second end76) from thedistal end12 of theelongate member10 can vary according to the device and application as long as the disconnect point is sufficiently close to the distal end of the device to allow for remote uncoupling within the work site. It has been determined that 6 cm is an advantageous coupling region length for many biliary devices of the present invention in that it provides a sufficient length to prevent accidental uncoupling, while still allowing for the anatomical constraints of the duct such that, in most instances, there remains sufficient room for the relative movement required for uncoupling.
• For biliary applications, the length of coupling region could range from less than 1 cm (e.g., a ring) to at least 15 cm. A more preferred range for most devices would be approximately 3-10 cm with the most preferred range being approximately 5-7 cm. For devices intended for the pancreatic duct, the ideal distance of theside access port15 to thedistal end12 would be 2-5 cm, given the shorter available distance in which to work. In devices intended for use in body cavities where space is even tighter, theside access port15 may need to be placed closely adjacent to or at thetip12 of the device in order for an exchange to be successfully accomplished. On the other hand, procedures in which loss of wire guide access in not particularly of concern, such as in certain vascular procedures and when working in long passageways, such as in the intestinal tract, there may be more options as to where theside access port15 andcoupling region14 can be located.
• The illustrativeside access port15 comprises a semicircular opening (in a cross-sectional view or ovoid shape from a top view) that typically comprises approximately ¼ to ⅓ of the width of the catheter; however, any opening size or shape that permits passage of the wire guide therethrough is possible. It may be advantageous to reinforce theside access port15 area with one or more wires, sheaths, bands, braiding, or other means which traverse, are bonded to, embedded within, or otherwise reinforce the tubular member at least within the area about the wire guide exit port (side access port) to prevent kinking at that location. Thewire guide11 extends proximally from thedistal opening19 of thefirst device10 and exits thepassageway31 andcoupling region14 proximally through theside access port15, thereby giving the physician access to the proximal end of the wire such that it can be manipulated and locked or otherwise secured during the procedure, if so desired. As noted above, a relatively short distance of thecoupling region14 advantageously allows the coupled devices to be moved relative to each another by a sufficient distance to disengage or uncouple one from the other by advancing thecatheter10 toward thedistal tip25 of thestationary wire guide11, withdrawing the wire guide until it pulls through the catheter and exits theside access port15/coupling region14, or a combination of forward catheter movement and wire guide withdrawal, all preferably in such a manner that the wire guide still remains within the work site (e.g., the duct) to facilitate access by subsequent devices over the indwelling wire.
• Insomuch that no external exchange is required with the present invention, it is only necessary to size the length of thewire guide11 to account for the furthest point thedistal portion60 is to be advanced into the work site (e.g., for uncoupling to take place), theintermediate portion97 extending from work site, to the outside of the patient or scope, and the proximal portion59 (FIG. 7) extending therefrom for a length sufficient to be manipulated by the operator, such as to lock the wire guide in place. In the illustrative biliary embodiment, thewire guide11 is 185 cm in length so as to provide a minimal, but adequate extension of the wire from the scope accessory channel; however, other procedures might necessitate a shorter or longer length. Although the length of thewire guide11 need only be of sufficient length to manipulate or lock or secure in place, if necessary, theproximal portion59 preferably should be sized to accommodate a traditional short wire exchange procedure, using the appropriately configured devices, if one is required (such as when remote uncoupling may not be possible or desirable for some reason). Thewire guide11 is preferably sized to slidably and releasably reside within the coupling region with minimal friction, although a mechanism is contemplated as part of the present invention in which the catheter (or coextending ancillary device) releasably engages and locks with the wire at a particular point therealong. Thecoupling region14 ofFIG. 5 comprises the distal portion of the passageway27 (passageway31), with theproximal portion28 of the passageway providing a continuation of the lumen that extends proximally from the point of theside access port15. Alternatively, theproximal passageway28 can be at least partially blocked or restricted (with a moveable flap or a permanent obstruction, such a plastic or metal insert) just proximal to theside access port15 to serve as a guide or ramp that helps the wire guide being loaded from thedistal opening19 to be able to more readily exit through the side access port, rather than continuing on into the proximal passageway. The blocking means (not shown) may also advantageously restrict fluid or other materials from passing through the passageway retrograde direction. In a related embodiment, thewire guide passageway27 extends proximally only to theside access port15, terminating at that point.
• While theillustrative coupling region14 ofFIGS. 4-5 represent a preferred embodiment for applications in which having thewire guide11 extending from thedistal opening19 of thetubular member77 is particularly advantageous, such as for primary access devices used to cannulate a tight stricture, such as the ampullary orifice, it should be noted that any structural adaptation that allows for temporary coupling of the wire guide to a device being introduced therewith or thereover can comprise an embodiment of thecoupling region14 for purposes of remote uncoupling. For example,FIG. 6 depicts a alternative embodiment of the present invention in which thecoupling region14 comprises an external coupling element orchannel30, rather than a portion of thetubular member passageway27. The illustrativeexternal channel30, which includes apassageway31 extending therethrough, can either be integrally formed with the catheter body, or can be bonded or otherwise attached to the outside thereof. Additionally, theexternal channel30 can comprise a short piece of sheath encircling thetubular member77, a plastic or metal ring, or any structure that can form apassageway31 capable of forming acoupling region14 with the wire guide.
• FIG. 30 depicts an embodiment of anexternal channel30 for a device not having an internal passageway. The elongatemedical device10 comprises a wire-guided wire111 in which thecoupling region14 comprises aouter channel30 comprising aouter sleeve112 of shrink wrap material bonded to the wire111 and ainner sleeve113 of a radiopaque material bonded to thefirst sleeve112 asindicator17,18 of the first and second ends75,76 of thecoupling region14. Either a standard wire guide (such as a 0.021″ METRO™ wire guide) is fed through the coupling region and the two wires are advanced through an already indwelling tubular member to the work site, or the wire-guide wire111 is fed over the proximal end of an indwelling standard wire guide (which could also be coupled to a tubular member) and advanced to the work site, where it is uncoupled therein.
• FIG. 14 depicts another alternative embodiment in which thecoupling region14 comprises acoupling ring63, which in the illustrative embodiment is attached to thedistal tip74 of aretrieval apparatus64, such as the illustrativewire retrieval basket64 for capturing biliary stones (a modification of the WEB™ Extraction Basket, Wilson-Cook Medical, Inc.). Theillustrative ring63 is advantageously made to pivot so that it can better accommodate thewire guide11 which passes therethrough to engage with thefirst device10. Coupling rings63, while not providing as secure of an engagement of the internal passageway, represents an option for certain types of devices lacking a suitable passageway within the shaft portion of the elongate medical device10 (made of coiled wire in this particular embodiment). Thering63 requires the least amount of relative movement between devices for uncoupling, which can be advantageous in short work sites or when faced with other anatomical constraints.
• FIGS. 31-36 depict a series ofalternative coupling region14 embodiments.FIG. 31 depicts atubular member77 in which thecoupling region14 is located on a separate element, which in the illustrative embodiment, comprises anelongate engagement member89 comprising ashaft portion164 slidably disposed in asecond passageway115 and extends from thedistal end12 of thetubular member77 and engages thewire guide11 via acannula portion115 that includes first andsecond openings75,76 through which thewire guide11 is fed. By locating theelongate engagement member89 within asecond passageway115, thefirst passageway27 remains available for infusing materials or passing a second wire guide therethrough. The embodiment ofFIG. 32 also includes a separateelongate engagement member89 in asecond passageway115 with theelongate engagement member89 further comprising thecoupling region14. In this illustrative embodiment, theelongate engagement member89 extends from theside access port15 and includes a distal ring orloop45 which ensnares the wire guide and couples the devices together. Optionally, theloop45 can be made collapsible to pull through thepassageway115 after uncoupling.
• FIG. 33 depicts a tubular member in which thefirst end75 of thecoupling region14 terminates proximal to thedistal end12 of the member, and thesecond end76 comprises aside access port15 located about thedistal portion13 of the tubular member. Thewire guide11 is fed into thecoupling region14 such that thedistal end25 ofwire guide11 is directed at an angle from thetip12 as it exits the most distal side access port (first end75). This configuration allows the physician to be able to rotate thetubular member77 to advantageously direct thetip25 of thewire guide11 in an intended direction, such as into aparticular branch48,49 of a bifurcated duct or vessel. Thedistal end12 of thetubular member77 can be closed, or it could include an opening about the tip that could represent a second, alternativefirst end75 of the coupling region so that if preferred, thewire guide11 can also be coupled in the manner similar toFIG. 5.
• FIGS. 34-35bdepict embodiments of the present invention in which thewire guide11 is adapted to hook into thecoupling region14 in a coupled configuration. In the embodiment ofFIG. 34, thewire guide11 includes a hookeddistal portion116, such as the illustrative ‘shepherd's crook’ in which thedistal end25 and adjacentdistal portion60 engage thecoupling region14 of thetubular member77 via theside access port15, residing within thepassageway27 by an amount sufficient to accomplish a secure engagement. Preferably, thewire guide11 is sized such that there is a adequate frictional engagement with thepassageway27 in which it resides to help prevent accidental dislodgement. In a related embodiment shown inFIGS. 35a-b, thedistal hook portion116 of thewire guide11 is configured to be inserted into thedistal opening19 of thetubular member77, which includes aradiopaque marker band17 closely proximate thereto. The illustrativedistal hook portion116 comprises nitinol or another superelastic material which allows it to be heat set in ahelical configuration117 that once disengaged from thepassageway31 of thecoupling region14, thehook116 assumes its predetermined shape and wraps back over itself to create aclosed loop end118. This configuration better permits a second device to be fed back over thewire guide11 without the hookedportion116 interfering with its passage thereover. Optionally, thetubular member77 can include an open longitudinal channel or recess extending proximally from theside access port15 ordistal opening19 in which the coupled wire guide11 can at least partially reside while the devices are being advanced together into the work site.
