US20160192830A1 - Endoscopic methods and devices for transnasal procedures - Google Patents

Abstract

Medical devices, systems and methods that are useable to facilitate transnasal insertion and positioning of guidewires and various other devices and instruments at desired locations within the ear, nose, throat, paranasal sinuses or cranium.

Description

CROSS-REFERENCE
• This application is a divisional application of application Ser. No. 11/647,530, filed Dec. 27, 2006, which claims the benefit of Provisional Application No. 60/844,874, filed Sep. 15, 2006, and which is a continuation-in-part application of application Ser. No. 11/522,497, filed Sep. 15, 2006, and which is also a continuation-in-part application of application Ser. No. 11/193,020, filed Jul. 29, 2005, which is a continuation-in-part application of application Ser. No. 10/829,917, filed Apr. 21, 2004; Ser. No. 10/944,270, filed Sep. 17, 2004; Ser. No. 11/116,118, filed Apr. 26, 2005; and Ser. No. 11/150,847, filed Jun. 10, 2005. Each of the aforementioned applications are hereby expressly incorporated by reference herein, in their entireties, and to which application we claim priority under 35 USC §120 and 35 USC §119, respectively.
• This application also claims the benefit of U.S. Provisional Application No. 60/844,874, filed Sep. 15, 2006, which application is expressly incorporated herein, in its entirety, by reference thereto and to which we claim priority under 35 USC §119.
FIELD OF THE INVENTION
• The present invention relates generally to medical apparatus and methods and more particularly to devices and methods that are useable to facilitate transnasal insertion and positioning of guidewires and various other apparatus at desired locations within the ear, nose, throat, paranasal sinuses or cranium.
BACKGROUND OF THE INVENTION
• Functional endoscopic sinus surgery (FESS) is currently the most common type of surgery used to treat chronic sinusitis. In a typical FESS procedure, an endoscope is inserted into the nostril along with one or more surgical instruments. The surgical instruments are then used to cut tissue and/or bone, cauterize, suction, etc. In most FESS procedures, the natural ostium (e.g., opening) of at least one paranasal sinus is surgically enlarged to improve drainage from the sinus cavity. The endoscope provides a direct line-of-sight view whereby the surgeon is typically able to visualize some but not all anatomical structures within the surgical field. Under visualization through the endoscope, the surgeon may remove diseased or hypertrophic tissue or bone and may enlarge the ostia of the sinuses to restore normal drainage of the sinuses. FESS procedures can be effective in the treatment of sinusitis and for the removal of tumors, polyps and other aberrant growths from the nose.
• The surgical instruments used in the prior art FESS procedures have included; applicators, chisels, curettes, elevators, forceps, gouges, hooks, knives, saws, mallets, morselizers, needle holders, osteotomes, ostium seekers, probes, punches, backbiters, rasps, retractors, rongeurs, scissors, snares, specula, suction cannulae and trocars. The majority of such instruments are of substantially rigid design.
• In order to adequately view the operative field through the endoscope and/or to allow insertion and use of rigid instruments, many FESS procedures of the prior art have included the surgical removal or modification of normal anatomical structures. For example, in many prior art FESS procedures, a total uncinectomy (e.g., removal of the uncinate process) is performed at the beginning of the procedure to allow visualization and access of the maxilary sinus ostium and/or ethmoid bulla and to permit the subsequent insertion of the rigid surgical instruments. Indeed, in most traditional FESS procedures, if the uncinate process is allowed to remain, such can interfere with endoscopic visualization of the maxillary sinus ostium and ethmoid bulla, as well as subsequent dissection of deep structures using the available rigid instrumentation.
• More recently, new devices, systems and methods have been devised to enable the performance of FESS procedures and other ENT surgeries with minimal or no removal or modification of normal anatomical structures. Such new methods include, but are not limited to, uncinate-sparing procedures using Balloon Sinuplasty™ tools and uncinate-sparing ethmoidectomy procedures using catheters, non-rigid instruments and advanced imaging techniques (Acclarent, Inc., Menlo Park, Calif.). Examples of these new devices, systems and methods are described in incorporated U.S. patent application Ser. No. 10/829,917 entitled Devices, Systems and Methods for Diagnosing and Treating Sinusitis and Other Disorders of the Ears, Nose and/or Throat; Ser. No. 10/944,270 entitled Apparatus and Methods for Dilating and Modifying Ostia of Paranasal Sinuses and Other Intranasal or Paranasal Structures; Ser. No. 11/116,118 entitled Methods and Devices for Performing Procedures Within the Ear, Nose, Throat and Paranasal Sinuses filed Apr. 26, 2005 and Ser. No. 11/150,847 filed Jun. 10, 2005, each of which is hereby incorporated herein, in its entirety. Procedures using Balloon Sinuplasty™ tools such as those described in the above-noted applications, for example, are performable using various types of guidance including but not limited to C-arm fluoroscopy, transnasal endoscopy, optical image guidance and/or electromagnetic image guidance.
• In FESS procedures, the surgeon typically holds or navigates the endoscope with one hand while using the other hand to handle the surgical instruments. Recognizing the desirability of integrating an endoscope with an operative device so that both could be moved with a single hand, application Ser. No. 11/234,395 filed Sep. 23, 2005 describes a number of transnasally insertable sinus guides that have endoscopes attached thereto or integrated therewith.
• There remains a need for further development of new devices and methodology to facilitate the integration of endoscopes with sinus guides and/or other instruments to facilitate endoscopic viewing of guidewires and/or other devices/instruments as they are transnasally inserted, positioned and used to treat disorders of the ear, nose, throat, paranasal sinuses or other intracranial disorders that are transnasally accessible.
SUMMARY OF THE INVENTION
• A beneficial aspect of the present invention is to allow a user to be able to see an adjustable view, with an endoscope, that is generally aligned with the same axis of movement of the user's working device. This is particularly useful when the axis of movement is at an angle with respect to the axis of entry into the patient. This aspect allows the user to see “around the corner” of anatomy that ordinarily would block his/her view and which would therefore require removal in a traditional FESS procedure to allow visualization. This aspect of the invention allows the user to also verify the location of his/her Balloon Sinuplasty™ tools without having to use fluoroscopy or image guidance systems, so that the procedure does not have to be performed in an operating room. Another beneficial aspect of the present invention is that it enables a reduction in the amount of fluoroscopy that needs to be performed by the user doing the procedure, resulting in a reduction in radiation exposure to the user and the patient.
• Another beneficial aspect of the present invention is that it allows a user to hold a tool with an endoscope attached or incorporated therein, such that both can be held with one hand while allowing the user to manipulate another tool with the other hand, thereby eliminating the need for an assistant.
• Another aspect of the invention is a disposable, flexible endoscope that is inexpensive enough for the user to dispose of after ten uses or less, or even after a single use, because the expensive optics that are normally present in the proximal end portion of a conventional flexible (or rigid) endoscope have been relocated in the present embodiments to a re-usable coupler. Also, steerability elements that are normally present in a conventional flexible endoscope have been removed in the present embodiments. Importantly, in at least one embodiment, the entire diameter of the flexible endoscope has an outer diameter of about 0.035 inches or less, so that interventional devices such as a dilatation catheter can be loaded onto and passed over the flexible endoscope. At least one embodiment of the present invention allows the user to load and remove the flexible endoscope from a curved tool, even one having an acute angle bend therein, without breaking or damaging the lens and/or fibers in the endoscope.
• In accordance with the present invention, there is provided a method for positioning a working device (e.g., a guidewire, catheter, instrument or other device useable to perform or facilitate a therapeutic or diagnostic task) at a desired location within the ear, nose, throat or cranium of a human or animal subject. In general, this method includes the steps of: (A) providing a guide device that comprises an elongate shaft, a distal end, a second channel into which a working device may be inserted and an first channel into which an endoscope may be inserted; (B) providing an endoscope sized to be received within the endoscope channel; (C) providing a working device sized to be received within the second channel; (D) positioning the endoscope in the endoscope channel; (E) inserting the guide device through a nostril of the subject; (F) using the endoscope to guide or visually verify the positioning of the guide device at the desired location; (G) inserting a working device into the second channel; and (H) advancing the working device to the desired location.
• Further in accordance with the present invention, there is provided an endoscope/sinus guide device that is useable to position a working device at a desired location within the ear, nose, throat or cranium of a human or animal subject. In general, this device comprises a transnasally insertable elongate shaft (e.g., a rigid or flexible catheter, cannula or tube) having a proximal end, a distal end, a working channel through which the working device may be advanced and an endoscope channel, a portion of which is angled relative to the elongate shaft, and into which an endoscope may be inserted such that the endoscope may be used to view at least an area beyond the distal end of the shaft. After the endoscope has been used to facilitate placement of the distal end of the guide device to or near the desired location, a working device (e.g., a guidewire, catheter, instrument or other device useable to perform or facilitate a therapeutic or diagnostic task) is then advanceable through the working channel and to the desired location. The elongate shaft of the endoscope/sinus guide device may be straight, curved, malleable or steerable.
• Still further in accordance with the present invention, there is provided a transnasally insertable guide system and method for positioning a guidewire at a desired location within the ear, nose, throat or cranium of a human or animal subject. In general, this system comprises a tubular guide (e.g., a sinus guide) that has an elongate shaft and a lumen. At least a portion of the elongate shaft has a predetermined shape, and may be straight, curved, malleable or steerable. A sheath is sized to be inserted into the lumen of the tubular guide. Such sheath comprises an elongate flexible body having a distal end, a scope lumen and a guidewire lumen. An endoscope is advanceable through the scope lumen of the sheath and a guidewire is advanceable through the guidewire lumen such that a distal portion of the guidewire extends out of the distal end of the sheath. The endoscope is useable to view at least a portion of the guidewire as it advances out of the distal end of the sheath. In this manner, the endoscope may be used to guide the advancement of the guidewire to or near the desired location. Thereafter, the sheath and endoscope may be removed leaving the tubular guide and guidewire in place. A working device (e.g., a guidewire, catheter, instrument or other device useable to perform or facilitate a therapeutic or diagnostic task) may then be advanced through the tubular guide and over the guidewire to the desired location where it is useable to perform or facilitate a therapeutic or diagnostic task. In some embodiments, a distal portion of the sheath may be advanceable out of and beyond the distal end of the tubular guide and such distal portion of the sheath may be deflectable (e.g., steerable) in situ. In such deflectable (e.g., steerable) embodiments, a handpiece may be attached to the proximal end of the sheath and such handpiece may include an actuator or other control that is useable to cause the distal portion of the sheath to deflect (e.g., steer) when so desired.
• Still further in accordance with the present invention, there is provided a guide system and method wherein a translucent body (e.g., a flexible guidewire tip) is mounted on the distal end of a guide member. An elongate scope is engageable with the translucent body such that light will be cast from the scope, through the translucent body and images will be received by the scope through the translucent body. In this manner, the scope is useable to view an area adjacent to the elongate guide tip, thereby facilitating advancement of the elongate guide tip to a desired location within the body of a human or animal subject. After the elongate guide tip has been advanced to or near the desired location, a working device (e.g., a catheter or other device useable to perform a diagnostic or therapeutic task) is then advanced over the endoscope, translucent member and guide tip. In this manner, the endoscope, translucent member and guide tip combine to perform a function of a continuous guidewire.
• Still further in accordance with the present invention, there is provided another guide system and method wherein an elongate guide member (e.g., a flexible guidewire tip) is attached to and extends from the distal end of a rigid or flexible catheter having a side opening. An endoscope is advanceable out of the side opening of the elongate catheter and useable, when so advanced, to view an area adjacent to the elongate guide tip, thereby facilitating advancement of the elongate guide tip to a desired location within the body of a human or animal subject. Thereafter, the endoscope may be retracted back into the catheter and a working device (e.g., a catheter or other device useable to perform a diagnostic or therapeutic task) is then advanceable over the catheter and guide member. In this manner, the catheter and the guide member combine to perform the function of a continuous guidewire.
• Further aspects, elements and advantages of the present invention will be understood by those of skill in the art upon reading of the detailed description set forth herebelow.
BRIEF DESCRIPTION OF THE DRAWINGS
• FIG. 1 is a perspective view of one embodiment of a guide system of the present invention.
• FIG. 2 is a perspective view of the guide system of the present invention in use on a human subject.
• FIG. 3A is a side view of the guide catheter of the system ofFIG. 1.
• FIG. 3B is a cross sectional view throughline3B-3B ofFIG. 3A.
• FIG. 3C is a cross sectional view throughline3C-3C ofFIG. 3A.
• FIG. 3D is a side view of the endoscope of the system ofFIG. 1.
• FIG. 3E is a cross sectional view through line3D-3D ofFIG. 3C.
• FIG. 3F is a side view of the connector/camera/light cable assembly of the system ofFIG. 1.
• FIG. 4A is a side view of another embodiment of a guide catheter device useable in the guide catheter systems of the present invention.
• FIG. 4B is a cross sectional view throughline4B-4B ofFIG. 4A.
• FIG. 4C is a cross sectional view throughline4C-4C ofFIG. 4A.
• FIGS. 5A-5C show steps in a method for using a flexible endoscope in conjunction with the guide catheter component ofFIG. 4A.
• FIG. 5D shows one embodiment of a fixture apparatus that is useable to facilitate passage of a flexible endoscope through the distal endoscope guide lumen of the guide catheter ofFIG. 4A.
