US20110125141A1 - Cryotherapy Methods for Treating Vessel Dissections and Side Branch Occlusion - Google Patents

Abstract

The present invention provides cryotherapy treatment of dissections in a blood vessel of a patient. The present invention further provides cryotherapy treatment of side branch occlusion in a bifurcated blood vessel. One method for treating potential or existing dissections in a blood vessel comprises cooling the blood vessel to a temperature and for a time sufficient to remodel the blood vessel such that dissections of the blood vessel are reduced. Another method for treating side branch occlusion in a bifurcated blood vessel, the bifurcated blood vessel having a side branch and a main branch, the main branch having plaque disposed thereon, comprises cooling an inner surface of the main branch to a temperature and for a time sufficient to inhibit plaque shift from the main branch into the side branch.

Description

CROSS-REFERENCE TO RELATED APPLICATIONS
• This is a continuation of U.S. patent application Ser. No. 10/867,986 filed on Jun. 14, 2004, which is divisional of U.S. patent application Ser. No. 09/953,500 filed on Sep. 14, 2001, which claims the benefit under 35 U.S.C. §119(e) of U.S. Provisional Patent Application No. 60/312,295 filed on Aug. 13, 2001, the entire contents of each are incorporated herein by reference.
BACKGROUND OF THE INVENTION
• 1. Field of the Invention
• The present invention relates generally to medical methods and kits. More particularly, the present invention provides methods and kits for cryogenically cooling a blood vessel within a patient's vasculature to treat potential or existing dissections in the blood vessel. The present invention further provides methods and kits for cryogenically cooling a bifurcated blood vessel to treat side branch occlusion. Vessel dissections and side branch occlusion often result from angioplasty or other intravascular procedures for treating atherosclerosis and other diseases of the vasculature.
• Atherosclerotic plaque is present to some degree in most adults. Plaques can severely limit the blood flow through a blood vessel by narrowing the open vessel lumen. This narrowing effect or stenosis is often responsible for ischemic heart disease. Fortunately, a number of percutaneous intravascular procedures have been developed for treating atherosclerotic disease in a patient's vasculature. The most successful of these treatments is percutaneous transluminal angioplasty (PTA). PTA employs a catheter having an expansible distal end, usually in the form of an inflatable balloon, to dilate a stenotic region in the vasculature to restore adequate blood flow beyond the stenosis. Other procedures for opening stenotic regions include directional atherectomy, rotational atherectomy, laser angioplasty, stents and the like. While these percutaneous intravascular procedures, particularly PTA, have provided significant benefits for treatment of stenosis caused by plaque, they continue to suffer from significant disadvantages. Particularly common disadvantages are the subsequent occurrence of vessel dissection, vessel recoil (acute and delayed), side branch occlusion, restenosis, and other procedure related trauma. Such disadvantages may affect up to 80% of all angioplasty patients to some extent.
• During conventional PTA, the inflated balloon tends to create large fissures or tears in the intima of the blood vessel wall, particularly at a junction between the plaque and the vessel wall. Such tears or fissures are referred to as dissections. Vessel dissections compromise the dilated vessel, often constricting or blocking blood flow within the vessel. A number of strategies have been proposed to treat vessel dissections. Previously proposed strategies include prolonged balloon inflation, treatment of the blood vessel with a heated balloon, stenting of the region following balloon angioplasty, and the like. While these proposal have enjoyed varying levels of success, no one of these procedures is proven to be entirely successful. In particular, stenting of the dilated region may address acute problems of intimal dissection and vessel recoil, however stents are believed to actually cause a marked increase in the degree of intimal restenosis or hyperplasia (re-narrowing of the an artery following an initially successful angioplasty). This in turn leads to greater late luminal loss, especially in smaller vessels which are more susceptible to re-closure due to restenosis. Moreover, stents may prove to be an impractical solution when dilating long periphery arteries that may require multiple stent placements. Stents may additionally not always be easily maneuvered to and positioned in dilated regions, especially in the coronary arteries.
• Another limitation associated with angioplasty is side branch occlusion in a bifurcated blood vessel during dilatation of a primary vessel lesion. Side branch occlusion can occur by several mechanisms. The “snow plow” effect may be the most common mode of side branch occlusion, in which plaque from a primary vessel is literally “plowed” or “shifted” into the adjacent side vessel during dilatation, narrowing or occluding the side vessel lumen. Known procedures for treating side branch occlusion include the “kissing balloon technique” where two guiding catheters are positioned in the bifurcated vessel, one in the primary vessel and the other in the side branch, and the balloons are inflated simultaneously or sequentially so that they potentially touch or “kiss.” However, such angioplasty techniques alone or in combination with stents, has not been entirely successful in preventing side branch occlusion.
• For these reasons, it would be desirable to provide methods and kits for the treatment of dissections in a blood vessel. It would be further desirable to provide methods and kits for the treatment of side branch occlusion in a bifurcated blood vessel. The methods should be suitable for intravascular and intraluminal introduction, preferably via a percutaneous approach. It would be particularly desirable if the new methods were able to deliver the treatment in a very controlled and safe manner with minimum side effects. At least some of these objectives will be met by the invention described herein.
• 2. Description of the Background Art
• Cryoplasty methods and devices are described in U.S. patent application Ser. No. 08/982,824, now U.S. Pat. No. 5,971,979; U.S. patent application Ser. No. 09/203,011; U.S. patent application Ser. No. 09/510,903, U.S. patent application Ser. No. 09/619,583, assigned to the assignee of the present application. A cryoplasty device and method are also described in WO 98/38934. Balloon catheters for intravascular cooling or heating a patient are described in U.S. Pat. No. 5,486,208 and WO 91/05528. A cryosurgical probe with an inflatable bladder for performing intrauterine ablation is described in U.S. Pat. No. 5,501,681. Cryosurgical probes relying on Joule-Thomson cooling are described in U.S. Pat. Nos. 5,275,595; 5,190,539; 5,147,355; 5,078,713; and 3,901,241. Catheters with heated balloons for post-angioplasty and other treatments are described in U.S. Pat. Nos. 5,196,024; 5,191,883; 5,151,100; 5,106,360; 5,092,841; 5,041,089; 5,019,075; and 4,754,752. Cryogenic fluid sources are described in U.S. Pat. Nos. 5,644,502; 5,617,739; and 4,336,691. The following U.S. patents may also be relevant to the present invention: U.S. Pat. Nos. 5,458,612; 5,545,195; and 5,733,280.