• Another embodiment of a method of coupling atubular member77 to awire guide11 is shown inFIGS. 36-37 in which the tubular member comprises a pair ofcoaxial members100,119 that each include a slotted opening orchannel120,121 extending the length of the coupling region14 (distal end12 to side access port15) such that when aligned with one another, thewire guide11 can laterally disengage from theopen passageway31, which is otherwise enclosed by one of the inner119 and outer100 sheath members when they are not aligned. Preferably, the proximal portions of the inner andouter members100,119 (not shown) include proximal makings or structure that allows the physician to determine when rotational alignment has occurred for uncoupling. Alternatively, theslots120,121 can include radiopaque stripes extending therealong that when superimposed on one another or are otherwise aligned in some manner, indicate radiographically that alignment has occurred such the wire guide can disengage from thepassageway31.
• Theabove coupling region14 embodiments are merely exemplary of the many options from which a skilled person might select to couple a catheter and wire guide together for introducing them to a work site, the choice being influenced by the nature of the procedure and the devices being used. Other selected examples include, but are not limited to releasable or breakable sutures or wires extending along or through the catheter to capture the wire, compatible, engageable surface structure or elements located on both devices, temporary or dissolvable bonds or adhesives, magnets, or other means of temporarily coupling two medical devices.
• Preferably, devices configured for remote uncoupling include an alignment indicator system that allows the clinician to determine the current state of alignment or engagement between a given device and the wire guide or guiding member to which it is temporarily coupled for a particular procedure. In procedures that utilize fluoroscopic guidance of devices within the work site, strategically located radiopaque indicia conveniently provide a means for determining relative alignment and confirmation that uncoupling has occurred. The invention does not require that a particular imageable maker be of a particular type. For example, ultrasonically reflective markers can be used in place of radiopaque bands or other markers. Further, the number and arrangement of the markers is not critical. The alignment indicator system of the present invention may comprise any suitable system in which the firstelongate device10 and wire guide11 include a predetermined or precalibrated method or means of providing guidance to the physician via external imaging, direct observation (external or endoscopic), tactile sensation, or monitoring of an audible or visual alarm sensor (e.g., activating an indicator light located about the proximal end of the apparatus) to indicate that uncoupling of the two device has occurred within the work site.
• Referring now toFIGS. 4 and 5, the procedure for uncoupling thefirst device10 and wire guide11 within the work site is greatly facilitated by the addition of a first system ofindicia16 located about thedistal portions13,60 of thefirst device10 and thewire guide11, respectively, that comprise a series of radiopaque markers which provide visual guidance under fluroscopic imaging to the physician or operator as to when the first device is coupled with the wire guide and when the wire guide has passed through and out of thecoupling region14. Since relatively few exchange procedures can be performed under direct visual observation, thedistal indicia16 typically include a series of externally imageable bands, marking, or other indicia comprising a radiopaque (high density) material, such as, iridium, platinum, tungsten, gold, barium, tantalum, etc. The indicia are overlaid upon, bonded to, or incorporated into the device at the desired locations, typically a location useful for relative alignment with other radiopaque indicia or structure. The illustrative first (or distal) system ofindicia16 comprises a series of radiopaque markings on both the first elongate medical device10 (tubular member77) and thewire guide11, including an optional distal imageable marking17 located about thedistal end12 of the tubular member (orfirst end75 of the coupling region), a proximal imageable marking18 located proximate and distal to theside access port15, and adistal imageable portion26 or marker located about thedistal end25 ordistal portion60 of thewire guide11. The illustrative distal marking17 ofFIG. 4 comprises radiopaque ink having sufficient radiopacity to contrast with the catheter shaft, which in the illustrative embodiment, is also made radiopaque by the addition of barium sulfate or other suitable material into the base polymer. The proximal imageable marking18 comprises an iridium or platinum band that is glued or otherwise affixed to the catheter surface closely adjacent the distal end of the scive comprising theside access port15. This band comprises sufficient radiopacity such that it contrasts well with the tubular member to which it is attached, which also may include radiopaque material or pigment. InFIG. 5, the distalradiopaque marker17 of thetubular member77 comprises a band similar toband18 at theproximal end76 of the coupling region (side access port15). The illustrative distal radiopaque wire guide portion26 (FIG. 5) comprises a coilspring comprising platinum, or another radiopaque material such as tungsten or gold. Use of radiopaque filler material or ink is also contemplated as a means for creating a radiopaque wireguide tip portion26. Placement of aradiopaque marker18 about thesecond end76 of thecoupling region14 advantageously provides a target point at which the physician knows if theradiopaque tip26 of the wire guide has passed proximal thereto and disengagement has occurred. Although in the illustrative embodiments, themarker18 is typically located proximal and closely adjacent to the side access port, it may also be placed in any suitable position that is useful for alignment with the wire guide, such as proximal of the port or in alignment therewith, such as depicted inFIG. 6. Alternatively, themarker18 can comprise a radiopaque stripe or sleeve that extends the length of the coupling region, rather than being limited to the area adjacent the side access port. One such example is depicted inFIG. 31 in which the illustrativemetal coupling cannula114 comprises a highly radiopaque material such as platinum or iridium. In the embodiments ofFIGS. 14 and 32, thecoupling region14 comprises acoupling ring63 which preferably includes enhanced radiopacity to assist the physician in determining when the radiopaquedistal portion26 of the wire guide has passed through and disengaged from the ring.
• A second system or type ofindicia21 is depicted inFIGS. 4 and 8, and is located on aproximal portion36 of thefirst device10/tubular member77 that is external to the patient when thedistal portion13 of the device is residing within the work site. During normal operation, theproximal indicia21 are directly visible by the clinician during the procedure as a primary or secondary means of determining alignment. In the biliary embodiment ofFIG. 8, theproximal indicia21 compriseindicia35 located about thetubular member77 and include a series of printed bands that are preferably of a color or pattern contrasting with that of thetubular member77, and which extend from160 cm (the first or distal end62) to the 166 cm mark (second or proximal end61), as measured from the distal tip of the catheter. The first end62 (160 cm) represents the point at which alignment with a correspondingproximal alignment mark37 located on the wire guide, comprises the point ofalignment81 which indicates that uncoupling is imminent with further relative repositioning between the twodevices10,11. Repositioning theproximal alignment mark37 of the wire guide toward thesecond end mark61 results in the two devices reaching the point ofdetachment82 at which uncoupling takes place, the colored bands serving as warning that the uncoupling is imminent with further repositioning. In the embodiment ofFIG. 4, theproximal indicia21 comprise a continuous band of contrasting coloration extending from 160 to 166 cm. As noted, the location of the proximal indicia is not particularly critical, but it is preferably configured such that it remains visible to the operator during a typical procedure. Theband35 can include a gradation of colors, (e.g., yellow to orange to red) to indicate the relative proximity to the point ofdetachment82. In the illustrative embodiment, the 166 cm mark at the proximal end of theindicia band35 lies proximate the distal end of an optional proximalside access port20, which comprises an entry point for a second wire guide into thepassageway27, the technique therefor being discussed below. For non-biliary applications, such as for vascular, pulmonary, or urological procedures, etc., anyproximal indicia21 most likely would be located at a different lengths from the distal tip of the catheter, one appropriately correlated with the distance required to access the work site. The length of the first device indicia35 (6 cm) preferably corresponds with the length of the coupling region14 (shown inFIG. 5).
• As noted above, the 160-166 cm area ofindicia35 of theproximal indica system21 advantageously provides a location on thetubular member77 that will most always be external to the patient and endoscope accessory channel such that it can be viewed by the clinician during the procedure. In the illustrative embodiment, thesecond alignment point37 of the wire guide is indicated by a color change between thedistal portion60, which includes helical striping characteristic of the METRO® Wire Guide (Wilson-Cook Medical, Inc.), and theproximal portion59, which comprises solid coloration, such as a section of shrink wrap or coating of a different color and/or pattern that visually contrasts with thedistal portion60 and/orintermediate portion97 such that the distal160 cm of the illustrative wire guide are distinct from and different in appearance from the proximal 25 cm. Alternatively, a contrasting color or ink or suitable material can be applied to the outer surface of thewire guide11, or a single band can be affixed about thejunction37 between the distal60 and proximal59 portions at an appropriate location to establish the point ofdetachment82 which occurs by alignment withpoint61 of thefirst device10. Thesecond alignment point37 is located on thewire guide11 such that when it is aligned with thedistal end62 of theproximal indicia21, thedistal end25 of the wire guide is aligned with thedistal end12 of thefirst device10/tubular member77. Alternatively, the wire guide could include a single, narrow marking at thesecond alignment point37, or multiple markings, e.g., corresponding to both the proximal and distal ends61,62 of theproximal indicia21. Theproximal indicia21 of thewire guide11 andcatheter10 comprise any suitable means of providing a visual indicator, such as shrink wrap, ink, bands, surface etching or other treatment, etc.
