US20120116486A1 - Microwave catheter apparatuses, systems, and methods for renal neuromodulation - Google Patents

Abstract

Microwave catheter apparatuses, systems, and methods for achieving renal neuromodulation by intravascular access are disclosed herein. One aspect of the present application, for example, is directed to apparatuses, systems, and methods that incorporate a catheter treatment device comprising an elongated shaft. The elongated shaft is sized and configured to deliver a microwave transmission element to a renal artery via an intravascular path. Renal neuromodulation may be achieved via dielectric heating in the presence of microwave irradiation that modulates neural fibers that contribute to renal function or alters vascular structures that feed or perfuse the neural fibers.

Description

CROSS-REFERENCE TO RELATED APPLICATION(S)
• This application claims the benefit of U.S. Provisional Application No. 61/406,534, filed Oct. 25, 2010, and incorporated herein by reference in its entirety.
TECHNICAL FIELD
• The technologies disclosed in the present application generally relate to catheter apparatuses, systems, and methods for intravascular neuromodulation. More particularly, the technologies disclosed herein relate to microwave catheter apparatuses, systems, and methods for achieving intravascular renal neuromodulation via dielectric heating.
BACKGROUND
• The sympathetic nervous system (SNS) is a primarily involuntary bodily control system typically associated with stress responses. Fibers of the SNS innervate tissue in almost every organ system of the human body and can affect characteristics such as pupil diameter, gut motility, and urinary output. Such regulation can have adaptive utility in maintaining homeostasis or in preparing the body for rapid response to environmental factors. Chronic activation of the SNS, however, is a common maladaptive response that can drive the progression of many disease states. Excessive activation of the renal SNS in particular has been identified experimentally and in humans as a likely contributor to the complex pathophysiology of hypertension, states of volume overload (such as heart failure), and progressive renal disease. For example, radiotracer dilution has demonstrated increased renal norepinephrine (NE) spillover rates in patients with essential hypertension.
• Cardio-renal sympathetic nerve hyperactivity can be particularly pronounced in patients with heart failure. For example, an exaggerated NE overflow from the heart and kidneys to plasma is often found in these patients. Heightened SNS activation commonly characterizes both chronic and end stage renal disease. In patients with end stage renal disease, NE plasma levels above the median have been demonstrated to be predictive for cardiovascular diseases and several causes of death. This is also true for patients suffering from diabetic or contrast nephropathy. Evidence suggests that sensory afferent signals originating from diseased kidneys are major contributors to initiating and sustaining elevated central sympathetic outflow.
• Sympathetic nerves innervating the kidneys terminate in the blood vessels, the juxtaglomerular apparatus, and the renal tubules. Stimulation of the renal sympathetic nerves can cause increased renin release, increased sodium (Na⁺) reabsorption, and a reduction of renal blood flow. These neural regulation components of renal function are considerably stimulated in disease states characterized by heightened sympathetic tone and likely contribute to increased blood pressure in hypertensive patients. The reduction of renal blood flow and glomerular filtration rate as a result of renal sympathetic efferent stimulation is likely a cornerstone of the loss of renal function in cardio-renal syndrome (i.e., renal dysfunction as a progressive complication of chronic heart failure). Pharmacologic strategies to thwart the consequences of renal efferent sympathetic stimulation include centrally acting sympatholytic drugs, beta blockers (intended to reduce renin release), angiotensin converting enzyme inhibitors and receptor blockers (intended to block the action of angiotensin II and aldosterone activation consequent to renin release), and diuretics (intended to counter the renal sympathetic mediated sodium and water retention). These pharmacologic strategies, however, have significant limitations including limited efficacy, compliance issues, side effects, and others. Accordingly, there is a strong public-health need for alternative treatment strategies.
BRIEF DESCRIPTION OF THE DRAWINGS
• FIG. 1 is a conceptual illustration of the sympathetic nervous system (SNS) and how the brain communicates with the body via the SNS.
• FIG. 2 is an enlarged anatomic view of nerves innervating a left kidney to form the renal plexus surrounding the left renal artery.
• FIGS. 3A and 3B provide, respectively, anatomic and conceptual views of a human body, depicting neural efferent and afferent communication between the brain and kidneys.
• FIGS. 4A and 4B are, respectively, anatomic views of the arterial and venous vasculatures of a human.
• FIG. 5 is a perspective view of a microwave system for achieving intravascular renal neuromodulation, comprising a treatment device and a microwave generator.
• FIGS. 6A and 6B are, respectively, a schematic view illustrating placement of a distal region of the treatment device ofFIG. 5 within a renal artery via an intravascular path, and a detailed schematic view of an embodiment of the distal region within the renal artery for delivery of microwave energy.
• FIG. 7 is a schematic side-sectional view of the distal region of an embodiment of the microwave treatment device ofFIG. 5 comprising a coaxial cable feed line and a coaxial antenna microwave transmission element.
• FIGS. 8A and 8B are schematic side-sectional views of the distal region of an embodiment of the microwave treatment device ofFIG. 5 in a low-profile delivery configuration and in an expanded deployed configuration, including a multi-filament centering element.
• FIG. 9 is a schematic side-sectional view of the distal region of an alternative embodiment of the microwave treatment device ofFIGS. 8A and 8B comprising an alternative multi-filament centering element.
• FIGS. 10A and 10B are, respectively, a schematic side-sectional view and a schematic cross-sectional view alongsection line10B-10B ofFIG. 10A of the distal region of an embodiment of the microwave treatment device ofFIGS. 8A and 8B comprising an expandable balloon centering element.
• FIGS. 11A and 11B are schematic cross-sectional views of the distal region of alternative embodiments of the microwave treatment device ofFIGS. 10A and 10B comprising an alternative expandable balloon centering element.
• FIG. 12 is a schematic side-sectional view of the distal region of another alternative embodiment of the microwave treatment device ofFIGS. 10A and 10B comprising another alternative expandable balloon centering element having proximal and distal balloons.
• FIG. 13 is a schematic side-sectional view of the distal region of another alternative embodiment of the microwave treatment device ofFIGS. 10A and 10B comprising another alternative expandable balloon centering element having conductive electrode traces applied on the surface of the balloon.
• FIGS. 14 and 15 are schematic side-sectional views of the distal regions of other alternative embodiments of the microwave treatment device ofFIGS. 10A and 10B comprising other alternative expandable balloon centering elements having one or more shields applied on the surface of the balloon.
• FIG. 16 is a schematic side-sectional view of the distal region of another alternative embodiment of the microwave treatment device ofFIGS. 10A and 10B comprising another alternative expandable balloon that places the microwave antenna off-center within a vessel.
• FIG. 17 is a schematic view of the distal region of an embodiment of the microwave treatment device ofFIG. 5 comprising a flow directing element.
• FIG. 18A is a schematic side-sectional view of the distal region of an embodiment of the microwave treatment device ofFIG. 5 configured for delivery over a guide wire.
• FIG. 18B is a schematic side-sectional view of the distal region of an embodiment of the microwave treatment device ofFIG. 5 configured for rapid exchange delivery.
• FIGS. 19A and 19B are schematic side-sectional views of the distal region of an embodiment of the microwave treatment device ofFIG. 5 illustrating dynamic variation of the coaxial antenna's radiating element.
• FIG. 20 is schematic side-sectional view of the distal region of an alternative embodiment of the microwave treatment device ofFIGS. 19A and 19B configured for dynamic variation of the coaxial antenna's radiating element.
• FIGS. 21A and 21B are schematic side-sectional views of the distal region of another alternative embodiment of the microwave treatment device ofFIGS. 19A and 19B configured for dynamic variation of the coaxial antenna's radiating element and for over-the-wire delivery.
• FIGS. 22A and 22B are schematic side-sectional views of the distal regions of embodiments of the microwave treatment device ofFIG. 5 configured for active cooling.
• FIG. 23A is a schematic side-sectional view of the distal region of an embodiment of a microwave treatment device having a shielding component.
• FIGS. 23B and 23C are cross-sectional views of the microwave treatment device ofFIG. 23A.
• FIGS. 23D and 23E are schematic side views of the distal region of an embodiment of a microwave treatment device having a shielding component and deflection capabilities.
DETAILED DESCRIPTION
• The present technology is directed to apparatuses, systems, and methods for achieving electrically- and/or thermally-induced renal neuromodulation (i.e., rendering neural fibers that innervate the kidney inert or inactive or otherwise completely or partially reduced in function) by percutaneous transluminal intravascular access. In particular, embodiments of the present technology relate to microwave apparatuses, systems, and methods that incorporate a catheter treatment device. The catheter treatment device may comprise an elongated shaft sized and configured to deliver at least one microwave transmission element within a renal artery via an intravascular path (e.g., a femoral artery, an iliac artery and the aorta, a transradial approach, or another suitable intravascular path). In one embodiment, for example, the microwave transmission element comprises an antenna that radiates microwaves within the renal artery in order to induce dielectric heating of target renal nerves or of vascular structures that perfuse target renal nerves. Microwaves are generated by a microwave generator, transferred along a feed or transmission line, and then radiated by the antenna. The microwave generator may be positioned along or near a proximal region of the elongated shaft external to the patient, while the feed line extends along or within the elongated shaft, and the antenna is positioned along a distal region of the shaft configured for placement in the renal artery via the intravascular path.