• Side branch occlusion is described by Stephen N. Oesterle inAngioplasty Techniques for Stenoses Involving Coronary Artery Bifurcations, Am J Cardiol, vol. 61, pp. 29G-32G (1988); Lefevre et al. inStenting of Bifurcation Lesions: Classification, Treatments, and Results, Catheterization and Cardiovascular Interventions, vol. 49, pp. 274-283 (2000); Chevalier et al. inPlacement of Coronary Stent in Bifurcation Lesions by the “Culotte” Technique, Am J Cardiol, vol. 82, pp. 943G-949G (1998). Cutting balloons are described at http://www.interventionaltech.com/Products/CuttingBallon.html. The full disclosures of each of the above references are incorporated herein by reference.
BRIEF SUMMARY OF THE INVENTION
• The present invention provides cryotherapy treatment of dissections in a blood vessel of a patient. The present invention further provides cryotherapy treatment of side branch occlusion in a bifurcated blood vessel. The blood vessel may be any blood vessel in the patient's vasculature, including veins, arteries, and particularly coronary arteries. The blood vessel will be at least partially stenosed, typically by eccentric calcified plaque (i.e. the plaque compromises a vessel lumen predominantly from one side) in the coronary and peripheral arteries. In particular, the present invention may limit, reduce, minimize, prevent, mitigate, and/or inhibit potential or existing dissections of a vessel and/or plaque shift from a main branch into a side branch of a bifurcated blood vessel so as to inhibit acute coronary syndrome.
• In a first aspect, the present invention provides a method for treating potential or existing dissections in a blood vessel. The method comprises cooling the blood vessel to a temperature and for a time sufficient to remodel the blood vessel such that dissections of the blood vessel are reduced. The cooling treatment will often be directed against all or a portion of a circumferential surface of a lumen of the blood vessel.
• Cooling of a vessel may be effected by introducing a catheter into a lumen of a blood vessel. A balloon is positioned within the vessel lumen adjacent the potential or existing dissection. Cryogenic cooling fluid is introduced into the balloon and exhausted. The balloon expands to radially engage the vessel lumen. Generally, the cooling temperature at the cell surface of the blood vessel lumen is in a range from about −3° C. to about −15° C. The tissue is typically maintained at the desired temperature for a time period in the range from about 10 seconds to about 60 seconds, more preferably from about 20 seconds to 40 seconds. Vessel dissection treatment may be enhanced by repeating cooling in cycles, typically with from about 1 cycle to 3 cycles, with the cycles being repeated at a rate of about one cycle every 60 seconds.
• The dissections may comprise flaps, residual plaque, and/or pieces of tissue resulting from fissuring or tearing of the intima of the blood vessel wall or plaque thereon. Typically, such dissections occur at a junction between the plaque and the vessel wall, wherein the plaque tears at its margins and sends a plane of dissection deep into the media of the vessel wall. Dissections are undesirable as they often compromise the integrity of the blood vessel by at least partially blocking the blood vessel. Such blockage can limit blood flow and potentially create a threat to acute vessel closure. The dissections may further create flow in an abnormal pattern (i.e. flow in planes other than the true vessel lumen or non laminar flow.)
• The blood vessel is subject to dissections resulting from treatment of a stenosis, wherein the treatment of the stenosis typically comprises percutaneous transluminal angioplasty. The cooling step may be performed before or after balloon angioplasty, and will preferably be performed during balloon angioplasty. Surprisingly, work in connection with the present invention has shown that cooling of the blood vessel reduces and/or inhibits potential or existing dissections so as to produce a “stent-like” angiographic result (i.e. dissection free lumen without the use of a stent). Moreover, cooling may further minimize or inhibit restenosis or hyperplasia (re-narrowing of the an artery following an initially successful angioplasty) and help maintain the patency of a body lumen. Cooling may also be efficiently effected in long periphery arteries and the cooling apparatus easily maneuvered to and positioned in the treatment vessel, especially in the coronary arteries, so that cooling may be effected in difficult to access areas.
• The cooling step may alter mechanical properties of the blood vessel wall or plaque thereon so the that fissuring or tearing of the blood vessel wall or plaque thereon is reduced. Particularly, the blood vessel wall and/or plaque is solidified so that there is not such a great disparity in compliance between the two. As such, the dilatation force applied by the angioplasty cooling balloon is more evenly distributed around a circumference of the vessel wall so that tearing of the vessel at the junction between the vessel wall and plaque is minimized (i.e. any resulting fissures in the vessel wall and plaque are small or micro cracks that do not compromise flow in the vessel). Cooling may also alter a fail mode of the vessel resulting from the modified mechanical properties. Cooling may alternatively or additionally enhance bonding between layers of the blood vessel wall so that fissuring or tearing of the blood vessel wall is reduced. In other applications, the cooling step may tack or re-attach existing vessel dissections, resulting from a prior angioplasty procedure, into the blood vessel wall.
• In some instances, cooling may soften or weaken the vessel wall or plaque thereon, particularly eccentric calcified plaque, so that the vessel can be dilated or expanded at much lower pressures than is used with conventional angioplasty. Specifically, cooling temperatures of about −10° C. may freeze fluid between spaces in the calcium which in turn breaks up the calcified plaque, softening the vessel so that it can dilated at a lower pressure. In addition to the softening or weakening of the vessel wall or plaque thereon, cooling at low temperatures may also freeze and harden non-treatment tissue adjacent to the calcified plaque so that the vessel wall may exhibit more uniform properties against the dilation force applied by the angioplasty cooling balloon.
• In another aspect, the present invention provides a method for treating potential or existing dissections in a blood vessel, said method comprising introducing a catheter into a lumen of the blood vessel and positioning a balloon within the vessel lumen adjacent the potential or existing dissection. Cryogenic cooling fluid is introduced into the balloon and exhausted. The balloon is expanded to radially engage the vessel lumen and cool the vessel lumen to a temperature and for a time sufficient to remodel the blood vessel such that dissections of the blood vessel are reduced and/or inhibited. Cooling may comprise adhering the cooling balloon to the blood vessel or plaque thereon so as to minimize any slippage of the cooling balloon. This is particularly advantageous in the treatment of a stenosis as plaque is often amorphous and slippery and as such conventional uncooled angioplasty balloons often slip and cause additional dissections or tears proximal and distal of the stenosis. Hence, cooling prevents the creation of any additional dissections by minimizing such slippage of the cooling balloon and in so doing further allows for controlled dilatation at the stenosis.
