US20100121357A1 - Tissue Penetrating Catheters having Integral Imaging Transducers and Their Methods of Use - Google Patents

Abstract

A catheter device that is useable to penetrate from a blood vessel in which the catheter device is positioned to a target location comprises a flexible catheter advanceable into the first blood vessel, a tissue penetrator lumen adapted to receive an operative tissue penetrator which is usable to penetrate from the blood vessel to the target location when properly aimed. Further said catheter including an imaging transducer fixedly mounted on or within the catheter body to provide an imaging signal from which an image of the target location can be obtained. The catheter device may include an imageable marker on the catheter to form on the image obtainable from the imaging signal a penetrator path indication that indicates the path that will be followed by the tissue penetrator when the tissue penetrator exits from the catheter. Alternatively, or addition thereto, the imaging transducer may comprise a plurality of imaging elements which are located so that the penetrator path indication can be obtained. A method of utilizing such a catheter device to bypass an arterial obstruction is also disclosed.

Description

RELATED APPLICATIONS
• This application claims priority to U.S. Application No. 60/080,196 filed Mar. 31, 1998 and is a continuation-in-part of U.S. patent application Ser. No. 08/837,294 filed on Apr. 11, 1997, which itself is a continuation-in-part of two-earlier filed applications, namely; U.S. patent application Ser. No. 08/730,327 filed Oct. 11, 1996 and 08/730,496, both of which were filed on Oct. 11, 1996 and both of which claim priority to earlier-filed U.S. Provisional Patent Application Nos. 06/005,164 filed Oct. 13, 1995 and 60/010,613 filed Feb. 2, 1996, the entire disclosures of all such related applications being expressly incorporated herein by reference.
FIELD OF THE INVENTION
• The present invention relates generally to medical devices and methods, and more particularly to catheter devices and methods that are useable to form channels (e.g., penetration tracts) between vessels such as arteries and veins and vessels and other anatomical structures, in furtherance of a therapeutic purpose such as bypassing an arterial blockage, delivering therapeutic agents, or performing other interventional procedures.
BACKGROUND OF THE INVENTION
• Atherosclerotic cardiovascular disease remains a major cause of premature death and morbidity, in most regions of the world. Various transluminal, catheter-based interventional techniques have been used, or proposed for use, to dilate or otherwise treat atherosclerotic obstructions that occur in coronary and/or peripheral arteries. These therapies have traditionally focused on treating the disease intraluminally, or from “within” the vessel lumen.
• Included among the newer interventional techniques are certain percutaneous, transluminal techniques for bypassing obstructions in coronary or peripheral arteries through the use of the adjacent vein(s) as in situ bypass conduit(s); (e.g. using catheters to perform extra luminal procedures outside the diseased vessel lumen. These procedures are described in U.S. Pat. No. 5,830,222 (Makower) and in published PCT Applications WO 98/16161 and WO 98/46119. As described therein, in some instances, these procedures may be performed by a venous approach wherein a tissue penetrating catheter is inserted into a vein and the desired passageway or puncture is initially formed by facilitating the passage of a tissue penetrator (e.g., a flow of energy or an elongate penetration member) from a catheter, through the wall of the vein in which the catheter is positioned, and into a target location such as the lumen of an adjacent vessel (e.g. the artery). Alternatively, some of these procedures may be performed by an arterial approach wherein the catheter is inserted into an artery and the desired passageway or puncture is initially formed by facilitating the passage of a tissue penetrator (e.g., a flow of energy or elongate penetration member) from the catheter, through the wall of the artery in which the catheter is positioned, and into the target location such as the lumen of an adjacent vessel (e.g. a vein). It is typically necessary for the tissue-penetrating catheter to be placed in proper rotational orientation within the blood vessel, prior to facilitating the passage of the tissue penetrator therefrom, to ensure that the tissue penetrator is aimed or positioned to enter the target. To facilitate such aiming of the tissue penetrator, some of the previously described tissue penetrating catheters have included a penetrator direction marker that indicates the direction in which the tissue penetrator will pass from the catheter and an imaging catheter lumen through which a separate intravascular ultrasound imaging catheter (IVUS catheter) can be advanced. After the separate IVUS catheter has been advanced into the imaging lumen of the tissue penetrating catheter, the IVUS is used to image the target and the penetrator direction marker. The catheter can then be rotated within the blood vessel until the penetrator direction marker is aligned with the target, thereby indicating that subsequent advancement of the tissue penetrator from the catheter will result in the formation of the desired penetration tract between the blood vessel in which the catheter is positioned and the target.
• Applicant has determined that, in cases where the tissue-penetrating catheter is to be placed in a relatively small blood vessel such as branches of the coronary artery, carotid arteries, or smaller vessels located in the peripheral vasculature (e.g. vessels in the arms or legs), it is desirable for the tissue penetrating catheter to be of reduced profile while still having sufficient column strength and torque transfer properties to allow the operator to rotate and maneuver the distal end of the catheter within the patients body by twisting, pushing and pulling the proximal end of the catheter that remains outside of the patient's body. Thus, because the provision of a separate imaging catheter lumen substantially increases the required diameter of the tissue penetrating catheter, it is desirable to devise new tissue penetrating catheter designs that do not include an imaging catheter lumen while still maintaining the capability of imaging from a vantage point near the catheter's distal end to facilitate proper rotational orientation of the tissue penetrating catheter to facilitate aiming of the tissue penetrator.
SUMMARY OF THE INVENTION
• This invention facilitates accurate and reliable orientation of a tissue penetrating catheter in a blood vessel so that an adjacently located blood vessel or other anatomical target can be accurately penetrated, while eliminating the need for formation of a separate imaging lumen within the tissue penetrating catheter. Thus, because the need for an imaging lumen has been eliminated, the tissue penetrating catheters of this invention may be of reduced profile (e.g., 5-7 French diameter).
• In accordance with the invention, there is provided a tissue penetrating catheter device that comprises an elongated catheter having an instrument lumen to facilitate the passage of a tissue penetrator, a penetrator direction marker, and an integral imaging transducer (e.g., an IVUS transducer). To facilitate orientation, the imaging transducer is useable to provide an imaging signal from which an image of the target structure and other adjacent anatomical structures can be obtained. The imaging transducer is fixedly mounted on or within the catheter, thereby eliminating the need for a separate imaging lumen which requires sufficient clearance in the lumen to allow a separate imaging transducer to be advanced and retracted in the lumen. This in turn enables the catheter to be of smaller cross sectional area. In addition, by fixedly mounting the imaging transducer on the catheter, its orientation relative to the catheter and certain components on the catheter can be specifically known.