• A third type ofalignment83 is depicted inFIGS. 26aand26bin which the first and secondendoscopic alignment indicators84,85 are located about the intermediate portions of the first elongate medical device10 (or second catheter, etc.) andwire guide11, respectively, in a location such that when the distal portions thereof are advanced within thework site41, the first andsecond indicators84,85 are typically disposed within theviewable area86 between the Papilla ofVater40 and thedistal end87 of the accessory channel. This allows the operator to monitor the relative alignment of both to determine when uncoupling has occurred within the duct41 (biliary system). In the illustrative example, the distal ends of the wire guide and first catheter member (not shown) have both traversed the Papilla ofVater40, and entered thebile duct41. Anoptional marking29 at 10 cm (depicted inFIG. 4 as a pair of printed bands) can be included on the first elongatemedical device10, which is viewable as the device is being introduced into theduct41. The 10cm mark29 can be used for guidance to indicate that thefirst device10 has been advanced a minimally ‘safe’ or sufficient distance into the duct, this occurring once the 10cm mark29 has disappeared from view, as shown inFIG. 26a-b. At this point, theendoscopic alignment indicators84,85 are normally located within theviewable area86. InFIG. 26a, the firstendoscopic alignment indicator84 of the catheter is located proximal to the corresponding second endoscopic (wire guide)indicator85, indicating that thewire guide11 is fully coupled to the first device10 (i.e., completely traversing the coupling region). In the illustrative method, the operator utilizes the intermediate system ofindicia83 to determine when uncoupling of thedevices10,11 has occurred by advancing thefirst device10 relative to the stationary wire guide11 (which typically is locked down or secured against movement to maintain access within the duct), as shown inFIG. 26b. As the twoindicators84,85 become aligned, the distal end of the wire guide exits the proximal end of the coupling region or side access port (not shown) and uncoupling or disengagement takes place. As a further endoscopic indicator to prevent loss of wire guide access out of the duct during uncoupling, the distal portion60 (e.g., the distal 6 cm) of thewire guide11 can comprise a different coloration, such as black, so that it contrasts with the intermediate portion97 (depicted inFIG. 7). When the physician sees the black portion of the wire guide emerging from the papilla, the wire should be advanced back into the duct to minimize the risk of having to recannulate. If uncoupling has yet to take place and the distalblack portion60 of the wire guide is visible endoscopically, then both thewire guide11 andtubular member77 should be advanced further into the duct so that uncoupling can safely take place without risking loss of access.
• An example of a non-visual system of alignment is depicted inFIG. 40 in which thewire guide11 includes asurface irregularity160, such as the illustrative bead, that is configured such that when it passes through thesecond end75 of thecoupling region14, e.g., through theside access port15, the operator feels or senses the contact between them, thus indicating that uncoupling is imminent with further repositioning. The illustrativeside access port15 is configured to include aflexible skirt158 that includes anopening159 sized to allow free passage of thewire guide11, but causing temporary resistance as thebead160 passes therethrough. Furthermore, theskirt portion158 can advantageously act as a seal to help prevent leakage of bile, blood, and air into the passageway of the tubular member. Other possibly surface irregularities include ridges, bumps, teeth, indentations, or a roughened portion that along with an appropriately configuredside access port15 orcoupling region14, provide tactile feedback to the operator and thus, guidance to the state of alignment and engagement between the two devices.
• Endoscopic devices used to perform medical procedures within the biliary system are typically divided into what could be called ‘primary access devices’, which typically comprise the initial device used in the procedure to cannulate the Spincter of Oddi and access the duct, and ‘secondary access devices’ for which the primary access device is exchanged to perform one or more operations within the work site. Examples of primary access devices of the present invention include sphincterotomes for ablating the sphincter to enlarge the opening to the duct (depicted inFIGS. 10-11), needles knives (not shown), which are also used to cut the sphincter, and ERCP catheters (FIGS. 4-5), which are adapted to infuse contrast media into the duct for radiographic imaging. Sphincterotomes and needles knives may also be configured to perform dual or multiple functions or operations, such as the infusion of contrast media and other agents. Some sphinctertomes include balloon used for sweeping the duct to remove calculi or stones lodged therein. Other devices, such as extraction balloons, may be used as both primary and secondary access devices. In pancreatobiliary procedures, primary access devices are exchanged for secondary access devices that are typically configured to perform a therapeutic function, such as to extract or crush stones, sample tissue, deliver radiation or light therapy, dilate or stent strictures (e.g., tumors), or place stents for drainage. If the secondary access device represents the last device used in a particular procedure, it need not be adapted for remote uncoupling, although it preferably would include at least a distal coupling region so the device can be advanced over a short wire without requiring an extension being added thereto. Generally speaking, virtually any secondary access device (extraction, dilation, or phototherapy balloons, dilator, forceps, brush, stent delivery catheter, brachytherapy catheter, lithotriptor, basket, snare, etc.) that is normally introduced into the biliary system over a wire can be adapted for remote uncoupling by the addition of a suitable coupling region within the distal portion of the device and preferably, but not necessarily, at least one of the three aforementioned systems of indicia to provide positive confirmation of uncoupling and relative alignment of the devices.
• An exemplary method of using a primary access device (first elongate medical device10), awire guide11, and a secondary access device (third elongated medical device44) of the present invention to access and perform a medical operation in awork site41 is depicted inFIGS. 9a-f. The initial steps of the illustrative method include a standard endoscopic technique for accessing thebiliary duct41 to perform diagnostic and therapeutic procedures.FIG. 9ashows aduodenoscope38 that has been introduced via the oral cavity into the duodenum39 to visualize the Papilla ofVater40 and Sphincter of Oddi, which lie at the opening to thecommon bile duct41 and the pancreatic duct. In the exemplary method, adilator catheter88 and wire guide11 are advanced from the accessory channel of thescope38 to cannulate astricture42 within the work site41 (duct). It is general physician preference that determines whether thewire guide11 is advanced past the tip of theprimary access device10 to assist in cannulation or whether thedistal end25 of the wire guide is within thepassageway27 during this part of the procedure. As depicted inFIG. 9b, the dilator catheter10 (or other secondary access device) is advanced over thewire guide11 with the proximal portion of the wire guide exiting theside access port15 and extending through the channel alongside the catheter so that both separately exit the accessory channel of the scope as depicted inFIG. 12. For applications where the size of the scope channel is restricted or other applications where there is limited room to accommodate both devices side by side, the catheter can be modified to allow for the wire guide to lie alongside without increasing the overall diameter. This can be done by forming an open channel (preferably one that would not capture the wire) or creating a flattened longitudinal portion along the length of the catheter (not shown).
• Still referring toFIG. 12, theproximal portion59 of thewire guide11 is typically, but not necessarily, secured in place once thedistal end25 thereof has been advanced to the desired position within thework site41. The illustrativewire guide holder50 represents an improvement over prior art devices in that it is configured to be partially inserted into or over the opening52 of theaccess port51 to the accessory channel and provide a seal, rather than being secured elsewhere on the scope. Theholder50 further includes an optionalintegrated sealing element65 having one or more types of seals, including duckbill, membrane with slit (e.g., polystyrene, silicone, or another compliant polymer material), foam seal with small central aperture (e.g., silicon, polyurethane, etc.), or other designs having the ability to seal around the catheter and wire guide to prevent any proximally migrating fluid from exiting the channel. Thewire guide11 is locked in place by interweaving it through a first series of spaces53 (or channels, grooves, slots, etc) between spaced elements located along one side of a lockingportion66 of the device, such as the illustrative curved ‘spine’, using an alternating under/over manner as depicted. The illustrative holder includes threeslots53 or spaces on the first side and a second series of threeslots54 or spaces on the opposite side of the lockingportion66 to accommodate a second wire, if one is necessary for the procedure.
• Unlike other wire guide exchange procedures where the proximal end of the wire guide is well out of the way of the physician, the short wires typically used in the illustrative remote uncoupling or ultra-short wire techniques usually result in the proximal end of the wire guide being within the physician's working area so that access thereto is readily available for introducing secondary devices to the work site. While the illustrative holder is configured to direct the proximal end portion of the wire guide downward and out of the way of the physician, the proximal end, when unsecured to feed another device over the wire, may deflect back up into the working area around the access port of the scope and can interfere with the physician during the procedure. To help alleviate this problem,FIG. 7 depicts awire guide11 in which theproximal end portion59 thereof is oriented at anangle79 with respect to the distal and intermediate portions of the wire so that theproximal end58/proximal end portion59 is typically oriented down and away from the operator (when rotated as such) and thus, out of the working area surrounding the access port of the endoscope while still allowing the physician to access the proximal end for the advancing the next device. In the illustrative embodiment, which comprises an 185 cm nitinolcore wire guide11 in which approximately 40-45 cm thereof typically is extending proximally out of the scope as the third elongate medical device is being advanced thereover, thebend80 or point of deflection is preferably located about 20-30 cm from the proximal end, although the useful range may be anywhere from 0-50 cm. Theuseful angle79 of deflection depends on physician preference, the configuration of the scope and wire guide holder, and other factors, but is generally about 30-120° for endoscopic procedures with a more preferred range of 45-90° for the illustrative embodiment. To create thebend80 in anitinol wire guide11, the material can either be heat set or mechanically overstressed (‘cold working’) to achieve the desiredangle79 of deflection and radius of the bend80 (e.g., small, relatively acute bend or a large, more gradual or rounded bend).
• Referring now toFIG. 9c, once the wire guide has been advanced to the desired location within the work site, the catheter is advanced or drawn back over the wire guide to position it for performing the intended operation. In the illustrative method, this involves the injection ofcontrast media43 into theduct41 to visualize the obstruction, which comprises astricture42 in this particular instance. Another common alternative approach to diagnosing potential obstructions in the ducts would be to initially introduce a sphincterotome32 (FIG. 10) to inject contrast media.43. If an obstruction is found, such as a stone, the sphincter might be ablated and a second device, such as a basket or balloon, is introduced over the original wire guide to extract the stone from the duct. A variety of other treatment possibilities exist and thus, it should be understood that the nature and sequence of the devices used is not critical to the present invention.
