U.S. patent application number 09/784625 was filed with the patent office on 2002-02-07 for apparatus and method for controlled removal of stenotic material from stents.
This patent application is currently assigned to Prolific Medical, Inc.. Invention is credited to Leary, James J., Patterson, Greg R., Williams, Ronald G..
Application Number | 20020016624 09/784625 |
Document ID | / |
Family ID | 27122026 |
Filed Date | 2002-02-07 |
United States Patent
Application |
20020016624 |
Kind Code |
A1 |
Patterson, Greg R. ; et
al. |
February 7, 2002 |
Apparatus and method for controlled removal of stenotic material
from stents
Abstract
Apparatus and methods for treating in-stent restenosis are
described for removing stenotic material from within previously
stented regions of a patient's vasculature. The apparatus includes
a catheter system having a stenotic material removal mechanism
mounted on a distal portion of an elongated inner catheter. A
sensing means, such as one or more sensing electrodes, are
positioned on an outer surface of the apparatus. In addition, the
apparatus optionally includes control means for diametrically
expanding the stenotic material removal mechanism for effective
recanalization of the stent. A coaxial outer catheter is provided
for aspirating stenotic material which is removed from within the
stent. In addition, embolic filter apparatus are described for
collecting the stenotic material removed from within the stent. The
methods comprise operating the stenotic material removal mechanism
within a body vessel, typically a coronary artery or other artery,
which has become restenosed or otherwise occluded following the
initial stent placement, and sensing the proximity or contact
between the stenotic material removal mechanism and the stent
within the arterial wall so that the stenosis can be effectively
recanalized without damaging the stent. The sensing means may be
used to indicate an unsafe condition that might lead to stent
damage, in response to which, the stenotic material removal
mechanism may be manually or automatically deactivated.
Alternatively or additionally, the sensing means may be used to
indicate an appropriate endpoint for the stenotic material removal
process.
Inventors: |
Patterson, Greg R.;
(Pleasanton, CA) ; Williams, Ronald G.; (Menlo
Park, CA) ; Leary, James J.; (Sunnyvale, CA) |
Correspondence
Address: |
TOWNSEND AND TOWNSEND AND CREW
TWO EMBARCADERO CENTER
EIGHTH FLOOR
SAN FRANCISCO
CA
94111-3834
US
|
Assignee: |
Prolific Medical, Inc.
|
Family ID: |
27122026 |
Appl. No.: |
09/784625 |
Filed: |
February 14, 2001 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
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09784625 |
Feb 14, 2001 |
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09260935 |
Mar 2, 1999 |
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6319242 |
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09260935 |
Mar 2, 1999 |
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08857659 |
May 16, 1997 |
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5941869 |
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08857659 |
May 16, 1997 |
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08798722 |
Feb 12, 1997 |
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5882329 |
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Current U.S.
Class: |
623/1.12 ;
606/168 |
Current CPC
Class: |
A61F 2/82 20130101; A61B
2017/00119 20130101; A61B 2217/005 20130101; A61B 2017/2212
20130101; A61B 17/221 20130101; A61B 17/320725 20130101; A61B
17/3207 20130101; A61B 2017/00026 20130101; A61B 2090/378
20160201 |
Class at
Publication: |
623/1.12 ;
606/168 |
International
Class: |
A61F 002/06; A61B
017/32 |
Claims
What is claimed is:
1. An apparatus for removing stenotic material from within a stent
located within a body vessel, said apparatus comprising: a stenotic
material removal mechanism for removing stenotic material from
within the stent, sensor means associated with said stenotic
material removal mechanism for sensing proximity or contact between
said stenotic material removal mechanism and the stent, whereby
said sensor means is used to determine an unsafe condition or an
appropriate endpoint for removal of stenotic material from within
the stent based on the sensed proximity or contact between said
stenotic material removal mechanism and the stent for effective
recanalization of the body vessel.
2. The apparatus of claim 1 further comprising a control means for
controlling a depth to which said stenotic material removal
mechanism removes the stenotic material from within the stent.
3. The apparatus of claim 2 wherein said control means comprises a
mechanism for diametrically expanding said stenotic material
removal mechanism.
4. The apparatus of claim 1 further comprising a means for
directing said stenotic material removal mechanism to remove
stenotic material from a selected area within the stent.
5. The apparatus of claim 1 further comprising a means for
diametrically expanding said stenotic material removal
mechanism.
6. The apparatus of claim 1 wherein said stenotic material removal
mechanism comprises at least one longitudinally oriented blade.
7. The apparatus of claim 1 wherein said stenotic material removal
mechanism comprises a plurality of longitudinally oriented
blades.
8. The apparatus of claim 7 wherein said longitudinally oriented
blades are resiliently biased to expand radially outward from a
central axis of said stenotic material removal mechanism.
9. The apparatus of claim 1 wherein said stenotic material removal
mechanism comprises a plurality of helically configured blades.
10. The apparatus of claim 9 wherein said helically configured
blades are resiliently biased to expand radially outward from a
central axis of said stenotic material removal mechanism.
11. The apparatus of claim 1 wherein said stenotic material removal
mechanism comprises a rotating blade.
12. The apparatus of claim 1 wherein said stenotic material removal
mechanism comprises a rotating abrasive tool.