• Specific details of several embodiments of the technology are described below with reference toFIGS. 1-23E. Although many of the embodiments are described below with respect to devices, systems, and methods for intravascular modulation of renal nerves using microwave apparatuses, other applications and other embodiments in addition to those described herein are within the scope of the technology. Additionally, several other embodiments of the technology can have different configurations, components, or procedures from those described herein. A person of ordinary skill in the art, therefore, will accordingly understand that the technology can have other embodiments with additional elements, or the technology can have other embodiments without several of the features shown and described below with reference toFIGS. 1-23E.
• As used herein, the terms “distal” and “proximal” define a position or direction with respect to the treating clinician or the clinician's control device (e.g., a handle assembly). “Distal” or “distally” are a position distant from or in a direction away from the clinician or clinician's control device. “Proximal” and “proximally” are a position near or in a direction toward the clinician or the clinician's control device.
I. PERTINENT ANATOMY AND PHYSIOLOGY
• The following discussion provides various details regarding pertinent patient anatomy and physiology. This section is intended to provide additional context regarding the disclosed technology and the therapeutic benefits associated with renal denervation, and to supplement and expand upon the disclosure herein regarding the relevant anatomy and physiology. For example, as mentioned below, several properties of the renal vasculature may inform the design of treatment devices and associated methods for achieving renal neuromodulation via intravascular access, and impose specific design requirements for such devices. Specific design requirements may include accessing the renal artery, facilitating stable contact between the energy delivery elements of such devices and a luminal surface or wall of the renal artery, and/or effectively modulating the renal nerves with the neuromodulatory apparatus.
• A. The Sympathetic Nervous System
• The Sympathetic Nervous System (SNS) is a branch of the autonomic nervous system along with the enteric nervous system and parasympathetic nervous system. It is always active at a basal level (called sympathetic tone) and becomes more active during times of stress. Like other parts of the nervous system, the sympathetic nervous system operates through a series of interconnected neurons. Sympathetic neurons are frequently considered part of the peripheral nervous system (PNS), although many lie within the central nervous system (CNS). Sympathetic neurons of the spinal cord (which is part of the CNS) communicate with peripheral sympathetic neurons via a series of sympathetic ganglia. Within the ganglia, spinal cord sympathetic neurons join peripheral sympathetic neurons through synapses. Spinal cord sympathetic neurons are therefore called presynaptic (or preganglionic) neurons, while peripheral sympathetic neurons are called postsynaptic (or postganglionic) neurons.
• At synapses within the sympathetic ganglia, preganglionic sympathetic neurons release acetylcholine, a chemical messenger that binds and activates nicotinic acetylcholine receptors on postganglionic neurons. In response to this stimulus, postganglionic neurons principally release noradrenaline (norepinephrine). Prolonged activation may elicit the release of adrenaline from the adrenal medulla.
• Once released, norepinephrine and epinephrine bind adrenergic receptors on peripheral tissues. Binding to adrenergic receptors causes a neuronal and hormonal response. The physiologic manifestations include pupil dilation, increased heart rate, occasional vomiting, and increased blood pressure. Increased sweating is also seen due to binding of cholinergic receptors of the sweat glands.
• The sympathetic nervous system is responsible for up- and down-regulating many homeostatic mechanisms in living organisms. Fibers from the SNS innervate tissues in almost every organ system, providing at least some regulatory function to things as diverse as pupil diameter, gut motility, and urinary output. This response is also known as sympatho-adrenal response of the body, as the preganglionic sympathetic fibers that end in the adrenal medulla (but also all other sympathetic fibers) secrete acetylcholine, which activates the secretion of adrenaline (epinephrine) and to a lesser extent noradrenaline (norepinephrine). Therefore, this response that acts primarily on the cardiovascular system is mediated directly via impulses transmitted through the sympathetic nervous system and indirectly via catecholamines secreted from the adrenal medulla.
• Science typically looks at the SNS as an automatic regulation system, that is, one that operates without the intervention of conscious thought. Some evolutionary theorists suggest that the sympathetic nervous system operated in early organisms to maintain survival as the sympathetic nervous system is responsible for priming the body for action. One example of this priming is in the moments before waking, in which sympathetic outflow spontaneously increases in preparation for action.
• 1. The Sympathetic Chain
• As shown inFIG. 1, the SNS provides a network of nerves that allows the brain to communicate with the body. Sympathetic nerves originate inside the vertebral column, toward the middle of the spinal cord in the intermediolateral cell column (or lateral horn), beginning at the first thoracic segment of the spinal cord and are thought to extend to the second or third lumbar segments. Because its cells begin in the thoracic and lumbar regions of the spinal cord, the SNS is said to have a thoracolumbar outflow. Axons of these nerves leave the spinal cord through the anterior rootlet/root. They pass near the spinal (sensory) ganglion, where they enter the anterior rami of the spinal nerves. However, unlike somatic innervation, they quickly separate out through white rami connectors which connect to either the paravertebral (which lie near the vertebral column) or prevertebral (which lie near the aortic bifurcation) ganglia extending alongside the spinal column.
• In order to reach the target organs and glands, the axons should travel long distances in the body, and, to accomplish this, many axons relay their message to a second cell through synaptic transmission. The ends of the axons link across a space, the synapse, to the dendrites of the second cell. The first cell (the presynaptic cell) sends a neurotransmitter across the synaptic cleft where it activates the second cell (the postsynaptic cell). The message is then carried to the final destination.
• In the SNS and other components of the peripheral nervous system, these synapses are made at sites called ganglia. The cell that sends its fiber is called a preganglionic cell, while the cell whose fiber leaves the ganglion is called a postganglionic cell. As mentioned previously, the preganglionic cells of the SNS are located between the first thoracic (T1) segment and third lumbar (L3) segments of the spinal cord. Postganglionic cells have their cell bodies in the ganglia and send their axons to target organs or glands.
• The ganglia include not just the sympathetic trunks but also the cervical ganglia (superior, middle and inferior), which sends sympathetic nerve fibers to the head and thorax organs, and the celiac and mesenteric ganglia (which send sympathetic fibers to the gut).
• 2. Innervation of the Kidneys
• AsFIG. 2 shows, the kidney is innervated by the renal plexus RP, which is intimately associated with the renal artery. The renal plexus RP is an autonomic plexus that surrounds the renal artery and is embedded within the adventitia of the renal artery. The renal plexus RP extends along the renal artery until it arrives at the substance of the kidney. Fibers contributing to the renal plexus RP arise from the celiac ganglion, the superior mesenteric ganglion, the aorticorenal ganglion and the aortic plexus. The renal plexus RP, also referred to as the renal nerve, is predominantly comprised of sympathetic components. There is no (or at least very minimal) parasympathetic innervation of the kidney.
• Preganglionic neuronal cell bodies are located in the intermediolateral cell column of the spinal cord. Preganglionic axons pass through the paravertebral ganglia (they do not synapse) to become the lesser splanchnic nerve, the least splanchnic nerve, first lumbar splanchnic nerve, second lumbar splanchnic nerve, and travel to the celiac ganglion, the superior mesenteric ganglion, and the aorticorenal ganglion. Postganglionic neuronal cell bodies exit the celiac ganglion, the superior mesenteric ganglion, and the aorticorenal ganglion to the renal plexus RP and are distributed to the renal vasculature.
• 3. Renal Sympathetic Neural Activity
• Messages travel through the SNS in a bidirectional flow. Efferent messages may trigger changes in different parts of the body simultaneously. For example, the sympathetic nervous system may accelerate heart rate; widen bronchial passages; decrease motility (movement) of the large intestine; constrict blood vessels; increase peristalsis in the esophagus; cause pupil dilation, piloerection (goose bumps) and perspiration (sweating); and raise blood pressure. Afferent messages carry signals from various organs and sensory receptors in the body to other organs and, particularly, the brain.
• Hypertension, heart failure and chronic kidney disease are a few of many disease states that result from chronic activation of the SNS, especially the renal sympathetic nervous system. Chronic activation of the SNS is a maladaptive response that drives the progression of these disease states. Pharmaceutical management of the renin-angiotensin-aldosterone system (RAAS) has been a longstanding, but somewhat ineffective, approach for reducing over-activity of the SNS.
• As mentioned above, the renal sympathetic nervous system has been identified as a major contributor to the complex pathophysiology of hypertension, states of volume overload (such as heart failure), and progressive renal disease, both experimentally and in humans. Studies employing radiotracer dilution methodology to measure overflow of norepinephrine from the kidneys to plasma revealed increased renal norepinephrine (NE) spillover rates in patients with essential hypertension, particularly so in young hypertensive subjects, which in concert with increased NE spillover from the heart, is consistent with the hemodynamic profile typically seen in early hypertension and characterized by an increased heart rate, cardiac output, and renovascular resistance. It is now known that essential hypertension is commonly neurogenic, often accompanied by pronounced sympathetic nervous system overactivity.
• Activation of cardiorenal sympathetic nerve activity is even more pronounced in heart failure, as demonstrated by an exaggerated increase of NE overflow from the heart and the kidneys to plasma in this patient group. In line with this notion is the recent demonstration of a strong negative predictive value of renal sympathetic activation on all-cause mortality and heart transplantation in patients with congestive heart failure, which is independent of overall sympathetic activity, glomerular filtration rate, and left ventricular ejection fraction. These findings support the notion that treatment regimens that are designed to reduce renal sympathetic stimulation have the potential to improve survival in patients with heart failure.