• One advantageous approach to imaging is to employ an imaging transducer which includes a plurality of imaging elements fixedly mounted on the catheter to provide an imaging signal from which an image of adjacent structures can be obtained. The imaging elements are mounted on the catheter at known circumferential locations relative to the path that will be followed by the tissue penetrator as the tissue penetrator exits from the catheter. The image obtained from the imaging signal from the imaging transducer is useable by the operator to rotationally orient the catheter such that, when the tissue penetrator subsequently exits the catheter, the tissue penetrator will extend into the desired target. In addition, the imaging transducer is useable to image other structures to allow several diagnostic functions such as assessing calcification of a vessel, distance of the target location to the vessel in which the catheter is positioned, and the presence of other devices.
• Another advantageous approach to imaging is to provide an imaging marker on the catheter to form, on the image obtainable from the imaging signal from the imaging transducer, a penetrator path indication. This penetrator path indication is indicative of the path that will be followed by the tissue penetrator when the tissue penetrator exits from the catheter. The imaging transducer and the marker are useable in cooperation with each other to enable the operator to rotationally orient the catheter until the penetrator path indicator is aimed at the target thereby indicating that when the tissue penetrator exits from the catheter it will extend to the target as desired. The imaging elements fixedly mounted on the catheter at known circumferential locations can also be used to orient the catheter without any imageable markers.
• When an imageable marker is used, it preferably includes a structure formed on the catheter including at least one longitudinal member disposed circumferentially about a hollow interior space. When a plurality of longitudinal members is employed, said longitudinal members are disposed at circumferentially spaced apart locations about a hollow interior space thereby forming a cage. At least one of such longitudinal members is located at a circumferential position that is axially aligned with the path or plane of the path that will be followed by the tissue penetrator as it exits from the catheter.
• The tissue penetrator may be any instrument for penetrating the target of interest. For example, the tissue penetrator may be or include a laser beam, flow of energy, or an instrument which will itself puncture or penetrate the target of interest. One preferred form of tissue penetrator includes a needle member formed of resilient material that is biased to a preformed curved configuration with the needle member being initially disposed in a retracted position within the catheter and subsequently advanceable from the catheter to an extended position wherein the needle member assumes its preformed curved configuration.
• The imaging transducer of the current invention is preferably an ultrasound imaging transducer and more preferably a phased array transducer. Because the phased array transducer can be fixed in a permanent manner on or within the catheter body, said phased array transducer has the advantage of being useable with or with out an imageable marker to obtain reliable and accurate orientation. Moreover, the nature of the imaging elements and the fact the imaging signal can be transmitted by multiplexing numerous signals on fewer lead wires contribute to the small profile of the catheter.
• The catheter may include an elongated catheter body having a proximal end, a distal end and a peripheral wall with at least a distal region of the catheter body being flexible enough to navigate through the coronary vessels. The catheter body has an penetrator lumen that terminates distally at an exit location on the peripheral wall and contains or is adapted to receive an instrument or other tissue penetrator for penetrating the blood vessel in which the catheter body is received (“resident blood vessel”) to a target adjacent to the resident blood vessel. The phased array transducer is preferably an onboard transducer which is mounted on or within the catheter body and is inseparable or not removable from the catheter body. The phased array transducer is carried by the catheter body in fixed relationship to the catheter body and in some instances, in a known orientation relative to the exit location. The phased array transducer provides an imaging signal for use in locating the target and identifying the angular orientation of the exit location. Accordingly, with the penetrator received in the penetrator lumen the catheter body can be rotated to properly orient the exit location so that the penetrator can penetrate the resident blood vessel into which the catheter body is receivable and into the target. The catheter body is of sufficiently small profile so that it can be received within a coronary artery, branch or peripheral vessel if desired.
• The catheter may be considered as including an imageable marker which may include a plurality of circumferentially spaced imageable members carried by the catheter body in a known circumferential orientation relative to the exit location. The imageable markers can be sensed by the phased array transducer and used to locate the target and in identifying the angular orientation of the exit location.
• The phased array transducer may comprise a plurality of imaging elements arranged on the catheter body with at least one of the elements being at a known circumferential location relative to the exit location so that such at least one element is useable to identify the angular orientation of the exit location. Alternatively or in addition thereto, the at least one element may form an image region that defines an acceptable zone of penetration for the tissue penetrator.
• In a preferred construction, the catheter body includes a major section which includes a proximal end and the exit location and a distal tip section extending from the major section to the distal end. The distal portion of the distal tip section has a smaller cross sectional area than the adjacent region of the major section. An active imaging apparatus is carried by the catheter body and includes imaging elements fixedly mounted on the distal tip section and a lead or leads extending proximally from the imaging elements along the catheter body. Accordingly, the reduced diameter portions of the catheter body are used to mount the imaging elements, to thereby minimize the profile of the catheter at this region of the catheter. Although various constructions are possible, in one preferred form of the invention, the major section terminates distally in a distal opening and a proximal portion of the distal tip section is received in the distal opening and a distal portion of the distal tip section extends distally of the distal opening.
• The method of this invention includes inserting and transluminally advancing the catheter of this invention into a first blood vessel, actuating the imaging transducer and moving the catheter within the first blood vessel until the penetrator path indication is aimed at the target, and thereafter facilitating the exit of the tissue penetrator from the catheter through the wall of the first blood vessels and into the target. Thereafter various procedures may be performed such as the delivery of therapeutic agents or diagnostic devices.