13. The apparatus of claim 1 wherein said stenotic material removal
mechanism comprises a cage-like network of filaments.
14. The apparatus of claim 1 further comprising a monitoring means
associated with said sensor means for monitoring the proximity or
contact between said stenotic material removal mechanism and the
stent.
15. The apparatus of claim 14 wherein said sensor means comprises
at least one electrical conductor on an exterior of said apparatus
and said monitoring means comprises a leakage current detector for
detecting a leakage current when said at least one electrical
conductor contacts said stent.
16. The apparatus of claim 14 wherein said sensor means comprises a
first electrical conductor and a second electrical conductor on an
exterior of said apparatus and said monitoring means comprises a
leakage current detector for detecting a leakage current when said
first electrical conductor and said second electrical conductor
contacts said stent.
17. The apparatus of claim 14 wherein said sensor means comprises
at least one electrical conductor within said apparatus and said
monitoring means comprises a means for detecting a change in
electrical impedance when said at least one electrical conductor
approaches said stent.
18. The apparatus of claim 14 wherein said sensor means comprises a
first electrical conductor and a second electrical conductor within
said apparatus and said monitoring means comprises a means for
detecting a change in electrical impedance when said first
electrical conductor and said second electrical conductor approach
said stent.
19. The apparatus of claim 14 wherein said monitoring means
produces a signal indicative of the proximity or contact between
said stenotic material removal mechanism and the stent.
20. The apparatus of claim 14 wherein said monitoring means
includes means for deactivating said stenotic material removal
mechanism when a predetermined level of proximity or contact
between said stenotic material removal mechanism and the stent is
detected.
21. The apparatus of claim 1 wherein said stenotic material removal
mechanism is positioned at a distal portion of a first elongated
catheter shaft.
22. The apparatus of claim 21 wherein said first elongated catheter
shaft includes a lumen for passage of a guidewire therethrough.
23. The apparatus of claim 21 further comprising a second elongated
catheter shaft positioned coaxially around said first elongated
catheter shaft.
24. The apparatus of claim 23 wherein said second elongated
catheter shaft includes an internal lumen for aspiration of
stenotic material removed from within the stent.
25. The apparatus of claim 1 further comprising a stenotic material
collection mechanism for collecting stenotic material removed from
within the stent.
26. The apparatus of claim 25 wherein said stenotic material
collection mechanism comprises an embolic filter positioned in
operative association with said stenotic material removal
mechanism.
27. The apparatus of claim 26 wherein said embolic filter is
positioned coaxially with said stenotic material removal
mechanism.
28. The apparatus of claim 25 wherein said stenotic material
collection mechanism is positioned internally to said stenotic
material removal mechanism.
29. An apparatus for removing stenotic material from within a stent
located within a body vessel, said apparatus comprising: a catheter
shaft having a proximal end and a distal end, a stenotic material
removal mechanism, and means coupled to the stenotic material
removal mechanism for increasing a depth to which the stenotic
material removal mechanism removes the stenotic material from
within the stent, wherein said means is limited to prevent further
increase in depth when or before the stenotic material removal
mechanism engages the stent.
30. The apparatus of claim 29 wherein said means deactivates said
stenotic material removal mechanism when or before the stenotic
material removal mechanism engages the stent.
31. The apparatus of claim 29 wherein said means includes a sensor
for sensing contact between said stenotic material removal
mechanism and the stent.
32. The apparatus of claim 29 wherein said means includes a sensor
for sensing proximity between said stenotic material removal
mechanism and the stent.
33. The apparatus of claim 29 wherein said means includes sensor
means for sensing contact and proximity between said stenotic
material removal mechanism and the stent.
34. The apparatus of claim 29 wherein said means includes a
mechanism for diametrically expanding said stenotic material
removal mechanism.
35. The apparatus of claim 29 further comprising a means for
directing said stenotic material removal mechanism to remove
stenotic material from a selected area within the stent.
36. The apparatus of claim 29 wherein said stenotic material
removal mechanism comprises at least one longitudinally oriented
blade.
37. The apparatus of claim 29 wherein said stenotic material
removal mechanism comprises a plurality of longitudinally oriented
blades.
38. The apparatus of claim 29 wherein said stenotic material
removal mechanism comprises a plurality of helically configured
blades.
39. The apparatus of claim 29 wherein said stenotic material
removal mechanism comprises a rotating blade.
40. The apparatus of claim 29 wherein said stenotic material
removal mechanism comprises a rotating abrasive tool.
41. The apparatus of claim 29 wherein said stenotic material
removal mechanism comprises a cage-like network of filaments.
42. An apparatus for removing stenotic material from within a body
vessel, said apparatus comprising: a stenotic material removal
mechanism for removing stenotic material from within the body
vessel, said stenotic material removal mechanism having a plurality
of elongated blades, and a stenotic material collection mechanism
for collecting stenotic material removed from within the body
vessel, said stenotic material collection mechanism including an
expandable filter medium enclosed and supported by said plurality
of elongated blades.
43. The apparatus of claim 42 further comprising a means for
diametrically expanding said stenotic material removal
mechanism.
44. The apparatus of claim 42 wherein said elongated blades are
resiliently biased to expand radially outward from a central axis
of said stenotic material removal mechanism.