• Both chronic and end stage renal disease are characterized by heightened sympathetic nervous activation. In patients with end stage renal disease, plasma levels of norepinephrine above the median have been demonstrated to be predictive for both all-cause death and death from cardiovascular disease. This is also true for patients suffering from diabetic or contrast nephropathy. There is compelling evidence suggesting that sensory afferent signals originating from the diseased kidneys are major contributors to initiating and sustaining elevated central sympathetic outflow in this patient group; this facilitates the occurrence of the well known adverse consequences of chronic sympathetic over activity, such as hypertension, left ventricular hypertrophy, ventricular arrhythmias, sudden cardiac death, insulin resistance, diabetes, and metabolic syndrome.
• (i) Renal Sympathetic Efferent Activity
• Sympathetic nerves to the kidneys terminate in the blood vessels, the juxtaglomerular apparatus and the renal tubules. Stimulation of the renal sympathetic nerves causes increased renin release, increased sodium (Na+) reabsorption, and a reduction of renal blood flow. These components of the neural regulation of renal function are considerably stimulated in disease states characterized by heightened sympathetic tone and clearly contribute to the rise in blood pressure in hypertensive patients. The reduction of renal blood flow and glomerular filtration rate as a result of renal sympathetic efferent stimulation is likely a cornerstone of the loss of renal function in cardio-renal syndrome, which is renal dysfunction as a progressive complication of chronic heart failure, with a clinical course that typically fluctuates with the patient's clinical status and treatment. Pharmacologic strategies to thwart the consequences of renal efferent sympathetic stimulation include centrally acting sympatholytic drugs, beta blockers (intended to reduce renin release), angiotensin converting enzyme inhibitors and receptor blockers (intended to block the action of angiotensin II and aldosterone activation consequent to renin release) and diuretics (intended to counter the renal sympathetic mediated sodium and water retention). However, the current pharmacologic strategies have significant limitations including limited efficacy, compliance issues, side effects and others.
• (ii) Renal Sensory Afferent Nerve Activity
• The kidneys communicate with integral structures in the central nervous system via renal sensory afferent nerves. Several forms of “renal injury” may induce activation of sensory afferent signals. For example, renal ischemia, reduction in stroke volume or renal blood flow, or an abundance of adenosine enzyme may trigger activation of afferent neural communication. As shown inFIGS. 3A and 3B, this afferent communication might be from the kidney to the brain or might be from one kidney to the other kidney (via the central nervous system). These afferent signals are centrally integrated and may result in increased sympathetic outflow. This sympathetic drive is directed towards the kidneys, thereby activating the RAAS and inducing increased renin secretion, sodium retention, volume retention and vasoconstriction. Central sympathetic over activity also impacts other organs and bodily structures innervated by sympathetic nerves such as the heart and the peripheral vasculature, resulting in the described adverse effects of sympathetic activation, several aspects of which also contribute to the rise in blood pressure.
• The physiology therefore suggests that (i) modulation of tissue with efferent sympathetic nerves will reduce inappropriate renin release, salt retention, and reduction of renal blood flow, and that (ii) modulation of tissue with afferent sensory nerves will reduce the systemic contribution to hypertension and other disease states associated with increased central sympathetic tone through its direct effect on the posterior hypothalamus as well as the contralateral kidney. In addition to the central hypotensive effects of afferent renal denervation, a desirable reduction of central sympathetic outflow to various other sympathetically innervated organs such as the heart and the vasculature is anticipated.
• B. Additional Clinical Benefits of Renal Denervation
• As provided above, renal denervation is likely to be valuable in the treatment of several clinical conditions characterized by increased overall and particularly renal sympathetic activity such as hypertension, metabolic syndrome, insulin resistance, diabetes, left ventricular hypertrophy, chronic end stage renal disease, inappropriate fluid retention in heart failure, cardio-renal syndrome, and sudden death. Since the reduction of afferent neural signals contributes to the systemic reduction of sympathetic tone/drive, renal denervation might also be useful in treating other conditions associated with systemic sympathetic hyperactivity. Accordingly, renal denervation may also benefit other organs and bodily structures innervated by sympathetic nerves, including those identified inFIG. 1. For example, as previously discussed, a reduction in central sympathetic drive may reduce the insulin resistance that afflicts people with metabolic syndrome and Type II diabetics. Additionally, patients with osteoporosis are also sympathetically activated and might also benefit from the down regulation of sympathetic drive that accompanies renal denervation.
• C. Achieving Intravascular Access to the Renal Artery
• In accordance with the present technology, neuromodulation of a left and/or right renal plexus RP, which is intimately associated with a left and/or right renal artery, may be achieved through intravascular access. AsFIG. 4A shows, blood moved by contractions of the heart is conveyed from the left ventricle of the heart by the aorta. The aorta descends through the thorax and branches into the left and right renal arteries. Below the renal arteries, the aorta bifurcates at the left and right iliac arteries. The left and right iliac arteries descend, respectively, through the left and right legs and join the left and right femoral arteries.
• AsFIG. 4B shows, the blood collects in veins and returns to the heart, through the femoral veins into the iliac veins and into the inferior vena cava. The inferior vena cava branches into the left and right renal veins. Above the renal veins, the inferior vena cava ascends to convey blood into the right atrium of the heart. From the right atrium, the blood is pumped through the right ventricle into the lungs, where it is oxygenated. From the lungs, the oxygenated blood is conveyed into the left atrium. From the left atrium, the oxygenated blood is conveyed by the left ventricle back to the aorta.
• As will be described in greater detail later, the femoral artery may be accessed and cannulated at the base of the femoral triangle just inferior to the midpoint of the inguinal ligament. A catheter may be inserted percutaneously into the femoral artery through this access site, passed through the iliac artery and aorta, and placed into either the left or right renal artery. This comprises an intravascular path that offers minimally invasive access to a respective renal artery and/or other renal blood vessels.
• The wrist, upper arm, and shoulder region provide other locations for introduction of catheters into the arterial system. For example, catheterization of either the radial, brachial, or axillary artery may be utilized in select cases. Catheters introduced via these access points may be passed through the subclavian artery on the left side (or via the subclavian and brachiocephalic arteries on the right side), through the aortic arch, down the descending aorta and into the renal arteries using standard angiographic technique.
• D. Properties and Characteristics of the Renal Vasculature
• Since neuromodulation of a left and/or right renal plexus RP may be achieved in accordance with the present technology through intravascular access, properties and characteristics of the renal vasculature may impose constraints upon and/or inform the design of apparatus, systems, and methods for achieving such renal neuromodulation. Some of these properties and characteristics may vary across the patient population and/or within a specific patient across time, as well as in response to disease states, such as hypertension, chronic kidney disease, vascular disease, end-stage renal disease, insulin resistance, diabetes, metabolic syndrome, etc. These properties and characteristics, as explained herein, may have bearing on the efficacy of the procedure and the specific design of the intravascular device. Properties of interest may include, for example, material/mechanical, spatial, fluid dynamic/hemodynamic and/or thermodynamic properties.
• As discussed previously, a catheter may be advanced percutaneously into either the left or right renal artery via a minimally invasive intravascular path. However, minimally invasive renal arterial access may be challenging, for example, because as compared to some other arteries that are routinely accessed using catheters, the renal arteries are often extremely tortuous, may be of relatively small diameter, and/or may be of relatively short length. Furthermore, renal arterial atherosclerosis is common in many patients, particularly those with cardiovascular disease. Renal arterial anatomy also may vary significantly from patient to patient, which further complicates minimally invasive access. Significant inter-patient variation may be seen, for example, in relative tortuosity, diameter, length, and/or atherosclerotic plaque burden, as well as in the take-off angle at which a renal artery branches from the aorta. Apparatus, systems and methods for achieving renal neuromodulation via intravascular access should account for these and other aspects of renal arterial anatomy and its variation across the patient population when minimally invasively accessing a renal artery.
• In addition to complicating renal arterial access, specifics of the renal anatomy also complicate establishment of stable contact between neuromodulatory apparatus and a luminal surface or wall of a renal artery. When the neuromodulatory apparatus includes an energy delivery element, such as an electrode, consistent positioning and appropriate contact force applied by the energy delivery element to the vessel wall are important for predictability. However, navigation is impeded by the tight space within a renal artery, as well as tortuosity of the artery. Furthermore, establishing consistent contact is complicated by patient movement, respiration, and/or the cardiac cycle because these factors may cause significant movement of the renal artery relative to the aorta, and the cardiac cycle may transiently distend the renal artery (i.e., cause the wall of the artery to pulse.
• Even after accessing a renal artery and facilitating stable contact between neuromodulatory apparatus and a luminal surface of the artery, nerves in and around the adventia of the artery should be safely modulated via the neuromodulatory apparatus. Effectively applying thermal treatment from within a renal artery is non-trivial given the potential clinical complications associated with such treatment. For example, the intima and media of the renal artery are highly vulnerable to thermal injury. As discussed in greater detail below, the intima-media thickness separating the vessel lumen from its adventitia means that target renal nerves may be multiple millimeters distant from the luminal surface of the artery. Sufficient energy should be delivered to or heat removed from the target renal nerves to modulate the target renal nerves without excessively cooling or heating the vessel wall to the extent that the wall is frozen, desiccated, or otherwise potentially affected to an undesirable extent. A potential clinical complication associated with excessive heating is thrombus formation from coagulating blood flowing through the artery. Given that this thrombus may cause a kidney infarct, thereby causing irreversible damage to the kidney, thermal treatment from within the renal artery should be applied carefully. Accordingly, the complex fluid mechanics and thermodynamic conditions present in the renal artery during treatment, particularly those that may impact heat transfer dynamics at the treatment site, may be important in applying energy (e.g., heating thermal energy) and/or removing heat from the tissue (e.g., cooling thermal conditions) from within the renal artery.