• Once the initial operation has been concluded, the firstelongate device10 can be removed from theduct41. As depicted inFIG. 9d, the operator can conduct a device IDE by repositioning the distal ends of the ERCP catheter andwire guide12,25 toward one another by advancing the catheter (as depicted), or preform a wire guide IDE by unlocking thewire guide11 from the wire guide holder and drawing it back until thedistal end25 disengages from the catheter. Alternatively, the clinician can disengage or uncouple the device andwire guide10,11 by moving both devices simultaneously until the wire guide exits the coupling region, typically keeping them within thework site41 while uncoupling takes place. As discussed earlier,imageable indicia18,26 on thedistal portion13 of thecatheter10 and thedistal end25 of thewire guide11, respectively, are utilized to confirm under fluoroscopy that disengagement or uncoupling has occurred, as shown inFIG. 9e. Theproximal indicia21, depicted inFIGS. 4 and 8, and/or intermediate indicia83 (FIGS. 26a-b) may also be utilized to provide confirmation that uncoupling has taken place within the work site. This optional step is shown inFIG. 12 in which thewire guide11 is in the lockedposition161 within the illustrativewire guide holder50, which is attached about theopening52 of the biopsy port of the scope (over the rim of the port and/or inserted therein), is subsequently disengaged and placed in theunlocked position162 adjacent theprimary access device10 so that theproximal indicia21 of the twodevices10,11 can be aligned. As long as theproximal mark37 of thewire guide11 remains distal of thealignment mark81 of theprimary access device10, the operator knows that distal tip of the wire guide is still protruding from the distal end of the catheter within the duct (not shown). When thewire guide11 is withdrawn (orprimary device10 advanced) such that the twomarks37,81 are in alignment, the operator knows the distal ends12,25 of the twodevices10,11 are generally aligned within the duct. As the operator continues to draw back thewire guide11 or advance thecatheter10, thealignment mark37 becomes aligned with thedisengagement mark82, which in the illustrative embodiment is indicative that the distal end of the wire guide has pulled completely out of the passageway or coupling area such that the two devices are uncoupled within the duct.
• Once uncoupling has taken place, eitherdevice10,11 becomes available as a conduit for introduction of a third elongate medical device to the work site. In the illustrative method depicted, the thirdelongate device44 comprises a dilation catheter88 (FIG. 9f) that is introduced over thewire guide11 by feeding theback end58 of the wire guide11 (not shown) into thedistal opening19 of thedilation catheter88 and out of theside access port15, then advancing thedilation catheter88 into the accessory channel of the scope, over the wire, and on into theduct41. Typically, the operator would choose to remove thefirst device10, if no longer needed, before introducing thethird device44. This is done simply by having the operator pull the catheter out of the duct and scope channel in one continuous motion while maintaining the wire guide in position (e.g., such as locked within thewire guide holder50 ofFIG. 12). Once thefirst device10 is removed and thethird device44 is advanced to the work site, the second medical operation (e.g., dilation of the stricture) can be performed. If another operation is required, a third catheter-type device (fourth elongate medical device) can be advanced over theoriginal wire guide11 and so on.
• As noted above, the present system of introducing and exchanging devices over a wire guide is adaptable such that a long wire guide can be introduced through a suitably configured medical device that has been introduced using the ultra-short wire method. In other instances, it may be desirable to convert an indwelling ultra-short wire to a longer wire for use with a non-compatible device.FIG. 13 depicts awire guide extender56 for use with the present system to accommodate an external exchange with either a conventional medical device (‘long wire’) lacking the side access port for intraductal exchange, or conventional rapid exchange devices in which a somewhat longer external exchange (e.g., 30 cm) is required. In the illustrative system, thewire guide11 includesa-coupling mechanism55, such as a thread or wire loop, on theproximal end58 that is configured to engage with asecond coupler57, such as the illustrative hook, located on the distal end of thewire guide extender56. This effectively extends the length of the wire guide so that a conventional over-the-wire exchange can take place in the event that a particular device not designed for ultra-short wire exchange is to be used with the present system. One skilled in the art would readily appreciate the various types of coupling mechanisms that would be suitable to accomplish the extension of the wire guide for purposes of an exchange. They include locking or screw mechanisms, sheaths, bands, etc. that permit the twoportions11,56 to be joined temporarily or permanently. Another option is to use an adhesive strip or similar device to attach thewire guide11 andextender56 to one another.
• The illustrative system of devices that allow for uncoupling within the work site and elimination of the external exchange over the wire can also be adapted for the introduction of second wire guide via an indwelling, uncoupled catheter into the work site, after placement of the first wire guide.FIG. 10 depictscatheter10 that includes a proximal access port20 (third opening) located within the proximal portion of the catheter at a point that typically lies outside of the patient during a procedure (approximately 166 cm in the illustrative biliary device example). The proximalside access port20 may include an optional sleeve cover that slides over and closes the access port when it is not in use.
• To introduce asecond wire46, theillustrative sphincterotome32, once disconnected from thefirst wire guide11, is not removed from the patient as in the method depicted inFIGS. 9a-f. Rather, the tip of the second wire guide46 (third elongate medical device44) is fed into thewire guide passageway27 via theproximal opening20 and advanced through the scope and into theduct41. In the example ofFIG. 11, thefirst wire guide11 resides in afirst branch48 of a bifurcation, such as where thecommon bile duct41 branches into the two lobes of the liver. Thesphincterotome32 carrying the second wire guide can be rotated and deflected by the physician, by using the handle to pull back the cutting wire, to advantageously direct the advancing second wire guide into theopposite branch49 such that each branch is now cannulated by thewire guide46. Asphincterotome32 having a handle that provides axial rotation of the catheter body is preferable for orienting thedistal cutting portion33 into or toward the opposite duct for placement of the wire. Once thesecond wire46 is in its desire location, it can be locked in place (e.g., using the second series ofslots54 of theillustrative wire holder50 ofFIG. 12). After the sphincterotome or otherprimary access device10 has been removed from thesecond wire46, bothwires11,46 are available for subsequent placement or introduction of additional devices, such as stents to restore or improve patency of the ducts.
• Removal of theoriginal catheter device10 from the shortsecond wire46 requires that either an exchange must take place, such as by adding thewire guide extender56 ofFIG. 13 to perform a long-wire exchange; or the catheter may be peeled off of thewire46 if the portion of thewire guide lumen27 that lies between the distal (side) and proximalside access ports15,20 is configured to allow wire to laterally exit the passageway. This can be accomplished in a number of well-known ways including forming a weakness in the wall, such as making a score line, slit67 or other pre-weakened area inside of the wall, such as that depicted inFIG. 15, or intermittent perforations formed partially or completely through the wall to weaken it longitudinally. Alternatively, the tubular member can comprise an intact catheter wall that is configured to fail when sufficient lateral pressure is exerted by the wire guide residing in the passageway. One method of doing this is to make thewall68 adjacent thewire guide lumen27 sufficiently thin (FIG. 16) and and/or of a suitable polymer such that when lateral force is applied against the catheter, thewire guide46 readily splits or tears through thethin wall68 as the catheter is being withdrawn from the patient. A material with a suitable molecular structure to encourage splitting, such as an isotropically oriented polymer, may be used or the polymer may be treated in some manner to encourage splittability. The entire catheter wall can be configured to facilitate splittability, or the splittable portion may be limited to one specific region along the circumference thereof, such as including a longitudinal coextrusion of a second, lower durometer extending to the outside of the wire guide lumen. Rather than (or in addition to) configuring the wall to increase splittability, a tab or other element can be attached or integrated into the catheter to facilitate a manual split to remove the wire guide. A sharp tool or similar device represents yet another alternative method of accessing the guide wire lumen to separate the catheter from the wire. Another option is to extend the groove completely through the wall to form a narrow, open channel or a sealable or locking seam such that the two edges either are biased against one another or interlock by virtue of their complimentary structure. The seam is designed to split open or unlock when the lateral force supplied by pulling the wire guide thereagainst is sufficient to force it open.
• Returning now to the IDE method depicted inFIGS. 9a-f, it has been noted that the friction encountered when introducing a primary access device and a coupled wire guide through the accessory channel of an endoscope can, in some instances, cause premature disengagement of the two device before they reach the work site.FIGS. 23-25 depict different embodiments of anelongate engagement member89 which is configured to releasably secure thewire guide11 to thetubular member77, such that unwanted disengagement or relative movement does not occur as the devices are being introduced or manipulated within the patient. InFIG. 23, the elongate engagement member comprises awire stop member90 preferably made of a flexible polymeric material with adequate column strength, such as nylon, which is similar in configuration to a standard pusher member. Preferably, thewire stop member90 comprises a diameter (e.g., 0.035″) that substantially fills the inner diameter of thepassageway27 of thetubular member77 such that when fully advanced to a point distal to theside access port15 where thewire guide11 enters the coupling region14 (passageway31), the wire stop member contacts and wedges thewire guide11 against the inner wall of the passageway, thereby substantially preventing longitudinal movement of thewire guide11 relative to thetubular member77.FIG. 23 illustrates thewire stop member90 disposed within a single-lumen tubular member77; however, it may be used in multi-lumen device (e.g., a sphincterotome) as well.FIG. 24 depicts the proximal hub92 (a male luer fitting) of thewire stop member90 in a retractedposition94 in which thewire stop member90 is not sufficiently advanced to engage and lock or wedge thewire guide11 within the passageway27 a region orpoint91 just distal to theside access port15. To do so, theproximal hub92 is advanced to aforward position95 in which thehub92 contacts and engages the proximal (female) fitting93 located at theproximal access port23 of theprimary access device10. Once the operator wishes to reposition the twodevices10,11 relative to one another, the proximal (male)hub92 is disengaged from the femaleproximal hub93 and drawn back until thewire guide11 is released. Preferably, but not necessarily, thewire stop member90 is removable from thepassageway27 such that agents, additional wire guides, etc., may be introduced therethrough. Anelongate engagement member89 is typically not used with a secondary access device insomuch that the wire is already indwelling within the work site and the need to secure the wire guide to the device is unnecessary.