• In another aspect, the present invention provides a method for treating side branch occlusion in a bifurcated blood vessel, the bifurcated blood vessel having a side branch and a main branch, the main branch having plaque disposed thereon. In some instances, the side branch may also be at least partially stenosed. The method comprises introducing a catheter into a lumen of the main branch and positioning a balloon within the main branch adjacent the plaque. Cryogenic cooling fluid is introduced into the balloon and exhausted. The balloon is expanded to radially engage the main branch lumen and an inner surface of the main branch is cooled to a temperature and for a time sufficient to inhibit plaque shift from the main or primary branch into the adjacent or side branch.
• The plaque comprises a combination of calcified, fatty, and fibrous tissues and is fairly amorphous and slippery so that it easily shifts by its structural nature. As such, the side branch is often subject to occlusion by plaque shift from the main branch into the side branch as a result of treatment of plaque in the main branch. Treatment of the plaque typically comprises balloon angioplasty, wherein the cooling step may be performed before, after, or preferably during balloon angioplasty. In some instances, the treatment of plaque in the main branch may be accompanied by simultaneous or sequential treatment of stenosis in the side branch. It is believed that the cooling step alters mechanical properties of the plaque (i.e. plaque compliance) so that plaque shift from the main branch to the side branch is inhibited. In particular, cooling may solidify the plaque so that it less amorphous and thus less susceptible to shifting. Plaque solidification may further be enhanced by the formation of a temporary ice cap on an orifice of the side branch due to a small portion of the cryoplasty balloon coming into contact with blood cells.
• In yet another aspect, the present invention provides a kit for treating potential or existing dissections in a blood vessel. The kit comprises a catheter having a proximal end, a distal end, and a cooling member. Instructions are included in the kit for use of the catheter. These instructions may comprise the step of cooling the blood vessel adjacent the potential or existing dissection to remodel the blood vessel such that dissections of the blood vessel are reduced. The kit may additionally or alternatively provide for the treatment of side branch occlusion in a bifurcate vessel, wherein the instructions recite the step of cooling a main branch lumen adjacent the plaque to inhibit plaque shift from the main branch into the side branch. Such kits may include instructions for performing one or more of the above described methods. The instructions will often be printed, optionally being at least in-part disposed on packaging. The instructions may alternatively comprise a videotape, a CD-ROM or other machine readable code, a graphical representation, or the like showing any of the above described methods.
• In another aspect, the present invention provides a method for treating potential elastic recoil in a blood vessel, the method comprising introducing a catheter into a lumen of the blood vessel and positioning a balloon within the vessel lumen adjacent tissue that may potentially recoil. The balloon is expanded to radially engage the vessel lumen and cool the vessel lumen to a temperature and for a time sufficient to remodel the blood vessel such that actual elastic recoil is inhibited.
• The cooling step may alter structural properties of collagen fibers of the vessel wall such that elastic recoil of the vessel is reduced. In particular, induction of a phase change in an aqueous component of the adjacent tissue during cooling may cause acute structural changes to the tissue matrix. Dilatation of the vessel by the cooling balloon may be accompanied by a drop in a balloon surface temperature below a phase transition threshold of physiologic saline. Thus, as the balloon expands and experiences a temperature drop, the aqueous saline in interstitial spaces (i.e. spaces between cells and fibers that constitute the vessel wall) in the adjacent tissue begin to freeze. As such, ice may be nucleated in the interstitial spaces and propagate radially outward through the tissue. The expanding ice may in turn impose mechanical compressive forces on collagen fibers and vessel cells. Correspondingly, the collagen fibers and cells may undergo morphological deformation in response to the mechanical forces. Any plastic deformation of the collagen fibers may produce permanent or semi-permanent alteration of the vessel tissue, and consequently may yield an alternation in the structural properties of the tissue. Specifically, possible compacting or compression of collagen fibers by cooling may substantially alter structural properties, such as elasticity, of the collagen fibers so that elastic recoil of the vessel is reduced.
• The blood vessel is typically subject to elastic recoil resulting from treatment of a stenosis. The treatment of stenosis typically comprises balloon angioplasty, wherein the cooling step may be performed before, after, or preferably during balloon angioplasty. Moreover, during balloon angioplasty the vessel is being expanded by balloon expansion which may exert radially directed mechanical forces on the vessel tissue. Hence, the dual action of mechanical compressive forces generated by concurrent dilation and cooling may produce a more beneficial effect than can be achieved by conventional angioplasty.
• In a still further aspect, the present invention provides a method for producing a smooth luminal surface in a blood vessel that is at least partially stenosed by fatty plaque, said method comprising introducing a catheter in a lumen of the blood vessel and positioning a balloon within the vessel lumen adjacent the fatty plaque. The balloon is expanded to radially engage the vessel lumen and cool the vessel lumen to a temperature and for a time sufficient to remodel the blood vessel so as to produce a smooth luminal surface. In particular, fatty lipid based plaque may undergo chemical or physical alterations in response to cooling of the plaque below a lipid phase change temperature (typically being in a range from about +15° C. to about 0° C.). This remodeling of the vessel and plaque thereon may in turn produce a smoother luminal surface than can be achieved with conventional angioplasty. A smoother luminal surface advantageously provides more laminar flow through the vessel wall, and further reduces any shear stresses on the vessel wall.
BRIEF DESCRIPTION OF THE DRAWINGS
• FIGS. 1A-1C are cross-sectional views of blood vessels having dissections.
• FIG. 2A is a cross-sectional view of a stenosed bifurcated blood vessel.
• FIG. 2B is a cross-sectional view illustrating plaque shift in the bifurcated blood vessel.
• FIG. 3 illustrates a cryotherapy catheter for treating vessel dissections and side branch occlusion constructed in accordance with the principles of the present invention.
• FIG. 4 is a cross-sectional view of the catheter taken along line4-4 inFIG. 3.
• FIG. 5 is a functional flow diagram illustrating the operation of automatic fluid shutoff mechanism of the catheter ofFIG. 3.