• The neuromodulatory apparatus should also be configured to allow for adjustable positioning and repositioning of the energy delivery element within the renal artery since location of treatment may also impact clinical efficacy. For example, it may be tempting to apply a full circumferential treatment from within the renal artery given that the renal nerves may be spaced circumferentially around a renal artery. In some situations, full-circle lesion likely resulting from a continuous circumferential treatment may be potentially related to renal artery stenosis. Therefore, the formation of more complex lesions along a longitudinal dimension of the renal artery via the mesh structures described herein and/or repositioning of the neuromodulatory apparatus to multiple treatment locations may be desirable. It should be noted, however, that a benefit of creating a circumferential ablation may outweigh the potential of renal artery stenosis or the risk may be mitigated with certain embodiments or in certain patients and creating a circumferential ablation could be a goal. Additionally, variable positioning and repositioning of the neuromodulatory apparatus may prove to be useful in circumstances where the renal artery is particularly tortuous or where there are proximal branch vessels off the renal artery main vessel, making treatment in certain locations challenging. Manipulation of a device in a renal artery should also consider mechanical injury imposed by the device on the renal artery. Motion of a device in an artery, for example by inserting, manipulating, negotiating bends and so forth, may contribute to dissection, perforation, denuding intima, or disrupting the interior elastic lamina.
• Blood flow through a renal artery may be temporarily occluded for a short time with minimal or no complications. However, occlusion for a significant amount of time should be avoided because to prevent injury to the kidney such as ischemia. It could be beneficial to avoid occlusion all together or, if occlusion is beneficial to the embodiment, to limit the duration of occlusion, for example to 2-5 minutes.
• Based on the above described challenges of (1) renal artery intervention, (2) consistent and stable placement of the treatment element against the vessel wall, (3) effective application of treatment across the vessel wall, (4) positioning and potentially repositioning the treatment apparatus to allow for multiple treatment locations, and (5) avoiding or limiting duration of blood flow occlusion, various independent and dependent properties of the renal vasculature that may be of interest include, for example, (a) vessel diameter, vessel length, intima-media thickness, coefficient of friction, and tortuosity; (b) distensibility, stiffness and modulus of elasticity of the vessel wall; (c) peak systolic, end-diastolic blood flow velocity, as well as the mean systolic-diastolic peak blood flow velocity, and mean/max volumetric blood flow rate; (d) specific heat capacity of blood and/or of the vessel wall, thermal conductivity of blood and/or of the vessel wall, and/or thermal convectivity of blood flow past a vessel wall treatment site and/or radiative heat transfer; (e) renal artery motion relative to the aorta induced by respiration, patient movement, and/or blood flow pulsatility: and (f) as well as the take-off angle of a renal artery relative to the aorta. These properties will be discussed in greater detail with respect to the renal arteries. However, dependent on the apparatus, systems and methods utilized to achieve renal neuromodulation, such properties of the renal arteries, also may guide and/or constrain design characteristics.
• As noted above, an apparatus positioned within a renal artery should conform to the geometry of the artery. Renal artery vessel diameter, D_RA, typically is in a range of about 2-10 mm, with most of the patient population having a D_RAof about 4 mm to about 8 mm and an average of about 6 mm. Renal artery vessel length, L_RA, between its ostium at the aorta/renal artery juncture and its distal branchings, generally is in a range of about 5-70 mm, and a significant portion of the patient population is in a range of about 20-50 mm. Since the target renal plexus is embedded within the adventitia of the renal artery, the composite Intima-Media Thickness, IMT, (i.e., the radial outward distance from the artery's luminal surface to the adventitia containing target neural structures) also is notable and generally is in a range of about 0.5-2.5 mm, with an average of about 1.5 mm. Although a certain depth of treatment is important to reach the target neural fibers, the treatment should not be too deep (e.g., >5 mm from inner wall of the renal artery) to avoid non-target tissue and anatomical structures such as the renal vein.
• An additional property of the renal artery that may be of interest is the degree of renal motion relative to the aorta, induced by respiration and/or blood flow pulsatility. A patient's kidney, which located at the distal end of the renal artery, may move as much as 4″ cranially with respiratory excursion. This may impart significant motion to the renal artery connecting the aorta and the kidney, thereby requiring from the neuromodulatory apparatus a unique balance of stiffness and flexibility to maintain contact between the thermal treatment element and the vessel wall during cycles of respiration. Furthermore, the take-off angle between the renal artery and the aorta may vary significantly between patients, and also may vary dynamically within a patient, e.g., due to kidney motion. The take-off angle generally may be in a range of about 30°-135°.
• E. Achieving Renal Denervation via an Intravascularly Delivered Microwave Field
• Microwave energy may be utilized to achieve renal neuromodulation via at least partial denervation of the kidney. For the purpose of this disclosure “microwave energy” and “microwave field” may be equivalent and interchangeable. Microwave energy is absorbed by tissue in a process called dielectric heating. Molecules in the tissue, such as water molecules, are electric dipoles that have a positive charge at one end and a negative charge at the other. The microwave energy induces an alternating electric field that causes the dipoles to rotate as they attempt to align themselves with the field. This molecular rotation generates heat as the molecules hit one another and cause additional motion. The heating is particularly efficient with liquid water molecules, which have a relatively high dipole moment. Tissue types that have relatively low water content, such as fat, do not absorb microwave energy as efficiently as other types of tissue.
• The friction and heat produced through dipole rotation increases tissue temperature in a process known as dielectric heating, ultimately leading to cell death (i.e., necrosis) via coagulation. Accordingly, one feature of microwave-induced dielectric heating is that such an arrangement is expected to provide therapeutically high temperatures in target tissue, large and consistent ablation volumes, and/or relatively fast ablation times.
• The renal arterial wall is comprised of intima, media and adventitia. Target renal nerves are positioned in and adjacent to the adventitia, and connective tissue surrounds the adventitia and nerves. Connective tissue is largely comprised of fat, which is a poor absorber of microwave energy due to its low water content, thereby reducing a risk of collateral damage to the fatty connective tissue during microwave irradiation of the renal nerves.
• A microwave transmission element positioned within the renal artery via intravascular access may deliver a microwave field through the vessel wall and tissue, for example, omni-directionally in a plane relatively perpendicular to the longitudinal axis of the vessel. The microwave field may modulate (e.g., necrose), the target renal nerves. The depth to which the microwave field penetrates the wall and tissue is frequency dependent. Relatively greater microwave frequencies will provide relatively lower tissue penetration, while relatively lower microwave frequencies will provide relatively greater tissue penetration.
• When delivered intravascularly, preferentially heating the adventitia while avoiding significant thermal exposure to the intima/media may be challenging. However, renal arterial blood flow may provide protective cooling of the intima/media. Alternatively, open or closed circuit cooling may be utilized to remove excess heat from the inner wall of the renal artery. Various methods, systems and apparatuses for active and open- and closed-circuit cooling have been described previously, for example, in U.S. patent application Ser. No. 13/279,205, filed Oct. 21, 2011, and International Patent App. No. PCT/US2011/033491, filed Apr. 21, 2011, both of which are incorporated herein by reference in their entireties.
II. MICROWAVE CATHETER APPARATUSES, SYSTEMS, AND METHODS FOR RENAL NEUROMODULATIONA. Overview
• As just described, the left and/or right RP surrounds the respective left and/or right renal artery. The RP extends in intimate association with the respective renal artery into the substance of the kidney.FIG. 5 shows amicrowave system10 for inducing neuromodulation via dielectric heating of the left and/or right RP by intravascular access into the respective left or right renal artery.
• Themicrowave system10 includes anintravascular treatment device12 such as a catheter with anelongated shaft16 having aproximal end region18 and adistal end region20. Theproximal end region18 of theelongated shaft16 is connected to ahandle assembly200. Thedistal end region20 of theelongated shaft16 carries at least onemicrowave transmission element24, such as a microwave antenna100 (seeFIG. 7). Theelongated shaft16 is sized and configured for placement of itsdistal end region20 within a renal artery by intravascular access. Themicrowave transmission element24 is also specially sized and configured for manipulation and use within a renal artery.
• Themicrowave system10 also includes a microwave source orgenerator26, such as a cavity magnetron, a klystron, a traveling wave tube, etc. Under the control of the caregiver orautomated control algorithm222, themicrowave generator26 generates a selected form and magnitude of microwave energy. The generator preferably generates microwaves at a medically acceptable frequency, such as 915 MHz, 2.45 GHz, and/or 5.1 GHz. As discussed previously, relatively greater microwave frequencies will provide relatively lower tissue penetration, while relatively lower microwave frequencies will provide relatively greater tissue penetration.