• A second embodiment of anelongate engagement member89, depicted inFIG. 25, comprises a thread-like snare member96 made of suture, wire, cable, or other strand of material which loops around, ensnares, or otherwise releasably engages the wire guide within thepassageway27. Thesnare member96 can be attached to an actuating portion of the handle to give the operator sufficient control over its operation. When the operator wishes to disengage thewire guide11 from thetubular member77, tension is released on thesnare member96, or it can be cut or one end released so that it can be withdrawn from thepassageway27. Alternatively, thesnare member96 can be disposed on the outside of thetubular member77 to releasably engage and secure thewire guide11. The depicted embodiments represent but two possible types of devices adapted for securing the first elongatemedical device10 and wire guide11 so that they can be co-introduced through a channel without disengaging therein.
• Theelongate engagement member89 embodiments ofFIGS. 31 and 32 also include thecoupling region14 of thedevice10 that may be configured to be partially retractable back into thesecondary passageway115. This action creates a frictional engagement with the wire guide such that theelongate engagement member89 further acts as a stop to prevent thewire guide11 from sliding freely within thecoupling region14.
• The present invention and method includes using devices in procedures where once the primary access device is used within the work site, a secondary access device is introduced over the guiding device (wire guide) which has been uncoupled from the primary device within the work site. In the biliary tree, a number of possible devices may be introduced to perform a variety of medical procedures, a few selected examples of which are depicted in FIGS.9F,14,17,19-22,27-28,39,41-44,51, and53. The exemplary devices are certainly not representative of all secondary access devices appropriate for use in the bilary tree, nor is their use particularly limited to being a secondary device used following a primary device. The illustrative devices depict some of the general types of medical devices used endoscopically in the biliary tree, as well as other non-biliary and non-endoscopic procedures performed elsewhere in the body.
• FIG. 17 depicts a system for delivering a biliary orpancreatic drainage stent69 mounted on a delivery catheter110 (elongate medical device10) of the present invention. The illustrative COTTON-LEUNG® Biliary Stent (Wilson-Cook, Medical Inc.) is mounted on an OASIS® One Action Stent Delivery System (Wilson-Cook Medical, Inc.), modified for IDE, which extends through theinternal lumen72 of thestent69, which is slidably mounted thereover (when used with a pusher member101 (seeFIGS. 29a-c). It should be noted that the illustrativestent delivery catheter110 is configured to accept different kinds of tubular drainage stents in addition to the type shown. Thecoupling portion14 of thedelivery catheter110 comprises thepassageway27 between thedistal opening19 and theside access port15, which is located 1.5-2.0 cm from the distal tip. Aproximal marking18, such as the illustrative iridium band, is located at about 1 cm, just distal to theaccess port15. Thewire guide11 exits theside access port15 at a point distal to thedistal end71 of thestent69 to advantageously provide a means for withdrawing thestent69 along with thedelivery catheter110, which greatly assists in the ability to reposition the stent within the duct. When thecatheter10 and wire guide11 are withdrawn together relative to the stent (which is held stationary by the pusher member), thedistal edge71 of thestent69, which is slidably positioned over the catheter, lodges in atriangular wedge point70 formed by the junction of the delivery catheter and the wire exiting therefrom. Thus, thestent69 is pulled backward along with the delivery catheter, providing the clinician with a simple and reliable means to pull the stent partially out of the duct so that the proximal anchor flaps73 can extend outside of the duct, if so desired. Once positioned at the desired location, thewire guide11 anddelivery catheter110 are uncoupled and the latter is withdrawn from thelumen72 of thestent69. In delivery systems in which thewire guide11 extends through thelumen72 of thestent69, pulling back on thedelivery catheter110 would not allow the clinician to pull the stent back with it without an additional mechanism to releasably couple the stent to the delivery catheter. It should be noted that this method can be readily adapted for other stent designs as well, particularly other non-expandable tubular stents and those having pusher members.
• The illustrative stent delivery system ofFIG. 17 is particularly well-adapted for placement of multiple stents as depicted in the method ofFIGS. 29a-e, insomuch that remote uncoupling of thewire guide11 andapparatus10 can be performed within the duct, unlike previous biliary stent delivery systems, thereby eliminating the need for recannulating the papilla for each stent placed. As depicted inFIG. 29a, theinner delivery member110, which is coupled to thewire guide11, is advanced out of theendoscope38, through theampullary orifice40 and into theduct41. Thewire guide11 does not extend through the lumen of thestent69 and pusher member, which is not yet shown. InFIG. 29b, thepusher member101 urges the stent over theinner member110 until thedistal end71 thereof reaches thejunction70 formed where thewire guide11 exits the side access port (alternatively, theinner member110 andstent69 can be pulled back while thepusher member101 contacts the stent and causes it to advance further up over the inner member110). As noted above, thejunction70 can be used to contact thedistal end71 of the stent and pull back or reposition thestent69, such as when it had been advanced too far into the duct for ideal deployment. Once thestent69 is in the proper position for deployment, as depicted inFIG. 29c, theinner member110 is advanced further into theduct41 so that there is sufficient room for the uncoupling procedure to take place. Thewire guide11 is unlocked from the wire guide holder50 (seeFIG. 12) and pulled back until it exits theside access port15, as depicted inFIG. 29d. Theinner member110 is then withdrawn through thestent69, along with thepusher member101, and removed from the channel of the endoscope. Thewire guide11 is then re-advanced further into the duct to serve as a conduit for the next stent delivery system, shown inFIG. 29e, such that asecond stent109 can be deployed alongside the first in the manner shown inFIGS. 29a-d. Subsequent deployments of additional stents can be also be made using the same technique over the original wire guide.
• Other stent or prosthesis delivery systems configured for use with the present invention are depicted inFIGS. 22, 27, and39.FIG. 22 depicts adelivery system99 for a self-expandingprosthesis98, which could include a self-expanding stent, such as the Wilson-Cook ZILVER™ Biliary Self-Expanding Stent or any nitinol, stainless steel, or other self-expanding stent; artificial valve (e.g., venous, heart, pulmonary, etc.) prosthesis, vessel occluder, filter, embolic protection device, shunt, stent graft, etc. The illustrative apparatus comprises an inner member (elongate medical device10) on which theprosthesis98 is mounted and anouter member100 or sheath which constrains the self-expandingprosthesis98 until deployment. Theside access port15 is located about 3 cm from thedistal tip12 of theinner member10 with thecoupling region14 being completely distal to theprosthesis98.
• An alternative system for deploying a self-expanding prosthesis is depicted inFIG. 39 which includes a series of corresponding slots in the inner andouter members10,100 to allow for relative repositioning during deployment (thesheath100 typically being drawn back while theinner member10 of the delivery system is maintained in position). This permits thecoupling region14 to extend through theprosthesis98 and allow thewire guide11 to exit theside access port15 proximal to theprosthesis98, which would allow the wire guide to reside inside and be deployed insideprosthesis98, and as a result, less chance of losing access to the work site. This may be especially advantageous in deployment of stents, other prostheses, and other ancillary devices, such as dilation balloons, within the vascular system in that recannulation through the deployed stent may be problematic, possibly leading to complications such as dislodgement or catching on the deployed stent, dislodgement of plaque, etc. With regard to placement of artificial venous and other types of artificial valves, maintaining wire guide access through the valve may be particularly advantageous in that recannulation through the leaflets or valve structure to deploy additional valves or introduce a seating balloon to fully expand the valve support frame against the walls of the vessel may prove particularly difficult, possibly leading to damage of delicate leaf structure and compromise of valve function.
• FIG. 27 depicts an endoscopicbiliary stent69 and pusher apparatus101 (typically 5.0-7.0 FR) which is configured for ultra-short wire and rapid exchange use. It primarily differs from the embodiment ofFIG. 17 in that it lacks the inner member. Both thestent69 and pusher member101 (the elongatemedical device10 in this particular embodiment) are introduced through anouter introducer member100, where thedistal end12 of thepusher apparatus101, which includes thecoupling region14 about itsdistal portion13, urges the stent forward for deployment within the duct. Theside access port15 is located about 6 cm from thedistal end12 of the pusher member101 (elongate medical device10) such that the wire guide traverses the passageway of thestent69.
• FIGS. 41-42 depict another embodiment in which thestent69 comprises apigtail drainage stent126, such as the illustrative naso-biliary drainage stent, that includes acurved anchor portion127 in the deployed configuration128 (FIG. 41) that is configured to assume a straightenedconfiguration129 when placed over awire guide11 for introduction into the bile duct, as shown inFIG. 42. Preferably, but not necessarily, the drainage holes130 disposed along the distal portion of thestent126 are sized such that thewire guide11 cannot readily exit therethrough (e.g., 0.025″), whereas theside access port15 is sized to easily accommodate the exiting wire guide (e.g., 0.035″ or larger). In the illustrative naso-biliary embodiment, there are five drainage holes distributed about 6 mm apart along thedistal portion13 distal to theside access port15 andmarker band18. In this particular embodiment, there is a series of optional drainage holes130 proximal to theside access port15 as well. The spacing of the drainage holes can vary according to the diameter of the curl, generally ranging from 5 mm to 1 cm or more. As thewire guide11 is repositioned relative to thestent126 to perform an intraductal exchange, the anchoringportion127 recoils into its intended shape when the wire guide is no longer inside thecoupling region passageway31. The illustrative embodiment could also be adapted for use as a naso-pancreatic drainage stent, ureteral or urethral stent, or other stent having one or more curved or pigtailed end portions and various configurations of drainage holes. The illustrative embodiment ofFIG. 41 further includes an intermediate curved portion that allows the stent to better conform with the anatomy of the pancreatobiliary tract and duodenum into which it is placed.
