US20080082036A1 - Cerebrospinal fluid shunt having long term anti-occlusion agent delivery - Google Patents

Abstract

The invention includes a shunt for at least partial implantation into a patient that includes an elongated conduit having at least one lumen therethrough, that includes a proximal end for receipt of bodily fluids for flow through the shunt and a distal end for discharge of the bodily fluids from the shunt, and a long term source of at least one occlusion resistant agent, wherein said at least a portion of the at least one occlusion resistant agent can permeate through at least a portion of the elongated conduit. The invention also includes kits and systems.

Description

FIELD OF THE INVENTION
• This invention relates to shunts and techniques to prevent blockage or occlusion of such a shunt. One embodiment of the invention relates to a cerebrospinal fluid shunt.
BACKGROUND OF THE INVENTION
• Hydrocephalic shunts are designed to remove excess fluid from the ventricular region of the brain to a different internal location, such as the peritoneal cavity. Alternatively, cerebral spinal fluid (CSF) shunts may have a proximal end placed into the patient's ventricular region and a distal end being connected external of the patient. In either configuration, a common problem involves the immune response and/or an inflammatory response of the patient or inflammatory response to the insertion of the foreign body, i.e., the catheter, therein. Additionally, occlusion of the catheter lumens often occur and preclude effective drainage of the CSF fluid. It is estimated that 40% of implanted hydrocephalic shunts fail within 5 years due to tissue proliferation into the shunt lumen.
• U.S. Pat. No. 6,110,155, issued to Baudino, and commonly owned by Applicant of the present application, shows an anti-inflammatory agent loaded catheter distal tip and method for preventing tissue fibrosis. The device and method utilizes, in one embodiment, dexamethasone sodium phosphate agent on a ventricular catheter tip to prevent encapsulation of the catheter. U.S. Pat. No. 6,348,042 B1, issued to Warren, Jr., discloses a bio-active shunt device and method by which the interior lumen surface of a shunt is coated with a matrix forming system having at least one enzyme configured for inciting activity to preclude the growth of obstructing cellular material. In one embodiment, the interior surface of the catheter lumen is impregnated with proteases or a matrix containing proteases that is impregnated onto the wall of the lumen to degrade cellular material including cells of the choroid plexus and peritoneum.
• U.S. Pat. Pub. No. US 2004/0220510, commonly assigned, discloses an occlusion resistant shunt for implantation into a patient to treat hydrocephalus. The shunts are constructed to include one or more occlusion resistant materials. Shunts for the treatment of hydrocephalus may remain implanted for the lifetime of a patient, therefore there remains a need for an extended duration of local delivery of agents to limit or prevent occlusion.
BRIEF SUMMARY OF THE INVENTION
• An occlusion resistant medical shunt, particularly a hydrocephalic shunt, is provided for implantation into a mammal. The shunt has an elongate wall structure configured as a tube having a lumen therethrough and a proximal end for receipt of bodily fluids. The bodily fluids, such as cerebrospinal fluid, flows through the shunt to a distal end for discharge of the bodily fluids. The wall structure of the shunt generally includes a biocompatible medical device material. The shunts of the present invention allow for long term delivery of one or more occlusion resistant materials to resist occlusion of the lumenal passage of the shunt.
• A fully implanted medical shunt of the invention for use as a hydrocephalus shunting device has a construction which controls the immunologic response that the recipient may experience after receipt of the shunt within the recipient's body, and through the lifetime of the implantation, which is often the lifetime of the patient. In various embodiments of the present invention, the shunt comprises an elongate wall structure configured as a tube having a lumen therethrough and a proximal end for receipt of bodily fluids and a distal end for discharge of said bodily fluids into another portion of the recipient's body. In one embodiment, the proximal end is located in the ventricular region of the brain and the distal end is located in the peritoneal structure at the abdomen. In another embodiment, the proximal end is located in the ventricular region of the brain and the distal end is located external of the patient. The wall structure generally includes a biocompatible elastomer material, such as silicone, and a source of one or more occlusion resistant materials at one or both of the proximal and distal ends. In addition to or alternatively, the distal end may have different material properties than the proximal end in order to optimize the resistance to both occlusion and/or infection.
BRIEF DESCRIPTION OF THE DRAWINGS
• FIG. 1A is a schematic view of one example of a shunt catheter in accordance with the invention.
• FIG. 1B is a planar cross section of the portion of the shunt depicted inFIG. 1A that is distal of the A axis.
• FIG. 1C is a schematic view of the portion of the shunt depicted inFIG. 1A that is distal of the A axis.
• FIG. 2A is a planar cross section of another example of a shunt catheter in accordance with the invention.
• FIG. 2B is a cross section of the portion of the shunt depicted inFIG. 2A that is distal of the B axis.
DETAILED DESCRIPTION OF THE INVENTION
• A shunt in accordance with the invention can be used in any medical application where it is necessary to move fluid from one part of the body to another. Examples of types of shunts where the invention can be utilized include, but are not limited to, cardiac shunts, cerebral shunts, glaucoma shunts, urinary catheters, and drainage catheters for trauma or post-surgical applications.