• FIG. 5E shows another embodiment of a fixture apparatus that is useable to facilitate passage of a flexible endoscope through the distal endoscope guide lumen of the guide catheter ofFIG. 4A.
• FIG. 6 is a partial perspective view of a guide catheter of the present invention with an optional linking apparatus for linking the endoscope to a guidewire to deter divergence of the endoscope away from the path of the guidewire.
• FIG. 7A shows another embodiment of a guide catheter device useable in the guide catheter systems of the present invention during insertion of a flexible endoscope into a dynamic endoscope lumen.
• FIG. 7B shows the guide catheter device ofFIG. 7A after the endoscope has been fully advanced through the dynamic endoscope lumen.
• FIG. 8A shows the guide catheter device ofFIG. 7A with an optional endoscope lumen retractor, during insertion of a flexible endoscope into a dynamic endoscope lumen.
• FIG. 8B shows the guide catheter device ofFIG. 8A after the endoscope has been fully advanced through the dynamic endoscope lumen.
• FIG. 9A shows an embodiment of a guide catheter of the present invention having a pivoting arm apparatus in an extended position to facilitate loading of an endoscope into the endoscope lumen.
• FIG. 9B shows the guide catheter ofFIG. 9A with the pivoting arm apparatus in a non-extended position after the endoscope has been loaded into the endoscope lumen.
• FIG. 10 is a side view of a prior art guidewire having an angled distal tip.
• FIG. 10A shows a step in a method for using a guide catheter system of the present invention in conjunction with the guidewire ofFIG. 10.
• FIG. 10B shows another step in a method for using a guide catheter system of the present invention in conjunction with the guidewire ofFIG. 10.
• FIG. 11A is a perspective view of the distal portion of a guide catheter device of the present invention having its endoscope lumen disposed on top of the curvature of the guide catheter.
• FIG. 11B is a perspective view of the distal portion of a guide catheter device of the present invention having its endoscope lumen disposed along side of the curvature of the guide catheter.
• FIG. 11C is a perspective view of the distal portion of a guide catheter device of the present invention having its endoscope lumen disposed below the curvature of the guide catheter.
• FIGS. 12A through 12D are illustrations of partial sagittal sectional views through a human head showing various steps of a method of gaining access to a paranasal sinus using a sinus guide.
• FIG. 13 illustrates a scope introduced on the side of the sinus guide.
• FIG. 14 shows an illuminating guidewire according to one embodiment of the present invention.
• FIG. 15 shows a distal end portion of a guidewire having a bent shape.
• FIG. 16 is a cross-sectional illustration of a distal end portion of a guidewire device showing a core support fixed to the coil.
• FIG. 17 shows a cross-sectional view of a guidewire device that includes a fiber optic bundle of light fibers.
• FIG. 18 shows an illuminating guidewire according to another embodiment of the present invention.
• FIG. 19 is a cross-sectional illustration of a distal end portion of the guidewire shown inFIG. 18.
• FIG. 20 shows an illuminating guidewire according to another embodiment of the present invention.
• FIG. 21 illustrates an alternative transparent portion that may be included in a device shown inFIG. 20.
• FIG. 22 illustrates another alternative transparent portion that may be included in a device shown inFIG. 20.
• FIG. 23A illustrates an illuminating guidewire device including a quick release connector that is optically coupled to a light source.
• FIG. 23B is a view of the arrangement ofFIG. 23A in which the quick release locking mechanism is in the locked position.
• FIG. 24A illustrates an alternative quick release connector.
• FIG. 24B illustrates the connector ofFIG. 24A mounted over a proximal end portion of an illuminating guidewire.
• FIG. 25 illustrates another alternative quick release connector.
• FIG. 26 illustrates another alternative quick release connector.
• FIGS. 27A-27E are illustrations of partial coronal sectional views through a human head showing various steps of a method for treating an ostium that opens to a frontal sinus.
• FIG. 28 illustrates a situation, like that described with regard toFIG. 13, where a scope has been inserted as far as possible without causing significant trauma to the patient. Additionally,FIG. 28 shows an illuminating guidewire having been extended distally of the limit of illumination of the scope, to effectively extend the illumination distance viewable by the scope.
• FIG. 29 illustrates non-limiting examples of where one or more filters may be placed in an illuminating guidewire device.
• FIG. 30A schematically illustrates a connector having a rotating shutter rotatably mounted therein.
• FIG. 30B is an illustration of a plan view of the shutter ofFIG. 30A.
• FIG. 31 shows a frontal ostium seeker instrument that can be used to access a sinus ostium.
• FIG. 32 shows a suction sinus instrument that is configured to evacuate blood and/or other fluids from a target surgical site, such as the frontal sinus.
• FIG. 33 shows an integrated wire dilatation catheter120 that includes an elongate, flexible catheter shaft having a balloon mounted thereon.
• FIG. 34 is a perspective view of another guide catheter system of the present invention incorporating the guide catheter component ofFIG. 4A in combination with a long flexible endoscope and camera assembly.
• FIG. 35 is a side view of a transnasal guide catheter.
• FIG. 36 is a side view of a sheath that is insertable through the guide catheter ofFIG. 7 to facilitate endoscopically guided advancement of a guidewire through the guide catheter ofFIG. 35.
• FIG. 37 is an enlarged view of a distal portion of the guide catheter ofFIG. 35 having the sheath ofFIG. 36, an endoscope and a guidewire operatively inserted therethrough.
• FIG. 37A is a cross sectional view throughline15A-15A ofFIG. 15.
• FIGS. 38A-38D show steps in a method for using the guide catheter ofFIG. 35 in combination with the sheath device ofFIG. 36 to facilitate endoscopically guided placement of a guidewire.
• FIG. 39A is a perspective view of a deflectable (e.g., steerable) sheath device of the present invention in combination with a transnasally insertable guide catheter, a guidewire and an endoscope.
• FIGS. 39B and 39C show steps in a method for using the deflectable sheath device ofFIG. 39A to facilitate placement of a guidewire.
• FIG. 39D shows the guidewire and guide catheter after removal of the steerable sheath and endoscope.
• FIG. 40A is a partial exploded view of a guide system having an elongate guide tip, a translucent body and an endoscope that is engageable with the translucent guide body.
• FIG. 40B shows the guide system ofFIG. 40A in an assembled, operative state.
• FIG. 40C is a schematic diagram of an endoscope monitor showing a view received by the endoscope component of the system shown inFIGS. 40A and 40B.
• FIG. 40D is a partial perspective view of a guide system having an elongate guide member attached to and extending from the distal end of a catheter that has a side opening out of which an endoscope advances to view an area adjacent to the guide member.
• FIG. 40E is a schematic diagram of an endoscope monitor showing a view received by the endoscope component of the system shown inFIG. 40D.
• FIG. 41A is a sectional view of a proximal connector device of the present invention positioned adjacent to the device ofFIG. 40A.
• FIG. 41A′ is a sectional view of a proximal connector device of the present invention operatively attached to the proximal end of the device ofFIG. 40A.
• FIG. 41B is a sectional view of a proximal connector device of the present invention positioned adjacent to the device ofFIG. 40D.
• FIG. 41B′ is a sectional view of a proximal connector device of the present invention operatively attached to the proximal end of the device ofFIG. 40D.
• FIGS. 42A-42C are partial perspective views of the distal ends of curved guide catheters of the present invention having an endoscope with a distal end for cleaning a flexible endoscope translatable in the channel.
DETAILED DESCRIPTION OF THE INVENTION
• Before the present devices and methods are described, it is to be understood that this invention is not limited to particular embodiments described, as such may, of course, vary. It is also to be understood that the terminology used herein is for the purpose of describing particular embodiments only, and is not intended to be limiting.
• Where a range of values is provided, it is understood that each intervening value, to the tenth of the unit of the lower limit unless the context clearly dictates otherwise, between the upper and lower limits of that range is also specifically disclosed. Each smaller range between any stated value or intervening value in a stated range and any other stated or intervening value in that stated range is encompassed within the invention. The upper and lower limits of these smaller ranges may independently be included or excluded in the range, and each range where either, neither or both limits are included in the smaller ranges is also encompassed within the invention, subject to any specifically excluded limit in the stated range. Where the stated range includes one or both of the limits, ranges excluding either or both of those included limits are also included in the invention.
• Unless defined otherwise, all technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art to which this invention belongs. Although any methods and materials similar or equivalent to those described herein can be used in the practice or testing of the present invention, the preferred methods and materials are now described. All publications mentioned herein are incorporated herein by reference to disclose and describe the methods and/or materials in connection with which the publications are cited.
• It must be noted that as used herein and in the appended claims, the singular forms “a”, “an”, and “the” include plural referents unless the context clearly dictates otherwise. Thus, for example, reference to “a channel” includes a plurality of such channels and reference to “the endoscope” includes reference to one or more endoscopes and equivalents thereof known to those skilled in the art, and so forth.
• The publications discussed herein are provided solely for their disclosure prior to the filing date of the present application. Nothing herein is to be construed as an admission that the present invention is not entitled to antedate such publication by virtue of prior invention. Further, the dates of publication provided may be different from the actual publication dates which may need to be independently confirmed.
• The following detailed description, the accompanying drawings and the above-set-forth Brief Description of the Drawings are intended to describe some, but not necessarily all, examples or embodiments of the invention. The contents of this detailed description do not limit the scope of the invention in any way.
• Sinus Guide with Continuous Endoscope Channel
• FIG. 1 shows one embodiment of asinus guide system10 of the present invention. Thissinus guide system10 comprises asinus guide12 and a camera/transmission/endoscope assembly14. This embodiment of thesinus guide12 is shown in more detail inFIGS. 3A-3C. As shown, thissinus guide12 comprises asinus guide body26 and anendoscope channel28 in generally side-by-side arrangement. Thesinus guide body26 comprises atube44 having a lumen45 (e.g., seeFIG. 3B), such as a polymer tube made of biocompatible polymeric material. Optionally, a liner46 (FIG. 3B) may be disposed within thelumen45 of thetube44. Such liner may be formed of lubricious or smooth material such as polytetrafluoroethylene (PTFE). Also, optionally, a proximal portion of thetube44 may be surrounded by anouter tube member42 formed of material such as stainless steel hypotube. In the embodiment shown, a distal portion oftube44 extends out of and beyond the distal end ofouter tube42. This protruding distal portion oftube44 may be straight or curved. Also, it may be pre-formed at the time of manufacture or malleable to a desired shape at the time of use. When intended for use in accessing the ostium of a paranasal sinus, the distal portion oftube44 may be curved to form an angle A from about 0 degrees to about 120 degrees. For example, a series of sinus guides12 having angles A of 0, 30, 70, 90 and 110 degrees may be provided thereby allowing the physician to select the sinus guide angle A that is most appropriate for the particular paranasal sinus ostium to be accessed. Additionally, in some embodiments, arotation grip60 may be positioned about a proximal portion of thesinus guide10, as seen inFIGS. 1, 3A and 3B. Thisrotation grip60 may have a smooth or textured round outer surface (e.g., it may be a cylindrical tube) that may be grasped between the fingers of the operator's hand and easily rotated, thereby facilitating rotation (e.g., rolling) of thesinus guide12 as it is being used. Such rotation of thesinus guide12 may be desirable for a number of reasons including but not limited to positioning of the distal end of thesinus guide12 at a desired location and/or maneuvering the location of anendoscope30 that is inserted through theendoscope channel28.
• Theendoscope channel28 may comprise any structure (e.g., tube, track, groove, rail, etc.) capable of guiding the advancement of a flexible endoscope. In the particular examples shown in these figures, theendoscope channel28 comprises a tube (e.g., a polymer tube) having a lumen29 extending therethrough. In the embodiment seen inFIGS. 1-3C, theendoscope channel28 is attached to and extends along substantially the entire length of thesinus guide body26. In another embodiment, theendoscope channel28 can be inside thesinus guide body26. In other embodiments, such as that shown inFIGS. 4A-4C and described herebelow, theendoscope channel28 may be interrupted, non-continuous or may extend over less than the entire length of thesinus guide body26. Anouter skin40 may be heat shrunk or otherwise disposed around thesinus guide body26 andendoscope channel28 to hold theendoscope channel28 at a desired position on the outer surface of thesinus guide body26. Alternatively, theendoscope channel28 may be attached to thesinus guide body26 at one or more locations by any other suitable attachment substance, apparatus or technique, including but not limited to adhesive, soldering, welding, heat fusion, coextrusion, banding, clipping, etc. The particular circumferential location of theendoscope channel28 can be important in some applications, particularly when thesinus guide body26 includes a curve formed in itsdistal portion44. In this regard, for some applications, theendoscope channel28 may be affixed at a particular circumferential location on thesinus guide body26 to allow aflexible fiber endoscope30 inserted through theendoscope channel28 to provide a view from a desired or optimal vantage point, without obstruction from adjacent anatomical structures. For example,FIGS. 11A, 11B and 11C show embodiments where theendoscope channel28_lower,28_sideand28_upperis attached to thesinus guide body26 at alternative locations and wherein a curve is formed in the distal portion oftube44.
• In the example ofFIG. 11A, theendoscope channel28_loweris on the lower side of the sinus guide body26 (e.g., the 6 o'clock position adjacent to the lesser aspect of the curve). This construction provides an endoscopic vantage point that is desirable for applications where the ostium of a sphenoid sinus is to be accessed.
• In the example ofFIG. 11B, theendoscope channel28_sideis on the right side of the sinus guide body26 (e.g., the 3 o'clock position adjacent to the right side of the curve). This construction provides an endoscopic vantage point that is desirable for applications where the ostium of a maxillary sinus is to be accessed. Alternatively, the maxillary lumen may terminate before the distal end of the guide, then it can be located on the outside or on the side of thesinus guide body26.