• Another embodiment of naso-biliary and naso-pancreatic drains is depicted inFIG. 43 that is similar to the embodiment ofFIGS. 41-42, except that it includes a pair of distal anchoring flaps180 and lacks the pigtail anchoring portion. Furthermore, the side access port is preferably located closer to thedistal end12 of the device (e.g., about 2 cm vs. about 6 cm for the pigtail embodiment). Typically naso-biliary drains are 5-10 FR in diameter while the naso-pancreatic drains are 5-7 FR. Both the pigtail and non-pigtail drain embodiments may advantageously include a stiffening stylet (depicted inFIG. 43) that extends to about theside access port15 and provides pushability, as well as straightening out a loop or bend, if present, located proximal to the side access port. Such a bend may allow the device to conform to the anatomy of the patient, such as to better traverse the contours of the duodenum. An example of the bend orcurved portion172 is shown inFIG. 41.
• FIGS. 19-20 depictballoon47 embodiments of the present invention that are adapted for short wire use.FIG. 19 comprises a dilation balloon47 (a modified QUANTUM™ Biliary Balloon, Wilson-Cook Medical, Inc.), which is made of a non-compliant material (e.g., PET) such thatballoon member102 can be inflated to a predetermined diameter to dilate a stricture within the duct.FIG. 20 comprises anextraction balloon47, such as a modified TRI-EX™ Triple Lumen Extraction Balloon (Wilson-Cook Medical, Inc.), which comprises a non-compliant material (latex, silicone, etc.) which is adapted for sweeping the duct of material, such as stones, sludge, etc. Both embodiments include aside access port15 about6 cm from thedistal end12 of thecatheter10 such that thecoupling region14 extends through theballoon member102 and exits proximal thereto. The embodiment ofFIG. 20 further illustrates aremovable stiffening stylet103 that is maintained within thepassageway27 of thecatheter member10 to provide rigidity, especially across the side access port15 (and optional proximal side access port, not shown) such that kinking is less likely to occur at that point. The stylet, preferably made of metal (e.g., stainless steel) or a relatively stiff plastic or other material, would not provide any engagement function similar to thedistal wire lock90 ofFIG. 23 in most applications since that would interfere with the ability to advance the device over the wire guide.
• FIG. 21 depicts abiopsy device104 for collecting cells within the biliary tree. The illustrative embodiment, which comprises a modified CytoMAX II™ Double Lumen Biliary Brush (Wilson-Cook Medical, Inc.), includes aside access port15 about 6 cm from thedistal end12 of thetubular portion77 of thedevice10 and abrush element105 disposed about the distal end and extending beyond such that thecoupling region14 terminates proximal of thebrush element105, thedistal opening19 for thewire guide11 being disposed about the distal end of thetubular member77 about the base of thebrush element105. An alternative device for delivering abiopsy device104 or other device within a work site is depicted inFIG. 39. Theillustrative tubular member77 includes astandard coupling region14 about the distal end except that thepassageway27 of the tubular member, rather than communicating with thepassageway31 of thecoupling region14, terminates about a rampedexternal opening122 that is configured to accommodate a separate elongate medical device for introduction to the work site which is not directly coupled to thewire guide11. Theillustrative biopsy device104 can be advanced to gather a tissue sample, then withdrawn back into thepassageway27 and either removed from the patient with the introducingmember77, or removed therefrom and a second medical device advanced into the passageway to perform a different procedure. In addition to theradiopaque marker band18 to indicate the location of the second end of thecoupling region14, the illustrative tubular member includes anadditional marker123 located about the ramped opening which provides additional guidance to the operator. The illustrative biopsy device is but one example of a device deliverable in the manner shown inFIG. 39.
• Another secondary access device is depicted inFIG. 38, which comprises a brachytherapy or radioactiveseed delivery catheter106 which includes apassageway27 for the wire guide11 (and which includes the coupling region14) and second, closed-endedpassageway107 for receiving aradioactive element108, such as a catheter, stylet, or individual radioactive seeds that are introduced thereinto. Thebrachytherapy device106 is introduced over thewire guide11 to the treatment site, where it is positioned for a period of time sufficient to deliver an effective therapeutic dose of radiation to adjacent tissue, such as a tumor within the biliary tree. Typically, theside access port15 is located about 6 cm from the tip which is preferably made of a pliable, atraumatic polymer material. The second passageway is preferably located centrally so that radiation is dispersed evenly in all directions. As a result, the first wire guide passageway may either terminate distal thereto, about theside access port15, or be offset therefrom, at least becoming so at a point proximal to theside access port15 andcoupling region14.
• FIGS. 44-57 depict a series of non-biliary devices configured for introduction through the patient's mouth, rather than through the accessory channel of a duodenoscope, such as the aforementioned embodiments. Placement of the embodiments ofFIGS. 44-57 typically involves using anultra-short wire guide11 that is advanced to the treatment site by being coupled to the outside of an endoscope. The wire guide is then uncoupled from the scope and locked in place to serve as a pathway for the introduction of other devices, such as within the esophagus or elsewhere within the gastrointestinal tract. Optionally, the wire guide11 (FIG. 57) can include a hydrophilic or otherwise lubricious coating or surface173 (e.g., SLIP-COAT® Biopolymer, STS Biopolymers, Inc., Henrietta N.Y.) to facilitate the advancement of devices thereover after the wire guide has been placed. The coating is advantageously restricted to a portion of thewire guide11, such as theintermediate portion97, with theproximal portion59 that extends out of the patient and is manipulated and locked by the operation (e.g., the proximal 10-15 cm) having a standard non-hydrophilic surface (e.g., PTFE) to make it easier to secure the wire guide in place. The distal portion60 (e.g., 2-6 cm) of the wire guide may also be left uncoated to give the operator a better degree of control to help avoid accidental, premature uncoupling of the wire guide from the coupling region of the devices being advanced thereover. The lubriciousintermediate portion97 of the illustrative wire guide ofFIG. 57 is especially advantageous when used in the small or colon to allow the device to slide more easily therewithin, while still allowing the wire to be secured at each end by the bite block anddistal loop144, respectively.
• FIG. 44 and45 depict adilator catheter88 and wire guide11 comprising a system for dilating strictures within the esophagus. Thedilator88 includes a system ofscale indicia133 located about the proximal portion of the tubular member. In the illustrative embodiment, which is about75 cm in length, indicia are located to indicate the 40, 50, and 60 cm mark to help align the device with theindwelling wire guide11, which includes a similar series ofindicia134, such as the illustrative bands that increase in number at each 10 cm interval to indicate the distance from a reference point. The alignment indicia133,134 advantageously permit accurate positioning of the device at the treatment site, such as the GE (gastroesophageal) junction, a stricture, or other site that is to be dilated, irradiated, or otherwise treated, after the treatment site has been confirmed using the endoscope used to carry the wire guide thereto.
• A method for introducing thewire guide11 anddilator catheter88 ofFIGS. 44 and 45 into the esophagus to perform a series of esophageal dilations using successively larger dilator catheters is depicted inFIGS. 55a-f. The basic method can also be used for introducing other devices that are too large to be introduced through an accessory channel of an endoscope or where standard endoscopic placement techniques either are not appropriate or not possible. As shown inFIG. 55a, thewire guide11 is carried to the work site using anendoscope38 and a wireguide carrying mechanism174, which in the illustrative embodiment comprises the endoscopicwire guide holder140 depicted inFIG. 48, which resides within theaccessory channel165 of the scope and includes a mechanism to couple with thewire guide11 via adistal loop144 about thedistal end25 thereof. As shown, the endoscopicwire guide holder140 comprises a catheter portion having alateral recess142 proximate thedistal end12 thereof and a longitudinalslidable pin member141, disposed within apassageway145 in theshaft146 ofwire guide holder140, that is adapted to traverse thedistal loop144 of the wire guide. Thepin member141 is advanced to secure theloop144 within therecess142 to carry thewire guide11, which is at least substantially outside of thescope accessory channel165, down to the work site, where it is released by the operator by actuating thefinger ring portion148 of thehandle147 relative to thethumb ring149 until theloop144 slips off the retractingpin member141. When thepin141 is fully advanced into a lockingchannel143 that extends distally from thelateral recess142, theloop144 is secured and cannot slip free. The endoscopicwire guide holder140, which is then withdrawn from the work site along with the endoscope, can either carry thewire guide11 while partially extending from the accessory channel, or be withdrawn into the accessory channel165 (as shown) such that thedistal end25 of the wire guide is pulled thereinto.
• A second embodiment of a wireguide carrying mechanism174 is depicted inFIGS. 46-47 comprising aring element136 that attaches to the outside of theendoscope38 about the distal end thereof using a friction fit, clamping mechanism, or some other well-known means, and is configured to releasably secure thewire guide11 being carried to the work site. Thewire guide11 includes adetachable element135, such as the illustrative distal ball, which is crimped, glued, or otherwise fastened about theend25 of the wire guide and designed to slide off or break apart with the application of a sufficient amount of pull force (e.g., 3 lbs.) and be safely passed through the gastrointestinal system or be absorbed thereby. Theball tip135 is inserted into anopen slot137 in thering136 and then slipped laterally beneath alip portion138 and into arecess139 that together, help secure the wire guide and allow it to be pulled along with the scope. With theball135 residing in therecess139 formed along the distal edge of the ring, thewire guide11 can be uncoupled from thescope38 by pulling on the proximal portion of the wire guide while maintaining a counter force against thescope38 to keep it in place. When theball135 is dislodged (FIG. 45a), thewire guide11 can slip under the lip portion138 (FIG. 47) and theendoscope38 can be withdrawn from the patient, leaving the wire guide in place.