• A feed ortransmission line28, such as a coaxial cable or a parallel wire, electrically transfers microwaves from themicrowave generator26 to the microwave transmission element24 (e.g., extends along or within theelongated shaft16 from thegenerator26 to the transmission element24). A control mechanism, such asfoot pedal110, can be connected (e.g., pneumatically or electrically) to thegenerator26 to allow the operator to initiate, terminate and, optionally, adjust various operational characteristics of themicrowave generator26, including, but not limited to, microwave energy delivery. Optionally, one or more sensors, such as one or more temperature (e.g., thermocouple, thermistor, etc.), impedance, pressure, optical, flow, chemical or other sensors, can be located proximate to or within the microwave transmission element to monitor delivery of the microwave field and/or to monitor dielectric heating in the vicinity of the microwave transmission element (seeFIG. 22B).
• As shown inFIG. 6A, thetreatment device12 provides access to the RP through anintravascular path14 that leads to a respective renal artery. Thehandle assembly200 is sized and configured to be securely or ergonomically held and manipulated by a caregiver outside theintravascular path14. By manipulating thehandle assembly200 from outside theintravascular path14, the caregiver can advance theelongated shaft16 through the sometimes tortuousintravascular path14 and remotely manipulate or actuate thedistal end region20 if necessary. Image guidance (e.g., CT, radiographic, IVUS, OCT, or another suitable guidance modality, or combinations thereof), can be used to aid the caregiver's manipulation. Further, in some embodiments, image guidance components (e.g., IVUS, OCT) may be incorporated into thetreatment device12 itself.
• As shown inFIG. 6B, thedistal end region20 of theelongated shaft16 can flex in a substantial fashion to gain entrance into a respective left/right renal artery by manipulation of theelongated shaft16. Optionally, thedistal end region20 of theelongated shaft16 can gain entrance to the renal artery following a path defined by a guide catheter, a guide wire, or a sheath (not shown). In such cases, the maximum outer dimension (e.g., diameter) of any section of theelongated shaft16, including themicrowave transmission element24 it carries, may be dictated by the inner diameter of the guide catheter through which theelongated shaft16 is passed. Assuming, for example, that an 8 French guide catheter (which has an inner diameter of approximately 0.091 inch (2.31 mm)) would likely be, from a clinical perspective, the largest guide catheter used to access the renal artery, and allowing for a reasonable clearance tolerance between the elongated shaft16 (i.e.,microwave transmission element24, centeringelement30, etc.) and the guide catheter, the maximum outer dimension can realistically be expressed as being less than or equal to approximately 0.085 inch (2.16 mm). However, use of a smaller 5 French guide catheter may require the use of smaller outer diameters along theelongated shaft16. For example, anelongated shaft16 that is to be routed within a 5 French guide catheter may have an outer dimension of no greater than 0.053 inch (1.35 mm). In another example, anelongated shaft16 that is to be routed within a 6 French guide catheter may have an outer dimension of no great than 0.070 inch (1.78 mm). In still further examples, other suitable guide catheters may be used, and outer dimensions and/or arrangements of thetreatment device12 can vary accordingly.
• Once entrance to a renal artery is gained, themicrowave transmission element24 optionally may be aligned with tissue along an interior wall of the respective renal artery. Optionally, themicrowave transmission element24 also may be centered within the renal artery via, for example, an expandable centeringelement30, such as a permeable centering element, an expandable braid or mesh, a cage, a basket, a balloon, stabilizing members, prongs, etc., that may be remotely expanded and collapsed via thehandle assembly200. The centeringelement30 has a low-profile delivery configuration for intravascular delivery to, and retrieval from, within the renal artery (e.g., through a guide catheter), and an expanded deployed configuration (as seen inFIG. 6B) wherein the centeringelement30 contacts the internal luminal surface of the renal artery and centers themicrowave transmission element24 within the artery.
• Once themicrowave transmission element24 is positioned as desired within the renal artery, the purposeful application of microwave energy from themicrowave generator26 to tissue by radiation from themicrowave transmission element24 induces one or more desired neuromodulating effects on localized regions of the renal artery and adjacent regions of the RP, which lay intimately within or adjacent to the adventitia of the renal artery. The purposeful application of neuromodulating effects can achieve neuromodulation along all or a portion of the RP.
• Neuromodulating effects can include thermal ablation, non-ablative thermal alteration, coagulation or damage (e.g., via sustained heating and/or dielectric heating), and electromagnetic neuromodulation. Desired dielectric heating effects may include raising the temperature of target neural fibers above a certain threshold to achieve non-ablative thermal alteration, or above a higher temperature to achieve ablative thermal alteration. For example, the target temperature can be above body temperature (e.g., approximately 37° C.) but less than about 45° C. for non-ablative thermal alteration, or the target temperature can be about 45° C. or higher for ablative thermal alteration. Desired non-thermal neuromodulation effects may include altering the electrical signals transmitted in a nerve.
• Specific embodiments of themicrowave system10, along with associated methods and apparatuses, will now be described in further detail. These embodiments are provided merely for the sake of illustration and should in no way be construed as limiting.
B.Specific Embodiments1. Coaxial Cable Feed Line and Coaxial Antenna Microwave Transmission Element
• As discussed previously, microwaves are transferred from themicrowave generator26 to themicrowave transmission element24 via thefeed line28. As seen, for example, inFIG. 7, thefeed line28 may comprise acoaxial cable50, and themicrowave transmission element24 may comprise, for example, acoaxial antenna100. Coaxial cables and antennas are described, for example, in U.S. Pat. No. 2,184,729, to Bailey, which is incorporated herein by reference in its entirety. Microwave catheters for use in cardiac ablation procedures and comprising coaxial cables and antennas are described, for example, in U.S. Pat. No. 4,641,649 to Walinsky et al., which is incorporated herein by reference in its entirety.
• Antennas convert electric current into electromagnetic radiation (and vice versa). Thecoaxial antenna100 is a type of dipole antenna. Thecoaxial cable50 connects themicrowave generator26 to thecoaxial antenna100. Thecoaxial cable50 comprises aninner conductor52,insulation54 coaxially disposed about the inner conductor, and anouter conductor56 comprising a tubular metal braid or shield that is coaxially disposed about theinsulation54. An outer delivery sheath orinsulation58 may cover theouter conductor56. Microwave energy is delivered down the length of thecoaxial cable50 that terminates in theantenna100 which is capable of radiating the energy into the surrounding tissue. The microwave energy is delivered through the space between theinner conductor52 and theouter conductor56. This space serves as a conduit while theouter conductor56 prevents energy from escaping. Where a gap is encountered in theouter conductor56 microwave energy is applied to the surrounding tissues. The gap may be perceived as an aperture instrumental in directing the microwave energy to the target in the controllable manner.
• Theinsulation54 between the inner andouter conductors52,56 electrically insulates and maintains a uniform distance between theinner conductor52 and theouter conductor56. Theinsulation54 may comprise a dielectric material, such as solid or foamed PolyEthylene (PE) or PolyTetraFluoroEthylene (PTFE). The space between the inner andouter conductors52,56 may have an impedance that is approximately matched with the tissue impedance. An impedance mismatch between theantenna100 and surrounding tissue may result in unbalanced currents on the inner andouter conductors52,56 of thefeed line28. In this case, a remainder current may flow along the outside of theouter conductor56 of thefeed line28.
• To form thecoaxial antenna100, an exposed element that is electrically connected to theinner conductor52 is unshielded by theouter conductor56. For example, the exposed element may be an extension of theinner conductor52 or an electrically conductive element that is electrically connected to theinner conductor52. The length of the exposed element may be a fraction of the wavelength of the microwave radiation (i.e., a fractional length), for example about ½ a wavelength. Adistal region102 of theouter conductor56 of thecoaxial cable50 optionally is exposed (i.e., outer insulation orsheath58 is optional) over a fractional length, for example, about ½ a wavelength. Thedistal regions102 and104 form aradiating element106 of dipolecoaxial antenna100. When driven by a microwave signal generated bygenerator26 and transferred bycoaxial cable50, the radiatingelement106 ofcoaxial antenna100 radiates microwaves outward in a torus or toroidal pattern. Microwave emission E is maximal and omni-directional in a plane perpendicular to the dipole (i.e., perpendicular to radiating element106) and substantially reduced in the direction of the dipole.
2. Expandable Multi-Filament Centering Elements
• It may be desirable to heat the renal nerves disposed within the adventitia while avoiding significant dielectric heating of the intima/media during microwave irradiation. Renal arterial blood flow may provide passive protective cooling of the intima/media. Thus, the centeringelement30 may be permeable (such as in the expandable mesh/braid ofFIG. 6B) and/or may not obstruct the entire vessel lumen, in order to ensure continued blood flow cooling of the renal artery intima/media during microwave-induced dielectric heating of target renal nerves. The centeringelement30, and/or some other element, also may increase the velocity of blood flow at or near the vessel wall to enhance or accelerate the transfer of heat from the wall to the blood.
• InFIGS. 8A and 8B, an expandable centeringelement830 comprises a plurality of resilient filaments32 (e.g., fingers or prongs), which are connected to thedistal region104 ofinner conductor52 at aconnector34. Theconnector34 may be conductive or non-conductive, such that the centeringelement830 may or may not, respectively, comprise a portion of the radiating element of an antenna800. Anose cone36 extends fromconnector34, and all or a portion of thenose cone36 also may or may not be conductive (i.e., may or may not comprise a portion of the radiating element), as desired. In embodiments in which expandable centeringelement830 is not a portion of the radiating element, it may be made from a dielectric material such as a polymer or ceramic.
• As seen inFIG. 8A, in the low-profile delivery configuration, theouter sheath58 serves as a delivery sheath that extends and distally tapers to an attachment with theatraumatic nose cone36, thereby constrainingfilaments32. As seen inFIG. 8B, upon proximal retraction of the delivery sheath (e.g., via actuation of the handle assembly200), thefilaments32 self-expand into contact with the vessel wall, thereby centering and aligning the coaxial antenna800 with the longitudinal axis of the vessel.