• Shunts for treatment of hydrocephalus are well known and have evolved over many decades. Typically, a hydrocephalic shunt includes tubing with a proximal end located in the brain tissue and a distal end located either within the patient at another location external to the brain or external of the patient altogether. Such shunts also typically include a valve structure designed to accommodate and/or control flow based on the intracranial pressure and the position of the patient or other factors. One example includes a valve that is configured for proper flow regulation when the patient is laying down versus standing up.
• A shunt may be occluded at three different locations. First, at an entry point such as the proximal location in the brain, second, at or near the valve system, commonly referred to as a “valve obstruction”, and third, at the distal end, referred to as a distal catheter occlusion. Shunts in accordance with one embodiment of this invention focus on either distal or proximal occlusions rather than valve obstructions, although valve obstructions may be a sequel of occlusions or infection migrating from the distal or proximal ends.
• Proximal occlusions are generally more common than distal occlusions, and often result from blood or cellular debris which block the lumen and distal holes on ventricular catheters. This growth may depend on artificial properties (chemistry and geometry) as well as the distance between catheter and tissues in the ventricular (catheter positioning and slit ventricles syndrome). Some ventricular catheter tip designs have been proposed for maintaining the holes of the ventricular catheter away from the walls of the ventricles and the choroids plexus in order to resolve this problem. However, such devices are likely unable to fully prevent proximal occlusion from occurring or may present further problems. Moreover, those known as flanged catheters actually promote firm attachment of the catheter tubing to the choroids plexus. Although distal obstructions are not as frequent as that at the proximal end, shunt-type catheters can be obstructed in the peritoneal cavity by ingrowth of mesothelial cells and fibroblasts.
• Shunts of the invention provide long term delivery of one or more occlusion resistant agents. The long term delivery of the one or more occlusion resistant agents is provided through a long term source of the one or more occlusion resistant agents. As used herein, the phrase long term source means that the shunt can deliver at least one occlusion resistant agent for at least 1 year. In another embodiment, the phrase long term source means that the shunt can deliver at least one occlusion resistant agent for at least 5 years. In yet another embodiment, the phrase long term source means that the shunt can deliver at least one occlusion resistant agent for at least 10 years. In a further embodiment, the term long term source means that the shunt can deliver at least one occlusion resistant agent for the entire period in which the shunt is implanted in the patient, or the lifetime of the patient. The long term source of the occlusion resistant agent can be provided by having a refilling port in the shunt, or can be provided from within the shunt itself.
• The at least one occlusion resistant agent can be delivered at a level, rate, or concentration that is effective to decrease, diminish, or prevent occlusion. The particular concentration that the occlusion resistant agent is effective at will depend at least in part on the identity of the occlusion resistant agent. Many occlusion resistant agents are effective at a concentration between about 1 nanomolar (nM) and about 1 millimoloar (mM). In one embodiment, where the at least one occlusion resistant agent is rapamycin, the concentration where rapamycin is effective is at a concentration of about 1 nM or higher.
• FIG. 1 shows one embodiment of the hydrocephalic orCSF shunt10 of the present invention, wherein theshunt10 includes anelongated conduit11 having aproximal portion12, one ormore ports13, one ormore valves14, acentral portion15, and adistal portion16. Theelongated conduit11 may be of any shape or size, but generally will be in the form of a tube made of an elastomeric material. As noted above,proximal portion12 is placed in the patient's head at the region of the ventricles while thecentral portion15 is routed subcutaneously along the patient's neck and torso. Thedistal portion16 may be placed for drainage of the cerebral spinal fluid into the peritoneal cavity where the fluid is then reabsorbed by the normal bodily processes or may extend out of the patients body for external drainage. In yet another embodiment, thedistal portion16 of ashunt20 in accordance with the invention is connected to a distal catheter that drains cerebral spinal fluid (for example) into another portion of the body.
• Theelongated conduit11 can be fabricated from a number of materials, as is known to one of skill in the art having read this specification. Examples of such materials include, but are not limited to poly(L-lactic acid), poly(lactide-co-glycolide), poly(hydroxybutyrate-co-valerate), silicones, polyurethanes, polyesters, vinyl homopolymers and copolymers, acrylate homopolymers and copolymers, polyethers, polyethylene, polypropylene, polycarbonate, polysulfone, cellulosics, polydimethylsiloxanes, methylhydrosiloxane-dimethylsiloxane copolymers, polymethylhydrosiloxanes, polyethylhydrosiloxanes, hydride terminated polyphenyl-(dimethylhydrosiloxy)siloxanes, methylhydrosiloxane-phenylmethylsiloxane copolymers, N-vinylpyrrolidone/methyl methacrylate copolymers, 2-hydroxyethylacrylate (e.g. polymacon), various copolymers of 2-hydroxyethylmethacrylate (e.g. hafilcon A and B, vifilcon A, tetrafilcon, dimefilcon, bufilcon, perfilcon, etc.), copolymers of N-vinylpyrrolidone (e.g. lidofilcon A and B, scafilcon A, surfilcon, vifilcon, filcon YA, etc.), polyamides, polyimides, fluoropolymers, polytetrafluoroethylenes, natural rubber and polyisoprene.