• FIGS. 6 and 7 illustrate a handle and removable energy pack for use in the cryotherapy catheter ofFIG. 3.
• FIGS. 8A-8D illustrate use of the catheter ofFIG. 3 for treatment of potential vessel dissections.
• FIGS. 9A-9C illustrate use of the catheter ofFIG. 3 for treatment of existing vessel dissections.
• FIGS. 10-10C illustrate use of the catheter ofFIG. 3 for treatment of side branch occlusion.
• FIG. 11 illustrates a vessel dissection or side branch occlusion treatment kit including the apparatus ofFIG. 3 and instructions for use.
• FIGS. 12A through 13E are angiographic results of experiments showing an actual and observed reduction in stenosis with a minimum amount of vessel dissection and side branch occlusion as described in the two Experimental sections provided hereinbelow.
DETAILED DESCRIPTION OF THE INVENTION
• The present invention provides cryotherapy treatment of dissections in a blood vessel of a patient.FIGS. 1A-1C illustrate cross-sectional views of ablood vessel100 havingdissections102 within alumen104 of the vessel. Thedissections102 generally comprise flaps, residual plaque, and/or pieces of tissue resulting from fissuring or tearing of the intima of the blood vessel wall or plaque thereon from primary treatments like balloon angioplasty. Typically,such dissections102 occur at a junction between the plaque and the vessel wall, wherein the plaque tears at its margins and sends a plane of dissection deep into the media of the vessel wall. As shown inFIG. 1B,dissections102 are undesirable as they often compromise the integrity of the blood vessel by at least partially blocking theblood vessel100. For example, thedissection102 may shift indirection106 to limit blood flow and potentially create a threat to acute vessel closure (FIG. 1B).Dissections102 may further create flow in planes other than the true vessel lumen as depicted byarrow108.
• The present invention further provides cryotherapy treatment of side branch occlusion in a bifurcated vessel.FIG. 2A illustrates a bifurcated blood vessel having a main orprimary branch112 and an adjacent orside branch114. Themain branch112 is at least partially stenosed116. Theplaque116 generally comprises a combination of calcium, fat, and lipids and is fairly amorphous and slippery so that it easily shifts by its structural nature. As such, theside branch114 is often subject to occlusion by plaque shift from themain branch112 into theside branch114, as depicted byarrows118, as a result of treatment of plaque in the main branch. Treatment of plaque typically comprises balloon angioplasty, wherein balloon dilatation shifts theplaque116 into theside branch114 as shown inFIG. 2B, narrowing or occluding the side branch lumen and potentially creating a threat to acute vessel closure.
• Referring now toFIGS. 3 and 4, a cryotherapy catheter10 (which is more fully described in co-pending application Ser. No. 09/619,583 filed Jul. 19, 2000, the full disclosure of which is incorporated herein by reference) for treatingdissections102 in a blood vessel100 (seeFIG. 1A) and/or side branch occlusion (seeFIG. 2B) will be described. Thecatheter10 comprises acatheter body12 having aproximal end14 and adistal end16 with a coolingfluid supply lumen18 and anexhaust lumen20 extending therebetween. Afirst balloon22 is disposed near the distal end of thecatheter body12 in fluid communication with the supply and exhaust lumens. Asecond balloon24 is disposed over thefirst balloon22 with athermal barrier26 therebetween. It will be appreciated that the following depictions are for illustration purposes only and does not necessarily reflect the actual shape, size, or dimensions of thecryotherapy catheter10. This applies to all depictions hereinafter.
• Theballoons22,24 may be an integral extension of thecatheter body12, but such a structure is not required by the present invention. Theballoons22,24 could be formed from the same or a different material as thecatheter body12 and, in the latter case, attached to thedistal end16 of thecatheter body12 by suitable adhesives, heat welding, or the like. Thecatheter body12 may be formed from conventional materials, such as polyethylenes, polyimides, and copolymers and derivatives thereof. Theballoons22,24 may also be formed from conventional materials used for angioplasty, preferably being inelastic, such as nylon, polyethylene terephthalate (PET), or polyethylene, elastic, such as urethane, latex, or silicone, or other medical grade material suitable for constructing a strong non-distensible balloon. Additionally, balloons22 and24 could be formed from different material to provide improved protection. For example, thefirst balloon22 could be formed from PET to provide strength while thesecond balloon24 could be formed from polyethylene to provide durability. Theballoons22,24 have a length of at least 1 cm each, more preferably in the range from 2 cm to 5 cm each in a coronary artery and 2 cm to 10 cm each in a periphery artery. Theballoons22,24 will have diameters in the range from 2 mm to 5 mm each in a coronary artery and 2 mm to 10 mm each in a peripheral artery.
• Thethermal barrier26 may comprise a gap maintained between theballoons22,24 by a filament. The filament typically comprises a helically wound, braided, woven, or knotted monofilament. The monofilament may be formed from PET or polyethylene napthlate (PEN), and affixed to thefirst balloon22 by adhesion bonding, heat welding, fasteners, or the like. Thethermal barrier26 may also comprise a gap maintained between theballoons22,24 by a plurality of bumps on an outer surface of thefirst balloon22 and/or an inner surface of thesecond balloon24. The plurality of bumps may be formed in a variety of ways. For example, the bumps may be intrinsic to the balloon (created during balloon blowing), or the bumps could be created by deforming the material of the balloon wall, by affixing mechanical “dots” to the balloon using adhesion bonding, heat welding, fasteners, or the like. Alternatively, thethermal barrier26 may comprise a gap maintained between theballoons22,24 by a sleeve. The sleeve may be perforated and formed from PET or rubbers such as silicone and polyurethane.
• Hubs34 and36 are secured to theproximal end14 of thecatheter body12. Hub34 provides aport38 for connecting a cryogenic fluid source to thefluid supply lumen18 which in turn is in fluid communication with the inner surface of thefirst balloon22. Hub34 further provides aport40 for exhausting the cryogenic fluid which travels fromballoon22 in a proximal direction through theexhaust lumen20. Hub36 provides aport42 for a guidewire which extends through aguidewire lumen44 in thecatheter body12. Typically, theguidewire lumen44 will extend through theexhaust lumen20, as shown inFIG. 4. Theguidewire lumen44 may also extend axially outside theexhaust lumen20 to minimize the occurrence of cryogenic fluid entering the blood stream via theguidewire lumen44. Optionally, theguidewire lumen44 may extend outside the inner surface of thefirst balloon22 or theguidewire lumen44 may allow for a guidewire to extend outside bothballoons22,24. Additionally, a reinforcingcoil46 may extend along thecatheter body12 proximal thefirst balloon22. The reinforcingcoil46 may comprise a simple spring having a length typically in the range from 6 cm to 10 cm to prevent thecatheter10 from kinking up inside the blood vessel.