45. A method for removing stenotic material from within a stent
located within a body vessel, said method comprising: operating a
stenotic material removal mechanism to remove stenotic material
from within the stent; sensing proximity or contact between said
stenotic material removal mechanism and the stent; and determining
an appropriate endpoint for removal of stenotic material from
within the stent based on the sensed proximity or contact between
said stenotic material removal mechanism and the stent for
effective recanalization of the body vessel.
46. The method of claim 45 further comprising controlling a depth
to which said stenotic material removal mechanism removes the
stenotic material from within the stent.
47. The method of claim 45 comprising diametrically expanding said
stenotic material removal mechanism.
48. The method of claim 45 comprising directing said stenotic
material removal mechanism to remove stenotic material from a
selected area within the stent.
49. The method of claim 45 further comprising producing a signal
indicative of the proximity or contact between said stenotic
material removal mechanism and the stent.
50. The method of claim 45 further comprising deactivating said
stenotic material removal mechanism when a predetermined level of
proximity or contact between said stenotic material removal
mechanism and the stent is detected.
51. The method of claim 45 further comprising monitoring the
proximity or contact between said stenotic material removal
mechanism and the stent.
52. The method of claim 51 wherein said sensor means comprises at
least one electrical conductor on an exterior of said stenotic
material removal mechanism and wherein the step of monitoring
comprises detecting a leakage current when said at least one
electrical conductor contacts the stent.
53. The method of claim 51 wherein said sensor means comprises a
first electrical conductor and a second electrical conductor on an
exterior of said stenotic material removal mechanism and wherein
the step of monitoring comprises detecting a leakage current when
said first electrical conductor and said second electrical
conductor contacts the stent.
54. The method of claim 51 wherein said sensor means comprises at
least one electrical conductor positioned on said stenotic material
removal mechanism and wherein the step of monitoring comprises
detecting a change in electrical impedance when said at least one
electrical conductor approaches the stent.
55. The method of claim 51 wherein said sensor means comprises a
first electrical conductor and a second electrical conductor
positioned on said stenotic material removal mechanism and wherein
the step of monitoring comprises detecting a change in electrical
impedance when said first electrical conductor and said second
electrical conductor approach the stent.
56. The method of claim 45 further comprising aspirating stenotic
material removed from within the stent.
57. The method of claim 45 further comprising collecting stenotic
material removed from within the stent.
58. The method of claim 45 further comprising inserting said
stenotic material removal mechanism into the body vessel on an
elongated catheter.
59. The method of claim 58 further comprising introducing said
stenotic material removal mechanism on said elongated catheter into
the body vessel through a percutaneous puncture.
60. A method for removing stenotic material from within a stent
located within a body vessel, said method comprising: engaging a
stenotic material removal mechanism to remove a portion of stenotic
material from within the stent; expanding the stenotic material
removal mechanism to remove additional portions of the stenotic
material; and limiting the expansion of the stenotic material
removal mechanism when or before the stenotic material removal
mechanism engages the stent.
61. The method of claim 60 comprising diametrically expanding said
stenotic material removal mechanism.
62. The method of claim 60 further comprising deactivating said
stenotic material removal mechanism when or before the stenotic
material removal mechanism engages the stent.
63. The method of claim 60 further comprising directing said
stenotic material removal mechanism to remove stenotic material
from a selected area within the stent.
64. The method of claim 60 further comprising sensing proximity or
contact between said stenotic material removal mechanism and the
stent.
65. The method of claim 64 further comprising deactivating said
stenotic material removal mechanism when a predetermined level of
proximity or contact between said stenotic material removal
mechanism and the stent is detected.
66. The method of claim 60 further comprising aspirating stenotic
material removed from within the stent.
67. The method of claim 60 further comprising collecting stenotic
material removed from within the stent.
68. The method of claim 60 further comprising inserting said
stenotic material removal mechanism into the body vessel on an
elongated catheter.
69. The method of claim 68 further comprising introducing said
stenotic material removal mechanism on said elongated catheter into
the body vessel through a percutaneous puncture.
70. A catheter kit comprising: (a) a catheter including: a catheter
shaft having a proximal end and a distal end, a stenotic material
removal mechanism, wherein said removal mechanism is expandable,
and (b) instructions for use setting forth the following steps:
percutaneously introducing the stenotic material removal mechanism
into a restenosed stent in a blood vessel; engaging the stenotic
material removal mechanism to remove a portion of stenotic material
from within the restenosed stent; expanding the stenotic material
removal mechanism to remove additional portions of the stenotic
material; and limiting the expansion of the stenotic material
removal mechanism when or before the stenotic material removal
mechanism engages the stent; and (c) a package holding the catheter
and the instructions for use.
Description
CROSS-REFERENCES TO RELATED APPLICATIONS
[0001] This patent application is a division of application Ser.
No. 08/857,659, filed May 16, 1997, which is a continuation-in-part
of co-owned, copending patent application, Ser. No. 08/798,722,
filed Feb. 12, 1997, the entire disclosures of which are
incorporated herein by reference.
BACKGROUND OF THE INVENTION
[0002] 1. Field of the Invention
[0003] The present invention relates generally to apparatus and
methods for removing occluding material from stented regions within
blood vessels which have restenosed. More particularly, the present
invention relates to apparatus and methods for sensing a stent
within the wall of a restenosed blood vessel and removing the
occluding material without damaging the stent.