• Referring again toFIG. 55a, the endoscope is typically positioned within thework site41 just proximal to the specific site (sphincter, stricture, lesion, etc.) therein that is to be treated. In the illustrative method, thescope38 is advanced to theGE junction156 while depth markings located about the proximal portion of the scope exiting the patient (not shown) provide the operator with the distance from the mouth to the treatment site. At this point, thedistal end25 of thewire guide11 is also generally positioned at theGE junction156 since it is engaged proximate the distal end of thescope38. Theendoscope38 and wire guide are advanced through theesophagus155 and positioned at theGE junction156, where that distance is noted. The operator may advance thescope38 10 cm (or some other similar, predetermined distance), which places thedistal end25 well within the stomach157 (about 10 cm past the GE junction156). Or, as depicted inFIG. 55b, the operator may advance the wireguide holding device140, which may include proximal depth indicia as well, a similar distance beyond thescope38 and into thestomach157. Thewire guide11 in the embodiments depicted inFIGS. 45 and 50 include areference mark175 located 10 cm from the distal end25 (or whatever distance the wire guide is to be advanced past the GE junction or other anatomical reference point). The wire guide11 of the illustrative embodiment depicted inFIG. 45 includes a series ofproximal indicia134 that can comprise varying numbers of markings at selected intervals therealong (e.g., 30,35,40,45,50, and 55 cm from the reference mark175). In another embodiment depicted inFIG. 50, the wire guide includes five 5cm bands150 of different colors that span from the 30 cm mark to the 55 cm mark as measured from thereference mark175 which is 10 cm from thetip25. Theindicia134 may further include 1 cm reference marks177 (e.g., hash marks) within eachcolored band150. Preferably, thebands150 of the embodiment ofFIG. 50 comprise colors that contrast with the adjacent band. For example, cool and warm colors may be advantageously placed adjacent one another to create a sequence such as yellow, green, red, blue, and then orange.
• Once thewire guide11 has been advanced 10 cm past theGE junction156, it is uncoupled from the wireguide carrying mechanism174 and secured in place by some means such as using theillustrative bite block151 depicted inFIG. 52 with integral wireguide securing portion154, and which includesstraps153 that secure thebite block151 around the patient's head. In addition to functioning as amechanism50 for securing the wire guide in place, it also maintains anopen working area152 through which the scope,wire guide11, and primary or secondary devices are passed to the work site.
• In instances where a narrow stricture exists that cannot accommodate the scope without risking creating a tear in the esophagus (at least without being properly dilated beforehand), the wireguide holding device140 advantageously provides a means to safely advance through and traverse the stricture to carry the wire therebeyond and serve as a pathway for advancing the dilators, the smallest of which may be less than the scope diameter.
• Now referring toFIG. 55c, theendoscope38 and wireguide holding device140 are typically withdrawn from thework site41 such that theprimary access device10, which in the illustrative method comprises afirst dilator167, can be advanced over thewire guide11 to perform a medical operation, as depicted inFIG. 55d. To advance thefirst dilator167, thewire guide11 is temporarily unlocked from the holding device so that the proximal end thereof can be threaded through thecoupling region14 of the dilator. Alternatively, the primary device10 (e.g., dilator167) can be coupled to thewire guide11 prior to the wire guide being advanced to thework site41. Theillustrative dilator167 includes optionalradiopaque marker bands18,132 located at theside access port15 and distal edge of the widest portion of the device before the tapered end, respectively. While it is the GE junction that is established as the anatomical reference point to which theillustrative wire guide11 andprimary access device10 are aligned, the region of the esophagus having the stricture to be dilated may lie anywhere proximal to the GE junction. Reference to the GE junction is preferred to provide a consistent known distance within the stomach for uncoupling.
• The dilator167 (FIG. 44) also preferably includes a series ofproximal indicia133 as well that are aligned with thewire guide indicia134 so that the operator can determine when a particular point along the dilator (e.g., distal end of thewidest portion132,distal tip12,side access port15, etc.) has reached the GE junction, the tip of the wire guide, or some other reference point.
• Once thefirst dilator167 has been advanced past the esophageal stricture or theGE junction156 as the first step of enlarging the opening thereof, thedistal portion13 is advanced fully into thestomach157 of the patient so that uncoupling can occur, as depicted inFIG. 55e. Typically, this is accomplished by advancing theside access port15 past thedistal end25 of thewire guide11, which remains locked in place, until thedistal end25 thereof slides free of thecoupling region14. As with the biliary techniques depicted inFIGS. 9a-fand29a-e, the uncoupledprimary access device10 is then removed from the patient and a secondary access device (third elongate medical device44) such as second (larger)dilator168, is introduced to thework site41 as depicted inFIG. 55f. Esophageal dilations typically involve passage of a series of progressively larger dilators, although one or more of the smaller sizes may be skipped if resistance is not felt during the initial dilation.
• An alternate embodiment of adilator catheter167 is shown inFIG. 56 in which theside access port15 is located on a proximally facing surface orplane169 formed as the distal (larger)diameter portion170 of the dilator transitions down to the smaller,proximal portion171. This advantageously eliminates having thewire guide11 lying alongside the widest part of thedilator167 during passage of both through the stricture. The illustrative stepped configuration can also be useful in other embodiments of the present invention to eliminate friction caused by a wire guide passing within a sheath or channel, such as within an endoscope.
• The general method ofFIGS. 55a-fcan also be adapted for placement of other devices outside of the endoscope, such as a photodynamic therapy (PDT)balloon47, depicted inFIG. 51, or anachalasia balloon53, depicted inFIG. 53. Both devices depicted are commercially available from Wilson-Cook Medical, Inc. and shown herein as modified for ultra short wire delivery. Positioning of thePDT balloon47 is performed by using the endoscope to locate the GE junction and place thewire guide11 at a suitable, known distance therebeyond, such as 10 cm, that distance corresponding to the reference (or ‘zero’)mark175 of the wire guide. In the illustrative embodiment ofFIGS. 50-52, the wire guide includescolored bands150 that correspond to those comprising theproximal indicia133 of thePDT balloon catheter47 such that when the colors are aligned (FIG. 52), thereference point176 of thedevice10, which in the case of the PDT balloon, is the distal edge of the light-emittingportion178 of theballoon member102, is located at the GE junction. This places the light-emittingportion178 at the optimal location to treat the disease (e.g., Barrett's esophagus). It should be noted that thecolored bands150 orother indicia133,134 of the illustrative embodiments are configured for aligning thetreatment device10 with thewire guide11 and thus, the site selected for treatment and may or may not have other functions such as to aid in the alignment of thetips12,25 of the device with one another or with theside access port15 to indicate that uncoupling is imminent. Separate indicia may be used for alignment relating to coupling and uncoupling. While thecolored bands150 of thewire guide11 are configured to refer back to thereference mark175 that corresponds (in this embodiment) to the GE junction, thecolored bands150 of theprimary access device10 are configured such that alignment with those of the wire guide places the device in the correct position for treating the disease. Thus, they are not necessarily (and usually are not) of the same reference scale.
• FIG. 53 depicts an embodiment in which theprimary access device10 comprises an achalasia balloon. With the treatment of achalasia differing in that the balloon is placed across the GE junction rather than proximal thereto, thereference point176 that corresponds to the proximal reference indicia (not shown) and permits the device to be aligned with the GE junction, is located at the center of theballoon member102 rather than the distal edge as in the PDT balloon.
• The technique of dragging the wire guide outside of the scope to the work site, uncoupling it, and advancing a device thereover, is also applicable to a number a larger diameter catheters (FIG. 54), such as feeding tubes (e.g., nasojejunal, nasoenteric, etc.) which are advanced via the mouth into the stomach or small intestines for placement. These catheters may advantageously include astiffening stylet103 in thepassageway27 to prevent the scope from dragging thecatheter device10 with it as it is being backed out of the work site, which in turn, could cause thewire guide11, which is typically locked in place, to pull out of thecoupling region14. The stiffeningstylet103 is removed prior to or after the devices are uncoupled using radiographic, endoscopic, and/or proximally visible indicia located on the twodevices10,11.
• While the gastrointestinal tract may at present provide the most obvious anatomical sites for practicing the methods and techniques of the present invention, further changes in interventional medicine may bring about increasing opportunities where remote uncoupling and ultra-short wire techniques may offer a viable alternative to traditional rapid exchange or other current techniques. For example, many common urological procedures were preformed using wire guide exchange until the introduction of videoendoscopes ideal for urological use. This resulted in direct visualization becoming the standard methodology for manipulating and placing devices in the urological tract. Future developments and improvement in external visualization methodology may result in a return to wire guided procedures where remote uncoupling offers a true advantage to the urologist. Similar advancements in other specialties, especially in vascular and coronary medicine, may create situations where the potential benefits of remotely uncoupling may be realized.
• Any other undisclosed or incidental details of the construction or composition of the various elements of the disclosed embodiment of the present invention or methods of their use are not believed to be critical to the achievement of the advantages of the present invention, so long as the elements possess the attributes needed for them to perform as disclosed. The selection of these and other details of construction are believed to be well within the ability of one of even rudimentary skills in this area, in view of the present disclosure. Illustrative embodiments of the present invention have been described in considerable detail for the purpose of disclosing a practical, operative structure whereby the invention may be practiced advantageously. The designs and methods described herein are intended to be exemplary only. The novel characteristics of the invention may be incorporated in other structural forms without departing from the spirit and scope of the invention. The invention encompasses embodiments both comprising and consisting of the elements and steps described with reference to the illustrative embodiments. Unless otherwise indicated, all ordinary words and terms used herein shall take their customary meaning as defined in The New Shorter Oxford English Dictionary, 1993 edition. All technical terms shall take on their customary meaning as established by the appropriate technical discipline utilized by those normally skilled in that particular art area. All medical terms shall take their meaning as defined by Stedman's Medical Dictionary, 27th edition.