• InFIG. 11C, theendoscope channel28_upperis on the upper side of the sinus guide body26 (e.g., the 12 o'clock position adjacent to the greater aspect of the curve). This construction provides an endoscopic vantage point that is desirable for applications where the ostium of a frontal sinus is to be accessed.
• Again referring toFIGS. 1-3C, aproximal Y connector41 may be attached to the proximal end of thesinus guide12. Afirst arm43bof this Y connector comprises a female Luer fitting that is connected to thelumen45 of thesinus guide body26. Theother arm43ais a female Luer fitting that is connected to the lumen29 of theendoscope channel26.
• A camera/cable/endoscope assembly14 is attachable to arm43a. In the particular embodiment shown inFIGS. 1 and 3F, the camera/cable/endoscope assembly14 comprises an adjustable scope/lock extension16, anendoscope18 having an elongateflexible scope body30 and integratedlight cable50, acamera20 and amonitor cable24. Thescope body30 is advanced through the scope/lock extension16 and through the lumen29 of theendoscope channel28. As shown inFIG. 2, thelight cable50 and monitorcable24 may be connected to console34 that houses amonitor36,light source38 andvideo recorder40.
• FIGS. 3D and 3E show aflexible endoscope30 attached to aproximal body member52 that engages and attaches to the adjustable scope/lock extension16. As seen in the cross section ofFIG. 3E, thescope30 comprises a flexible shaft having animage fiber bundle54 that extends coaxially through the center withlight transmitting fibers56 disposed about the periphery. In one preferred embodiment, the flexible shaft is a braided polyimide sheathing that has a maximum outer diameter of 0.0375 inches and a length of two feet. Preferably, the image fiber bundle is made up of 10,000 thin image fibers and the light transmitting fibers are illumination fibers with a diameter of between about 0.008 and 0.020 inches, with a minimum lux of about 10,000. Preferably, the distal end of the flexible shaft has a lens with a minimum field of view of about seventy degrees.
• Sinus Guide with Proximal and Distal Endoscope Channel
• FIGS. 4A-5E show another embodiment of a sinus guide12awhich differs from the above-describedsinus guide12 ofFIGS. 1 and 3A only in that it does not have a singlecontinuous endoscope channel28 that extends over its entire length, but rather aproximal endoscope channel28pthat is spaced apart from adistal endoscope channel28d. These proximal anddistal endoscope channels28p,28dmay comprise any structure (e.g., tube, track, groove, rail, etc.) capable of guiding the advancement of an endoscope.
• Theproximal endoscope channel28pextends along a proximal portion of thesinus guide body26 and thedistal endoscope channel28dextends along a distal portion of thesinus guide body26. Theproximal channel28panddistal channel28dare oriented at an angle relative to one another such that there is an angle A between the respective longitudinal axes of the two channels. Also, this sinus guide12amay optionally include a longitudinallymoveable sheath61 which is moveable from a retracted position (Shown inFIGS. 5A and 5D described below) and an extended position (shown inFIG. 5C described below). In the Figs., this embodiment of the sinus guide12ais shown without arotation grip60. However,such rotation grip60 may be included in this and all other embodiments. If arotation grip60 is included, themoveable sheath61 will be positioned oversuch rotation grip60, or located distally of the distal edge of therotation grip60, when thesheath61 is in its retracted position.
• FIGS. 5A-5C show a method for loading theflexible fiber endoscope30 into this embodiment. As seen inFIG. 5A, with the optionalmoveable sheath61 in a retracted position, theflexible fiber endoscope30 is advanced through theproximal endoscope channel28psuch that its distal end emerges out of the distal end of theproximal endoscope channel28p. Thereafter, as seen inFIG. 5B, the distal end of theflexible fiber endoscope30 may be grasped, pulled in the distal direction and oriented at an angle with a gentle curve in the flexible endoscope and the distal most portion of the flexible endoscope being straight so that the fragile lens in the distal most portion of the flexible endoscope is not broken or damaged, but will facilitate insertion of the distal end of theflexible fiber endoscope30 into or through thedistal endoscope channel28d. With theflexible fiber endoscope30 so oriented, it is inserted into or through thedistal endoscope channel28d, as shown. Then, as seen inFIG. 5C, the optional moveable sheath61 (if present) is moved to its advanced position so as to compress any slack in theflexible endoscope30 and to hold a portion of theflexible endoscope30 between theproximal endoscope channel28pand thedistal endoscope channel28pin juxtaposition to the adjacentsinus guide body26.
• FIGS. 5D and 5Eshow fixture devices240,240athat may be used during loading of theflexible endoscope30 to ensure that the distal end of theflexible endoscope30 is oriented at an angle that will facilitate insertion into or through thedistal endoscope channel28d, while at the same time protecting the lens in the distal most portion of theflexible endoscope30.
• InFIG. 5D, thefixture device240 comprises a rigid body formed of suitable material, such as molded plastic. Agroove242, shaped to correspond to a distal portion of thesinus guide device12, is formed in the upper surface of thefixture device240. Theouter edge243 of thefixture device240 is shaped such that, when theendoscope30 is extended along and in contact withsuch edge243, the distal end of theendoscope30 will be in an orientation that facilitates its passage into or through thedistal endoscope channel28d. After the distal end of theendoscope30 has been successfully passed into or through thedistal endoscope channel28d, the sinus guide12aandendoscope30 are removed from thefixture device240, the loading of theendoscope30 is completed in accordance withFIG. 5C described above.
• FIG. 5E shows anotherfixture device240awhich is substantially same as thefixture device240 shown inFIG. 5D, but wherein anendoscope receiving groove244 is also formed in the upper surface of thefixture device240. Thisendoscope receiving groove244 is shaped such that, when theendoscope30 is placed ingroove244, the distal end of theendoscope30 will be in an orientation that facilitates its passage into or through thedistal endoscope channel28d.
Optional Linkage of Endoscope to Working Device
• In some applications, it may be desirable to advance theflexible endoscope30 out of and beyond the distal end of theendoscope channel28,28d. For example, as shown inFIG. 6, theendoscope30 may sometimes be advanced along side a working device, such as aguidewire110, so as to view the advancement, positioning and/or use of the working device. In such instances, it is desirable to prevent the endoscope from diverging away from the working device and/or to maintain theendoscope30 at a specific spaced distance away from the working device. To accomplish this, anoptional linkage device62 may be used to link (e.g., couple, connect or attach) theendoscope30 to theguidewire110 or other working device.
• Sinus Guide with Dynamic Endoscope Channel
• FIGS. 7A-7B show another embodiment of asinus guide12bwhich incorporates a spring loaded curvedsinus guide body26aand adynamic endoscope channel28a. In this example, theendoscope channel28acomprises a flexible tube, wherein only the distal end of thedynamic endoscope channel28ais attached to thesinus guide body26a. Aspring64 is mounted betweenstop47 andproximal sleeve49 such thatspring64 may be compressed in the distal direction. As shown inFIG. 7A, theflexible endoscope30 is inserted into thedynamic endoscope lumen28aand advanced until the distal end of the endoscope begins to navigate the curve near the distal end of the device. This causes theendoscope channel28ato deform or move outwardly and exerts distally directed pressure onspring64, thereby compressingspring64. As seen inFIG. 7B, as the distal end of the endoscope navigates the curve and advances to a position where it is flush with or extended out of the distal end of theendoscope channel28a, thespring64 will relax and thedynamic endoscope lumen28awill return to a position where it extends along side of thesinus guide body26, as shown.
• FIGS. 8A and 8B show thesinus guide12bas seen inFIGS. 7A and 7B with the inclusion of anoptional retraction member260, such as an elastic band, to assist thedynamic endoscope channel28ain returning to its position along side thesinus guide body26aafter the distal end of the endoscope has successfully navigated the curve.
• FIGS. 9A and 9B show another embodiment of asinus guide12cwhich is the same as thefirst embodiment12 shown inFIG. 1 except that only a distal portion of theendoscope channel28bis attached to thesinus guide body26, a singlefemale Luer hub45 is on the proximal end of the sinus guide body and a separatesingle Luer hub47 is on the proximal end of theendoscope channel28b. Apivot arm262 is pivotally attached to thesinus guide body26, as shown. Theproximal hub47 of theendoscope channel28bis slidably engaged within a spring loadedtrack264 on the pivot arm. During loading of theendoscope30, thepivot arm262 is placed in an extended position and a spring within spring loadedtrack264 causes the proximalproximal hub47 to be located at the outer end of the spring loadedtack264, as shown inFIG. 9A. This causes theendoscope channel28bto be held in a position that facilitates passage of theendoscope30 through the endoscope channel and around the curve formed near its distal end. After theendoscope30 has been advanced around the curve, thepivot arm262 is moved to the collapsed position shown inFIG. 9b, thereby causing the spring within the spring loadedtack264 to compress andproximal hub47 to move to the opposite end of spring loadedtrack262. In this manner, theendoscope channel28bextends along side of thesinus guide body26 and theproximal hub47 of theendoscope channel28bis held in an accessible position adjacent to theproximal hub45 of thesinus guide body26.
Operation and Positioning of the Endoscope and Working Device
• In the examples of sinus guides12,12a,12b,12cdescribed above, theflexible fiber endoscope30 may be freely advanced to or beyond the end of the sinus guide and retracted during use, in order to facilitate endoscopic viewing of the desired anatomical structures and/or to view, guide and/or verify the positioning of the sinus guide device or a working device that has been inserted through the sinus guide. The ability to advance the tip of theflexible fiber endoscope30 beyond the end of the sinus guide allows the tip to be positioned closer to anatomy or to reach spaces in the paranasal sinuses that the sinus guide tip cannot travel to due to size constraints.
• In some instances, it may be desired to advance aguidewire110 into or through a specific body opening, such as an opening of a paranasal sinus. In such applications, as shown inFIG. 10, it is sometimes desirable to form a bend in theguidewire110 near its distal end DE so that rotation of the guidewire in situ will redirect its distal end DE. The guidewire may be maneuvered into the opening by simply rotating theguidewire110.FIGS. 10A and 10B show an example of such a procedure, wherein theguide device12 is advanced to a position where its distal end is a spaced distance D from the opening O into which theguidewire110 is to be inserted. In some instances, the user may use fluoroscopy and/or a surgical navigation system to position the guide device as described in previous applications to which this application claims priority and which have been incorporated herein by reference. With theguide device12 so positioned, an endoscope inserted through theendoscope channel28 may be used to view the distal end DE of theguidewire110 as it advances out of the distal end of thesinus guide body26. With theflexible endoscope30 so positioned, the user has a view generally along the same axis as the distal opening of the guide device, rather than the proximal axis of the guide device. Furthermore the view can be from behind anatomy that normally would block a conventional endoscope view. InFIG. 10A, the view provided by the endoscope allows the operator to see that the distal end of theguidewire110 is not directed into the opening O. As a result, the operator may rotate theguidewire110 causing its distal end DE to be directed into the opening O as verified by the view provided from the endoscope. Thus, in these sorts of applications, it is desirable to place the distal end of thesinus guide device12 at a spaced distance D back from the opening O rather than advancing it to a point where the distal end of the sinus guide body is immediately adjacent to or within the opening O. In an alternative embodiment, the guidewire can be an illuminating guidewire as described in co-pending application Ser. No. 11/522,497, titled “Methods and Devices for Facilitating Visualization in a Surgical Environment”, filed Sep. 15, 2006, which was incorporated by reference above, in its entirety, and/or as described in the following section.
Illuminating Guidewire
• FIGS. 12A through 12D are illustrations of partial sagittal sectional views through a human head showing various steps of a method of gaining access to a paranasal sinus using a sinus guide. InFIG. 12A, a first introducing device in the form of asinus guide12 is introduced through a nostril and through anasal cavity1012 to a location close to anostium1014 of asphenoid sinus1016.Sinus guide12 may be straight, malleable, or it may incorporate one or more preformed curves or bends as further described above, as well as in U.S. Patent Publication Nos. 2006/004323; 2006/0063973; and 2006/0095066, for example, each of which are incorporated herein, in their entireties, by reference thereto. In embodiments where sinus guide12 is curved or bent, the deflection angle of the curve or bend may be in the range of up to about 135 degrees.
• InFIG. 12B, a second introduction device comprising aguidewire110 is introduced through the first introduction device (i.e., sinus guide12) and advanced so that the distal end portion ofguidewire110 enters thesphenoid sinus1016 through theostium1014.
• InFIG. 12C, a workingdevice1006, for example aballoon catheter100, is introduced overguidewire110 and advanced to extend the distal end portion ofdevice1006,100 into thesphenoid sinus1016. Thereafter, inFIG. 12D, workingdevice1006,100 is used to perform a diagnostic or therapeutic procedure. In this particular example, the procedure is dilatation of thesphenoid sinus ostium1014, as is illustrated inFIG. 12D, where the balloon ofdevice1006 is expanded to enlarge the opening of theostium1014. After completion of the procedure,sinus guide12,guidewire110 and workingdevice1006,100 are withdrawn and removed. It will be appreciated that the present invention may also be used to dilate or modify any sinus ostium or other man-made or naturally occurring anatomical opening or passageway within the nose, paranasal sinuses, nasopharynx or adjacent areas. As will also be appreciated by those of ordinary skill in the art, in this or any of the procedures described in this patent application, the operator may additionally advance other types of catheters, and thatguidewire110 may be steerable (e.g. torquable, actively deformable) or shapeable or malleable.
• FIGS. 12B-12D show anoptional scope30 in dotted lines, that may be inserted to provide visualization of advancement ofsinus guide12 and/or inserted alongside sinus guide12 to provide visualization of all or at least a portion of workingtool1006,100. It is to be appreciated thatoptional scope30 may comprise any suitable types of rigid or flexible endoscope and such optional scope may be separate from or incorporated into the working devices and/or introduction devices of the present invention, as further described herein. In one preferred embodiment,endoscope30 is aflexible fiber endoscope30 as described herein.