[0004] Percutaneous transluminal angioplasty (PTA) and percutaneous
transluminal coronary angioplasty (PTCA) procedures are widely used
for treating stenotic atherosclerotic regions of a patient's
vasculature to restore adequate blood flow. Catheters having an
expansible distal end, typically in the form of an inflatable
balloon, are positioned in an artery, such as a coronary artery, at
a stenotic site. The expansible end is then expanded to dilate the
artery in order to restore adequate blood flow to regions beyond
the stenosis. While PTA and PTCA have gained wide acceptance, these
angioplasty procedures suffer from two major problems: abrupt
closure and restenosis.
[0005] Abrupt closure refers to rapid reocclusion of the vessel
within hours of the initial treatment, and often occurs in patients
who have recently suffered acute myocardial infarction. Abrupt
closure often results from either an intimal dissection or from
rapid thrombus formation which occurs in response to injury of the
vascular wall from the initial angioplasty procedure. Restenosis
refers to a re-narrowing of the artery over the weeks or months
following an initially apparently successful angioplasty procedure.
Restenosis occurs in up to 50% of all angioplasty patients and
results at least in part from smooth muscle cell proliferation and
migration.
[0006] Many different strategies have been proposed to ameliorate
abrupt closure and reduce the rate of restenosis. Of particular
interest to the present invention, the implantation of vascular
stents following angioplasty has become widespread. Stents are
thin-walled tubular scaffolds which are expanded in the arterial
lumen following the angioplasty procedure. Most commonly, the
stents are formed from a malleable material, such as stainless
steel, and are expanded in situ using a balloon. Alternatively, the
stents may be formed from a shape memory alloy or other elastic
material, in which case they are allowed to self-expand at the
angioplasty treatment site. In either case, the stent acts as a
mechanical support for the artery wall, inhibiting abrupt closure
and reducing the restenosis rate as compared to PTCA.
[0007] While stents have been very successful in inhibiting abrupt
closure and reasonably successful in inhibiting restenosis, a
significant portion of the treated patient population still
experiences restenosis over time. Most stent structures comprise an
open lattice, typically in a diamond or spiral pattern, and cell
proliferation (also referred to as intimal hyperplasia) can intrude
through the interstices between the support elements of the
lattice. As a result, instead of forming a barrier to hyperplasia
and restenosis, the stent can become embedded within an accumulated
mass of thrombus and tissue growth, and the treatment site once
again becomes occluded.
[0008] To date, proposed treatments for restenosis within
previously stented regions of the coronary and other arteries have
included both follow-up balloon angioplasty and directional
atherectomy, e.g. using the Simpson directional atherectomy
catheter available from Guidant Corporation, Santa Clara, Calif.
Neither approach has been wholly successful. Balloon angioplasty
can temporarily open the arterial lumen, but rarely provides
long-term patency. Directional atherectomy can successfully debulk
the lumen within the stent, but typically does not fully restore
the stented lumen to its previous diameter because the catheter
removes the stenotic material in an asymmetric pattern. Moreover,
it has been found that the atherectomy cutting blades can damage
the implanted stent. Such adverse effects were reported by Bowerman
et al. in Disruption of a coronary stent during atherectomy for
restenosis in the December 1991 issue of Catheterization and
Cardiovascular Diagnosis and by Meyer et al. in Stent wire cutting
during coronary directional atherectomy in the May 1993 issue of
Clinical Cardiology. The possibility of such adverse outcomes is
likely to limit the application of atherectomy as a treatment for
stent restenosis and will probably result in more tentative use of
the atherectomy cutter within the stented region when it is
applied, leading to less complete removal of the stenosis.
[0009] For these reasons, it would be desirable to provide improved
methods for treating restenosis within regions of the vasculature
which have previously been implanted with stents. More
particularly, it would be desirable to provide an apparatus for
removal of stenotic material from within a stent which includes a
sensing means for sensing when the stenosis removal mechanism is
approaching or contacting the stent within the arterial wall so
that the occluded artery can be effectively recanalized without
damaging the stent. The stenosis removal mechanism of the apparatus
may advantageously be a directional cutting or debulking device for
selectively removing the stenotic material from within a stent or
it may be a symmetrical cutting or debulking device for removing
the stenotic material uniformly from the entire inner periphery of
the stent.
[0010] 2. Description of the Background Art
[0011] Post-angioplasty restenosis is discussed in the following
publications: Khanolkar (1996) Indian Heart J. 48:281-282; Ghannem
et al. (1996) Ann. Cardiol. Angeiol. 45:287-290; Macander et al.
(1994) Cathet. Cardiovasc. Diagn. 32:125-131; Strauss et al. (1992)
J. Am. Coll. Cardiol. 20:1465-1473; Bowerman et al. (1991) Cathet.
Cardiovasc. Diagn. 24:248-251; Moris et al. (1996) Am. Heart. J.
131:834-836; Schomig et al. (1994) J. Am. Coll. Cardiol.
23:1053-1060; Haude et al., "Treatment of In-Stent Restenosis," in
______, Chapter 52, pages 357-365; Gordon et al. (1993) J. Am.
Coll. Cardiol. 21:1166-1174; and Baim et al. (1993) Am. J. Cardiol.