• In the embodiment depicted inFIG. 1A, theport13 can provide long term delivery of one or more occlusion resistant agents or materials to resist occlusion of the lumenal passage of the shunt. The at least oneport13 can be constructed as would be known to those of skill in the art having read this specification.
• In one embodiment, theport13 can include a conventional percutaneous fill port that includes a membrane that can be penetrated by a hypodermic needle and is self-sealing after the needle is removed. In one embodiment, the fluid that is injected from the needle goes through a structure that functions as a funnel to a reservoir. The fluid, which generally comprises one or more occlusion resistant agents, flows from the reservoir to the one or more portions of the shunt where occlusion is to be minimized. In one embodiment, a percutaneous fill port also includes a valve to control the rate at which the fluid travels from the reservoir to the one or more portions of the shunt where occlusion is to be minimized. An example of a percutaneous fill port that could function asport13 can be found in U.S. Pat. No. 5,697,951, the disclosure of which is incorporated by reference herein. Other examples of types of structure that could be utilized as aport13 include, but are not limited to the center reservoir fill ports of the MEDTRONIC SYNCHROMED® Infusion System and the MEDTRONIC ISOMED® Constant-Flow Infusion System.
• Thevalve14 can be, but need not be part of theshunt20 of the invention. In one embodiment, thevalve14 is a separate component that is configured to be connected to and work with ashunt20 of the invention. One of skill in the art, having read this specification, will understand the particular types of valves that may be utilized. In embodiments of the invention that are to be used for drainage of cerebral spinal fluid from the brain to another portion of the body, commercially available valves, including, but not limited to, PS Medical Strata® valve, and PS Medical Delta® valve can be utilized.
• In one embodiment, depicted inFIGS. 1B and 1C, theproximal end12 is at least one of the areas where occlusion is to be minimized. One embodiment of ashunt10 includesapertures17 that allow the receipt of bodily fluids, such as CSF into theshunt10. Thewall18 is generally made of an absorptive material. As used herein, the term “absorptive material” refers to a material that can absorb some amount of at least one occlusion resistant agent. Thewall18 can be constructed of one type of absorptive material, more than one type of absorptive material, or one or more types of absorptive material and one or more other materials. For example, at least theproximal portion12 can be constructed of one type of absorptive material and can haveapertures17 formed therein. In another embodiment, at least theproximal portion12 can be constructed of materials that are commonly known to those of skill in the art for shunt construction, and the absorptive material can be added to the proximal portion. In such an embodiment, the absorptive material could be attached to the commonly used shunt materials. Examples of methods of attachment include, but are not limited to, solvent bonding, thermal bonding, adhesives, and other methods known to those of skill in the art having read this specification.
• In one embodiment, absorptive materials can include any material that can absorb at least some of at least one occlusion resistant agent. In one embodiment, an absorptive material can include a material that has an affinity for the occlusion resistant agent due at least in part by the fact that it is delivered in solution. In another embodiment, absorptive materials can have a selective affinity for at least one occlusion resistant agent. Selective affinities can include gross chemical properties, such as hydrophobic attraction, hydrophilic attraction, or ionic attraction; or more specific affinities such as immuno-based affinity, and molecular imprinting based affinity. Other embodiments can include absorptive materials that have affinities based on gross chemical properties, specific affinities, or any combination thereof. Examples of types of absorptive materials include, but are not limited to, alumina, silica, activated charcoal, cross-linked polystyrene beads, high molecular weight gels such as polyethylene glycol (PEG), silicone polyurethanes, and open-celled foams. One particular example of an open-celled foam that may be useful in embodiments of the invention is a hydrophilic medical grade foam available from Avitar Technologies (Canton, Mass.). These exemplary materials or materials like them could then be modified to provide one or more selective affinities as discussed above. One of skill in the art, having read this specification, would understand and be able to modify such materials in order to alter the affinities thereof in a fashion to make them more or less selective for one or more occlusion resistant agents.
• A cross section of another embodiment of the invention that can provide long term delivery of one or more occlusion resistant agents is depicted inFIG. 2A. In this embodiment, theelongated conduit11 of theshunt20 includes at least two lumens, thefluid conduit21 and thedrainage conduit22. Thedrainage conduit22 is also referred to herein as theCSF drainage conduit22, because in some embodiments it serves as the conduit for the CSF from theapertures17 of theproximal portion12 through the central portion15 (not shown) to the distal portion (also not shown) where it drains either into another body space of the patient or external to the patient. Thefluid conduit21 is in fluid communication with theport13. The fluid that is injected into theport13 can travel from theport13 into thefluid conduit21. The fluid, containing the occlusion resistant agent can then permeate through the surface of thefluid conduit21 so that the occlusion resistant agent is delivered to the space around theshunt20 in the ventricular space, the volumes within theapertures17, and the volume within theCSF conduit22 in at least theproximal portion12 of theCSF shunt20. Although not necessarily depicted inFIG. 2A, thefluid conduit21 can be used to communicate between theport13 and theproximal portion12 of theshunt20. Thefluid conduit21 can therefore allow for fluid communication throughout the length of theshunt20.