• Microwave radiation from themicrowave generator26 then may be transferred along thecoaxial cable50 to the antenna800 and radiated omni-directionally into the vessel wall to target renal nerves. The microwaves dielectrically heat the target renal nerves, as discussed previously, which induces neuromodulation (e.g., denervation).Filaments32 of the centeringelement830 do not significantly obstruct blood flow, and thereby facilitate passive blood flow cooling of non-target intima and media. Upon completion of renal neuromodulation, microwave irradiation may be halted, and the centeringelement830 may be collapsed for retrieval within theouter sheath58 and/or within a guide catheter.
• With reference now toFIG. 9, an alternative embodiment of a centering element930 is illustrated whereinfilaments32 are distally coupled to thenose cone36 to form an expandable basket38. The basket38 may self-expand into contact with the vessel wall and/or may be actively expanded.FIG. 9 illustratively shows the basket38 in the deployed configuration. Embodiments comprising expandable filaments or baskets for centering elements930 may have a multiple number of filaments32 (e.g., two, three, four, five, etc.), which may have variations of geometric shapes (e.g., straight, curved, helical, coiled, etc.).
3. Expandable Balloon Centering Elements
• As seen inFIGS. 10A and 10B, an expandable centering element1030 optionally may comprise an expandable balloon1040. The balloon1040 may be delivered in a low-profile configuration, expanded within the renal artery prior to and during application of the microwave field, and then collapsed for retrieval. As illustrated in the side-sectional view ofFIG. 10A, expansion of the balloon1040 into contact with the vessel wall may center anantenna1000 within the vessel and align it with the longitudinal axis of the vessel to facilitate omni-directional microwave radiation into the wall. The balloon1040 may be expanded by injecting a fluid/gas (e.g. nitrogen, carbon dioxide, saline, or other suitable liquids or gases) through an injection lumen (see, e.g.,injection lumen69 inFIG. 16). To contract the balloon the injected fluid or gas can be extracted through the same injection lumen, or through a separate lumen (not shown). A chilled fluid (e.g., chilled saline) may be used to inflate the balloon1040 and may be circulated by injecting the fluid through an injection lumen and extracting the fluid through a separate extraction lumen to allow continuous or semi-continuous flow. Circulation of chilled fluid may have an added benefit of cooling the surface layers of the artery while allowing the deeper adventitia and renal nerves to heat and become neuromodulated (e.g., ablated).
• As shown inFIG. 10A, a balloon may inflate to about the same diameter as the lumen of the artery and thereby occlude the artery (as shown inFIG. 10B). Alternatively (as illustrated in the cross-section ofFIGS. 11A and 11B), the balloon1040 may not completely obstruct the lumen of the renal artery, thereby allowing blood flow to cool and protect non-target intima and media during microwave irradiation of target renal nerves. By reducing the unobstructed cross-sectional area of the arterial lumen, the balloon1040 may increase the velocity of blood flow through the unobstructed area, which may enhance the rate of heat transfer at the vessel wall along unobstructed portions of the lumen.
• InFIG. 11A, a centeringelement1130acomprises aballoon1140ahaving twoopposed lobes42 that contact the inner wall of the renal artery.FIG. 11B illustrates an alternative embodiment of a centeringelement1130bcomprising aballoon1140bhaving threelobes42 spaced equidistantly about the circumference of the vessel. As will be apparent, balloons1140a,1140bmay comprise any number of lobes, as desired.
• FIG. 12 illustrates another embodiment of anantenna1200 having a plurality of balloons (illustrated individually as1240aand1240b) positioned proximal and distal of radiatingsection106 of theantenna1200. Optionally, theballoons1240aand1240bcomprise multiple lobes and do not fully obstruct the lumen of the renal artery. Providing proximal and distal balloons may better center theantenna1200 within the renal artery.
• In another embodiment as shown inFIG. 13, an expandableballoon centering element1340 and thedistal region104 of theinner conductor52 may be combined such that thedistal region104 comprises one or more conductive electrode traces55 applied on the surface of theballoon1340 for improved microwave energy delivery. In this example, the emitting antenna is themetallic spiral pattern55 applied or deposited on the inner or outer surface of theballoon1340. Balloons comprising electrodes have been fabricated, for example, by MicroPen Technologies of Honeoye Falls, N.Y. Themetallic spiral pattern55 is electrically connected to theinner conductor52 by a joint57 that can be a weld or a solder joint. The antenna is thus implemented by a metalized path printed, deposited, or otherwise applied on the wall of theballoon1340 and can be joined to theinner conductor52 of the coaxial cable by an extension of theinner conductor52 or by a separate interconnecting wire (not shown).
• As in previous examples to form the antenna, thedistal region104 of theinner conductor52 of thecoaxial cable50 is exposed over a length equal to a fraction of the wavelength of the microwave radiation. To achieve optimal length of the exposedinner conductor52 and at the same time achieve the desired dimensions of thedistal region104 of the renal artery catheter, it may be desired to have the exposed conductor longer than the length of theballoon1340. The proposed spiral pattern achieved when the balloon is expanded and the antenna is unfurled, is one of the many metallic surface patterns that can be used to achieve the desired length of the antenna in a compact device suitable for renal artery deployment. Alternative zigzag patterns can be proposed, for example, instead of a spiral. Common to these embodiments, the deposited metal forms an antenna that is electrically connected to one of the conductors in the feed line and is longer than the length of the balloon. The shape of the field expected from these embodiments is toroidal and substantially similar to the microwave field produced by the linear dipole antenna.
• FIGS. 14 and 15 illustrate embodiments ofantennas1400 and1500, respectively, where expandableballoon centering elements1440 and1540, respectively, comprise one or more conductive areas applied on the surfaces of the balloons for improved microwave energy delivery, where the conductive areas are not electrodes but shields.
• Theinner conductor52 is in electric connection with the exposed segment of theantenna1400,1500 that is the emitter of the microwave field and energy. The appliedmetallic patterns1462,1463, and1564 are not intended to emit energy but to reshape the microwave field and to improve the antennae matching network and thus ultimately change the geometry of the periarterial lesion. These designs can be useful when the toroidal shape of the microwave field is not desired in order to preferentially treat one area of the renal artery and spare another to reduce the risk of stenosis or for other medical reasons. In other words, to prevent direct penetration of microwaves into the tissue surrounding the balloon catheter, the balloon envelope is provided with a metallic coating in selected areas. Themetallic patterns1462,1463, and1564 and other possible patterns (e.g., helical shielding patterns or shielding lines that are parallel to the axis of the vessel) distort the microwave field and shield certain areas of the renal artery in a predictable fashion. The unprotected areas receive a relatively high concentration of microwave energy.
• FIG. 15 also illustrates incorporation of aconductive element101 into anatraumatic tip1536. Such an element can be instrumental in tuning up the antenna. Thenose cone1536 can incorporate a cap useful in the cap and choke antennae designs intended to improve impedance matching. The choke is a conductive sleeve placed above the coaxial feed assembly right before the area where the emitter antenna emerges from the coaxial shield.
• FIG. 16 illustrates an embodiment of anantenna1600 where aballoon1640 is asymmetric relative to the catheter shaft and theantenna1600. The purpose of such aballoon1640 is to increase the delivery of microwave energy to one side of the internal lumen of the renal artery and decrease the delivery to the opposite side.
4. Flow Directing Elements
• FIG. 17 illustrates an embodiment of amicrowave system1710 comprising an expandable centering element1730 in combination with a flow directingvelocity enhancement element1745. InFIG. 17, the centering element1730 illustratively comprises multipleresilient filaments32, as discussed previously. Flow directingelement1745 illustratively comprises an expandable balloon having a diameter less than the diameter of the lumen of the renal artery in which treatment is conducted.Microwave transmitting element24/antenna1700 may be positioned within theflow directing element1745.
• In the expanded deployed configuration ofFIG. 17, the centering element1730 aligns and centers the antenna1700 within the renal artery, while theflow directing element1745 obstructs the center of the artery. This central obstruction directs blood flow around theflow directing element1745 and toward the luminal wall of the renal artery, where protective cooling is desired during microwave irradiation and dielectric heating of the target renal nerves. The central obstruction also increases flow velocity, which in turn increases the rate of protective heat transfer from the vessel wall to the blood during such microwave irradiation.
5. Over-The-Wire and Rapid Exchange Microwave Catheters
• It may be desirable for themicrowave system10 to comprise anintravascular treatment device12 configured for delivery over a guide wire. In any of the previously described embodiments, thecoaxial cable50 andcoaxial antenna100 may be modified such that theinner conductor52 comprises a tubular inner conductor with a guide wire lumen (e.g., a coiled tube, a braided metal tube, or a flexible polymer tube coated with a conductive material, such as silver). For example,FIG. 18A illustrates an alternative embodiment of the microwave system ofFIG. 7 having anantenna1800 wherein theinner conductor52 comprises a tubular inner conductor having aguide wire lumen53. In the embodiment illustrated inFIG. 18A, theguide wire lumen53 extends completely through theshaft16 from the proximal opening of theshaft16 at an adaptor (e.g., at thehandle200 shown inFIG. 5) to the distal opening of theshaft16 in an over-the-wire (OTW) configuration, whereas in the embodiment illustrated inFIG. 18B, aguide wire183 and theguide wire lumen53 extend through only a portion of theshaft16 in a rapid exchange (RX) configuration. Although the proximal end of theguide wire lumen53 is shown inFIG. 18B extending through the sidewall of theshaft16 at thedistal region20, in other embodiments, the proximal end of theguide wire lumen53 can be accessible anywhere between the proximal and distal ends of theshaft16. Theguide wire lumen53 shown inFIGS. 18A and 18B, or variations thereof, may be included in various embodiments described herein to facilitate navigation through the vasculature. Suitable OTW and RX guide wire configurations are disclosed in U.S. Pat. No. 5,545,134, filed Oct. 27, 1994, U.S. Pat. No. 5,782,760, filed May 23, 1995, U.S. Patent App. Publication No. US 2003/0040769, filed Aug. 23, 2001, and U.S. Patent App. Publication No. US 2008/0171979, filed Oct. 17, 2006, each of which is incorporated herein by reference in its entirety.