71:364366. These publications include descriptions of follow-up
angioplasty and atherectomy as possible treatments for
restenosis.
[0012] Atherectomy catheters having ultrasonic imaging transducers
are described in U.S. Pat. Nos. 5,000,185 and 5,100,424. Rotary
ablation catheters having selectively expandable burr components
are described in U.S. Pat. Nos. 5,217,474 and 5,308,354. A catheter
carrying an expandable filter is described in U.S. Pat. No.
4,723,549.
[0013] Thrombectomy and atherectomy catheters having rotating brush
and filament structures are described in U.S. Pat. Nos. 5,578,018;
5,535,756; 5,427,115; 5,370,653; 5,009,659; and 4,850,957; WO
95/29626; DE 39 21 071 C2; and Netherlands 9400027.
[0014] Representative atherectomy catheters are described in U.S.
Pat. Nos. 4,273,128; 4,445,509; 4,653,496; 4,696,667; 4,706,671;
4,728,319; 4,732,154; 4,762,130; 4,790,812; 4,819,634; 4,842,579;
4,857,045; 4,857,046; 4,867,156; 4,883,458; 4,886,061; 4,890,611;
4,894,051; 4,895,560; 4,926,858; 4,966,604; 4,979,939; 4,979,951;
5,011,488; 5,011,489; 5,011,490; 5,041,082; 5,047,040; 5,071,424;
5,078,723; 5,085,662; 5,087,265; 5,116,352; 5,135,483; 5,154,724;
5,158,564; 5,160,342; 5,176,693; 5,192,291; 5,195,954; 5,196,024;
5,209,749; 5,224,945; 5,234,451; 5,269,751; 5,314,438; 5,318,576;
5,320,634; 5,334,211; 5,356,418; 5,360,432; 5,376,100; 5,402,790;
5,443,443; 5,490,859; 5,527,326; 5,540,707; 5,556,405; 5,556,408;
and 5,554,163.
[0015] The disclosures of these patent are incorporated herein by
reference in their entirety.
SUMMARY OF THE INVENTION
[0016] The present invention provides apparatus and methods for
removing stenotic material from within previously stented regions
of a patient's vasculature. The present invention is particularly
intended for treating regions of restenosis within a stent which
result from accumulation of cellular, thrombotic, and other
material over the weeks and months following an initially
successful stent implant. The present invention will also be useful
for treating relatively rapid thrombus formation which may
sometimes occur during the hours and days following a stent
placement procedure.
[0017] Methods according to the present invention comprise
operating a stenotic material removal mechanism within a blood
vessel, typically a coronary artery or other artery, which has
become restenosed or otherwise occluded following the initial stent
placement, and sensing the proximity or contact between the
stenotic material removal mechanism and the stent within the
arterial wall so that the occluded vessel can be effectively
recanalized without damaging the stent. The sensing means for
sensing the proximity or contact between the stenotic material
removal mechanism and the stent may be used to indicate an unsafe
condition that might lead to stent damage, in response to which,
the stenotic material removal mechanism may be manually or
automatically deactivated. Alternatively or additionally, the
sensing means may be used to indicate an appropriate endpoint for
the stenotic material removal process.
[0018] According to this second aspect, the indication of the
proximity or contact between the stenotic material removal
mechanism and the stent provided by the sensing means may be used
as feedback for controlling the stenotic material removal process
in the following ways: When used in conjunction with a directional
stenotic material removal mechanism, the sensing means may be used
to guide the directional stenotic material removal mechanism either
to remove stenotic material from selected portions of the interior
of the stent or to remove stenotic material uniformly from the
entire inner periphery of the stent. When used in conjunction with
a controllable-depth stenotic material removal mechanism, the
indication from the sensing means may be used as feedback to
manually or automatically control the depth of stenotic material
removal, preferably to remove stenotic material uniformly from the
entire inner periphery of the stent. When used in conjunction with
a controllable-width or diameter stenotic material removal
mechanism, the indication from the sensing means may be used as
feedback to manually or automatically control the width or diameter
of the blood flow channel created within the stent. In certain
embodiments of the method, the feedback from the sensing means may
be used to control a combination of the directionality and the
depth or diameter of the stenotic material removal process either
to remove stenotic material from selected portions of the interior
of the stent or to remove stenotic material uniformly from the
entire inner periphery of the stent.
[0019] In a preferred aspect of the method of the present
invention, a catheter carrying the stenotic material removal
mechanism is positioned on one side of the restenosed stented
region. The stenotic material removal mechanism is advanced from
the catheter and positioned across the stenosis within the stent.