• In procedures where it may be advantageous to perform subsequent procedures over a guidewire, such as the formation of passageways between a first blood vessel and a target, the method may also include advancing a first crossing guidewire through the lumen of the tissue penetrator and into the target, such as the lumen of the second blood vessel or other target and retracting the tissue penetrator into the catheter leaving the first crossing guidewire in place.
• In some procedures, such as those novel procedures more fully described in U.S. Pat. No. 5,830,222 and in U.S. patent application Ser. Nos. 08/730,496, 09/048,147 and 09/048,147, and other means of revascularizing oxygen starved tissues or delivering therapeutic substances to vessels, tissue and other organs, it may be advantageous to obtain a second point of access to the same vessel into which the catheter was initially introduced at some point distal of the first crossing. However, this access may be limited due to the presence of calcium or other vessel disease blocking the lumen of the vessel. To obtain catheter access to a second point, distal of a diseased section in the same blood vessel, the first crossing guidewire is removed from the lumen of the tissue penetrator and reintroduced into the main guidewire lumen of the catheter and the catheter may be readvanced over the first crossing guidewire to a position wherein the catheter extends through the lumen of the first blood vessel, and through the openings created in the walls of the first and a second blood vessel. Thereafter, the catheter can be advanced distally in the lumen of the second blood vessel. To gain access back to the first blood vessel at a different location (e.g. past the disease or obstruction), the imaging transducer is actuated and the catheter is moved within the second blood vessel as required to cause the penetrator path indication to be aligned with the lumen of the first blood vessel. The tissue penetrator is advanced from the catheter through the wall of the second blood vessel and through the wall and into the lumen of the first blood vessel. To obtain guidewire access to the first blood vessel, a second crossing guidewire is advanced through the lumen of the tissue penetrator and into the lumen of the first blood vessel. The tissue penetrator is retracted into the catheter leaving the second crossing guidewire in place such that it extends from the lumen of the first blood vessel into the lumen of the second blood vessel and back into the lumen of the first blood vessel.
• As part of the invention envisioned herein, a radial expandable connector can be used to provide a blood flow passageway between the blood vessels. For example, a connector delivery catheter can be advanced over the second crossing guidewire and the connector implanted such that the connector extends from the lumen of the first blood vessel through the openings created in the walls of the first and second blood vessels through the lumen of the second blood vessel through the openings created in the walls of the first and second blood vessels and back into the lumen of the first blood vessel.
• The invention together with additional features and advantages thereof may best be understood by reference to the following description taken in connection with the accompanying illustrated drawings.
BRIEF DESCRIPTION OF THE DRAWINGS
• FIG. 1 is schematic illustration showing the catheter of this invention in use on a human patient.
• FIG. 2 is an elevational view of one form of catheter constructed in accordance with the teachings of this invention.
• FIG. 3ais an enlarged fragmentary elevational view partially in section showing a distal portion of the catheter.
• FIG. 3a′ is an enlarged, cut-away view of the wire braid formed within the distal section of the catheter body.
• FIG. 3a″ is a diagram of a catheter braid illustrating the braid angle and pick count of the braid.
• FIG. 3bis an enlarged elevational view showing the distal tip section of the catheter.
• FIGS. 3c,3dand3eare cross sectional views taken generally alonglines3c-3c,3d-3d, and3e-3eofFIG. 3 respectively.
• FIG. 3fis a perspective view of the marker structure of the catheter embodiment shown inFIGS. 3a-3b.
• FIG. 3gis a cross sectional view throughFIG. 3g-3gofFIG. 3a.
• FIG. 4 is an elevational view similar toFIG. 3aillustrating a second embodiment of the catheter.
• FIGS. 4aand4a′ are schematic diagrams of a annular phased array transducers that may be mounted within catheters of the present invention.
• FIG. 4bis a schematic diagram of an alternative single element transducer that is rotatable within or in conjunction with the catheter.
• FIGS. 5aand5bare elevational views of the screen of the imaging apparatus showing standard quadrant-indicating hash marks on the screen, and illustrating the manner in which the fixed-transducer catheter ofFIG. 4 can be rotationally oriented within the blood vessel to cause a penetrator-path-indicating element (and hence the penetrator) to become aimed at a target location to which the penetrator is intended to travel.
• FIGS. 5cand5dare elevational views of the screen of an imaging apparatus whereon a line has been marked to denote the location of the particular penetrator-path-indicating element of the fixed-transducer catheter ofFIG. 4, and illustrating the manner in which the line can be used to facilitate rotational orientation of the catheter within the resident blood vessel such that the penetrator-path-indicating transducer element (and hence the penetrator) are aimed at the target location.
• FIGS. 5eand5fare elevational views of the screen of an imaging apparatus displaying an image from a fixed-transducer catheter as inFIG. 4 wherein the penetrator-path-indicating element(s) of the imaging transducer is/are electronically modified to produce an image that is i) visually distinct from the images produced by the other elements of the transducer array, or ii) modified to produce multiple lines that define a path region, and illustrating the manner in which the visually distinct image of the penetrator-path-indicating transducer can be used to facilitate rotational orientation of the catheter within the resident blood vessel such that the penetrator-path-indicating transducer element (and hence the penetrator) are aimed at the target location or conversely, the path region incorporates the target location within its scope.
• FIGS. 6aand6bare views similar toFIGS. 5aand5brespectively illustrating how the catheter embodiment ofFIG. 3acan be rotationally oriented within the blood vessel to cause the image created by the penetrator-path-indicating member of the marker structure (i.e., the particular strut member of the marker structure that is aligned with the path that will be followed by the tissue penetrator when the penetrator is advanced from the catheter body) to be aimed at the target location to which the penetrator is intended to travel.
• FIGS. 7a-8dillustrate the triangle of Brock-Moscheau (a name given to the formation bounded by the relationship between the arterial and venous system on the heart) and show by way of example as preferred method that can be carried out in accordance with the teachings of this invention.
DETAILED DESCRIPTION OF PREFERRED EMBODIMENTS
• Set forth herebelow are detailed descriptions of certain embodiments and examples of the catheter devices and methods of the present invention.
A. First EmbodimentCatheter with Phased Array (or Rotatable) Imaging Transducer and Marker Structure for Indicating Penetrator Path