• Althoughscope30 may be useful to reduce or eliminate the need for fluoroscopic visualization during placement ofsinus guide12 and/or for visualization of the procedure performed by workingdevice1006,100, it does not provide stand-alone capability to see inside the sinus (e.g.,sphenoid sinus1016 or other sinus of interest), and therefore cannot provide sufficient visual feedback for use in guidingguidewire110 into the desired sinus (e.g., frontal sinus, or some other sinus of interest) or sufficient visual image confirmation of correct placement ofguidewire110 into the desired sinus.
• Further, depending upon the particular configuration of the sinus passageways to be traversed to gain access to a target ostium, thescope30, due to physical limitations (e.g., outside diameter, degree of rigidity, etc.) may be unable to visualize as deep as the location of the ostium of interest. For example,FIG. 13 illustrates a situation wherescope30 has been inserted as far as possible without causing significant trauma to the patient. The range of adequately illuminated visibility in this case does not extend all the way toostium1020, as indicated schematically by therays1009 shown extending distally fromscope30. In this case, adequately illuminated visualization ofguidewire110 intoostium1020 would not be possible viascope30. Additionally, if sinus guide12 is physically capable of being extended further distally to place the distal end thereof at the approach toostium1020,scope30 would also not be capable of adequately visualizing this. Thus, prior to the provision of an illuminated guidewire11 as described herein, fluoroscopic or other x-ray visualization of these procedures was required, in order to ensure that the devices approach (and extend through) theappropriate ostium1020 and not another adjacent opening, such asopening1024.
• In order to overcome these and other problems, theguidewire devices110 of the present invention include their own light emitting capability. By illuminating a distal end portion ofguidewire110, a process known as transillumination occurs asguidewire110 traverses through the sinus passageways, passes through an ostium and enters a sinus cavity. Transillumination refers to the passing of light through the walls of a body part or organ. Thus, whenguidewire110 is located in a sinus, the light emitted fromguidewire110 passes through the facial structures and appears as a glowing region on the skin (e.g., face) of the patient. It is noted that the light emitted fromscope30, such as positioned inFIG. 13, for example, results in transillumination as well, but the resultant glow is much more diffuse and larger in area. As the light source inguidewire110 gets closer to the surface of the structure that it is inserted into (e.g., the surface of the sinus), the transillumination effect becomes brighter and more focused (i.e., smaller in area). Additionally, the movements of theguidewire110 can be tracked by following the movements of the transillumination spot produced on the skin of the patient.
• FIG. 14 shows an illuminatingguidewire110 according to one embodiment of the present invention.Device110 includes a flexibledistal end portion110dthat provides a similar degree of flexibility to a standard, non-illuminating type of guidewire.Distal end portion110dmay include acoil110cas an exterior portion thereof, to help provide the desired flexibility to this portion. Theproximal end portion110pofdevice110 extends the device to provide a sufficient length so thatdevice110 extends proximally out of the patient (and, when inserted through another device, such as a sinus guide, proximally out of the device into which guidewire110 is inserted), at all times, including the deepest location into which the distal end ofdevice110 is placed. Theproximal end portion110pcan have visible markings, preferably spaced at equal intervals, that can be observed by the user to confirm how far theguidewire110 has been placed in the patient.Proximal end portion110palso provides the necessary mechanical properties required to make the guidewire function properly. These mechanical properties include torquability, i.e., the ability to torque theproximal end portion110pfrom a location outside of the patient and have that torque transmitted to thedistal end portion110p; pushability, i.e., sufficient rigidity, so that when an operator pushes on theproximal end portion110pfrom a location outside of the patient, the pushing force transmits to thedistal portion110dto advance thedistal portion110pwithout buckling thedevice110; and tensile strength so that an operator can pull on theproximal end portion110pfrom a location outside of the patient and withdrawdevice110 from the patient without significant plastic deformation or any disintegration of the device.
• Coil110cmay be formed from a stainless steel wire, for example. The diameter of the coil wire can be between about 0.004 and about 0.008 inches, typically about 0.006 inches. Alternative materials from whichcoil110cmay be formed include, but are not limited to: ELGILOY®, CONICHROME® or other biocompatible cobalt-chromium-nickel alloy; nickel-titanium alloys, or other known biocompatible metal alloys having similar characteristics. Further alternatively, distal end portion may comprise a braided metallic construction of any of the aforementioned materials in lieu of a coil.
• The external casing of theproximal portion110pcan be made from a polyimide sheath, a continuous coil (optionally embedded in polymer or having polymer laminated thereon), a hypotube (e.g., stainless steel hypotube), a laser-cut hypotube, a cable tube, or a tube made from PEBAX® (nylon resin) or other medical grade resin. In any of these cases the construction needs to meet the required torquability, pushability and tensile requirements of the device.
• In the example shown,coil110cis joined toproximal portion110pby solder, epoxy or other adhesive or mechanical joint. One ormore illumination channels110iare provided indevice110 and extend the length thereof.Illumination channels110iare configured to transport light from the proximal end ofdevice110 to and out of the distal end ofdevice110. In the example shown, two illumination channels are provided, each comprising a plastic illumination fiber. The plastic used to make the illumination fibers is compounded for light transmission properties according to techniques known and available in the art. As one example, ESKA™ (Mitsubishi Rayon), a high performance plastic optical fiber may be used, which has a concentric double-layer structure with high-purity polymethyl methacrylate (PMMA) core and a thin layer of specially selected transparent fluorine polymer cladding. In one example, illumination fibers each have an outside diameter of about 0.010″. The illumination fibers can have an outside diameter in the range of about 0.005 inches to about 0.010 inches. Alternatively, a single plastic illumination fiber10imay be used that has an outside diameter of about 0.020″. Further alternatively, glass illumination fibers may be substituted which are much smaller in outside diameter, e.g., about 0.002″. In this case, more illumination fibers may be provided in a bundle, e.g., about six to fiftyglass fibers110imay be provided.
• The distal end ofdevice110 is sealed by a transparent (or translucent)seal110swhich may be in the form of epoxy or other transparent or translucent adhesive or sealing material.Seal110smaintains the distal ends ofillumination fibers110icoincident with the distal end ofdevice110 and also provides an atraumatic tip of thedevice110. Further, seal110sprevents entrance of foreign materials into the device. The distal end can be designed to either focus or distribute the light as it emanates therefrom, to achieve maximum transillumination effects. In this regard, the distal end can include a lens, prism or diffracting element.
• The proximal end ofdevice110 is also sealed by a transparent (or translucent)seal110pswhich may be in the form of epoxy or other transparent or translucent adhesive or sealing material.Seal110psmaintains the proximal ends ofillumination fibers110icoincident with the proximal end ofdevice110. The proximal end ofdevice110 maybe further prepared by grinding and polishing to improve the optical properties at the interface of the proximal end ofdevice110 with a light source. Theillumination fibers110iat locations intermediate of the proximal and distal ends need not be, and typically are not fixed, since no mapping of these fibers is required, asdevice110 provides only illumination, not a visualization function like that provided by an endoscope. Further, by leaving illumination fibers free to move at locations between the proximal and distal ends, this increases the overall flexibility and bendability ofdevice110 relative to a similar arrangement, but where theillumination fibers110iare internally fixed.
• The outside diameter ofdevice110 may be in the range of about 0.025 inches to about 0.040 inches, typically about 0.030 to 0.038 inches, and in at least one embodiment, is about 0.035″±0.005″. At least thedistal portion110pofdevice110 is provided with acore support110cwthat is contained therein. In the example shown inFIG. 14,core support110cwis a wire that is fixed toproximal section110psuch as by laser welding, epoxy or other adhesive or mechanical fixture.Core support110cwmay extend substantially the full length ofdevice110. In any case,core support110cwis typically formed from stainless steel NITINOL (nickel-titanium alloy) or other biocompatible nickel-titanium alloys, cobalt-chromium alloys, or other metal alloys that are biocompatible and provide the necessary rigidity and torquability.Core support110cwmay be formed as a wire, as in the example shown inFIG. 14, or alternatively, may be braided from any of the same materials or combination of materials mentioned above.Core support110cw, when formed as a wire can be ground to different diameters to provide varying amounts of rigidity and torquability. When formed as a braid, the braid can be formed to have varying amounts of rigidity and torquability along the length thereof. For example,core wire110cwhas a larger outside diameter at the proximal end portion than at the distal end portion so that it is more rigid and transfers more torque from the proximal portion ofdevice110, whereas at the distal end portion,core110cwis relatively more flexible and twistable. For core supports110cwthat extend throughproximal portion110p, the portion of core support near the proximal end ofdevice110 may have an even larger outside diameter.
• Core support110cwparticularly increases the pushability and the torquability ofcoil110cwhich, by itself, is quite flexible and twistable. Combined with thecore support110cw, the distal portion is much more effective at transferring pushing and torquing forces without buckling or twisting. Additionally,core support110cwmay be plastically deformed or memory set into a bent shape, an example of which is shown inFIG. 5. Bend110bprovides a steerability function, allowing an operator to direct the distal end ofdevice110 in different directions by torquing device about the longitudinal axis of the device, as indicated by the arrows inFIG. 15. In some embodiments this bending can be performed by an operator in the midst of a procedure, which can be particularly useful in combination with ascope30, as viewing through the scope may make it apparent to the operator that theguidewire110 needs to be inserted or directed at an angle offset from where the straight direction along the longitudinal axis of the device would direct it to. In some embodiments, theguidewire110 does not have a core support or core wire. In these embodiments, the outer jacket (e.g., a coil, cable tube, laser-cut hypotube, braided polymer tube, etc.) provides the support for torque, pushability and tension. An advantage of not having a core wire/core support is that the full inner diameter of the guidewire is then available to be filled with illumination fibers.
• The illumination fibers, as noted above, can be free to move about radially within the device. Further, there is no need to center theillumination fibers110iwith respect todevice110 even at the distal and proximal ends of the device.FIG. 16 is a sectional illustration of a distal end portion ofdevice110showing core support110cwfixed tocoil110c, withillumination fibers110iresiding adjacent tocore support110cw, but not fixed to eithercore support110cworcoil110c.
• The plastic orglass illumination fibers110iof the device shown inFIG. 14 are typically used to transmit light from a light source such as one provided in an operating room for use by endoscopes, e.g., xenon light source, halogen light source, metal halide light source, etc. Alternatively,device110 may be configured to transmit light from other light sources, such as a laser light source, whereinlaser fibers110fwould be substituted for the illumination fibers described above, and extend throughdevice110 in a fiber optic bundle as illustrated in the cross-sectional view ofFIG. 17. The fiber optic bundle, like theillumination fibers110i, contributes to stiffness (in both bending and torquing motions) ofdevice110, thereby enhancing trackability, steering and other torquing.
• FIG. 18 illustrates another embodiment of an illuminatingguidewire110. In this example, proximal end portion ofdevice110 is formed externally by a coil with a polymer layer laminated thereon, but any of the other arrangements described above may be substituted. In this example, illumination is provided by a high intensity light emitting diode (LED)110idfitted at the distal end ofdevice110. The proximal end ofdevice110 may be sealed such as with epoxy, or any of the other alternatives mentioned above with regard to the proximal end ofdevice110 inFIG. 14, in order to prevent pulling on thewires110iwat the connections withLED110id, as well as to seal the proximal end of the device. Grinding and polishing are not necessary, as the proximal end ofdevice110 inFIG. 18 does not transmit light.
• Device110 inFIG. 18 performs substantially similar to thedevice110 ofFIG. 14 with regard to the properties of pushability, torquability and tensile properties.Device110 ofFIG. 18, however, does not require illumination fibers or laser fibers. Instead, a pair of insulated lead wires are electrically connected to the terminals ofLED110id(not shown) and then extend withindevice110 over the length ofdevice110 to extend proximally from the proximal end ofdevice110. The free ends ofwires110ware configured to be connected to a power source that functions as the source of electrical power, to deliver electrical energy toLED110idto illuminate it.FIG. 19 illustrates a cross-sectional view of a distal end portion ofdevice110 ofFIG. 18. In this example,core support110cwis in the form of a flattened distal end core wire or shaping ribbon as known in the art, that extends between the twowires110w.FIG. 19 also illustrates theinsulation layer110iwover each wire.
• Any of thedevices110 described herein may optionally include one or more radiopaque markers and/or electromagnetic coils on the tip of thedevice110 and/or elsewhere along the device for enhancing visibility by fluoroscopy systems, image guided surgery (IGS) systems, or other visualization systems.
• FIG. 20 shows an alternative design ofdevice110 in which light is emitted proximally of the distal end of the device. This configuration may employ any of the various light transmission means described above (e.g., illumination fibers, laser fibers, LED). Theproximal portion110pmay be constructed in any of the manners described above with regard to other embodiments ofdevice110. Thedistal portion110dincludes a transparentproximal end portion110dpthat mounts over the distal end ofproximal end portion110pof thedevice110. Thetransparent portion110dppermits the illumination emitted fromillumination member110ior110idto pass out of thedevice110 at the location oftransparent portion110dp. The illumination member(s)110ior110idthus terminate at theproximal end portion110dpof the distal end portion ofdevice110. Distally of thistransparent portion110dp, thedistal portion110ddofdistal end portion110dofdevice110 extends as a floppy guidewire leader or tip. This floppy guidewire leader ortip110ddmay include acoiled section110cand may optionally include acore support110cwin the manner described above with regard toFIG. 14. The light emitted from illumination fibers will disperse naturally through thetransparent portion110dp. Optionally, adeflector111, such as a convex mirror (e.g., parabolic or other convex) shape or other reflective surface may be provided distally of illumination fibers/light emitting portion110i,110idofdevice110 to deflect light rays out of the transparent portion. Additionally, or further alternatively,illumination fibers110imay be angled at the distal end portions thereof to direct the emitted light out through the transparent portion.