• In such an embodiment therefore, the material that forms thefluid conduit21 is at least somewhat permeable the one or more occlusion resistant agent. Examples of material that can be used to construct thefluid conduit21 include, but are not limited to silicone rubber, and polyurethane. In one embodiment, thefluid conduit21 is made of silicone rubber.
• Thefluid conduit21 can have variable properties across its length. For example, it may be advantageous to have thicker walls at some points along thefluid conduit21 in order to provide structural integrity to particular portions of theproximal portion12 of theshunt12 or to slow the passage of the occlusion resistant agent across some portions of thefluid conduit21. It may also be advantageous to have thinner walls at some points along thefluid conduit21 in order to increase the rate and/or the amount of occlusion resistant agent that is delivered to the space around some portions ofshunt20. Therefore, in one embodiment of the invention, the thickness of the wall of thefluid conduit21 can vary over its length. The particular thicknesses, and locations of different thicknesses can be chosen based on a number of factors, including but not limited to, the structural integrity of theshunt20, a desire to slow passage or decrease the amount of the one or more occlusion resistant agent to some portions of the area around or within theshunt20, a desire to speed passage or increase the amount of the one or more occlusion resistant agent to some portions of the area around or within theshunt20, or some combination thereof.
• One exemplary embodiment of the invention includes ashunt20 with a variable wallthickness fluid conduit21. One example includes afluid conduit21 that has a wall that is thinner on the outer surface of theshunt20 than it is on the inner surface (the surface facing the CSF conduit22) of theshunt20. It should also be noted that other properties of the material making up thefluid conduit21 wall could be modified in order to change the rate and/or amount of occlusion resistant agent that permeates thefluid conduit21.
• FIG. 2B illustrates how a shunt in accordance with this embodiment of the invention could function to both drain CSF from the ventricles and release occlusion resistant agent. In this depiction, the CSF flow is represented by the thin arrows, of which some are designated23. The CSF flows from the space around theshunt20 through theapertures17 and into theCSF conduit22. The flow of the occlusion resistant agent is represented by the thick arrows, of which some are designated25. The occlusion resistant agent permeates the walls of thefluid conduit21 and flows into the space around the shunt20 (exemplified byarrow25a), the space within the CSF conduit22 (exemplified byarrow25b), and into the volume within the apertures17 (exemplified byarrow25c). It should be noted that any one or more of the directions of flow of the occlusion resistant agent could be controlled or modified at least in part by changing the thickness of the wall through which that particular flow occurs. For example, to configure a shunt that preferentially flows occlusion resistant agent to the space around theshunt20 as opposed to flowing occlusion resistant agent to the area within theCSF conduit22, the outside walls of thefluid conduit21 could be made thinner than the inside walls (those facing the CSF conduit22). Such an embodiment may function to minimize the flow depicted byarrow25b. Other results could also be obtained by varying the wall thicknesses of different areas of thefluid conduit21.
• Another possible embodiment that is similar to that depicted inFIG. 2B is to have a spiral configuration to the apertures in thefluid conduit21. Such a configuration may provide a compromise between total aperture volume and structural integrity that may be advantageous or desirable.
• Another embodiment of the invention includes ashunt20 that includes aCSF conduit22, afluid conduit21, and absorptive material within thefluid conduit21. In such an embodiment, the absorptive material can be included in the entirefluid conduit21, or some portion thereof. In one embodiment, the absorptive material is included in a proximal portion of thefluid conduit21. In such an embodiment, the fluid that is injected into thefluid conduit21 via theport13 would reach the absorptive material via thefluid conduit21 and the occlusion resistant agent could be absorbed at least in part by the absorptive material.
• Another embodiment of the invention includes ashunt20 that includes aCSF conduit22, afluid conduit21, and a saturated solution containing one or more occlusion resistant agents. In one embodiment, the saturated solution includes at least one carrier fluid, and at least one occlusion resistant agent in solid form. In one embodiment, the at least one occlusion resistant agent is at a concentration that is higher than it's solubility in the carrier liquid. In one embodiment, the carrier fluid is water, saline, buffered saline. In one embodiment, the at least one occlusion resistant agent is a hydrophobic compound with a relatively low water solubility. In one embodiment the at least one occlusion resistant agent is a hydrophobic compound with a water solubility of less than about 1 milligram/milliliter (mg/mL).
• In an embodiment that includes a saturated solution containing one or more occlusion resistant agents with the occlusion resistant agent at a concentration that is higher than it's solubility, an equilibrium will be maintained between the occlusion resistant agent in the saturated solution in thefluid conduit21 and outside wall of thefluid conduit21. This equilibrium allows the saturated solution itself to act as a long term source of the at least one occlusion resistant agent. The equilibrium of the occlusion resistant agent and diffusion of the occlusion resistant agent through the wall of thefluid conduit21 will allow theshunt20 to deliver an almost constant concentration of the occlusion resistant agent into the area around and within theshunt20.