• FIG. 2 shows acatheter11 constructed in accordance with the teachings of this invention, whileFIG. 1 shows thecatheter11 in use on a human patient. In the embodiment illustrated, thecatheter11 includes anelongated catheter body13 having aproximal end15, adistal end17, ahandle19 and ahub21 coupled to the proximal end of thecatheter body15 and to the handle. Thehandle19 may also serve as a controller for use in advancing and retracting the penetrating instrument, such as atissue penetrator85 described more fully below.
• The Catheter Body
• Thecatheter body13 includes a relatively rigidproximal section23 shown inFIGS. 2 and 3awhich may be constructed, for example, of a metal hypo tube and an elongated flexible distal section orregion25 suitably joined to the proximal section. Ahand piece19 is attached to the proximal end of theproximal section23, as shown. In the preferred embodiment thehand piece19 andproximal section23 are approximately 100 cm in length. The flexibledistal section25 may incorporate a reinforcement member such as awire braid400 as shown inFIGS. 3aand3a′ and, in the preferred embodiment is approximately 30 cm in length. Thebraid400 terminates approximately 3 cm from thedistal end17.
• It has been determined that material expansion and changes in the physical properties of certain materials may occur after thecatheter11 is inserted into the patient's body and warmed from room temperature to body temperature. This material expansion and changes in the physical properties of certain materials can result in variation in the tolerances and sizing of the catheter11 (e.g. elongation or shrinking) and can thus give rise to an unwanted modification of the position of thetissue penetrating member85. This could, in at least some cases, interfere with the precise aiming and advancement of the tissue penetrating member as desired.FIG. 3a″ illustrates the braid angle A and pick count PC of thecatheter braid400. The “pick count” PC of the braid is, as is well known in the art, a function of the braid angle A (i.e., the greater the braid angle the more picks per inch). Also, the torque transmission and stiffness of the braideddistal section25 is a function of the braid angle (i.e., a braid angle of 90 degrees provides maximum torque transfer and a braid angle of 0 degrees provides minimum torque transfer). Typically, cardiovascular catheters used in procedures such as those described herein utilizing a venous approach have braid angles A that result in a pick count of 50-70 picks per inch. However, applicant has determined that by decreasing the braid angle A of thebraid400 within thedistal section25 of thecatheter11 to result in a lower pick count, it is possible to minimize or eliminate the unwanted longitudinal expansion of thecatheter11 and/or its components, while retaining sufficient torque transmission and acceptable stiffness to accomplish the procedures for which thecatheter11 is intended (examples of such procedures are illustrated inFIGS. 7a-8dherebelow). This variation in braid angle or picks per inch may vary depending on the material of construction of the catheter and/or the braid fiber, and the diameter of the catheter body.
• In instances where thecatheter11 is intended for use in a coronary artery, at least thedistal section25 of thecatheter11 is sized to be received within a coronary artery, and therefore can be received within either a coronary artery or a coronary vein or other lumens of equal diameter. Thecatheter body section13 has apenetrator lumen27 that terminates distally at an exit location or exit port29 (FIG. 3a) on a peripheral wall31 of the catheter body. Thepenetrator lumen27 extends proximally from theexit port29 to theproximal end15 of thecatheter body13 and communicates with the interior of thehandle19 through thehub21. The penetrator lumen27 contains or is adapted to receive an instrument, such as thetissue penetrator85 shown inFIG. 3a, for penetrating out of the blood vessel in which thecatheter11 resides (i.e., the “resident vessel”) and to a target location. Theexit port29 is preferably located a short distance proximally of thedistal end17. A radiopaque marker33 is mounted on thelumen27 adjacent theexit port29.
• Thecatheter body13 also has a guidewire lumen35 (FIG. 3a) which extends to thedistal end17 of thecatheter body15. In this embodiment, theguidewire lumen35 extends proximally to aninlet port37 at the peripheral wall31 closely adjacent theproximal section23. The catheter body also has a lead lumen39 (FIG. 3c) for a purpose described below.
• A major section51 of thecatheter body13 terminates distally in a distal opening53, and the catheter body includes adistal tip section55 of soft, flexible, biocompatible material (FIGS. 3aand3b). A proximal portion56 of thedistal tip section55 is received in the distal opening53 and a distal portion of the distal tip section extends distally to thedistal end17. The distal portion of thedistal tip section55, i.e. the portion of thedistal tip section55 which extends beyond the distal end of the major section51 is of smaller cross sectional area than the adjacent region of the major section to thereby define anannular shoulder57 on thecatheter body13. Theexit port29 is spaced slightly proximally of theshoulder57.
• Phased Array Transducer
• An imaging transducer81 is fixedly mounted on thecatheter11, and in the embodiment illustrated inFIG. 3a, the imaging transducer is mounted on thedistal tip section55 just distally of theshoulder57. In this embodiment, the imaging transducer81 is a phased array transducer of the type shown schematically inFIG. 4aand is operative to image 360° about thecatheter11. This imaging transducer81 comprises an annular array of individual crystals orelements121 is coupled to a multiplex circuit83 which is within the major section51 of thecatheter body13 adjacent theshoulder57, and the multiplex circuit83 is in turn coupled to leads85 which extend through thelead lumen39 and a port87 (FIG. 2) of thehub21 to animaging console89. When activated, the imaging transducer emits ultrasound signals and receives back echoes or reflections which are representative of the nature of the surrounding environment. The imaging transducer provides an imaging signal from which an image of the surrounding structure can be created by signal processing apparatus located in theimaging console89 and viewed on a standard display screen located near the operating table on which the patient is positioned. In a preferred practice of this invention, the phased array transducer and the accompanying circuitry and theimaging console89 may be obtained from Endosonics of Rancho Cordova, Calif. or Intravascular Research Limited (United Kingdom).
• Alternative Rotatable Transducer
• In an alternate embodiment of this invention, a rotatable imaging transducer81rof the type illustrated schematically inFIG. 4bmay be used. This alternative transducer81rcomprises one (or more than one) imaging element121rthat is mounted on arotating shaft82 that extends through a portion of the catheter body (e.g., and out of port39) such that it can be rotated relative to the catheter body. Alternatively, it will be appreciated that this transducer81rmay be fixedly mounted within or upon the catheter body and the entire catheter body may be rotated in order to effect rotational movement of the transducer element121r.
• Marker Structure