• This configuration may be beneficial in further protecting the illumination emitter(s)110i,110idfrom foreign materials inside the body, as well as from trauma that may be induced by bumping the illumination emitter up against structures within the body. Further, afloppy guidewire leader110ddof this type may provide more flexibility and maneuverability than a device in which the illumination emitter is located on the distal tip of the device.
• Transparent portion110dpmay be provided as a clear plastic or glass integral tube, or may have openings orwindows110tprovided therein (see the partial view ofFIG. 21). Further alternatively, transparent portion may be formed by a plurality ofstruts110stcircumferentially arranged to interconnect the distalfloppy tip110ddwith theproximal end portion110pofdevice110 as shown in the partial illustration ofFIG. 22. Alternativelymembers110stmay be intersecting in a criss-crossing cage like configuration or other cage configuration. In any of these alternative configurations,members110stmay be transparent, but need not be and could be formed of non-transparent materials, such as metals or opaque plastics, for example.
• Device110 should be readily connectable to and disconnectable from a power source to enable attachment for providing illumination for positioning theguidewire110 and/or other devices during a procedure, detachment to allow another device to be slid onto theguidewire110 from a free proximal end thereof, and reattachment to again provide illumination, to assist in guidance/visualization of the device being passed over theguidewire110, for example.
• FIGS. 23A and 23B illustrate one example of a coupler orconnector1120 that is configured for quick connection and disconnection of anillumination guidewire110 that employsillumination fibers110iorlaser fibers110f.Coupler1120 is connected to alight source1030, such as a conventional endoscope light source, for example, or other light source capable of delivering preferably at least 10,000 lux throughcoupler1120.Light cable1032 optically connectsconnector1120 withlight source1030 to deliver light from thelight source1030 toconnector1120.Light cable1032 can optionally be a fluid-filled light cable, such as the type provided with DYMAX BlueWave™ 200 and ADAC Systems Cure Spot™ light cables, for example. A liquid filled light cable comprises a light conducting liquid core within plastic tubing. The liquid is non-toxic, non-flammable and transparent from 270 to 720 nm. The ends of a liquid filled light cable can be sealed with high quality quartz glass and metal spiral tubing surrounded by a plastic sleeve for exterior protection.
• Connector1120 includes a proximal channel, slot or bore1122 that has an inside dimension or circumference that is slightly greater than the outside diameter or circumference ofdevice110 at theproximal end portion110p. A quickrelease locking mechanism1124 is provided for locking and unlockingdevice110 withinconnector1120. Quick release locking mechanism is biased toward the locking position shown inFIG. 23B, in which the locking portion1124aofmechanism1124 is driven into channel slot or bore1122 and may even abut against the opposite wall of the channel, slot or bore1122, when noguidewire110 has been inserted.Locking mechanism1124 may be spring-biased toward the locked position, for example. Additionally,locking mechanism1124 may include a ball and detent arrangement, or other temporary locking means to maintain themechanism1124 in the locked configuration. An additional, similar mechanism may be provided to temporarily fixlocking mechanism1124 in the unlocked configuration shown inFIG. 23A. Alternative locking mechanisms may be employed, such as a pivoting lock arm, for example, that is manually pivotable between the locked and unlocked orientations, or other mechanism that would be apparent to one of ordinary skill in the mechanical arts, such as a collapsible silicone valve that grips the device, for example.
• Light cable1032 generally has a much larger inside diameter than the inside diameter or combined inside diameters of theillumination fibers110i. Accordingly, the proximal end portion ofconnector1120 provides a tapering or funnel shapedpathway1126 having a proximal inside diameter that is substantially equivalent to the inside diameter ofcable1032 or greater, and which tapers to a distal inside diameter that is about the same or only slightly greater than the inside diameter or combined inside diameters of the illumination fiber(s), or alternatively, that is about the same or only slightly greater than the outside diameter of the proximal end ofdevice110. Thelight cable1032 generally has a larger diameter bundle of illumination fibers than that contained within the illuminatingguidewire110. Accordingly, thetaper1126 is used to transition between the larger bundle in thelight cable1032 and the smaller bundle in theguidewire110. With this arrangement, light delivered throughlight cable1032 is concentrated or focused down to a pathway where most of the light can be transmitted through the illumination fibers.
• To insertdevice110 intoconnector1120, an operator retracts quickconnect locking mechanism1124 to the open position shown inFIG. 23A. Ifquick connect mechanism1124 is provided with a temporary locking mechanism as referred to above, then quick connectlocking mechanism1124 can be temporarily fixed in the orientation shown inFIG. 23A, without the operator having to hold it open. Otherwise, the operator will holdconnector1124 open in the position shown inFIG. 23A. The proximal end ofdevice110 is next inserted into the open channel, slot or bore1122 and slid proximally with respect toconnector1120 until the proximal end ofdevice110 abuts against the proximal end of channel, slot or bore1122. Quick release mechanism is next released by the operator (in embodiments when there is no temporary locking mechanism to maintain the quick release in the open configuration) or released from the temporary locked open configuration, so that the locking arm1124ais advanced toward theproximal end portion110pofdevice110, by the biasing of quickconnect locking mechanism1124 described above. Locking arm1124acontacts device110 and holdsdevice110 under compression between locking arm1124aand the opposite inner wall of channel, slot or bore1122, with sufficient force to preventdevice110 from sliding out ofconnector1120 even if the distal tip ofdevice110 is pointed straight down in a vertical direction. Optionally, locking arm1124amay be additionally temporarily locked in place by a ball and detent mechanism, or other temporary locking mechanism, as mentioned above. To removedevice110 from connector120, quickconnect locking mechanism1124 is repositioned to the open or unlocked orientation shown inFIG. 23A and the device is slid distally with respect to the connector until it is free from theconnector1120.
• FIGS. 24A-24B illustrate analternative connector1120 that includes a quickrelease locking mechanism1124. In this example, two ormore locking arms1124 are provided circumferentially about the distal end ofconnector1120.Arms1124 are biased to the closed or locked configuration as shown inFIG. 24A. For example,arms1124 may be made from resilient spring steel, nickel-titanium alloy or resilient plastic and formed to assume the configuration shown in24A when mounted toconnector1120 and when in an unbiased state. Installation ofdevice110 intoconnector1120 is simplified by the automatic grasping and temporary locking functions provided by quickrelease locking mechanism1124. The proximal end ofdevice110 is simply inserted between the two ormore arms1124.Arms1124 included ramped orcammed surfaces1124bthat guide the proximal end ofdevice110 intoconnector1120, and, asdevice110 is pushed against thesesurfaces1124b,arms1124 are deflected into the opened, biased configuration shown inFIG. 24B. The biasing/resiliency ofarms1124 imparts compressive forces to the shaft ofdevice110 via temporary locking surfaces1124a, so thatdevice110 is gripped and held in position as shown inFIG. 24B. To removedevice110, the operator need simply pull ondevice110, while holdingconnector1120 relatively immobile, with a force sufficient to overcome the compressive and frictional forces imparted by surfaces1124a. Theresilient arms1124 then return to the unbiased configuration shown inFIG. 24A. Optionally, surfaces1124amay be coated with, or include a friction enhancing surface, such as rubber or other elastomer, and/or be roughened, such as by knurling or other surface roughening technique.
• In the example shown inFIGS. 24A-24B, thelight cable1032 that is provided has an inside diameter that is about the same as the diameter of the proximal end ofdevice110 and thus, no taperingchannel1126 is required. However, for arrangements where thelight cable1032 is much larger, as is usually the case when using a conventionalendoscope light source1030,connector1120 may be provided with a taperinglight channel1126 in the same manner as described above with regard to the embodiment ofFIGS. 23A-23B.
• FIG. 25 illustrates a longitudinal sectional view of aconnector1120 that is quickly connectable and releasable from aguidewire device110 and is also connectable to and releasable from standard light source cables that are typically found in operating rooms. Thus, thisconnector1120 functions both as an adapter to connect to a conventional endoscope light source channel or cable, and as a quick release locking connector to connect to and release from a proximal end portion ofguidewire110.
• The proximal end ofconnector1120 is provided with alight post1128 that is configured to mate with a connector on the distal end of a light cable extending from a conventional endoscope light source. For example,light post1128 may be an ACMI light post (ACMI Corporation) or other standard connector typically used to connect endoscopes to operating room light sources. Because the cable extending from an operating room light source generally has a much larger inside diameter than the inside diameter or combined inside diameters of the illumination fibers ofdevice110, and larger than the diameter of the proximal end ofguidewire110, the proximal end portion ofconnector1120 includes a light tapering or funnel-shapedpathway1126 like that described above with regard toFIG. 23A.
• The quickrelease locking mechanism1124 in this example includes acollet1124cthat is configured to center the proximal end ofdevice110 with the distal end of taperingpathway1126. A threadedcap1124dis threaded over mating threads1124ton the body ofconnector1120, so that whencap1124dis torqued in a direction to advancecap1124dproximally with respect to the body ofconnector1120, inner ramped orcammed surfaces1124eofcap1124dride over outer ramped orcammed surfaces1124fofcollet1124c, thereby functioning as a pin vise and clampingcollet1124cagainst the proximal end portion ofdevice110 to clamp and maintaindevice110 in its current position relative toconnector1120. To insertdevice110,cap1124dis rotated in a reverse direction from that described above to open the distal opening of the inner channel1124gofcollet1124cto a dimension larger than the outside diameter of the proximal end ofdevice110, so thatdevice110 can be easily slid through the channel1124guntil the proximal end ofdevice110 abuts the proximal end portion ofcollet1124c, or approximates the same. Thecap1124dis then turned with respect to the body ofconnector1120 to clampdevice110 into position, as described above. Removal ofdevice110 can be performed by turningcap1124din a reverse direction relative toconnector body1120, thereby loosening the grip ofcollet1124condevice110, after whichdevice110 can be easily slid out from connection withconnector1120. Components ofconnector1120 may be made from metal, such as stainless steel or other biocompatible metals, or temperature-resistant thermosetting polymer, for example.
• Light post1128 is rotatable with respect to thelight cable1032 of thelight source1030 whenconnector1120 is connected to the distal end connector of thelight cable1032. This allowsdevice110, when connected toconnector1120 in this arrangement, to be rotated during use without building up significant twisting or rotational counter forces within thelight cable1032. For example, in thelight post1128 shown, the female receptacle (not shown) of thelight cable1032 couples overlight post1128 and engages ingroove1128g, about which the female receptacle is then rotatable relative tolight post1128.FIG. 26 is a longitudinal sectional view of aconnector1120 that is similar to theconnector1120 described with regard toFIG. 25 above. One difference in the example ofFIG. 26 is that the taperedlight guide1126 is provided in thelight post1128, as contrasted with being provided in the proximal end portion of the main body ofconnector1120 inFIG. 25. However, in both cases, the function is the same.
• Turning now toFIGS. 27A-27E, illustrations of partial coronal sectional views through a human head showing various steps of a method for treating an ostium that opens to a frontal sinus are shown. The methods described here, and all other methods disclosed herein may also comprise a step of cleaning or lavaging anatomy within the nose, paranasal sinus, nasopharynx or nearby structures including but not limited to irrigating and suctioning. The step of cleaning the target anatomy can be performed before and/or after a diagnostic or therapeutic procedure. The methods of the present invention may also include one or more preparatory steps for preparing the nose, paranasal sinus, nasopharynx or nearby structures for the procedure, such as spraying or lavaging with a vasoconstricting agent (e.g., 0.025-0.5% phenylephyrine or Oxymetazoline hydrochloride (Neosynephrine or Afrin) to cause shrinkage of the nasal tissues, an antibacterial agent (e.g., provodine iodine (Betadine), etc. to cleanse the tissues, etc.
• InFIG. 27A, a first introducing device in the form of asinus guide12 is introduced through a nostril and through anasal cavity1012 to a location close to anostium1034 of afrontal sinus1036.Sinus guide12 may be as described previously herein, or as described in the applications incorporated herein by reference. The advancement of sinus guide12 can be visualized with a scope inserted into thenasal cavity1012 and advanced as close to theostium1034 as possible without causing significant trauma to the tissues therein.
• Once the surgeon is satisfied that the distal end of thesinus guide12 is positioned close enough to theappropriate ostium1034, illuminatingguidewire110, connected to a light source as described by any of the techniques mentioned above, is inserted throughsinus guide12 and advanced therethrough, seeFIG. 27B. There may be some transillumination from the light emitted from the scope which can be used to confirm that thesinus guide12 is positioned in the correct general area, which confirmation can be made even before the distal tip ofguidewire110 exits the distal end ofsinus guide12. However, much more specific transillumination effects are produced when the tip ofguidewire110 exits the distal end ofguide12 and especially when the light emitting portion ofguidewire110 touches or approximates an intended target surface, such as an inner wall of a sinus, for example. As theguidewire110 is advanced, transillumination on the face of the patient can be observed as a glowing spot that moves as the distal end portion ofdevice110 moves, thereby making it possible to visibly track the location of the light emitting portion ofdevice110 without the need to use radiographic imaging, such as by fluoroscopy, for example.