The stenotic material removal mechanism is then expanded within the
stenosis. The expansion may occur passively, as with a resilient
stenotic material removal mechanism having one or more resilient
members, such as one or more wire-shaped cutting blades, which are
released from a tubular sheath and allowed to expand. Otherwise,
the expansion may occur actively and controllably, such as with a
stenotic material removal mechanism having one or more wire-shaped
cutting blades which are actively and controllably extended outward
to increase the width or diameter of the stenotic material removal
mechanism, or such as a stenotic material removal mechanism having
a cutter within a housing and an inflatable balloon located on one
side of the housing which is inflated to increase the width or
diameter of the stenotic material removal mechanism. The stenotic
material removal mechanism is then activated for removing the
stenotic material from within the stent. This is typically done by
rotating and/or translating the entire stenotic material removal
mechanism or a component of it within the stenosis. Medications,
chemicals, ionizing radiation or energy, such as electrical,
magnetic, ultrasonic, hydraulic, pulsed hydraulic, laser or thermal
energy may be applied to assist in removal of the stenotic material
and/or for denaturing the remaining tissue to discourage further
restenosis at the treatment site. A sensing means which is located
on or adjacent to the stenotic material removal mechanism monitors
the proximity or contact between the stenotic material removal
mechanism and the stent. When the stenotic material removal
mechanism has approached close enough to the stent to indicate
effective recanalization of the stenosis, the stenotic material
removal mechanism is deactivated. In this way, the sensing means
provides an interaction between the stenotic material removal
mechanism and the stented vessel to achieve effective
recanalization of the stenosis without damaging or dislodging the
stent within the vessel wall.
[0020] In an alternative aspect of the method of the present
invention, the catheter carrying the stenotic material removal
mechanism is positioned on one side of the restenosed stented
region. The stenotic material removal mechanism is extended from
the catheter and advanced part-way into the stenosis within the
stent. The stenotic material removal mechanism is then expanded
within the stenosis, either passively or actively and controllably
as described above, to increase the width or diameter of the
stenotic material removal mechanism. The stenotic material removal
mechanism is then activated for removing the stenotic material from
within a portion of the stent. This may be done by rotating and/or
translating the entire stenotic material removal mechanism or a
component of it within the stenosis. Medications, chemicals,
ionizing radiation or energy, such as electrical, magnetic,
ultrasonic, hydraulic, pulsed hydraulic, laser or thermal energy
may be applied to assist in removal of the stenotic material and/or
for denaturing the remaining tissue to discourage further
restenosis at the treatment site. A sensing means which is located
on or adjacent to the stenotic material removal mechanism monitors
the proximity or contact between the stenotic material removal
mechanism and the stent. When the stenotic material removal
mechanism has approached close enough to the stent to indicate
effective recanalization of that portion of the stenosis, the
stenotic material removal mechanism is advanced farther into the
stenosis. The stenotic material removal mechanism may be
deactivated and advanced step-wise into the stenosis by contracting
or compressing the stenotic material removal mechanism, advancing
it a short distance and expanding it again in a new portion of the
stent. Otherwise, the stenotic material removal mechanism may be
advanced continuously, relying on either the resiliency of the
stenotic material removal mechanism or active control for adjusting
the width or diameter of the stenotic material removal mechanism as
it advances. When the sensing means indicates that the new portion
of the stent has been effectively recanalized, the stenotic
material removal mechanism is advanced again along the stenosis
until the entire stented region has been recanalized.
[0021] Alternatively, the stenotic material removal mechanism may
be extended from the catheter and advanced all the way across the
stenosis in a contracted or compressed state. The stenotic material
removal mechanism is then expanded within the far end of the
stenosis or within the vessel beyond the stenosis, either passively
or actively and controllably as described above, to increase the
width or diameter of the stenotic material removal mechanism. The
stenotic material removal mechanism is then activated for removing
the stenotic material while withdrawing the stenotic material
removal mechanism toward the catheter to advance it through the
stenosis in either a step-wise or continuous fashion. Medications,
chemicals, ionizing radiation or energy, such as electrical,
magnetic, ultrasonic, hydraulic, pulsed hydraulic, laser or thermal
energy may be applied to assist in removal of the stenotic material
and/or for denaturing the remaining tissue to discourage further
restenosis at the treatment site. The sensing means which is used
to monitor the proximity or contact between the stenotic material
removal mechanism and the stent in order to control the diameter
and/or the rate of advancement of the stenotic material removal
mechanism for effective recanalization of the stenosis within the
stent.
[0022] The methods of the present invention may include providing a
sensing means in the form of one or more open, exposed electrodes
which are located on or adjacent to the stenotic material removal
mechanism. A direct or alternating current reference voltage is
applied to a unipolar electrode or applied between two bipolar
electrodes, and the current leakage of the electrode or electrodes
is monitored. When one or more of the electrodes contacts the
metallic stent, the leakage current increases indicating that the
stenotic material has been removed down to the stent support
members for effective recanalization of the stenosis within that
portion of the stent. Alternatively, the methods of the present
invention may include providing a sensing means in the form of two
exposed or insulated bipolar electrodes which are located on or
adjacent to the stenotic material removal mechanism. An alternating
current reference voltage is applied between the bipolar
electrodes, and the complex impedance between the electrodes is
monitored. As the electrodes approach the metallic stent, the
capacitive and inductive characteristics of the electrode circuit
change, which can be detected as a change in the complex impedance
between the electrodes. When the complex impedance between the
electrodes has changed a sufficient amount to indicate effective
recanalization of the stenosis within that portion of the stent,
the stenotic material removal mechanism may be deactivated or
advanced along the stenosis as appropriate. The sensing means can
be used to control or guide the stenotic material removal mechanism
to remove the stenotic material to within a predetermined thickness
of the stent support members or the stenotic material can be
removed all the way down to the stent support members without fear
of damaging the stent. If exposed electrodes are used in this
method, monitoring the complex impedance between the electrodes
will indicate when the stenotic material removal mechanism is
approaching the metallic stent, then when one or more of the
electrodes contacts the metallic stent, it will ground to the stent
which can be detected as an extreme change in the complex impedance
or as a rise in the leakage current. Thus, the sensing means can be
used to separately indicate proximity and contact between the
stenotic material removal mechanism and the stent. The sensing
means can operate with very low voltage and current that will not
create any adverse physiological effects on the vascular wall or
the tissues and nerve pathways of the heart.