• In this first embodiment (FIGS. 3a-3e), animageable marker structure101 is fixedly mounted on thecatheter body13 in a known circumferential orientation relative to theexit port29. In the embodiment ofFIG. 3a, themarker structure101 is in the form cage (FIG. 3f) and the transducer81 is within the cage. Thismarker structure101 comprises a plurality oflongitudinal members103 and103ppdisposed at circumferentially spaced apart locations about a hollowinterior space105. Thehollow space105 receives thedistal tip section55 and the transducer81, and the transducer81 is an onboard transducer in that it is inseparable from and not removable from thecatheter body13. In this embodiment the transducer81 is attached to or wrapped around thecatheter body13 and permanently retained by a suitable potting composition or adhesive. As shown inFIG. 3g, one of thelongitudinal members103ppis designated as the penetrator path indicating member and is positioned at a circumferential position that is axially aligned with theexit port29 or otherwise positioned to be indicative of the path that will be followed by thetissue penetrator85 as it is advanced from thecatheter body13 through theexit port29. Thus, theimageable marker structure101 forms on the image obtainable from the imaging signal from the imaging transducer a penetrator path indication that indicates the path that will be followed by the tissue penetrator when thetissue penetrator85 exits from the catheter.
• With the construction described above, the imaging transducer81 and themarker101 are both mounted on thedistal tip section55 which has a smaller cross sectional area than does the adjacent region of the major section51 of thecatheter body13. Accordingly, the cross sectional area of thecatheter body13 at the region containing the imaging transducer81 and themarker101 can still be relatively small. Also, theexit location29 is closely adjacent to the imaging transducer81 and may be, for example, about 3 mm from the imaging transducer. This minimizes the likelihood of any significant torsional displacement of theexit location29 relative to themarker101 andimaging transducer89. It may also be appreciated that the imaging transducer may be mounted such that the exit port is located directly at the point at which the transducer is affixed to the catheter, eliminating any displacement.
• FIGS. 6aand6bshow an image of what the operator sees on the display screen of theimaging console89 when thecatheter11 is advanced into the resident blood vessel. Specifically,FIG. 6ashows an image of thecatheter11, animage143 of the resident blood vessel into which thecatheter11 has been inserted (i.e., the blood vessel in which thecatheter11 resides) and an image of atarget blood vessel145 adjacent to theblood vessel143. In this particular illustration, the blood vessels represented byimages143 and145 are a coronary artery and coronary vein, respectively. InFIG. 6a, the image created by the penetrator-path-indicatingmember103ppof themarker structure101, as represented by line orartifact147, does not extend into the lumen of thetarget blood vessel145. Thus, if thetissue penetrator85 were to be advanced from thecatheter11 while thecatheter11 is in the rotational orientation shown inFIG. 6a, the tissue penetrator would not advance into the lumen of thetarget blood vessel145, as desired. However, by rotating thecatheter11 within theresident blood vessel143, the operator may cause the image created by the penetrator-path-indicatingmember103ppof themarker structure101, as represented by line orartifact147, to extend into the lumen of thetarget blood vessel145 as illustrated inFIG. 6b. Thus, if thetissue penetrator85 were to be advanced form thecatheter11 while thecatheter11 is in the rotational orientation shown inFIG. 6b, thetissue penetrator85 would advance into the lumen of thetarget blood vessel145, as desired.
B. Second EmbodimentCatheter with Fixedly Mounted Imaging Transducer Useable without Marker Structure
• FIG. 4 shows a second embodiment of the catheter11awhich is identical to thecatheter11 in all respects not shown or specified as being different herebelow. Portions of the catheter11acorresponding to portions of thecatheter11 are designated by corresponding reference numerals followed by the letter a.
• The primary difference between thecatheters11 and11ais that the catheter11ahas noimageable marker structure101. Instead, itsimaging transducer81ais mounted in a fixed position such that oneparticular element121pp(or a group of particular elements) is/are designated as the penetrator path but rather is mounted in a fixed orientation within or upon the catheter such that a selected one (or selected ones) of the individual imaging elements121 (e.g., crystals) of the phased array is positioned in known spacial relation to the path or plane of the path that will be followed by the tissue penetrator as exits from the catheter. This selected one (or ones) of theimaging elements121 shall be referred to herein as the “penetrator-path-indicatingelement121pp.” Theimaging elements121, which may be adhered to thecatheter body13a, are mounted on thecatheter11 at known circumferential locations relative to the path that will be followed by a tissue penetrator as the tissue penetrator advances from thecatheter11 through theexit port29a. The image obtained from the imaging signal from theimaging transducer81ais thereby useable by the operator to rotationally orient thecatheter11 such that when the tissue penetrator subsequently exits from the catheter, the tissue penetrator will extend into the target as desired. Thus, because the imaging elements121aare mounted on thecatheter body13 in fixed relationship to the catheter body and in a known circumferential orientation relative to theexit location29a, theimaging transducer81acan be used to provide an imaging signal for use in locating an adjacent blood vessel or other structure and identifying the angular orientation of the exit location. If desired, the imaging elements of the imaging transducer81 of thecatheter11 can be oriented in the same fashion as described above for the catheter11a. In this event, the only difference between thecatheters11 and11awould be that thecatheter11 has animaging marker101 and the catheter11adoes not.
• FIG. 5ashows animage151 of the catheter11a(FIG. 4) in theresident blood vessel143 in which that catheter is positioned, as well as an image of thetarget location145, shown here as another blood vessel. Standard serial hash marks300a,300b,300cand300dare formed on the imaging screen as shown, generally dividing the screen into four quadrants. In this instance, the transducer81bis fixedly mounted within the catheter11asuch that its penetrator path indicatingtransducer element121ppis in the 12 o'clock position and aligned with the top array of hash marks300aon the imaging screen. Thus, the top array of hash marks300aserve as a visual indicator of the path that will be followed by thetissue penetrator85 as it is advanced from the catheter11a. In the showing ofFIG. 5a, one can see that the top hash marks300ado not enter thetarget location145 and thus, it can be concluded from this image that thetissue penetrator85 is not properly aimed at the target location. However, by rotating the catheter11ain theresident blood vessel143, to the position shown inFIG. 5b, the top array of hash marks300ais caused to pass directly through thetarget location145, thus indicating to the operator that thetissue penetrator85 can now be advanced from theexit port29ato properly penetrate from theresident vessel143 into thetarget location145, as desired.