• While there may be some diffuse transillumination on the forehead of the patient overlying thefrontal sinus1036 as the light emitting portion ofdevice110 approaches theostium1034, the glow on the forehead becomes brighter and smaller in dimension (more focused) as the light emitting portion passes through theostium1034 and enters thefrontal sinus1036,FIG. 27C. Asdevice110 is further advanced, the glowing spot becomes most defined and brightest as the light emitting portion approaches and contacts a wall of thefrontal sinus1036. Further, as noted, the movement of the transilluminated spot can be visibly followed to confirm that theguidewire110 is indeed moving within the location of the frontal sinus, as can be confirmed by the surgeon's knowledge of the particular anatomy of the patient being treated. In this regard, a CAT scan or other image of the sinus anatomy can be performed prior to this procedure and studied by the surgeon, to apprise the surgeon of any distinctive or unusual patterns in the individual patient's sinus anatomy which might be useful in tracking and confirmation of where the guidewire is located, as indicated by the transillumination.
• Once properly positioned, the proximal end ofdevice110 is disconnected fromconnector1120, while leavingguidewire110 in its current position. A workingdevice1006, for example aballoon catheter100, is the introduced overguidewire110 and advanced thereover so that the proximal end ofdevice110 extends proximally beyond a proximal end ofdevice1006,100.Device110 is then reconnected toconnector1120 so that light is again emitted from the light emission portion of the distal end portion ofdevice110. Thus it can be visually confirmed, without radiography, that the distal end portion of theguidewire110 remains properly in thefrontal sinus1036 as the workingdevice1006,100 is advanced towardostium1034 and the balloon ofballoon catheter100 is extended across the ostium,FIG. 27D. The proper positioning of the working end (distal end portion) of workingdevice1006,100 can be visualized with the scope and/or fluoroscopy.
• Once proper placement of the workingdevice1006,100 has been confirmed, workingdevice1006,100 is used to perform a diagnostic or therapeutic procedure. In this particular example, the procedure is dilatation of thefrontal sinus ostium1034 by expansion of the balloon ofballoon catheter100 thereagainst, to enlarge the opening of theostium1034. However, it will be appreciated that the present invention may also be used to dilate or modify any sinus ostium or other man-made or naturally occurring anatomical opening or passageway within the nose, paranasal sinuses, nasopharynx or adjacent areas. Further,other working tools1006 may be inserted and used according to these same techniques. After the completion of the procedure,sinus guide12,guidewire110 and workingdevice1006,100 are withdrawn and removed, completing the procedure, seeFIG. 27E.
• Illuminatingguidewire device110 can also be used to facilitate visualization and placement of thesinus guide12 in the procedure described above with regard toFIGS. 27A-27E, or in another procedure in which a sinus guide, sinus guide or guide tube is placed in the sinus pathways.FIG. 28 illustrates a situation, like that described above with regard toFIG. 13, wherescope30 has been inserted as far as possible without causing significant trauma to the patient. The range of visibility in this case does not extend all the way toostium1034, as indicated schematically by therays1009 shown extending distally fromscope30. In this case, adequate visualization of sinus guide12 byscope30 is possible only up to the extent of therays1009 shown. Thus, if sinus guide12 is flexible enough to be advanced more closely toostium1034, then adequate visualization of this movement would not be possible viascope30. That is, if sinus guide12 is physically capable of being extended further distally to place the distal end thereof at the approach toostium1034,scope30 would not be capable of adequately visualizing this. However, by inserting illuminatingguidewire110 throughsinus guide12 as shown inFIG. 28, additional illumination can be provided distally of the illuminating range ofscope30. This additional illumination can be received byscope30 to enable visualization up to the illumination portion ofdevice110 and potentially even extending to illumination range ofdevice110, as long as there is a straight pathway of the field of view. Thus, advancement of thesinus guide12 can be visualized further distally by thescope30 using this technique, and potentially all the way up to theostium1034.
• Additionally, this technique can be used to visualize placement of theguidewire110 up to and into the desiredostium1034. Alternatively, this can be carried out without thesinus guide12, wherein theguidewire110 is inserted and thescope30 can be used to visualize placement ofguidewire110 into the target ostium with the assistance of the light emitted by thescope30 in addition to the light emitted byguidewire110.
• In any of these procedures where ascope30 is used for visualization and an illuminatingguidewire110 is inserted, some transillumination of the target sinus may occur from the light emitted by thescope30 alone. However, this transillumination will be diffuse and show a rather dim, large area of transillumination on the patient's skin. When theillumination guidewire110 is inserted and advanced, as noted earlier, a smaller, brighter transillumination spot will be visible when the illuminating portion of the guidewire has entered the sinus. Additionally, even before entering the sinus, the light emitted from theguidewire110 will produce a moving transillumination spot asguidewire110 is advanced, which also helps distinguish the location of the distal portion of theguidewire110, relative to any diffuse transillumination produced by the scope light.
• If theguidewire110 is advanced into an ostium other than the target ostium (e.g.,ostium1035 shown inFIG. 28), this may be possible to be viewed byscope30, depending upon the line of sight. However, even if it is not, the transillumination resulting from entrance into a different sinus than the target sinus will be evident by the different location on the patient's face. Also, in the example shown,guidewire110 would not be able to be advanced very far through ostium135 before it was diverted and curled by the relatively small sinus space that ostium135 leads into. Thus, by tracking the movement of the illumination spot produced byguidewire110, the surgeon could confirm thatguidewire110 was misplaced as the guidewire would be diverted by a much smaller space then that characterized by the targetfrontal sinus1036.
• Thus, by using an illuminatingguidewire device110 in the methods as described above, the use of fluoroscopy or other X-ray visualization can be reduced as it is not required to confirm proper placement of the guidewire in some cases.
• Similar procedures may be carried out in other sinuses. For example, a similar procedure to that described above with regard toFIGS. 27A-27E may be carried out to open or expand an opening of an ostium leading to a maxillary sinus. In this case, when illuminatingguidewire device110 passes through the ostium that opens to the target maxillary sinus and enters the maxillary sinus, a relatively bright, relatively small, defined transillumination spot can be observed to move across the cheek region of the patient. Asguidewire110 is advanced further distally along the maxillary sinus, the maxillary sinus typically tends to track in an inferior direction relative to the skull, and the bottom wall of the maxillary sinus is very close to the palate of the patient. Therefore as the illuminating portion of guidewire approaches and/or touches the bottom wall of the maxillary sinus, a transillumination spot can be observed on the roof of the patient's mouth by looking into the mouth of the patient. At the same time, the transillumination spot on the cheek that was caused by the guidewire will diminish, or not be visible at all at this time. This viewability on the roof of the mouth is further confirmation that the guidewire has entered the maxillary sinus. Movement of the transillumination spot on the roof of the mouth can also be observed as theguidewire110 is advanced and/or retracted.
• It is further noted that some wavelengths of light may be more effective in producing the transillumination effects described herein, for the purpose of locating the position of the guidewire. In this regard, particular wavelengths of visible light can be selected for this purpose. Alternatively, or in addition, infrared wavelengths may be particularly effective. In this regard, guidewires that employ illuminating fibers may be provided with afilter1112 to define the color/wavelength of the light emitted bydevice110. As schematically shown inFIG. 29,filter1112 may be provided distally of the illumination fibers, such as at the distal tip ofdevice110, proximally of the illumination fibers, such as at the proximal end ofdevice110, or in the light pathway at a location withinconnector1120, for example. Multiple filters may be placed at one or more of these locations. Fordevices110 that employ an LED light emitting component, different color LEDs may be employed to emit different wavelengths of light. Fordevices110 that employ laser fibers, different types of lasers may be used that emit different wavelengths of light.
• Another optional feature that guidewire110 may be provided with is the ability to emit strobed, flashing or flickering light. The transillumination produced by a flashing light can be further distinguished from diffuse transillumination produced by other light sources, such as endoscopes, for example, since the transillumination produced by theguidewire110 in this case will flicker or vary in intensity between bright and dim. To produce this type of light, either a light source having strobing capability could be connected to thedevice110, orconnector1120 may be provided with this capability. When using a laser light source or an LED as the light emitter, as described in embodiments above, a blinking or strobing effect can be electronically generated according to techniques known in the electronics and lighting arts.FIG. 30A schematically illustrates aconnector1120 having arotating shutter1127 rotatably mounted therein so that thevanes1127vandgaps1127gbetween the vanes (see plane view inFIG. 30B) become successively aligned with the light pathway through theconnector1120 to alternate emission and blocking of light transmission out of theconnector1120 and ultimately throughdevice110 when adevice110 is connected thereto.Shutter1127 can be powered by amotor1129 that is either battery powered or connectable to an operating room power source, and motor can be operated by the user viaactuator1131, which can be configured to turn the motor on and off, and optionally can be configured to vary the speed of rotation. Alternatively, shutter can be configured so thatvanes1127vextend through a slot inconnector1120 whereby a user can manually rotate the shutter to cause the light emitted fromdevice110 to flicker.
• Other instruments that are designed to be inserted into a sinus, or at least to be positioned at the ostium of a sinus can also be provided with illumination capability according to any or all of the features described above with regard to illumination guidewires.FIG. 31 shows afrontal ostium seeker1100 instrument that can be used to access a sinus ostium. For example,seeker1100 may be provided with a length of about 175 mm to about 250 mm (about 208 mm in the example shown) and a ball tip at one or bothends1102 of the instrument. InFIG. 31,seeker1100 is also provided with alight emitter1104 at one or both ends of thedevice1100 that can be used to locate an end ofdevice1100 as it is being advanced to seek an ostium, by the transillumination effects as discussed above.Light emitters1104 may be provided by LED, light illumination fibers or laser illumination fibers, for example. One or both end portions of the instrument may include a light fiber bundle or electrical wires for connection to a light source or power source in a manner as described above.
• FIG. 32 shows asuction sinus instrument1110 that is configured to evacuate blood and/or other fluids from a target surgical site, such as the frontal sinus, sphenoid sinus or other sinus, to improve visibility of a surgical procedure.Instrument1110 includes anelongated shaft1116 with a distal end that opens to deliver suction via asuction lumen end1112. Additionally, alight emitter1114 is provided at the distal end ofshaft1116, which may be an LED or one or more illumination fibers configured to transmit light in a manner as described above.Shaft1116 is configured and dimensioned to be inserted into the sinus passageways and sinuses. The proximal end portion ofinstrument1110 may include alight fiber bundle1118 or electrical wires for connection to a light source or power source in a manner as described above.
• FIG. 33 shows an integratedwire dilatation catheter1200 that includes an elongate,flexible catheter shaft1260 having aballoon1280 mounted thereon. Aproximal Luer hub1220 is attached to the proximal end of thecatheter shaft1260. An inflation device (not shown) may be attached to theLuer hub1220 and used to inflate and deflate theballoon1280. A non-removable,integrated guide member1240 extends out of and beyond the distal end of thecatheter shaft1260.Guide member1240 can extend through the length ofcatheter shaft1260 and extend proximally thereof as shown inFIG. 33. The proximal end portion may be configured with a polished proximal end containing illumination fibers, as described previously, or may have one or more electrical wires extending proximally thereof for connection with an electrical power source to deliver electrical power to an LED, for example. Alight emitter1250 may be provided at the distal tip ofintegrated guide member1240, as shown inFIG. 33 and may be one or more LEDs or one or more illumination fibers, according to any of the different embodiments described above. Alternatively,light emitter1250 may be provided proximally of the distal tip ofguide member1240, in a manner like that described with regard toFIG. 20, for example. Further alternatively, guide member may not extend through the entire length ofcatheter1260 or may not extend proximally ofballoon member1280 at all. In these examples, light emitter may be an LED, wherein wires can be threaded through or alongside ofcatheter1260 and intoguide member1240 to connect with the LED. Further alternatively, iflight emitter1250 comprises one or more illumination fibers, the illumination fibers may extend proximally of the proximal end of theguide member1240, and proximally throughcatheter1260 where they are not surrounded by an external sheath in a guidewire formation.
• In one preferred embodiment for adult applications,balloon catheter1200 has an overall length of approximately 43.5 cm and itsshaft1260 has an outer diameter of about 0.058 inches. Further details about integrated wire dilatation catheters that may be configured with a light emitter in a manner as described herein can be found in co-pending application Ser. No. 11/438,090 filed May 18, 2006 and titled “Catheters with Non-Removable Guide Members Useable for Treatment of Sinusitis. Application Ser. No. 11/438,090 is hereby incorporated herein, in its entirety, by reference thereto.
Extra Long Endoscope
• As seen inFIG. 2, when thesystem10 shown inFIG. 1 is used, the camera/transmission/endoscope assembly14 is attached to the proximal end of thesinus guide device12 and must be held or supported a spaced distance above the subject's chest during performance of the procedure.FIG. 34 shows analternative system10awhich incorporates a longflexible endoscope30a, and a different camera/transmission/endoscope assembly14a.