• Thecryotherapy catheter10 inFIG. 3 additionally illustrates a safety mechanism that monitors the containment of the first andsecond balloons22,24. Thefirst balloon22 defines a volume in fluid communication with the supply and exhaust lumens. A fluid shutoff is coupled to a cryogenic fluid supply with thesupply lumen18. Thesecond balloon24 is disposed over thefirst balloon22 with a vacuum space52 therebetween. The vacuum space52 is coupled to the fluid shutoff so as to inhibit flow of cryogenic fluid into thefirst balloon22 in response to a change in the vacuum space52.
• FIG. 5 illustrates a functional flow diagram of the automaticfluid shutoff mechanism54. Thefluid shutoff54 typically comprises a vacuum switch56 connected to a shutoff valve58 by a circuit, the circuit being powered by abattery60. The switch56 may remain closed only when a predetermined level of vacuum space52 is detected in thesecond balloon24. The closed switch56 allows the shutoff valve58, in fluid communication with thecryogenic fluid supply62, to be open. Alternatively, the circuit may be arranged so that the switch56 is open only when the predetermined vacuum space52 is present, with the shutoff valve58 being open when the switch is open. The vacuum space52 is reduced when either thefirst balloon22 is punctured, allowing cryogenic fluid to enter the vacuum space52, or thesecond balloon24 is punctured, allowing blood to enter the vacuum space52. In addition to monitoring the containment of bothballoons22,24, in the event of a failure, the vacuum switch56 will be triggered to prevent the delivery of additional cryogenic fluid from thefluid supply62 into thesupply lumen18. Thesecond balloon24 also acts to contain any cryogenic fluid that may have escaped thefirst balloon22. Theexhaust lumen20 is fluidly connected to apressure relief valve21 which in turn will typically vent to atmosphere. In some instances, apressure transducer23 will also trigger the shutoff valve58 when a particular threshold pressure is measured.
• The vacuum space52 may be provided by a simple fixedvacuum chamber64 coupled to the vacuum space52 by avacuum lumen66 of thebody12 via a vacuum port68 (SeeFIG. 3). In one embodiment, a positive displacement pump (ideally being similar to a syringe) is disposed withinhandle74 and may be actuated by actuator75, as seen inFIG. 6. The vacuum space52 should comprise a small volume of vacuum in the range from 1 mL to 100 mL, preferably 10 mL or less, as a smaller vacuum space52 facilitates detection of a change in the amount of vacuum when a small amount of fluid leakage occurs. The battery may be electrically coupled to aheater61 for heating thefluid supply62 and cryogenic fluid therein to room temperature or warmer so as to enhance the fluid pressure and cooling system performance, as is more fully described in co-pending application Ser. No. 09/268,205, the full disclosure of which is incorporated herein by reference. Thecryogenic fluid supply62,heater61, andbattery60 for powering the circuit may be packaged together in anenergy pack70, as seen inFIG. 7. Theenergy pack70 is detachable from aproximal handle74 of the catheter body and disposable. A plurality of separate replaceable energy packs70 allow for multiple cryogenic cooling cycles. Additionally, an audio alert orbuzzer76 may be located on thehandle74, with the buzzer providing an audio warning unless the handle is maintained sufficiently upright to allow flow from thefluid supply62. The cryotherapy catheter may additionally comprise ahypsometer72 coupled to the volume by a thermistor (via thermistor wires71), thermocouple, or the like located in thefirst balloon22 or handle to determine the pressure and/or temperature of fluid in thefirst balloon22. The hypsometer allows for accurate real time measurements of variables (pressure, temperature) that effect the efficacy and safety of cryotherapy treatments.
• Referring now toFIGS. 8A through 8D, use of thecryotherapy catheter10 ofFIG. 3 for treatment ofpotential vessel dissections102 will be described. As illustrated inFIGS. 8A and 8B,catheter10 will be introduced into alumen104 of theblood vessel100 over a guidewire GW. Theblood vessel100 may be any blood vessel in the patient's vasculature, including veins, arteries, and particularly coronary arteries. Theblood vessel100 will typically be at least partially stenosed116. Thefirst balloon22 is positioned within theblood vessel lumen104 adjacent thepotential dissection102. Cryogenic cooling fluid is introduced into the first balloon22 (in which it often vaporizes) and exhausted. Thesecond balloon24 expands to radially engage the vessel wall, as illustrated byFIG. 8C. The vaporized fluid serves to inflate balloon22 (and expand balloon24) so as to simultaneously dilate and cool thestenosed blood vessel100. Theblood vessel100 is cooled to a temperature and for a time sufficient to remodel the blood vessel such thatdissections102 of theblood vessel wall100 are reduced. The cooling treatment will be directed at all or a portion of a circumferential surface thevessel lumen104.
• Preferably cooling will reduce and/or inhibit potential dissections so as to produce a “stent-like” angiographic result (i.e. dissection free lumen without the use of a stent), as shown inFIG. 8D. Cooling may alter mechanical properties of theblood vessel100′ orplaque116′ thereon so the that fissuring or tearing of the blood vessel wall or plaque thereon is reduced. Particularly, theblood vessel wall100′ and/orplaque116′ is solidified so that there is not such a great disparity in compliance between the two. As such, the dilatation force applied by the angioplasty cooling balloon is more evenly distributed so that tearing of the vessel at the junction between the vessel wall and plaque is minimized. Cooling may further enhance bonding between layer of theblood vessel wall100′ (i.e., intimal layer, medial layer, adventitial layer) so that fissuring or tearing of the blood vessel wall is reduced. Heat transfer will also be inhibited between the first andsecond balloons22,24 by thethermal barrier26 so as to limit cooling to a desired temperature profile. Additionally, containment of the first andsecond balloons22,24 will be monitored during cooling by the fluid shutoff mechanism (seeFIG. 5).
• Suitable cryogenic fluids will preferably be non-toxic and may include liquid nitrous oxide, liquid carbon dioxide, cooled saline and the like. The cryogenic fluid will flow through thesupply lumen18 as a liquid at an elevated pressure and will vaporize at a lower pressure within thefirst balloon22. For nitrous oxide, a delivery pressure within thesupply lumen18 will typically be in the range from 600 psi to 1000 psi at a temperature below the associated boiling point. After vaporization, the nitrous oxide gas within thefirst balloon22 near its center will have a pressure typically in the range from 50 psi to 150 psi. Preferably, the nitrous oxide gas will have a pressure in the range from 75 psi to 125 psi in a peripheral artery and a range from about 75 psi to 125 psi in a coronary artery.
• Generally, the temperature of the outer surface of thefirst balloon22 will be in a range from about 0° C. to about −50° C. Preferably, the temperature of the outer surface of thefirst balloon22 in a peripheral artery will be in a range from about 0° C. to about −40° C. The temperature of the outer surface of thesecond balloon24 will be in a range from about −3° C. to about −15° C. This will provide a desired treatment temperature in a range from about −3° C. to about −15° C. The tissue is typically maintained at the desired temperature for a time period in the range from about 1 to 60 seconds, preferably being from 20 to 40 seconds. Vessel dissection minimization may be further enhanced by repeating cooling in cycles, typically with from about 1 to 3 cycles, with the cycles being repeated at a rate of about one cycle every 60 seconds.