• FIGS. 5cand5dshow animage151aof the catheter11a(FIG. 4) in theresident blood vessel143 in which that catheter is positioned, as well as an image of thetarget location145, shown here as another blood vessel. Avertical line146 has been created on thescreen146 in alignment with the position of a penetrator path indicatingtransducer element121ppof the phased array transducer81b. Thus, theline146 serves as a visual indicator of the path that will be followed by thetissue penetrator85 as it is advanced from the catheter11a. It will be appreciated by those of skill in the art that thisline146 may be created on theimaging screen89 electronically (e.g., as an illuminated or colored line on the image) or it may be physically marked on the screen89 (e.g., by felt tipped marker or other suitable marking material or apparatus such as a template). In the showing ofFIG. 5c, one can see that theline146 does not enter thetarget location145 and, thus, it can be concluded form this image that thetissue penetrator85 is not properly aimed at thetarget location145. However, by rotating the catheter11ain theresident blood vessel143, to the position shown inFIG. 5d, theline146 is caused to pass directly through thetarget location145, thus indicating to the operator that thetissue penetrator85 can now be advanced from theexit port29ato properly penetrate from theresident vessel143 into thetarget location145, as desired.
• FIGS. 5eand5fshow animage151bof the catheter11a(FIG. 4) in theresident blood vessel143 in which that catheter is positioned, as well as an image of thetarget location145, shown here as another blood vessel. The penetratorpath indicating element121ppof the phased array transducer81bhas, in this case, been modified to provide an image that is enhanced or otherwise visually discernible from the images produced by theother transducer elements121bof the array. In this manner, apenetrator path region148 is visible on thescreen89 in the region that is imaged by the penetratorpath indicating element121pp. Thus, thepenetrator path region148 serves as a visual indicator of the path that will be followed by thetissue penetrator85 as it is advanced from the catheter11a. It will be appreciated by those of skill in the art that thispenetrator path region148 may be created by causing the penetratorpath transducer element121ppto receive more power than theother transducer elements121bor by otherwise modifying or processing the signal received from that penetrator path indicatingtransducer element121pp. In the showing ofFIG. 5e, one can see that thetarget145 is not encompassed by thepenetrator path region148 and, thus, it can be concluded from this image that thetissue penetrator85 is not within acceptable range of thetarget location145. However, by rotating the catheter11ain theresident blood vessel143, to the position shown inFIG. 5f, thetarget145 is brought within an appropriate range of thepenetrator path region148, thus indicating to the operator that thetissue penetrator85 can now be advanced from theexit port29ato properly penetrate from theresident vessel143 into thetarget location145, as desired. Additionally, it is to be understood that the penetrator path indicatingtransducer element121ppor the output on the imaging console may be additionally modified to allow imaging or project images of only that region within a predetermined distance (e.g., up to 3 mm) of theresident vessel143 thereby signalling to the operator the possible target locations that are out of the intended range of thetissue penetrator85 or subsequent systems or devices that may be employed to complete the intended procedure.
• As an alternative to creating a penetrator path region by increasing the power transmitted to the penetrator path element transducer(s), it will be appreciated that thisregion148 may be created on theimaging screen89 electronically (e.g., as an illuminated or colored sector on the image) or it may be physically marked on the screen89 (e.g., by felt tipped marker or other suitable marking material or apparatus such as a template). In addition, the penetrator path region may be defined by the enhancement (e.g. electronic illumination, marker or template) of two lines such as that depicted byline146, modified to define boundaries to theregion148 within which is defined an acceptable range of penetration zone.
• It will be appreciated that the electronically enhanced penetratorpath indicating transducer121ppmay be used in conjunction with the hash marks300a,300b,300c, and300dshown inFIGS. 5a-5band/or theline146 shown inFIGS. 5cand5d, thereby enabling the operator to utilize multiple indicia to determine the appropriateness of the size and distance range of thetarget location145 before advancing thetissue penetrator85. In this way, the operator is provided with a range of acceptable accuracy depending on the desired result and taking into account what procedures may be performed subsequently (i.e. placement of a connection device or other catheter devices).
C. Examples of Methods and Procedures
• Thecatheters11 and11amay be used in the performance of various revascularization procedures including, as described in detail herebelow, a Percutaneous In Situ Coronary Artery Bypass (PICAB) procedure as well as a Percutaneous In Situ Coronary Venous Arterialization (PICVA) procedure. It will be appreciated that, in addition to the particular PICAB and PICVA examples described in detail herebelow, the catheter system of the present invention may also be useable to perform various other procedures such as directed drug delivery procedures of the type described in co-pending U.S. patent application Ser. No. 09/048,147 and other revascularization procedures.
• i. A Preferred Method for Performing the PICVA Procedure:
• The PICVA procedure is useable to effectively provide arterial perfusion of
• an ischemic region of myocardium, even in cases where a coronary artery is so extensively obstructed that no patent distal portion of the artery remains available to carry bypassed arterial; flow.
• FIG. 7ais a diagram of a portion of the coronary vasculature known as known as the Triangle of Brouck-Moscheau. The Triangle of Brock-Moscheau is defined by the left anterior descending coronary artery LAD, the circumflex coronary artery CX, the anterior inter ventricular vein AIV. The arteries CX and LAD are both joined to and receive blood from the left main artery. The great coronary vein GCV forms a downwardly opening U-shaped configuration with the legs of the U being adjacent to arteries CX and LAD. Obstructions resulting from a build up of plaque may be found in either or both of the arteries CX and LAD. For example and for purposes of illustrating a preferred embodiment of the method of this invention,FIG. 7ashows anobstruction171 in the left anterior descending artery LAD.
• In the first step of the procedure, shown inFIG. 7b, acoronary guide catheter173 is advanced into the left coronary ostium and aguidewire175 such as a 0.014 inch guidewire is advanced through theguide catheter173 into the lumen176 of the left anterior descending artery (LAD) to a location just proximal of theobstruction171 as shown inFIG. 7b.
• Next, as shown inFIG. 7c, thetissue penetrating catheter11 is percutaneously inserted and transluminally advanced through theguide catheter173 and over theguidewire175 into the left anterior descending artery LAD to a location just proximal of the obstruction171 (FIG. 7c). The axial position of theguidewire175 and of thecatheter11 within the artery LAD is known by conventional techniques which may include, for example, fluoroscopy and the radiopaque marker33. Although this procedure is described with reference to thecatheter11, it should be understood that an identical procedure would be followed for the catheter11a. As shown inFIG. 7d, with thecatheter11 in position within the LAD, theleads85 are coupled to theimaging console89 and the imaging transducer81 is actuated to obtain images as shown, by way of example, inFIG. 6a. Thecatheter11 is moved, and more specifically rotated within the artery LAD until theexit port29 and hence a penetrator path indication orpath region148 is aimed at the lumen of the vein AIV. At this point, thetissue penetrator85 is advanced through the exit opening29 from thecatheter11 through the walls of the artery LAD and the vein AIV and into thelumen177 of the vein AIV upstream of theobstruction171 as shown inFIG. 7d.