[0023] In embodiments where the stenotic material removal mechanism
uses direct or alternating current electrical energy to assist in
removal of the stenotic material and/or for denaturing the
remaining tissue to discourage further restenosis at the treatment
site, for example by heating or by radio frequency ablation, the
heating or ablation electrodes can serve double duty as the sensing
means electrodes for monitoring proximity or contact with the
metallic stent.
[0024] Other types of proximity sensors sensitive to the metallic
stent may be used in place of those described. Alternatively,
optical or ultrasonic sensors may be used in place of the
electronic detectors described for detection of both metallic and
nonmetallic stents. For example, a nonimaging, A mode ultrasonic
transducer can be used to detect both metallic and nonmetallic
stents and to measure their depth within the arterial wall based on
echoes caused by the difference in acoustic impedance between the
stent material and the arterial tissue or stenosis.
[0025] The methods of the present invention will optionally further
comprise collecting and withdrawing the removed stenotic material
from the blood vessel. Collection and withdrawal of the removed
stenotic material may be accomplished using the same catheter or
catheter assembly which carries the stenotic material removal
mechanism, typically by aspiration, entrapment, filtering or some
combination thereof. It will be appreciated that various catheter
assemblies can be put together using coaxially arranged components
which may be introduced through a single vascular access point,
such as a femoral or brachial artery. Alternatively, collection and
withdrawal can be accomplished using separate collection apparatus,
such as a catheter or catheter assembly, which is introduced
through a separate access point. In some instances, it may be
desirable to partially or totally isolate the stented region from
circulation during recanalization. For example, embolic filters or
occlusion balloons may be placed upstream and downstream of the
treatment site. Alternatively or additionally, the methods of the
present invention may optionally further comprise comminution of
the removed stenotic material into microscopic particles that will
not cause embolization downstream of the treatment site.
[0026] The methods of the present invention will also optionally
comprise the use of introducer means, such as introducer needles,
guidewires and/or introducer sheaths for introducing the catheter
or catheter system into the vascular system and guide means, such
as steerable guidewires and selective and/or subselective guiding
or delivery catheters for guiding and advancing the catheter or
catheter system through the vasculature to the treatment site and
supporting it during the treatment. The selective and subselective
guiding or delivery catheters may also serve the functions of
aspiration, collection and withdrawal of the removed stenotic
material, as well as for infusion of therapeutic substances.
[0027] Apparatus according to the present invention include
catheters, catheter systems, and catheter kits which are specially
intended and adapted for performing the methods described above. In
particular, the apparatus are designed to afford percutaneous
intravascular placement of a catheter carrying a stenotic material
removal mechanism for removing stenotic material from within a
previously stented region of the vasculature and a sensing means
for sensing when the stenotic material removal mechanism is
approaching or contacting the stent within the vascular wall. This
inventive combination facilitates the effective recanalization of
previously placed vascular stents that have become restenosed
without risking damaging the stent. To that end, catheter systems
according to the present invention may comprise an inner catheter
shaft having a proximal end and a distal end. The stenotic material
removal mechanism is disposed near the distal end of the inner
catheter shaft. The inner catheter shaft will preferably include a
guidewire lumen for introduction of the catheter system over a
steerable guidewire. The inner catheter shaft may have additional
lumens or actuating mechanisms associated with the stenotic
material removal mechanism. Various embodiments of the stenotic
material removal mechanism will be more fully described below. In
embodiments where the stenotic material removal mechanism comprises
resilient members which are radially compressible, the catheter
system may also include a tubular sheath which serves to maintain
the stenotic material removal mechanism in a compressed state as it
is maneuvered to, and potentially across, the stenosis. The
catheter system will usually further include an outer catheter tube
having a proximal end, a distal end and an inner lumen. The outer
catheter tube will usually have an aspiration port near its
proximal end so that dislodged stenotic material can be aspirated
from the vasculature. The outer catheter tube may optionally have
selective or subselective curves formed near the distal end of the
catheter tube for directing and maneuvering the catheter system
through the vasculature to the site of the stenosis. In addition,
an outer guiding catheter, for example a coronary guiding catheter,
may be used for guiding the catheter system into the desired part
of the vasculature and supporting it during the treatment.