• Because a large quantity of the occlusion resistant agent can be stored in thefluid conduit21 by using a saturated solution, the saturated solution can be it's own long term source for the occlusion resistant agent, and therefore ashunt20 that utilizes a saturated solution does not necessarily have to include aport13.
• The inclusion of an occlusion resistant agent in ashunt20 can be utilized in any region of the shunt. One of skill in the art, having read this specification, would understand how to, for example, utilize a fluid conduit portion in a region other than theproximal portion12 of theshunt20. Other regions that could be configured to deliver occlusion resistant agents on a long term basis include theproximal portion12, thedistal portion18,valve portion14, or any combination thereof. Generally, the occlusion resistant agent is delivered through portions of the shunt where clotting or tissue growth tend to occlude the lumen of the shunt.
• Occlusion resistant agents can include a number of different types of agents that can be selected from multiple classes. Such classes include anti-inflammatory drugs, immuno-suppressive drugs, anti-cancer drugs, anti-proliferatives, anti-migratories, anti-angiogenic drugs, radioactive or radiation-emitting material. Such classes may further include anti-neoplastics, anti-coagulents, anti-thrombogenics, anti-oxidants, cyclooxygenase inhibitors, calcium entry blockers, anti-neoplastics, anti-mitotics, anti-microbials, nitric oxide donors, cell cycle inhibitors, anti-arthritis agents, anti-diabetic agents, thrombin inhibitors, thrombolytics, antibiotics, antiviral agents, anti-proliferatives, anti-thrombogenics, anti-oxidants, cyclooxygenase inhibitors, calcium entry blockers, anti-mitotics, anti-microbials, nitric oxide donors, cell cycle inhibitors, anti-cancer agents, and gene therapy agents.
• The following classes of anti-occlusion agents with examples in each class are exemplary occlusion resistant agents that can be utilized in the invention. For example classes of anti-occlusion agents that may be utilized in embodiments of the invention include immunosuppressives, anti-inflammatories, anti-neoplastics, anti-angiogenics, anti-coagulants, analgesics, antipyretics, anti-proliferatives, anti-thrombogenics, anti-oxidants, cyclooxygenase inhibitors, calcium entry blockers, anti-neoplastics, anti-mitotics, anti-microbials, antifungals, nitric oxide donors, cell cycle inhibitors, anti-cancer agents, anti-arthritis agents, anti-diabetic agents, thrombin inhibitors, thrombolytics, antibiotics, antiviral agents, and gene therapy agents. The following list provides additional examples of occlusion resistant agents that may be utilized in the invention.
• Anti-inflammatory agents that may be utilized in the invention include, but are not limited to selective NF-kappaB modulators, NF-kappaB modulators (non-specific), steroids, inflammatory cytokine inhibitors, P38 inhibitors/stress kinase inhibitors, IL-1 specific inhibitors, TNF specific inhibitors, adhesion inhibitors, chemokines and their receptor inhibitors, MMP inhibitors or other protease inhibitors, NO modulators, non-steroidal anti-inflammatory drugs (NSAIDs), and COX inhibitors.
• Non-steroidal anti-inflammatory agents including their racemic mixtures or individual enantiomers where applicable—ibuprofen, flurbiprofen, ketoprofen, aclofenac, diclofenac, aloxiprin, aproxen, aspirin, diflunisal, fenoprofen, indomethacin, mefenamic acid, naproxen, phenylbutazone, piroxicam, salicylamide, salicylic acid, sulindac, desoxysulindac, tenoxicam, tramadol, ketoralac, flufenisal, salsalate, triethanolamine salicylate, aminopyrine, antipyrine, oxyphenbutazone, apazone, cintazone, flufenamic acid, clonixerl, clonixin, meclofenamic acid, flunixin, coichicine, demecolcine, allopurinol, oxypurinol, benzydamine hydrochloride, dimefadane, indoxole, intrazole, mimbane hydrochloride, paranylene hydrochloride, tetrydamine, benzindopyrine hydrochloride, fluprofen, ibufenac, naproxol, fenbufen, cinchophen, diflumidone sodium, fenamole, flutiazin, metazamide, letimide hydrochloride, nexeridine hydrochloride, octazamide, molinazole, neocinchophen, nimazole, proxazole citrate, tesicam, tesimide, tolmetin, triflumidate, nepafenac, etodolac, rebamipide, and zaltoprofen.
• Other types of not previously categorized anti-inflammatory agents may also be utilized in the invention, examples include, but are not limited to tranilast, rituximab, piroxicam, loxoprofen, doxycyclin, drotrecogin alfa, and tretinoin.
• Antineoplastic/antiangiogenic—antimetabolite agents, alkylating agents, cytotoxic antibiotics, vinca alkaloids, mitosis inhibitors, platinum compounds, tissue growth factor inhibitors, cisplatin and etoposide
• Immunosuppressant agents—cyclosporine A, mycophenolic acid, tacrolimus, rapamycin, rapamycin analogues, such as rapamycin ABT-578 analogue produced by Abbott Laboratories, azathioprine, recombinant or monoclonal antibodies to interleukins, T-cells, B-cells and/or their receptors.
• Antithrombogenic Factors—Anticoagulents, such as heparin and chondroiten sulfate; Platelet inhibitors such as ticlopidine; Vasodilators such as cyclandelate, isoxsuprine, papaverine, dipyrimadole, isosorbide dinitrate, phentolamine, nicotinyl alcohol, co-dergocrine, nicotinic acid, glycerl trinitrate, pentaerythritol tetranitrate and xanthinol; and Thrombolytic agents, such as stretokinase, urokinase and tissue plasminogin activators.
• Antiproliferative agents—paclitaxel, actinomycin D, rapamycin, tacrolimus, everolimus, dexamethasone and rapamycin analogue (ABT-578) produced by Abbott Laboratories;
• Analgesics and antipyretics—the opioid analgesics such as buprenorphine, dextromoramide, dextropropoxyphene, fentanyl, alfentanil, sufentanil, hydromorphone, methadone, morphine, oxycodone, papaveretum, pentazocine, pethidine, phenopefidine, codeine dihydrocodeine; acetylsalicylic acid (aspirin), paracetamol, and phenazone;