• The longflexible endoscope30ahas an extended length, preferably at least about two feet long, such that a portion of theflexible endoscope30 extends between the proximal end of thesinus guide12 and the camera/transmission/endoscope assembly14a, thereby allowing the camera/transmission/endoscope assembly14ato rest upon the subject's chest or on a nearby structure (e.g., a tray, clip, clamp, on the adjacent surface of the operating table, etc.). This eliminates the need for the operator to hold or support the weight of the camera/transmission/endoscope assembly14ain addition to that of thesinus guide12. Rather, with the camera/transmission/endoscope assembly14aresting upon the subject's chest or on a nearby structure, the operator need only hold or support thesinus guide12, thereby enabling the operator to potentially handle or operate other secondary devices, such as a second endoscope that may be inserted separately from and in addition to theendoscope30athat passes through thesinus guide12. The longflexible endoscope30ahas utility in both therapeutic and diagnostic uses.
• The modified camera/transmission/endoscope assembly14ashown inFIG. 34 need not include a connector for rigidly attaching it to theproximal hub41 of thesinus guide device12. Rather, this camera/transmission/endoscope assembly14acomprises aneyepiece70 and alight post72, preferably an ACMI light post with an integrated light taper, to which alight cable78 may be attached. A length of theflexible endoscope30aextends from this eyepiece to theproximal hub41 of thesinus guide12 and beyond through the guide. Acamera74 has a coupler on its distal end so as to clamp onto the proximal end of theeyepiece70. Animage cable76 extends from thecamera74 to a monitor where the image is displayed. Theflexible endoscope30ahas a coherent bundle of extremely small and highly packed fiber optic fibers with light fibers around the image fibers. For example, theflexible endoscope30acan be a fiber scope having about 6,000 thin image fibers in a bundle, preferably at least about 10,000 thin image fibers for better resolution of the image. The light fibers are preferably illumination fibers with a diameter between about 0.008 and 0.020 inches and a minimum lux of about 10,000. The diameter of theflexible endoscope30aranges from about 0.25 mm to about 1 mm and is preferably about 0.3 mm in diameter, and has a flexible outer sheathing of braided polyimide. The field of view is preferably about 70 degrees. The field of view could also be “straight ahead” (i.e., zero degrees) or at other angles (e.g., 30, 45 or 60 degrees) as is available in commercial endoscopes.
• Guide Systems with Removable Endoscope/Guidewire Sheaths
• FIGS. 35-38D show another transnasally insertable guide system useable to position a guidewire at a desired location within the ear, nose, throat or cranium of a human or animal subject. This guide system comprises a straight or curvedtransnasal sinus guide80 and asheath90 that is insertable through thesinus guide80. Thesheath90 has anendoscope lumen85 through which aflexible endoscope30 may be inserted and aguidewire lumen87 through which aguidewire110 may be inserted. Anendoscope30 inserted through theendoscope lumen85 may be advanced substantially parallel to theguidewire110 inserted through theguidewire lumen87 so as to view, guide or verify the positioning of theguidewire110. As noted earlier, guidewire110 can also be used to extend the viewing range ofendoscope30 when the guidewire used is an illuminatingguidewire110 and the illuminating portion of theguidewire110 is extend distally beyond the viewing portion ofendoscope30.
• Examples of transnasal sinus guides80 useable in this system include those described in U.S. patent application Ser. No. 11/193,020 and those currently available commercially as Relieva™ Sinus Guide Catheters from Acclarent, Inc., Menlo Park, Calif.
• The details of thesheath90 are shown inFIG. 36. Thesheath90 comprises an elongateflexible shaft92 through which theendoscope lumen85 andguidewire lumen87 extend. Aproximal hub94 having threearms96,98,100 is mounted on the proximal end of the flexible shaft.Arm96 leads into theendoscope lumen85 andarm100 leads into theguidewire lumen87.
• FIGS. 37 and 37A show thesheath90 inserted through one type of sinus guide80 with anendoscope30 and guidewire110 inserted through therespective lumens85,87 of the sheath. The sinus guide comprises atube44 having alumen45, such as a polymer tube made of biocompatible polymer. Optionally, a liner (not shown inFIG. 15A) may be disposed within thelumen45 of thetube44. Such liner may be formed of lubricious or smooth material such as polytetrafluoroethylene (PTFE). Also, optionally, a proximal portion of thetube44 may be surrounded by anouter tube member42 formed of material such as stainless steel hypotube. In the embodiment shown, a curved distal portion oftube44 extends out of and beyond the distal end ofouter tube42. Additionally, a radiographicallyvisible marker86 may optionally be formed on or attached to the distal end of thesinus guide80. Theflexible shaft92 of thesheath90 is advanceable throughlumen45 oftube44. As seen inFIG. 15, a distal portion of thesheath shaft92 may extend out of and beyond the distal end of thesinus guide80. Also, as seen inFIG. 37, distal portions of theendoscope30 and guidewire110 may advance out of and beyond the distal end ofshaft92.
• FIGS. 38A-38D show an example of steps in a method for using theguide catheter80 andsheath90 shown inFIGS. 35-37A to perform a procedure wherein a balloon catheter is used to dilate an anatomical structure such as the ostium of a paranasal sinus.
• Initially, as seen inFIG. 38A, thesinus guide80 is inserted transnasally and advanced to a position where the distal end of the sinus guide is substantially aligned with but a spaced distance away from the anatomical structure to be dilated (see an example of such spacing inFIGS. 10A and 10B). Thereafter, theshaft92 ofsheath90 is advanced through thelumen45 of the sinus guide such that a distal portion of the sheath is flush with or protrudes out of the distal end of thesinus guide80. Theguidewire110 is then advanced out of the end ofsheath90 while theendoscope30 is used to view, guide and/or verify the position of the guidewire. In some instances, it may be desirable to advance theendoscope30 along with theguidewire110 so that the distal end of the scope remains an optimal distance behind the distal end of the guidewire, as seen inFIG. 38B. Such positioning of theendoscope30 may allow the operator to observe the distal end of theguidewire110 as it is advanced into or through the anatomical structure to be dilated.
• After theguidewire110 has been advanced into or through the anatomical structure to be dilated, thesheath90 andendoscope30 are withdrawn and removed, leaving thesinus guide80 and guidewire110 in place, as seen inFIG. 38C.
• Thereafter, as shown inFIG. 38D, aballoon catheter100 is advanced over theguidewire110 and through thesinus guide80 to a position where itsballoon102 is positioned within the ostium or other anatomical structure to be dilated. Theballoon102 is then inflated, thereby performing the desired dilation.
• In the example ofFIGS. 38A-38C, aflexible sheath90 is advanced through a straight orcurved sinus guide80. However, in some applications, it may be desirable to steer thesheath90 within the body, thereby allowing thesheath90 to be navigated through tortuous anatomical regions and/or around anatomical structures. In this regard,FIGS. 39A through 39D show another system which utilizes a straight sinus guide80ain conjunction with asteerable sheath122 that has endoscope and guidewire lumens extending therethrough. Ahandpiece124 on the proximal end of thesheath122 has anactuator126 that moves a pull wire or otherwise causes adistal portion128 of thesheath122 to deflect or bend. Thedistal portion128 of thissheath122 may be slightly deflected as seen inFIG. 39A, severely deflected as seen inFIG. 39B, not deflected (straight) as seen inFIG. 39C, or any variations therebetween.
• In operation, the sinus guide80ais inserted into or through a nostril and thesheath122 is inserted through the sinus guide and is advanced to a desired location. During such advancement of thesheath122, theendoscope30 may be used to view the area immediately ahead of thesheath122 and the operator may useactuator126 to steer or deflect thesheath122 as needed to navigate thesheath122 to the desired location. After thesheath122 has been navigated to a desired position, theguidewire110 may be advanced, under endoscopic guidance, as described above with respect to the example ofFIGS. 38A-38D. After theguidewire110 has been advanced to the desired location, thesteerable sheath122 andendoscope30 are withdrawn and removed, leaving the sinus guide80aandguidewire110 in place, as seen inFIG. 39D. Thereafter, a working device (e.g., a balloon catheter or other diagnostic or therapeutic apparatus) may be advanced over the110 and used to perform a therapeutic or diagnostic function.
Guide Systems Having Small Diameter Endoscopes Attached to Guidewire Tips
• FIGS. 40A through 41B′ are directed to guide systems wherein a guidewire tip is attached to an endoscope and used to view, guide or verify the position of the guidewire tip. After the guidewire tip has been advanced to an intended location, a working device (e.g., another catheter, balloon catheter, etc.) may be advanced over the endoscope and over the guidewire tip. To allow devices to be advanced over the endoscope, it is necessary to remove any bulky or large diameter hubs or attachments from the proximal end of the endoscope. Thus, as shown on theFIG. 41 series, this invention includes removable proximal hubs for endoscopes of this type.
• Referring specifically toFIGS. 40A-40C, there is provided aguide system130 comprising aflexible endoscope30a, a translucent endoscope-receivingbody134 and anelongate guide tip132, such as a flexible guidewire tip. The distal end of theendoscope30ais inserted into or otherwise coupled or attached to the proximal end of thetranslucent body134 such that light will be cast from theendoscope30a, through thetranslucent body134 and images will be received by theendoscope30athrough thetranslucent body134. In this manner, theendoscope30ais useable to view an area adjacent to theelongate guide tip132 thereby facilitating advancement of the elongate guide tip to a desired location within the body of a human or animal subject. In some embodiments, theendoscope30amay provide a 360 degree view around the periphery of theelongate guide tip132 as shown in the diagram ofFIG. 40C.
• After theelongate guide tip132 has been advanced to a desired location (e.g., into or through the ostium of a paranasal sinus) as working device (e.g., a catheter such as a balloon catheter or other diagnostic or therapeutic device) is advanceable over theendoscope30a, over thetranslucent body member134 and over theelongate guide tip132. This may require detachment of any large diameter or bulky hub or other component from the proximal end of the endoscope. The detachability configuration described in regard toFIGS. 41A and 41A′ applies to other scope embodiments herein and helps to keep the cost of the disposable elements to a minimum.FIGS. 41A and 41A′ show adetachable hub224 that may be attached to and detached from the proximal end of the endoscope30A. Thishub224 comprises abody226 having a scope-receivingchannel227 in its distal end, alight input cable230 and animage output cable228. As seen inFIG. 41A′, the proximal end of theendoscope30ais inserted into scope-receivingchannel227, thereby causing a light fiber contact on the proximal end of theendoscope30ato optically couple to a corresponding contact at the proximal end of scope-receivingchannel227 so that light fromlight cable230 will be transmitted in the distal direction through the light fibers of theendoscope30a. Also, this will cause an image contact formed on theendoscope30bto be optically coupled to a corresponding contact on the inner wall of the scope-receivingchannel227 such that images from the scope's image fibers will be transmitted throughimage cable28 to a camera/monitor, eyepiece or other image viewing apparatus known in the art of endoscopy. After theelongate guide tip132 has been placed in the desired position, the proximal end of theendoscope30amay be pulled out of scope-receivingchannel227 and thehub224 may be removed, thereby allowing the working device to advance over and be guided by the body of theendoscope136,translucent member134 andelongate guide tip132.
• Referring specifically toFIGS. 40D-40E, there is provided anotherguide system140 comprising anendoscope30battached to anelongate guide tip132a, such as a flexible guidewire tip. In this example, theendoscope30bcomprises an outer tube having aside opening144 and aflexible endoscope tip146 that is advanceable out of and retractable back into theside opening144. When advanced out of theside opening144, theendoscope tip146 is useable to view an area adjacent to theelongate guide tip132a, thereby facilitating advancement of theelongate guide tip132ato a desired location. When the endoscope tip is advanced out of theside opening144, it may provide a view along one side of theguide tip132a, as seen in the diagram ofFIG. 40E. After theelongate guide tip132ahas been advanced to the desired location, theendoscope tip146 is retracted back into the endoscope's outer tube throughside opening144 and a working device (e.g., a catheter such as a balloon catheter or other diagnostic or therapeutic device) is advanceable over theendoscope30band over theelongate guide tip132a. To facilitate this, the above-describeddetachable hub224 may be used in conjunction with thisendoscope30b, as seen inFIGS. 41B and 41B′.
Self Cleaning Endoscope Feature
• Any of the sinus guides12,12a,12b,12c,80 of this invention may incorporate apparatus, such as a drip line, mist, suction or feature on the sinus guide, for cleaning debris from the endoscope without requiring the device to be removed from the subject's body. In this regard,FIGS. 42A-20C show one example of anendoscope sinus guide12dhaving ascope cleaning member260 at the distal end of itsendoscope channel28. In this example, thescope cleaning member260 comprises an elastomeric diaphragm disposed transversely over the distal end of theendoscope channel28 and having a self-closing slit through which theendoscope30 passes. It will be appreciated, however, that suchscope cleaning member260 need not necessarily be a slit elastomeric diaphragm, but may comprise various other types of members that wipe or frictionally clear the distal end of theendoscope30 as the endoscope is advanced or retracted.
• In the example shown, the endoscope is advanced through the slit and out of theendoscope channel28, where it is used to observe the advancement of aguidewire110 from the adjacentsinus guide body26. During such procedure, a quantity of debris262 (e.g., blood, mucous, etc.) accumulates on the distal end of the endoscope, thus interfering with obtainment of a suitable quality image from theendoscope30. To remedy this, the endoscope is briefly retracted back through thescope cleaning member260 such that the slit rides over the outer surface of theendoscope30 and closes over the distal tip of theendoscope30 as it is retracted. This removes thedebris262 from theendoscope30, as shown inFIG. 42C. Thereafter, theendoscope30 may be re-advanced throughscope cleaning member260 and may once again be used to obtain an endoscope image of theguidewire110 and/or other areas around the distal end of thesinus guide device12d.
• It is to be appreciated that the invention has been described hereabove with reference to certain examples or embodiments of the invention but that various additions, deletions, alterations and modifications may be made to these examples and embodiments and or equivalents may be substituted without departing from the intended spirit and scope of the invention. For example, any element or attribute of one embodiment or example may be incorporated into or used with another embodiment or example, unless to do so would render the embodiment or example unsuitable for its intended use. In addition, many modifications may be made to adapt a particular situation, material, composition of matter, process, process step or steps, to the objective, spirit and scope of the present invention. All such modifications are intended to be within the scope of the claims appended hereto.