Claims (19)

1. An apparatus for delivering a prosthesis into a work site within a bodily lumen of a patient comprising:

an elongate inner member comprising a shaft extending between a distal end and a proximal end, a lumen extending through at least a portion of the shaft, a distal opening in communication with the lumen and disposed near the distal end of the shaft, a proximal opening in communication with the lumen and disposed a substantial distance from the proximal end of the shaft and a relatively shorter distance from the distal end of the shaft;

an elongate outer member slidably disposed over the shaft of the elongate inner member, the elongate outer member including a distal end portion having a distal end; and

a wire guide removably disposed through the lumen of the elongate inner member,

wherein the prosthesis is disposed over the shaft of the elongate inner member and is engaged by the distal end of the elongate outer member; and

wherein the prosthesis is prevented from being removed from the elongate inner member when the wire guide is disposed through the lumen of the elongate inner member, and is permitted to be removed from the elongate inner member when the wire guide is not disposed through the lumen of the elongate inner member.

2. The apparatus ofclaim 1, wherein the wire guide engages the prosthesis when the wire guide is disposed through the lumen of the elongate inner member.

3. The apparatus ofclaim 2, wherein a proximal end of the prosthesis abuts the distal end of the elongate outer member and a distal end of the prosthesis abuts the wire guide when the wire guide is disposed through the lumen of the elongate inner member.

4. The apparatus ofclaim 1, wherein the proximal opening in the elongate inner member comprises a port through a wall of the shaft that is located distal of the distal end of the elongate outer member when the wire guide is disposed through the lumen of the elongate inner member.

5. The apparatus ofclaim 4, wherein a proximal end of the prosthesis abuts the distal end of the elongate outer member and a distal end of the prosthesis abuts the wire guide when the wire guide is disposed through the lumen of the elongate inner member, the prosthesis abutting a portion of the wire guide extending out from the lumen and through the port in the wall of the shaft.

6. The apparatus ofclaim 1, wherein the wire guide does not extend through the elongate outer member when the wire guide is disposed through the lumen of the elongate inner member.

7. The apparatus ofclaim 1, wherein the prosthesis comprises a non-expanding stent.

8. The apparatus ofclaim 7, wherein the non-expanding stent comprises a plurality of anchor flaps projecting from an exterior surface thereof, the anchor flaps configured to engage an interior surface of the bodily lumen of the patient.

9. The apparatus ofclaim 7, wherein the non-expanding stent comprises a proximal end that abuts the distal end of the elongate outer member.

10. The apparatus ofclaim 1, wherein the prosthesis comprises a self-expanding stent.

11. The apparatus ofclaim 10, wherein the self-expanding stent is expandable from a contracted delivery configuration to an expanded delivered configuration, the self-expanding stent being maintained in the contracted delivery configuration by being disposed within the elongate outer member, the self-expanding stent being allowed to expand to the expanded delivered configuration when not disposed within the elongate outer member.

12. A method for delivering a non-expanding prosthesis into a work site within a bodily lumen of a patient comprising the steps of:

a) providing a wire guide;

b) providing a delivery catheter comprising an elongate inner member and an elongate outer member, the elongate inner member having a shaft and a wire guide lumen extending between a distal opening and a proximal opening, the distal opening being located near a distal end of the shaft, the proximal opening being located a substantial distance from a proximal end of the shaft, the elongate outer member being slidably disposed over the shaft of the elongate inner member;

c) positioning a distal end of the wire guide within the work site;

d) positioning the prosthesis on the delivery catheter by placing the prosthesis over the elongate inner member so as to abut against a distal end of the elongate outer member;

e) inserting a proximal end of the wire guide through the distal opening, the lumen, and the proximal opening of the elongate inner member, the wire guide engaging the prosthesis so as to secure the prosthesis to the delivery catheter;

f) passing the delivery catheter over the wire guide in a distal direction until the prosthesis is within the work site; and

g) moving the prosthesis in a proximal direction by retrieving the delivery catheter along the wire guide in a proximal direction, the wire guide preventing the prosthesis from separating from the delivery catheter.

13. The method ofclaim 12, wherein step g) comprises the step of retrieving the prosthesis from the work site and removing the stent from the patient.

14. The method ofclaim 12, wherein step g) comprises the step of re-positioning the prosthesis within the work site of the patient.

15. The method ofclaim 14, further comprising the following steps:

h) uncoupling the wire guide from the delivery catheter by moving the wire guide in a proximal direction relative to the elongate inner member until distal end of the wire guide has been retracted from the lumen of the elongate inner member; and

i) delivering the prosthesis within the work site by moving the elongate inner member in a proximal direction relative to the elongate outer member until the prosthesis has been pushed off the distal end of the elongate inner member.

16. The method ofclaim 12, wherein step e) comprises the step of abutting a distal end of the prosthesis against a portion of the wire guide exiting outwardly from the proximal opening of the elongate inner member.

17. A method for delivering a plurality of non-expanding prosthesis into a work site within a bodily lumen of a patient comprising the steps of:

a) providing a wire guide;

b) providing a delivery catheter comprising an elongate inner member and an elongate outer member, the elongate inner member having a shaft and a wire guide lumen extending between a distal opening and a proximal opening, the distal opening being located near a distal end of the shaft, the proximal opening being located a substantial distance from a proximal end of the shaft, the elongate outer member being slidably disposed over the shaft of the elongate inner member;

c) positioning a distal end of the wire guide within the work site;

d) positioning a first prosthesis on the delivery catheter by placing the prosthesis over the elongate inner member so as to abut against a distal end of the elongate outer member;

e) inserting a proximal end of the wire guide through the distal opening, the lumen, and the proximal opening of the elongate inner member;

f) passing the delivery catheter over the wire guide in a distal direction until the first prosthesis is within the work site;

g) uncoupling the wire guide from the delivery catheter by moving the wire guide in a proximal direction relative to the elongate inner member until distal end of the wire guide has been retracted from the lumen of the elongate inner member;

h) maintaining the distal end of the wire guide within the work site, the wire guide being disposed in a side-by-side configuration with the first prosthesis;

i) delivering the first prosthesis within the work site by moving the elongate inner member in a proximal direction relative to the elongate outer member until the first prosthesis has been pushed off the distal end of the elongate inner member;

j) removing the delivery catheter from the patient;

k) positioning a second prosthesis on the delivery catheter by placing the prosthesis over the elongate inner member so as to abut against a distal end of the elongate outer member;

l) re-inserting the proximal end of the wire guide through the distal opening, the lumen, and the proximal opening of the elongate inner member;

m) passing the delivery catheter over the wire guide in a distal direction until the second prosthesis is within the work site;

n) uncoupling the wire guide from the delivery catheter by moving the wire guide in a proximal direction relative to the elongate inner member until distal end of the wire guide has been retracted from the lumen of the elongate inner member; and

o) delivering the second prosthesis within the work site by moving the elongate inner member in a proximal direction relative to the elongate outer member until the second prosthesis has been pushed off the distal end of the elongate inner member.

18. The method ofclaim 17, wherein step o) comprises the step of positioning the second prosthesis in a side-by-side configuration with the first prosthesis.

19. The method ofclaim 17, wherein step f) further comprises the step of moving the prosthesis in a proximal direction by retrieving the delivery catheter along the wire guide in a proximal direction, the prosthesis being engaged by the wire guide so as to prevent the prosthesis from separating from the delivery catheter during proximal movement of the delivery catheter.

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