• Antimicrobials—the cephalosporins such as cephalexin, cefoxytin and cephalothin;
• Antifungals—amorolfine, isoconazole, clotrimazole, econazole, miconazole, nystatin, terbinafine, bifonazole, amphotericin, griseo fulvin, ketoconazole, fluconazole and flucytosine, salicylic acid, fezatione, ticlatone, tolnaftate, triacetin, zinc, pyrithione and sodium pyrithione;
• Antiviral agents—acyclovir and acyclovir prodrugs, famcyclovir, zidovudine, didanosine, stavudine, lamivudine, zalcitabine, saquinavir, indinavir, ritonavir, n-docosanol, tromantadine and idoxuridine;
• Local anesthetics—benzocaine, bupivacaine, amethocaine, lignocaine, lidocaine, cocaine, cinchocaine, dibucaine, mepivacaine, prilocalne, etidocaine, veratridine (specific c-fiber blocker) and procaine;
• Other miscellaneous antibiotics—chloramphenicol, clindamycin, erythromycin, erythromycin ethyl carbonate, erythromycin estolate, erythromycin glucepate, erythromycin ethylsuccinate, erythromycin lactobionate, roxithromycin, lincomycin, natamycin, nitrofurantoin, spectinomycin, vancomycin, aztreonarn, colistin IV, metronidazole, tinidazole, fusidic acid, trimethoprim, and 2-thiopyridine N-oxide; halogen compounds, particularly iodine and iodine compounds such as iodine-PVP complex and diiodohydroxyquin, hexachlorophene; chlorhexidine; chloroamine compounds; and benzoylperoxide;
• Other pharmaceutical agents—beta-radiation emitting isotopes, beclomethasone, fluorometholone, tranilast, ketoprofen, curcumin, cyclosporin A, deoxyspergualin, FK506, sulindac, myriocin, 2-aminochromone (U-86983), colchicines, pentosan, antisense oligonucleotides, mycophenolic acid, etoposide, actinomycin D, camptothecin, carmustine, methotrexate, adriamycin, mitomycin, cis-platinum, mitosis inhibitors, vinca alkaloids, tissue growth factor inhibitors, platinum compounds, cytotoxic inhibitors, alkylating agents, antimetabolite agents, tacrolimus, azathioprine, recombinant or monoclonal antibodies to interleukins, T-cells, B-cells, and receptors, bisantrene, retinoic acid, tamoxifen, compounds containing silver, doxorubicin, azacytidine, homoharringtonine, selenium compounds, superoxide-dismutase, interferons, heparin, analogs, homologs, and derivatives of the above group.
• Embodiments of the invention can include one or more of the above exemplified occlusion resistant agents. Embodiments of the invention can also utilize any combination of the above occlusion resistant agents. Embodiments of the invention can also include other agents, including but not limited to, stabilizing agents such as anti-oxidants, radiopaque agents, MRI detectable agents, and ultrasound detectable agents.
• An example of the use of one of the occlusion resistant agents is illustrated herein. In an embodiment that includes a saturated solution, one example of an occlusion resistant agent that may be utilized includes rapamycin. Rapamycin is an anti-proliferative agent that can be effective at a concentration of about 1 nM.
• Generally, the flow rate of CSF in a young patient (mean 28.7 years old) is 26.6±14.4 ml/hr; and in an elderly patient (mean 77.1 years old) is 11.4±4.2 ml/hr. Therefore, the highest likely flow rate would be 26.6+14.4 ml/hr or about 41 ml/hr. If one of skill in the art wanted a CSF shunt with a saturated solution to deliver an effective concentration of rapaymycin over the period of 10 years (as an example), the amount of rapamycin that would have to be loaded in the CSF shunt would be about 0.033 g.
• $\begin{array}{c}\frac{914g}{1\mathrm{mol}}\times \frac{10\times {10}^{-9}\mathrm{mol}}{1L}\times \frac{0.041L}{1\mathrm{hour}}\times \frac{24\mathrm{hours}}{1\mathrm{day}}\times \frac{365\mathrm{days}}{1\mathrm{year}}\times \\ 10\mathrm{years}=32\text{,}827\text{,}224\times {10}^{-9}g\approx 0.033g\end{array}$
• Another method of calculating the amount of rapamycin that would be needed for a CSF shunt containing a saturated solution to deliver an effective concentration over the period of 10 years (an exemplary period of time) follows:
• If the rate of formation of CSF is about 500 ml/day, then:
• $10\mathrm{yrs}\times \frac{365\mathrm{days}}{1\mathrm{year}}\times \frac{500\mathrm{ml}}{\mathrm{day}}\cong 1\text{,}825\text{,}000\mathrm{ml}\cong 1\text{,825}\mathrm{liters}\mathrm{of}\mathrm{CSF}\mathrm{formed}\mathrm{in}10\mathrm{years}$
• If it is assumed that the minimal rapamycin concentration (e.g. IC₅₀) of rapaymcin should be about 1×10⁻⁸M, then:
• $\frac{10\times {10}^{-9}\mathrm{moles}}{1\mathrm{liter}}\times \frac{914g}{1\mathrm{mole}}=\frac{9\text{,}140\times {10}^{-9}g}{1\mathrm{liter}}$
• Then the amount of rapamycin necessary for 10 years is:
• $1\text{,}825\mathrm{liters}\mathrm{CSF}\times \frac{9\text{,}140\times {10}^{-9}g}{1\mathrm{liter}}=0.01668\mathrm{grams}\mathrm{rapamycin}\cong 0.017\mathrm{grams}\mathrm{rapamycin}$
• If the saturated solution contained 50% solid rapamycin; 10% anti-oxidant stabilizers; 20% radiopacity agents; and 20% fluid (saline, water, etc.), then the volume of saturated solution that would be necessary would be about 0.066 ml (assuming the density of the saturated solution was about 1.0 g/mL). One of skill in the art, having read this specification, will be able to adjust the concentration of the components to achieve iso-osmotic strength relative to CSF fluid to minimize swelling or shrinkage due to osmotic driven transport of water across the device wall.
• The invention also includes a system having at least one shunt of the invention. In one embodiment, a system includes a shunt in accordance with the invention, having a valve, and a distal catheter. The invention also includes kits that include at least one shunt of the invention. In one embodiment, a kit includes a shunt in accordance with the invention, a valve, and a distal catheter.
• One skilled in the art will appreciate that the present invention can be practiced with embodiments other than those disclosed. The disclosed embodiments are presented for purposes of illustration and not limitation, and the present invention is limited only by the claims that follow.