• As shown inFIG. 7e, with thecatheter11 and thetissue penetrator85 in the position shown inFIG. 7d, afirst crossing guidewire179 is advanced through the lumen851 of thetissue penetrator85 and into thelumen177 of the vein AIV. Thetissue penetrator85 is then retracted into thecatheter11 leaving the crossingguidewire179 in place such that it extends from the lumen176 of the artery LAD into thelumen177 of the vein AIV.
• As shown inFIG. 7f, thecatheter11 is then removed by retracting it back over theguidewire175 and out through theguide catheter173 leaving theguidewires175 and179 in place.
• Thereafter, as shown inFIG. 7g, if it is necessary to enlarge or modify the penetration tract created by thepenetrator85, a tract modification orenlargement apparatus190 may be advanced over the first crossing guidewire179 to enlarge or otherwise modify the penetration tract. Thistract modifying apparatus190 may comprise a balloon catheter or radiofrequency tissue severing device as described in U.S. patent application Ser. No. 09/056,589, the entirety of which is expressly incorporated herein by reference.
• As shown inFIG. 7h, after any necessary enlargement or modification of the penetration tract has been complete, thetract modifying apparatus190 andfirst crossing guidewire179 are removed, leaving open the passageway PW between the artery LAD and vein GCV/AIV. Also, a catheter191 is introduced into the coronary venous sinus CS and aguidewire198 is advanced through the catheter191 and into the vein GCV.
• As shown inFIG. 7i, the catheter191 is then removed and a coronarysinus guide catheter196 is introduced over theguidewire198 into the coronary venous sinus. Asubselective sheath192 andintroducer194 are then advanced through the coronary sinus guide catheter191, over theguidewire179 and into the vein GCV proximal to the passageway PW. This coronarysinus guide catheter196,subselective sheath192 andintroducer194 may be of the type described in detail in concurrently filed U.S. patent application Ser. No. ______ entitled CATHETERS, SYSTEMS AND METHODS FOR PERCUTANEOUS IN SITU ARTERIO-VENOUS BYPASS, the entirety of which is expressly incorporated herein by reference.
• Thereafter, as shown inFIG. 7j, theintroducer194 is removed leaving thesubselective sheath192 and guidewire194 in place.
• Thereafter, as shown inFIG. 7k, anembolic blocker200 is advanced through thesubselective sheath192 and implanted in the vein GCV proximal to the passageway. This completes the PICVA procedure, allowing arterial blood to flow from the artery LAD, through the passageway PW and into the vein GCV/AIV where it flows in the direction opposite normal venous return so as to retro-perfuse the ischemic myocardium through the coronary vein(s).
• i. A Preferred Method for Performing the PICAB Procedure:
• FIGS. 8a-8dshow, in step-by-step fashion, an example of the manner in which a two channel PICAB procedure may be performed, or in the alternative, how the above-described PICVA procedure (FIGS. 7a-7k) may be converted into a two-channel PICAB procedure. This PICAB procedure will typically be used in cases where theobstruction171adoes not extend into the distal LAD and thus, a patent distal LAD is available to carry blood flow to the ischemic myocardium.
• As shown inFIG. 8a, if the two channel PICAB technique is to be employed then in lieu of the placement of theembolic blocker200 being placed (starting from the step referenced inFIG. 7g) theguidewire175 is withdrawn and thecatheter11 is advanced over the crossingguidewire179 to the position shown inFIG. 8a. To accomplish this, the tissue penetrator is retracted over the crossing guidewire189 to remove the first crossing guidewire from thetissue penetrator85 and then the crossingguidewire179 is introduced into themain guidewire lumen35 of thecatheter11. Consequently, thecatheter11 can be advanced over the crossingguidewire179 to the position ofFIG. 8awherein the catheter extends through the lumen176 of the artery LAD, through the openings created in the walls of the artery LAD and the vein AIV and into thelumen177 of the vein AIV. The longitudinal or axial position of thecatheter11 in the vein AIV relative to theobstruction171 is known using conventional techniques. With thecatheter11 in the position shown inFIG. 8a, the imaging transducer81 is again actuated and the catheter ills rotated within the vein AIV as required and as explained above in connection withFIGS. 6aand6bto cause the penetrator path indication to be aimed at the lumen of the artery LAD at a location downstream of theobstruction171. With the penetrator path indication and theexit port29 properly aimed at theartery171, thetissue penetrator85 is advanced from thecatheter11 through the walls of the vein AIV and the artery LAD and into the lumen of the artery LAD as shown inFIG. 8a. Also, as shown, asecond crossing guidewire181 is advanced through the lumen85L of thetissue penetrator85 and into the lumen of the artery LAD.
• As shown inFIG. 8b, thetissue penetrator85 is then retracted into thecatheter11 leaving the second crossing guidewire181 in the artery LAD. Thecatheter11 and thefirst crossing guidewire179 are then removed leaving the second crossing guidewire181 in place such that it extends from the artery LAD into thelumen177 of the vein AIV and back into the artery LAD as shown inFIG. 8b.
• To create a blood flow channel around theobstruction171, an expandable connector191 may be employed. As shown inFIGS. 8cand8d, the connector191 is implanted such that the connector extends from the artery LAD through the openings created in the walls of the artery LAD and the vein AIV, through thelumen177 of the vein AIV, through the openings created in the walls of the vein and artery LAD distally of theobstruction171 and back into the artery LAD. The expandable connector may be implanted, for example, by utilizing a connector delivery catheter (not shown) and advancing such connector delivery catheter over thesecond crossing guidewire181. After implantation of the connector191, the second crossing guidewire is withdrawn and so is theguide catheter173. It will be appreciated that instead of deploying one expandable connector, it may be preferred to employ two shorter connectors (not shown) at each of the first and second crossing sites. In this approach, a proximal and distal embolic blocker may be required to be placed in the vein proximal to the first crossing site (in the GCV) and distal to the second crossing site (in the AIV) to complete the bypass circuit.
• Although exemplary embodiments of the invention have been shown and described, many changes, modifications and substitutions may be made by those having ordinary skill in the art without necessarily departing from the spirit and scope of this invention. For example, where this patent application has listed the steps of a method or procedure in a specific order, it may be possible (or even expedient in certain circumstances) to change the order in which some steps are performed, and it is intended that the particular steps of the method or procedure claims set forth herebelow not be construed as being order-specific unless such order specificity is expressly stated in the claim. Another example is that, although the specific procedures described in detail in this application may involve penetrating through an “acceptable penetration zone,” such acceptable penetration zone need not be occupied by tissue but rather such acceptable penetration zone may fully or partially comprise an open space such as a body cavity or void. Accordingly, it is intended that all such additions, deletions, modifications and variations be included within the scope of the following claims.