• Referring now toFIGS. 9A through 9C, the cooling step may also tack or re-attach existingvessel dissections102 resulting from a prior angioplasty procedure into theblood vessel wall100 to produce a “stent-like” angiographic result, as shown inFIG. 9C. Cooling may additionally comprise adhering the coolingballoon24 to the blood vessel or plaque thereon so as to minimize any slippage of the cooling balloon and in so doing further allow for controlled dilatation of the vessel.
• Referring now toFIGS. 10A through 10C, use of thecryotherapy catheter10 ofFIG. 3 for treatment of side branch occlusion in abifurcated blood vessel110 will be described. As illustrated inFIG. 10A, the bifurcatedblood vessel110 has aside branch114 and amain branch112, themain branch112 havingplaque116 disposed thereon. In some instances, theside branch114 may also be at least partially stenosed116. Acatheter10 is introduced into a lumen of themain branch112 and afirst balloon22 positioned within themain branch112 adjacent theplaque116. Cryogenic cooling fluid is introduced into theballoon22 and exhausted. Asecond balloon24 is expanded to radially engage the main branch lumen, as seen inFIG. 10B, and an inner surface of themain branch112 is dilated and cooled to a temperature and for a time sufficient to inhibit plaque shift from the main orprimary branch112 into the adjacent orside branch114. Cooling may alter mechanical properties of theplaque116′ (i.e. plaque compliance) so that plaque shift from themain branch112 to theside branch114 is inhibited, as seen inFIG. 10C. In particular, cooling may solidify theplaque116′ so that it is less amorphous and thus less susceptible to shifting.Plaque solidification116′ may further be enhanced by the formation of a temporary ice cap on an orifice of theside branch114 due to a small portion of thecryoplasty balloon24 coming into contact with blood cells (not shown).
• Akit126 including acatheter10 and instructions foruse128 is illustrated inFIG. 11.Catheter10 may comprise the dual balloon catheter ofFIG. 3 or a catheter having a proximal end, a distal end, and a cooling member near its distal end.
• Instructions foruse128 may describe any of the associated method steps set forth above for treatment of vessel dissections and/or side branch occlusion. Instructions foruse128 will often be printed, optionally appearing at least in part on asterile package130 forballoon catheter10. In alternative embodiments, instructions foruse128 may comprise a machine readable code, digital or analog data graphically illustrating or demonstrating the use ofballoon catheter10 to treat vessel dissections and/or side branch occlusion. Still further alternatives are possible, including printing of the instructions for use onpackaging132 ofkit126, and the like. In the following Experimental sections, protocol and results of human clinical studies are given. In particular, angiographic images show a baseline where a significant amount of plaque is present within a lumen of a vessel wall, particularly the superficial femoral artery or popliteal artery. The effects of cryoplasty dilatation are captured by another set of angiographic images which generally show alleviation of the stenotic condition with a minimum amount of vessel dissection and side branch occlusion.
Experimental I:Peripheral Cryoplasty Clinical ExperiencePurpose
• Human clinical cases were conducted to evaluate the safety and effectiveness of the CVSi CryoPlasty Catheter and Cryolnflation Unit in the dilation of stenotic lesions in diseased superficial femoral and popliteal arteries. Patients with peripheral vascular disease were treated with the CVSi CryoPasty System. This was a non-randomized registry of fourteen (14) patients.
Patient Selection
• The interventionalists for these cases identified patients with stenotic lesions in the superficial femoral artery (SFA) and popliteal arteries, which were amenable to percutaneous treatment. Eligibility requirements included the following: the patient was at least 18 years of age; the patient had stenotic lesions within the SFA or popliteal artery which required treatment; the target lesion contained a stenosis between 50% and 100%; the patient had a clinical examination within one month prior to treatment including ABI measurement. Patients were excluded if any of the following applied: the patient had an evolving myocardial infarction, or suffered a myocardial infarction within the past 48 hours; the patient was participating currently in another investigational drug or device trial; or the patient suffered a stroke or transient ischemic neurological attack (TIA) within the past two months.
Equipment
• Equipment used for these cases may be found in any interventional catheterization laboratory (including but not limited to fluoroscopy unit with cine film acquisition; sterile accessories such as sheaths and guidewires). The test equipment was the CVSi CryoPlasty System, which is composed of the CryoPlasty Catheter, Cryolnflation Unit and accessories (battery, battery receptacle, nitrous oxide cylinder). The operating parameters of the current cases are treatment time of 50 seconds and surface temperature of −10±5° C.
Methods
• Procedures used were no different than typical interventional percutaneous transluminal angioplasty (PTA) procedures. The investigators had a thorough understanding of the technical principals, clinical applications, and risks associated with PTA. In addition, training on the CVSi CryoPlasty System and its Instructions For Use were given prior to clinical use of the device. After diagnostic angiography of the target vessel confirmed the presence of a lesion suitable for endovascular therapy, the patients received the following treatment. The patient was pre-treated with conventional doses of heparin and aspirin. Baseline angiographic images were recorded as illustrated inFIGS. 12A through 12L. The operators chose whether or not to predilate the lesion with other percutaneous transluminal devices. If they did predilate, an angiographic image of the interim outcome was recorded. Next, the CVSi CryoPlasty Catheter was advanced across the lesion, and inflated with the Cryolnflation Unit. After deflation, the catheter was either repositioned for additional cryoinflations, or removed. At the conclusion of the procedure, final cryoplasty angiograms were recorded as illustrated inFIGS. 12A through 12L.
Data Collection
• Results of the percutaneous interventions were assessed for acute outcomes and in-hospital adverse events. Baseline and post-cryoplasty dilation angiography were compared in each treated section. In addition, ankle-brachial indexes (ABI) were measured and recorded prior to intervention, 24 hours post-intervention, and at one-month (see Results Table I). ABI is an assessment of flow distal to the treated sections. Technical success was based primarily on the acute angiographic appearance and flow characteristics (24-hour ABI) immediately post-cryoplasty dilation compared to the baseline image and the pre-procedural ABI, respectively.