Claims (39)

1. A shunt for at least partial implantation into a patient comprising:

an elongated conduit having at least one lumen therethrough, wherein said elongated conduit comprises a proximal end for receipt of bodily fluids for flow through said shunt and a distal end for discharge of said bodily fluids from said shunt; and

a long term source of at least one occlusion resistant agent, wherein said at least a portion of said at least one occlusion resistant agent can permeate through at least a portion of the elongated conduit.

2. The shunt according toclaim 1 wherein the long term source comprises a refill port that is in fluid communication with the lumen of the elongated conduit.

3. The shunt according toclaim 2, wherein the refill port includes a percutaneous access port.

4. The shunt according toclaim 1 wherein said elongated conduit comprises at least two lumens therethrough.

5. The shunt according toclaim 4, wherein said at least two lumens comprise:

a fluid conduit that functions as a conduit for the at least one occlusion resistant agent;

and a drainage conduit that functions as a conduit for CSF drainage.

6. The shunt according toclaim 5, wherein the fluid conduit comprises a surface through which the at least one occlusion resistant agent can permeate.

7. The shunt according toclaim 5 further comprising a refill port that is in fluid communication with the fluid conduit.

8. The shunt according toclaim 7, wherein the refill port includes a percutaneous access port.

9. The shunt according toclaim 5, wherein at least a portion of the fluid conduit contains at least one absorptive agent and the at least one occlusion resistant agent.

10. The shunt according toclaim 9, wherein the absorptive agent is alumina, silica, activated charcoal, cross-linked polystyrene beads, high molecular weight gels, silicone polyurethanes, open-celled foams or some combination thereof.

11. The shunt according toclaim 4, wherein at least a portion of the fluid conduit contains a saturated solution that includes the at least one occlusion resistant agent.

12. The shunt according toclaim 11, wherein the at least one occlusion resistant agent has a solubility of less than 1 mg/mL in water.

13. The shunt according toclaim 11, wherein the at least one occlusion resistant agent is rapamycin.

14. The shunt ofclaim 1 further comprising at least one valve.

15. The shunt ofclaim 1 wherein the occlusion-resistant material comprises an immunosuppressive, an anti-inflammatory, an anti-neoplastic, a radiation emitting material, an anti-angiogenic, an anti-coagulant, an anti-proliferative, an anti-thrombogenic, an anti-oxidant, a cyclooxygenase inhibitor, a calcium entry blocker, an anti-neoplastic, an anti-mitotic, an anti-microbial, a nitric oxide donor, a cell cycle inhibitor, an anti-cancer agent, an anti-arthritis agent, an anti-diabetic agent, a thrombin inhibitor, a thrombolytic, an antibiotic, an antiviral agent, a gene therapy agent, or some combination thereof.