Claims (11)

1-19. (canceled)

20. A percutaneous, transluminal method for creating a flow channel between a first blood vessel that has a wall and a lumen and a second blood vessel that has a wall and a lumen, said method comprising the steps of:

A. providing a catheter device that comprises:

i. a catheter having a proximal end and a distal end, said catheter being advanceable into the lumen of the first blood vessel;

ii. a tissue penetrator that is advanceable in a lateral direction from the catheter, said tissue penetrator being operative to penetrate from the lumen of a first blood vessel, through the walls of the first and second blood vessels and into the lumen of a second blood vessel when the catheter is positioned and rotationally oriented within the first blood vessel such that the tissue penetrator is aimed at the second blood vessel;

iii. an imaging transducer fixedly mounted on the catheter to provide an imaging signal from which an image of the second blood vessel and other anatomical structures located adjacent the first blood vessel can be obtained; and,

iv. an imageable marker on the catheter to provide, on the image obtainable from the imaging signal from the imaging transducer, a penetrator path indication indicative of the path that will be followed by the tissue penetrator when the tissue penetrator is advanced from the catheter;

B. percutaneously inserting and transluminally advancing the catheter into the first blood vessel;

C. actuating the imaging transducer and moving the catheter within the first blood vessel until the penetrator path indication is aimed at the lumen of the second blood vessel; and,

D. advancing the tissue penetrator from the catheter, through the walls of the first and second blood vessels and into the lumen of the second blood vessel.

21. The method ofclaim 20 wherein the tissue penetrator is an elongate member that has a lumen extending longitudinally therethrough and wherein said method further comprises the step of:

E. advancing a first crossing guidewire through the lumen of the tissue penetrator and into the lumen of the second blood vessel.

22. The method ofclaim 21 wherein the method further comprises:

F. retracting the tissue penetrator into the catheter leaving the first crossing guidewire in place such that it extends from the lumen of the first blood vessel into the lumen of the second blood vessel.

23. The method ofclaim 22 wherein the catheter device provided in Step A has a main guidewire lumen that extends longitudinally through at least a portion of the catheter and wherein the method further comprises the steps of:

G. moving the first crossing guidewire from the lumen of the tissue penetrator, and reintroducing a crossing guidewire into the main guidewire lumen of the catheter; and,

H. readvancing the catheter over the first crossing guidewire to a position wherein the catheter extends through the lumen of the first blood vessel, through the openings created in the walls of the first and second blood vessels by advancement of the tissue penetrator in Step D, and into the lumen of the second blood vessel.

24. The method ofclaim 23 wherein the method further comprises the steps of:

I. actuating the imaging transducer and moving the catheter within the second blood vessel as required to cause the penetrator path indication to be aligned with the lumen of the first blood vessel; and

J. advancing the tissue penetrator from the catheter, through the walls of the first and second blood vessels and into the lumen of the first blood vessel.

25. The method ofclaim 24 further comprising the step of:

K. advancing a second crossing guidewire through the lumen of the tissue penetrator and into the lumen of the first blood vessel.

26. The method ofclaim 25 wherein the method further comprises:

L. retracting the tissue penetrator into the catheter leaving the second crossing guidewire in place such that it extends from the lumen of the first blood vessel into the lumen of the second blood vessel and back into the lumen of the first blood vessel.

27. The method ofclaim 26 wherein the method further comprises the steps of:

M. providing a connector delivery catheter accompanying a radially expandable connector;

N. advancing the connector delivery catheter over the second crossing guidewire and implanting the radially expandable connector such that the connector extends from the lumen of the first blood vessel, through the openings created in the walls of the first and second blood vessels in Step D, through the lumen of the second blood vessel, through the openings created in the walls of the first and second blood vessels in Step J and back into the lumen of the first blood vessel.

28. The method ofclaim 24 wherein the method is carried out to bypass an obstruction in the first blood vessel and wherein the openings created in the walls of the first and second blood vessels in Step D are proximal to the obstruction and the openings created in the walls of the first and second blood vessels in Step J are distal to the obstruction.

29-47. (canceled)

Images