• RESULTS TABLE I
  CLINICAL SUMMARY OF PERIPHERAL PATIENTS

  Ankle-Brachial

  Patient

  Age/

  Lesion

  Indices

  No.	Gender	Site	Description	Pre		24 hr	1M

  1G	65 yr	LSFA	80% stenosis distal to stent,	0.70	1	1
  	M	(ISR)	90% stenosis proximal to stent
  2G	88 yr	LSFA-	Total occlusion, 10-12 cm	0.30	0.30	0
  	F	pop
  3G
  	74 yr	LSFA	98% stenosis with calcified plaque	0.65	1	1
  	M
  4G	75 yr	LSFA	(4) subtotal focal occlusions,	0.70	1	1
  	M		calcified, 8-10 cmtotal length
  5G
  	61yr	R pop		70% focal stenosis	0.70	1	1
  	M
  6G	67 yr	L pop	Subtotal popliteal occlusion,	0.25	0.70	1
  	F		12-15 cm long
  1C	52 yr	RSFA	70% stenotis, focal calcified lesion	0.75	1	1
  	M
  2C
  	61 yr	L pop	15 mm long, 80% stenotic lesion in	0.70	1.06	1
  	F		proximal popliteal and a 10 mm
  			long, 50% stenotic lesion in the
  			mid popliteal
  3C	63 yr	LSFA	10 mm long, 70% stenotic lesion in	0.85	1.06	1
  	M		the proximal SFA and a 10 mm long,
  			80% stenotic lesion in the distal SFA
  4C	41 yr	Right	heavily calcified sub-occlusive	0.60	1.0	1
  	M	com.	focal lesion inthe right common
  		fem.	femoral artery (15 mm long,
  			90% stenotic)
  5C	73 yr	LSFA-	diffuse sub-occlusive (12-16 cm	0.57	0.84	0.75
  	F	pop	long, 70-80% stenotic) disease in
  			proximal to distal SFA, and 2 focal
  			occlusive lesions in midpopliteal
  			artery
  6C
  	74 yr	LSFA	6-8 cm long total occlusion	0.57	0.85	0.80
  	F
  7C	57 yr	LSFA-	calcified focal lesions in SFA	0.58	0.89	0.97
  	M	pop	(15 mm long, 80% stenotic) and
  			in proximal popliteal artery
  			(10 mm long, 70% stenotic).
  8C	61 yr	RSFA	two adjacent 95% stenotic focal	0.60	1.08	0.90
  	M		lesions

Conclusions and Discussion
• Procedural safety was demonstrated by the absence of any incidence of acute serious adverse events or acute percutaneous access site and hemorrhagic adverse events. Investigators were able to use the CryoPlasty device for primary treatment (i.e. were able to cross severe stenosis and dilate the lesion with the CVSi device without predilation) in ten of the fourteen cases (71%). Twelve of the fourteen cases (86%) were technical successes based on acute angiographic appearance and flow characteristics, with <30% residual stenosis by visual assessment of the final angiographic results in the treated segments. Within that 12 patient subset of technical success, the 24-hour post-procedural ABI showed improved blood flow to the lower extremity compared to the pre-procedural measurement. Bail-out stenting was not required in any of the cryotreated segments. Some observations that were noted that contributed to the high technical success rate were minimum amount of vessel dissection post-CryoPlasty dilation (also known as “vessel annealing”) and maintained patency of the side branch and collateral vessels at the treated segments (no/minimal plaque shift), as illustrated inFIGS. 12A through 12L and the ABI data in Results Table I.
• The registry demonstrated the safety and effectiveness of the CVSi CryoPlasty System in the dilation of stenotic lesions in diseased vessels, and brought to light some distinct advantages of CryoPlasty over conventional PTA dilation that often requires bail-out stenting due to dissection or poor flow characteristics.
Experimental II:Coronary Cryoplasty Clinical ExperiencePurpose
• Five patients with coronary artery disease were treated with the CVSi CryoPlasty System to evaluate the safety and effectiveness of the CVSi System in the treatment of de novo and in-stent restenotic lesions. Patients were assessed for acute outcomes and in-hospital adverse events.
Patient Selection
• Patients with either a de novo or in-stent restenosis lesion in a coronary artery that was amenable to percutaneous treatment were identified by experienced intervention-alists. Lesion inclusion criteria was very broad and included very complex lesions, such as, lesion lengths ranging from 10 mm to 25 mm, stenoses from 90% to total occlusions, and calcified, fibrotic, and soft plaque. Other contributing factors were severe access angulations, high cholesterol, diabetes, and smoking.
Methods
• After diagnostic angiography of the target vessel confirmed the presence of a lesion suitable for endovascular therapy, each patient received the following treatment. The patient was pretreated with conventional doses of heparin and aspirin. Baseline angiographic images were recorded as illustrated inFIGS. 13A through 13E. The operator could choose whether or not to predilate the lesion with conventional transluminal percutaneous procedures. Next, the CVSi CryoPlasty Catheter was advanced across the lesion, and the balloon inflated one or more times with the CVSi Cryolnflation Unit. After the final cryotreatment, the balloon was deflated and the CVSi Catheter was removed. At the conclusion of the procedure, a final angiography was recorded as illustrated inFIGS. 13A through 13E.
Results
• The operators were able to use the CryoPlasty device for primary therapy (i.e. were able to cross severe stenosis and dilate the lesion with the CVSi device without predilation) in all the lesions (100%). Additionally, the CryoPlasty device provided good tracking in vessels with >90° turns. A total of six lesions were treated (including one patient who had two lesions in one vessel). All of the lesions treated had <30% residual angiographic stenosis in the dilated artery, as illustrated inFIGS. 13A through 13E and the Results Table II. Patients tolerated the procedure well (i.e. no patient sensation of treatment) and four to six week clinical follow-upreports 0% major adverse cardiac events (MACE).