16. The shunt ofclaim 15 wherein the occlusion-resistant material includes a material selected from the group consisting of beta-radiation emitting isotopes, dexamethasone, beclomethasone, cortisone, hydrocortisone, prednisone, methylprednisone, fluorometholone, tranilast, ketoprofen, curcumin, cyclosporin A, deoxyspergualin, FK506, sulindac, myriocin, 2-aminochromone (U-86983), colchicines, pentosan, antisense oligonucleotides, mycophenolic acid, paclitaxel, etoposide, actinomycin D, camptothecin, carmustine, methotrexate, adriamycin, mitomycin, cis-platinum, mitosis inhibitors, vinca alkaloids, tissue growth factor inhibitors, platinum compounds, cytotoxic inhibitors, alkylating agents, antimetabolite agents, tacrolimus, rapamycin, azathioprine, recombinant or monoclonal antibodies to interleukins, T-cells, B-cells, and receptors, bisantrene, retinoic acid, tamoxifen, compounds containing silver, doxorubicin, azacytidine, homoharringtonine, selenium compounds, superoxide-dismutase, interferons, heparin, rapamycin ABT-578 and analogs, homologs, derivatives or combinations of the above group.

17. The shunt ofclaim 16 wherein the occlusion resistant material includes a material selected from the group consisting of mycophenolic acid, rapamycin, rapamycin ABT-578, derivatives or combinations thereof.

18. The shunt ofclaim 16 wherein the occlusion resistant material includes mycophenolic acid.

19. The shunt ofclaim 16 wherein the occlusion resistant material includes a combination of mycophenolic acid and, rapamycin or rapamycin ABT-578.

20. The shunt ofclaim 15 wherein the occlusion-resistant material permeates at different rates at different portions of the shunt.

21. A shunt for at least partial implantation into a patient comprising:

an elongated conduit having a fluid conduit and a drainage conduit, wherein said elongated conduit comprises a proximal end for receipt of bodily fluids for flow through said shunt and a distal end for discharge of said bodily fluids from said shunt; and

a long term source of at least one occlusion resistant agent, wherein said at least a portion of said at least one occlusion resistant agent can permeate through at least a portion of the elongated conduit,

wherein said fluid conduit functions as a conduit for the at least one occlusion resistant agent and the drainage conduit functions as a conduit for CSF drainage, and

wherein at least a portion of the fluid conduit contains at least one absorptive agent and the at least one occlusion resistant agent.

22. The shunt according toclaim 21, wherein the absorptive agent is alumina, silica, activated charcoal, cross-linked polystyrene beads, high molecular weight gels, silicone polyurethanes, open-celled foams or some combination thereof.

23. The shunt according toclaim 21, wherein at least a portion of the fluid conduit contains a saturated solution that includes the at least one occlusion resistant agent.

24. The shunt according toclaim 23, wherein the at least one occlusion resistant agent has a solubility of less than 1 mg/mL in water.

25. The shunt according toclaim 23, wherein the at least one occlusion resistant agent is rapamycin.

26. The shunt ofclaim 21 further comprising at least one valve.

27. A kit comprising:

a shunt for at least partial implantation into a patient comprising:

an elongated conduit having at least one lumen therethrough, wherein said elongated conduit comprises a proximal end for receipt of bodily fluids for flow through said shunt and a distal end for discharge of said bodily fluids from said shunt; and

a long term source of at least one occlusion resistant agent, wherein said at least a portion of said at least one occlusion resistant agent can permeate through at least a portion of the elongated conduit;

a valve; and

a distal catheter.

28. The kit according toclaim 27, wherein the long term source comprises a refill port that is in fluid communication with the lumen of the elongated conduit.

29. The kit according toclaim 28, wherein the refill port includes a percutaneous access port.

30. The kit according toclaim 27 wherein said elongated conduit comprises at least two lumens therethrough.

31. The kit according toclaim 30, wherein said at least two lumens comprise:

a fluid conduit that functions as a conduit for the at least one occlusion resistant agent;

and a drainage conduit that functions as a conduit for CSF drainage.

32. The kit according toclaim 31, wherein the fluid conduit comprises a surface through which the at least one occlusion resistant agent can permeate.

33. The kit according toclaim 31 further comprising a refill port that is in fluid communication with the fluid conduit.

34. The kit according toclaim 33, wherein the refill port includes a percutaneous access port.

35. The kit according toclaim 31, wherein at least a portion of the fluid conduit contains at least one absorptive agent and the at least one occlusion resistant agent.

36. The kit according toclaim 35, wherein the absorptive agent is alumina, silica, activated charcoal, cross-linked polystyrene beads, high molecular weight gels, silicone polyurethanes, open-celled foams or some combination thereof.

37. The kit according toclaim 30, wherein at least a portion of the fluid conduit contains a saturated solution that includes the at least one occlusion resistant agent.

38. The kit according toclaim 37, wherein the at least one occlusion resistant agent has a solubility of less than 1 mg/mL in water.

39. The kit according toclaim 37, wherein the at least one occlusion resistant agent is rapamycin.

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