6. Inner Conductors With Dynamically Variable Exposed Length
• When utilizing a coaxial antenna, it may be desirable to provide theinner conductor52 with a dynamically variable exposed length in order to better match the antenna to the surrounding media (i.e., blood and tissue). Media matching depends on multiple factors, including electrical characteristics of the media (e.g., dielectric properties), frequency of the microwave signal, and power of the microwave signal, as well as geometrical parameters of the radiatingelement106 of the antenna. Dynamically varying the exposed length of theinner conductor52 dynamically varies the geometrical parameters of the radiatingelement106, which may be utilized to facilitate better media matching.
• Referring now toFIGS. 19A and 19B, in one embodiment, acoaxial antenna1900 may comprise an adjustable gap for dynamically varying the exposed length of theinner conductor52. As seen inFIG. 19A, the distal region ofouter conductor56 may comprise a firstouter conductor56aand a secondouter conductor56bspaced longitudinally from the firstouter conductor56a. Likewise the (dielectric)insulation54 comprises afirst insulation54aand asecond insulation54bspaced longitudinally from thefirst insulation54a. Theouter sheath58 is attached to the secondouter conductor56b, but may freely slide relative to firstouter conductor56a.
• InFIG. 19A, radiatingelement106 ofantenna1900 comprises the exposed portion ofinner conductor52 positioned between the first and second outer conductors. As seen inFIG. 19B, proximal retraction ofouter sheath58 proximally retracts the secondouter conductor56band thesecond insulation54brelative to theinner conductor52, thereby dynamically altering the radiatingelement106 of theantenna1900. As will be apparent, in an alternative embodiment, the microwave system ofFIGS. 19A and 19B may be modified such that theinner conductor52 comprises a tubular inner conductor having a guide wire lumen to facilitate over-the-wire delivery of thetreatment device12. The microwave system may alternatively be modified for RX delivery of thetreatment device12.
• FIG. 20 illustrates another embodiment of anantenna2000 having aninner conductor52 with a dynamically variable exposed lengthdistal region104. InFIG. 20, the exposed length along thedistal region104 of theinner conductor52 includes aconductive wire loop60 that loops back and extends within alumen61 through anelongated shaft16 of anintravascular treatment device12. As illustrated by dotted lines inFIG. 20, the medical practitioner may dynamically extend and retract thewire loop60 to dynamically vary the exposed length of theinner conductor52.
• FIGS. 21A and 21B illustrate an over-the-wire embodiment of a microwave system having aninner conductor52 with a dynamically variable exposed length. As seen inFIG. 21A, thedistal end region20 of theelongated shaft16 having acoaxial antenna2100 with tubularinner conductor52 having aguide wire lumen53 may be advanced over aguide wire108 into the renal artery. As seen inFIG. 21B, theguide wire108 then may be removed and replaced with aradiator70 that is electrically coupled to the tubularinner conductor52. Theradiator70 may, for example, comprise protrusions that contact the inner wall of theinner conductor52 to electrically couple to the tubularinner conductor52.
• Theradiator70 extends beyond thedistal end region20 of theelongated shaft16 to form the exposeddistal region104 of theinner conductor52, thereby forming a portion of the radiatingelement106 of theantenna2100 during microwave irradiation of the renal nerves. The length of the exposeddistal region104 ofinner conductor52 may be varied by dynamically varying how far theradiator70 extends beyonddistal end region20 ofelongated shaft16.
7. Active Cooling
• In addition to the passive cooling provided by blood flow, active cooling may be provided in the vicinity of the microwave transmission element via a coolant (e.g., a circulating coolant). For example, as seen inFIG. 22A, acoolant112 may be introduced into an annular space between thecoaxial cable50 and dielectric orinsulator2258. As seen inFIG. 22B, the annular space may extend over acoaxial antenna2200. Optionally, the coolant may be circulated to enhance heat transfer. Optionally, a temperature sensor, such as a thermistor orthermocouple59, may be positioned within the coolant in the vicinity of the radiating element of theantenna2200 to monitor temperature. Temperature data collected with the temperature sensor may be utilized in a feedback loop to control or alter delivery of the microwave field and/or the coolant in response to the measured temperature (e.g., to maintain the temperature within a desired range).
• Additionally or alternatively, the inner layers of an artery may be spared from heat if microwave energy is delivered in pulses. During pauses of energy delivery, blood will flow away from the area of energy application and be replaced by colder blood. At the same time tissues surrounding the inner lumen of the artery will continue to accumulate heat leading to the desired targeted tissue destruction. Pulsed delivery of microwave energy can be achieved by setting the duty cycle of the microwave energy generator. The thermal inertia of the targeted tissues will ensure the desired build up of heat while sparing the inner lumen of the blood vessel.
8. Directed Application of a Microwave Field
• The specific embodiments described above provide toroidal-shaped, omni-directional emission of microwaves from a microwave transmission element24 (i.e., from the radiatingelement106 of coaxial antenna100). While such an omni-directional microwave energy deposition delivered intravascularly may desirably provide a circumferential treatment about the renal artery, it may be desirable under certain circumstances to target a specific non-circumferential area (e.g., to more narrowly direct application of the microwave energy deposition to specific target renal nerves). Thus, amicrowave transmission element24 may include shielding or other means for directional application of microwave energy.
• For example,FIG. 23A illustrates a shielding65 substantially surrounding the radiatingelement106 of thecoaxial antenna100.FIGS. 23B and 23C are cross-sectional views of theantenna100 along lines B-B and C-C, respectively. Referring toFIGS. 23A-23C, the shielding65 includes awindow21 through which the microwave emissions E may be directed. Thewindow21 can take up various proportions of the circumference of the shielding65. For example, in one embodiment, thewindow21 comprises approximately 30% of the circumference of the shielding65 over the length of the emitting portion of theantenna100. In further embodiments, thewindow21 can comprise more or less of the circumference of the shielding65 and can extend only part of the length of the emitting portion of theantenna100. In some embodiments, it may be desirable for the shielding65 to possess reflective properties such that a substantial portion of the omni-directional field that encounters the shielding65 is redirected through thewindow21. In further embodiments, the shielding65 can include more than one window (e.g., multiple longitudinally offset windows facing opposite directions, or a helical window, etc.). The lesion geometry will accordingly match the window geometry.
• In some embodiments, it may also be desirable for the elongated shaft16 (FIG. 5) to have deflection capability at or near itsdistal region20 proximal of theantenna100 to facilitate positioning of the shieldingwindow21 within the renal artery. For example, as illustrated inFIGS. 23D and 23E, deflection capability may be provided by acontrol wire23 running through the catheter from the handle to or near thedistal region20 proximal of theantenna100, where the catheter includes a flexibly biased structure such as alaser cut tube25. When thecontrol wire23 is pulled or pushed by an actuator in the handle (not shown), the flexibly biased structure is deflected in the flexibly biased direction.
• In one embodiment, pulling or pushing thecontrol wire23 can cause thedistal region20 to deflect in the direction of thewindow21 to facilitate positioning of thewindow21 in substantial contact with the vessel wall (as illustrated inFIG. 23E). In another embodiment, pulling or pushing thecontrol wire23 can cause the catheter to deflect in a direction opposite that of thewindow21 to ensure that there is sufficient space between thewindow21 and targeted area of the vessel wall to allow for blood flow to cool non-target intima/media tissue. Other embodiments disclosed herein (e.g., balloon-centering embodiments), can similarly employ anelongated shaft16 having deflection capabilities to control positioning of theantenna100 in the renal artery.
III. CONCLUSION
• Although the specific embodiments of a microwave system have been described with a feed line comprising a coaxial cable and a microwave transmission element comprising a coaxial antenna, it should be understood that any alternative feed lines and microwave transmission elements may be utilized. For example, a feed line may comprise a parallel wire. Likewise, a microwave transmission element may, for example, comprise a waveguide or an alternative type of antenna, such as a patch antenna, a slot antenna, another form of dipole antenna, a Yagi-Uda antenna, a parabolic antenna, etc.
• The above detailed descriptions of embodiments of the technology are not intended to be exhaustive or to limit the technology to the precise form disclosed above. Although specific embodiments of, and examples for, the technology are described above for illustrative purposes, various equivalent modifications are possible within the scope of the technology, as those skilled in the relevant art will recognize. For example, while steps are presented in a given order, alternative embodiments may perform steps in a different order. The various embodiments described herein may also be combined to provide further embodiments.
• Moreover, unless the word “or” is expressly limited to mean only a single item exclusive from the other items in reference to a list of two or more items, then the use of “or” in such a list is to be interpreted as including (a) any single item in the list, (b) all of the items in the list, or (c) any combination of the items in the list. Where the context permits, singular or plural terms may also include the plural or singular term, respectively. Additionally, the term “comprising” is used throughout to mean including at least the recited feature(s) such that any greater number of the same feature and/or additional types of other features are not precluded. It will also be appreciated that specific embodiments have been described herein for purposes of illustration, but that various modifications may be made without deviating from the technology. Further, while advantages associated with certain embodiments of the technology have been described in the context of those embodiments, other embodiments may also exhibit such advantages, and not all embodiments need necessarily exhibit such advantages to fall within the scope of the technology. Accordingly, the disclosure and associated technology can encompass other embodiments not expressly shown or described herein.