Claims (21)

1-95. (canceled)

96. A dilation system, comprising:

(a) a body having a distal end and a proximal end;

(b) a guide member coupled to the distal end of the body and extending distally therefrom;

(c) a dilation member having an expandable dilator, wherein the dilation member is configured to move relative to the guide member;

(d) an endoscope assembly including an endoscope, the endoscope extending through the body and configured to extend along the guide member for viewing an area beyond the distal end of the body; and

(e) a lock feature operatively connected to the endoscope and configured to engage the endoscope thereby locking the position of the endoscope relative to the body.

97. The dilation system ofclaim 96, wherein the lock feature comprises an adjustable extension.

98. The dilation system ofclaim 96, wherein the lock feature is positioned between the endoscope assembly and the guide member.

99. The dilation system ofclaim 96, wherein the endoscope assembly and the body at least partially define a handpiece, and wherein the handpiece is configured to be grasped by a single hand of an operator such that the body, the guide member, the dilation member, the endoscope, and the lock feature are configured to be manipulated with the single hand via the handpiece.

100. The dilation system ofclaim 99, wherein the handpiece further includes an actuator and the guide member and the dilation member at least partially define a distal system portion, and wherein the actuator is operatively connected to the distal system portion and is configured to move a portion of the distal system portion.

101. The dilation system ofclaim 100, wherein the actuator is movably coupled with the body.

102. The dilation system ofclaim 101, wherein the actuator is translatably coupled with the body.

103. The dilation system ofclaim 99, wherein the endoscope assembly includes a camera.

104. The dilation system ofclaim 96, wherein the guide member defines an endoscope channel and a lumen, wherein the endoscope channel moveably receives the endoscope therein, and wherein the lumen movably receives the dilation member.

105. The dilation system ofclaim 104, wherein the endoscope channel translatably receives the endoscope, and wherein the lumen translatably receives the dilation member.

106. The dilation system ofclaim 96, wherein the expandable dilator comprises a balloon.

107. The dilation system ofclaim 96, further comprising a guidewire extending along the guide member, wherein the guidewire receives the dilation member thereon for guiding movement of the dilation member.

108. A dilation system, comprising:

(a) a handpiece including:

(i) a body having a distal end and a proximal end, and

(ii) an actuator;

(b) a guide member coupled to the distal end of the body and extending distally therefrom;

(c) a dilation member having an expandable dilator, wherein the dilation member is configured to move relative to the guide member; and

(d) an endoscope assembly including an endoscope, the endoscope extending through the body and configured to extend along the guide member for viewing an area beyond the distal end of the body,

wherein the guide member and the dilation member at least partially define a distal system portion, and wherein the actuator is operatively connected to the distal system portion and configured to move a portion thereof, and

wherein the handpiece is configured to be grasped by a single hand of an operator such that the body, the guide member, the dilation member, and the endoscope, are configured to be manipulated with the single hand via the handpiece.

109. The dilation system ofclaim 108, wherein the actuator is movably coupled with the body.

110. The dilation system ofclaim 109, wherein the actuator is translatably coupled with the body.

111. The dilation system ofclaim 108, wherein the guide member defines an endoscope channel and a lumen, wherein the endoscope channel moveably receives the endoscope therein, and wherein the lumen movably receives the dilation member.

112. The dilation system ofclaim 108, wherein the expandable dilator comprises a balloon.

113. The dilation system ofclaim 108, further comprising a guidewire extending along the guide member, wherein the guidewire receives the dilation member thereon for guiding movement of the dilation member.

114. The dilation system ofclaim 108, wherein the endoscope assembly includes a camera.

115. A dilation system, comprising:

(a) a handpiece including a body, the body having a distal end and a proximal end;

(b) a guide member coupled to the distal end of the body and extending distally therefrom;

(c) a dilation member having an expandable dilator, wherein the dilation member is configured to move relative to the guide member; and

(d) an endoscope assembly including an endoscope, the endoscope extending through the body and configured to extend along the guide member for viewing an area beyond the distal end of the body,

wherein the handpiece is configured to be grasped by a single hand of an operator such that the body, the guide member, the dilation member, and the endoscope, are configured to be manipulated with the single hand via the handpiece.

Images