• RESULTS TABLE II
  CLINICAL SUMMARY OFCORONARY PATIENTS

  BUC	Age/				Baseline		Residual
  #	Sex	Site	Type	Factors	Stenosis	Treatments/Comments	Stenosis
  1	64/F	LCx prox	D	Total occlusion, severe	100%	(2) CryoPlasty Inflations;	20%
  		20 mm ×		angulation >100°, some		distal dissection grade B-not
  		2.75 mm		calcification		requiring stent placement;
  						Nopain
  2	55/M	LAD prox	D	Stress angina,ST	90%	(1) CyroPlasty inflation;	10%
  		15 mm ×		changes after 25 meters,		Occlusion angina
  		3.0 mm		237 chol
  3	49/F	LAD prox	D	Unstable angina 7 days	95%	(1)CryoPlasty inflation	0%
  		10 mm ×		before, admitted, acute	subtotal
  		3.0 mm		MI 1996; sig. angulation
  				at bifurcation; allergic to
  				ASA; narrowing back to
  				bifurcation
  4	58/F	RCA mid	I	Diabetic, hypertension,	95%	(4) CryoPlasty inflations	30%
  		25 mm ×		dyslipidemia,
  		3.5		PTCA/stent 11/00;
  				PTCA cutting balloon
  				2/01
  		RCA prox	D			90%	(2) CryoPlasty inflations >	0%
  		10 mm ×				Grade B-C dissection >
  		3.5				3.5 mm × 16 mm stent
  						(post cryo)
  5	74/M	LCx mid	D	Colon tumor, surgery	95%	(1)CryoPlasty	0%
  		12 mm ×		prep; calcification
  		3.5 mm

Conclusion
• Cryogenic treatment of atherosclerotic stenoses may effectively limit restenosis in both coronary and peripheral arteries, as well as minimize the amount of vessel dissections and plaque shift post-CryoPlasty dilation. Clinical trial data illustrates that CryoPlasty may represent a simple solution to one of the most vexing problems experienced to date in interventional therapy.
• Although certain preferred embodiments and methods have been disclosed herein, it will be apparent from the foregoing disclosure to those skilled in the art that variations and modifications of such embodiments and methods may be made without departing from the true spirit and scope of the invention. Therefore, the above description should not be taken as limiting the scope of the invention which is defined by the appended claims.

Claims (20)

1. A cryotherapy delivery system comprising:

a cryotherapy catheter comprising a catheter body, the catheter configured to deliver a cryogenic fluid from a proximal end of the catheter body toward a distal end of the catheter body; and

a controller configured to:

control a rate of flow of the cryogenic fluid, in response to a measured temperature received via a sensor, to cool an inner surface of a main branch of a bifurcated blood vessel having plaque disposed thereon to a temperature and for a time sufficient to inhibit plaque shift from the main branch into a side branch of the bifurcated blood vessel,

wherein the cooling time is in a range from about 1 second to less than about 20 seconds, and wherein the cooling temperature of the inner surface of the main branch is in a range from about −3° C. to about −15° C.

2. The system ofclaim 1, wherein the main branch is an artery.

3. The system ofclaim 1, wherein the plaque comprises a combination of calcium, fat, and lipids.

4. The system ofclaim 1, wherein the side branch is subject to occlusion by plaque shift from the main branch into the side branch as a result of treatment of plaque in the main branch.

5. The system ofclaim 4, wherein the treatment of plaque in the main branch comprises balloon angioplasty.

6. The system ofclaim 5, wherein the cooling step is performed before, during, and/or after balloon angioplasty.

7. The system ofclaim 6, wherein the side branch is at least partially stenosed.

8. The system ofclaim 7, wherein the treatment of stenosis in the side branch comprises balloon angioplasty.

9. The system ofclaim 8, wherein the main branch and the side branch are treated simultaneously or sequentially.

10. The system ofclaim 1, wherein the cooling step alters mechanical properties of the plaque so that plaque shift from the main branch to the side branch is inhibited.

11. The system ofclaim 10, wherein the cooling step solidifies the plaque so that it is less amorphous.

12. The system ofclaim 11, wherein the plaque solidification is enhanced by the formation of a temporary ice cap on an orifice of the side branch.

13. A cryotherapy delivery system comprising:

a cryotherapy catheter comprising a catheter body, the catheter configured to deliver a cryogenic fluid from a proximal end of the catheter body toward a distal end of the catheter body; and

a controller configured to control a rate of flow of the cryogenic fluid, in response to a measured temperature received via a sensor, to cool a blood vessel lumen defined by a blood vessel wall, with a balloon, to a temperature and for a time sufficient to remodel the blood vessel such that an existing dissection of the blood vessel wall is reduced.

14. The system ofclaim 13, wherein cooling the vessel lumen tacks or re-attaches existing vessel dissections into the blood vessel wall.

15. A cryotherapy delivery system comprising:

a cryotherapy catheter comprising a catheter body, the catheter configured to deliver a cryogenic fluid from a proximal end of the catheter body toward a distal end of the catheter body; and

a controller configured to control a rate of flow of the cryogenic fluid, in response to a measured temperature received via a sensor, to cool an inner surface of a blood vessel having an existing dissection with the balloon to a temperature and for a time sufficient to tack or re-attach a flap of tissue of the dissection to a blood vessel wall of the blood vessel.

16. The system ofclaim 15, wherein the cooling time is in a range from about 10 seconds to about 60 seconds, and wherein the cooling temperature of the inner surface of the blood vessel is in a range from about −3° C. to about −15° C.

17. The system ofclaim 15, wherein the blood vessel is an artery.

18. The system ofclaim 15, wherein the dissection comprises flaps, residual plaque, or pieces of tissue resulting from fissuring or tearing of the blood vessel wall or plaque thereon.

19. The system ofclaim 15, wherein the dissection at least partially blocks the blood vessel.

20. The system ofclaim 15, wherein the dissection limits blood flow.

Images