Claims (29)

1. A catheter apparatus, comprising:

an elongated shaft having a proximal portion, a distal portion, and a central lumen;

a therapeutic assembly at the distal portion of the elongated shaft, wherein the therapeutic assembly is configured for intravascular delivery to a renal artery of a human patient; and

a microwave transmitting element carried by the therapeutic assembly, wherein the microwave transmitting element is configured to radiate microwaves through a wall of the renal artery to modulate a renal nerve at a treatment site within the renal artery.

2. The catheter apparatus ofclaim 1 wherein the therapeutic assembly comprises a tubular inner conductor, an outer conductor, and an insulator separating at least a portion of the inner conductor and the outer conductor.

3. The catheter apparatus ofclaim 1, further comprising a radiating element and a shield at least parially surrounding the radiating element, wherein the shield is configured to preferentially direct the radiated microwaves.

4. The catheter apparatus ofclaim 1, further comprising a radiator positioned in the central lumen.

5. The catheter apparatus ofclaim 4 wherein:

the therapeutic assembly comprises a tubular inner conductor, an outer conductor, and an insulator separating at least a portion of the inner conductor and the outer conductor, and

the radiator comprises protrusions configured to contact an inner wall of the inner conductor to electrically couple the radiator to the inner conductor.

6. The catheter apparatus ofclaim 4 wherein the radiator extends distally beyond a distal end of the elongated shaft.

7. The catheter apparatus ofclaim 1 wherein the central lumen comprises a coolant supply channel configured to deliver coolant in a vicinity of the microwave transmitting element.

8. The catheter apparatus ofclaim 7, further comprising a temperature sensor coupled to the elongated shaft and configured to sense the temperature in a vicinity of the microwave transmitting element.

9. The catheter apparatus ofclaim 1, further comprising a guide wire positioned in the central lumen, wherein the therapeutic assembly is configured to be delivered over the guidewire for placement within the renal artery.

10. A method for treatment of a human patient via renal denervation, the method comprising:

intravascularly positioning a catheter having a microwave transmitting element within a renal artery of the patient;

generating microwaves with a microwave generator positioned externally to the patient and transferring the microwaves through the catheter to the microwave transmitting element; and

radiating the microwaves from the microwave transmitting element through a wall of the renal artery to modulate neural function of a renal nerve of the patient.

11. The method ofclaim 10 wherein modulating neural function of the renal nerve comprises dielectrically heating the renal nerve.

12. The method ofclaim 11 wherein dielectrically heating the renal nerve comprises inducing necrosis in the renal nerve.

13. The method ofclaim 10 wherein intravascularly positioning a catheter having a microwave transmitting element within a renal artery of the patient comprises centering the microwave transmitting element within the renal artery.

14. The method ofclaim 13 wherein centering the microwave transmitting element within the renal artery comprises centering the microwave transmitting element within the artery without fully occluding blood flow through the renal artery.

15. The method ofclaim 10 wherein generating microwaves with a microwave generator comprises generating microwaves with a cavity magnetron.

16. The method ofclaim 10 wherein intravascularly positioning a catheter having a microwave transmitting element comprises positioning a catheter having a microwave antenna.

17. The method ofclaim 16 wherein intravascularly positioning a catheter having a microwave antenna comprises positioning a catheter having a coaxial antenna.

18. The method ofclaim 17 wherein transferring the microwaves through the catheter to the microwave transmitting element comprises transferring the microwaves through a coaxial cable to the coaxial antenna.

19. The method ofclaim 17 wherein the coaxial antenna includes a radiating element, and wherein radiating the microwaves from the microwave transmitting element comprises dynamically varying a length of the radiating element.

20. The method ofclaim 17 wherein the coaxial antenna includes a radiating element, and wherein radiating the microwaves from the microwave transmitting element further comprises shielding a portion of the radiating element of the coaxial antenna to preferentially direct the radiated microwaves.

21. The method ofclaim 10 wherein radiating the microwaves from the microwave transmitting element comprises preferentially directing the radiated microwaves.

22. The method ofclaim 10 wherein intravascularly positioning a catheter having a microwave transmitting element within the renal artery comprises advancing the catheter to the renal artery over a guide wire via an intravascular path.

23. The method ofclaim 10, further comprising redirecting arterial blood flow within the renal artery of the patient while radiating the microwaves.

24. The method ofclaim 23 wherein redirecting arterial blood flow comprises increasing a velocity of the blood flow near a wall of the renal artery in order to enhance a rate of heat transfer between the wall and the blood flow.

25. The method ofclaim 10, further comprising actively cooling the microwave transmitting element while radiating the microwaves.

26. The method ofclaim 25 wherein actively cooling the microwave transmitting element comprises circulating a coolant in a vicinity of the microwave transmitting element.

27. The method ofclaim 25, further comprising monitoring a temperature of the microwave transmitting element while radiating the microwaves.

28. The method ofclaim 27, further comprising altering the active cooling or the microwave radiation in response to the monitored temperature of the microwave transmitting element.

29. The method ofclaim 10, further comprising monitoring a temperature of the microwave transmitting element.

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