[0028] The stenotic material removal mechanism which is disposed
near the distal end of the inner catheter shaft may take one of
several possible forms. In a first illustrative embodiment of the
apparatus, the stenotic material removal mechanism is in the form
of a cutting head having a plurality of longitudinally oriented
cutting blades arranged radially about the central axis of the
inner catheter. In a second illustrative embodiment of the
apparatus, the stenotic material removal mechanism is in the form
of a cutting head having a plurality of helically configured
cutting blades arranged radially about the central axis of the
inner catheter. In these first and second illustrative embodiments,
each of the cutting blades is preferably shaped like a flattened
wire with one or both lateral edges of the wire sharpened into a
cutting edge. The wire-shaped cutting blades are resilient so that
they can expand radially outward from the central axis of the inner
catheter. Preferably, the wire-shaped cutting blades maintain an
approximately parallel orientation to one another as they expand
and contract in the radial direction so that the overall
configuration of the cutting head is roughly cylindrical. The
cutting head can be passively expandable, in which case the
resilient wire-shaped cutting blades are treated by coldworking or
heat treatment to have an elastic memory that predisposes them to
expand outward when they are released from the radial constraint of
the tubular sheath. Alternatively, the cutting head can be
configured to be actively and controllably expandable. In this
case, the resilient wire-shaped cutting blades are attached on
their proximal ends to the inner catheter shaft and on their distal
ends to an inner actuating member which is coaxially slidably with
respect to the inner catheter shaft. When the inner actuating
member is moved proximally with respect to the inner catheter
shaft, the resilient wire-shaped cutting blades expand radially
outward from the central axis of the inner catheter, and when the
inner actuating member is moved distally with respect to the inner
catheter shaft, the resilient wire-shaped cutting blades contract
radially inward toward the central axis of the inner catheter. The
resilient wire-shaped cutting blades may be treated by coldworking
or heat treatment to have an elastic memory so that they are biased
toward the contracted position, the expanded position or an
intermediate position, each alternative having various advantages.
The inner actuating member may be tubular, such as a polymer tube,
a hollow flexible cable or a flexible metallic tube, so that the
guidewire lumen can pass coaxially through the inner actuating
member. Alternatively, the inner actuating member may be a thin
wire which runs parallel to and alongside the guidewire lumen.
[0029] The stenotic material removal mechanism is operated by
rotating the cutting head to remove the stenotic material from
within the stent by the cutting action of the longitudinally
oriented cutting blades. The rotating action of the blades may be
accompanied by axially advancing or withdrawing the cutting head
through the stenosis and/or by expanding the width or diameter of
the cutting head. In accordance with the methods described above,
one or more of the longitudinally oriented cutting blades includes
a sensing means for sensing the proximity or contact between the
cutting blades and the stent. The sensing means may be in the form
of one or more electrode wires which are positioned on the cutting
blades. When the sensing means detects sufficient proximity or
contact between the cutting blades and the stent to indicate
effective recanalization of the stenosis, the cutting head is
deactivated and withdrawn from the stented vessel.
[0030] Additionally or alternatively, energy, such as electrical,
ultrasonic or thermal energy may be applied through the cutting
blades to assist in removal of the stenotic material and/or for
denaturing the remaining tissue to discourage further restenosis at
the treatment site. In this case, electrodes used for heating or
ablation can serve double duty as the sensing means electrodes for
monitoring proximity or contact with the stent.
[0031] In a third illustrative embodiment of the apparatus, the
stenotic material removal mechanism is in the form of a blade which
is extendible and retractable from within a cavity or lumen located
near the distal end of the inner catheter. The blade is actuated to
extend radially from the inner catheter by advancing an actuating
member which extends through an inner lumen of the catheter to an
advancement knob located near the proximal end of the inner
catheter. Preferably, the blade maintains an approximately parallel
orientation to the inner catheter as it extends and retracts in the
radial direction. The stenotic material removal mechanism may
operate by cutting action, in which case the blade is preferably
shaped like a flattened wire with one or both lateral edges of the
wire sharpened into a cutting edge, or it may operate by
application of electrical or thermal energy, in which case the
blade may be flat, round or any convenient shape.
[0032] The stenotic material removal mechanism is operated by
advancing the actuating member to extend the blade radially from
the inner catheter, then rotating the catheter about its
longitudinal axis to remove the stenotic material from within the
stent. The rotating action of the blades may be accompanied by
axially advancing or withdrawing the inner catheter through the
stenosis. A sensing means for sensing the proximity or contact
between the blade and the stent is positioned on the blade of the
catheter. The sensing means may be in the form of one or more
electrode wires which are positioned on the cutting blade. If the
stenotic material removal mechanism operates by electrical or
thermal heating or ablation, the heating or ablation electrodes can
also serve as the sensing means electrodes for monitoring proximity
or contact with the stent. When the sensing means detects
sufficient proximity or contact between the blade and the stent to
indicate effective recanalization of the stenosis, the cutting
blade is deactivated and withdrawn from the stented vessel.
[0033] In a fourth illustrative embodiment of the apparatus, the
stenotic material removal mechanism has a cutter positioned within
a housing. The housing has a side aperture which exposes the cutter
and an inflatable balloon located on the back of the housing
opposite the side aperture. The balloon can be inflated to increase
the width or diameter of the stenotic material removal mechanism
and thereby to control the depth of cut and the diameter of the
blood flow channel created. The cutter may be a cup-shaped rotating
blade, a rotating linear or helical blade, a rotating abrasive burr
or a reciprocating or axially movable cutting blade. Additionally
or alternatively, medications, chemicals, ionizing radiation or
energy, such as electrical, magnetic, ultrasonic, hydraulic, pulsed
hydraulic, laser or thermal energy may be applied through the
cutter to assist in removal of the stenotic material and/or for
denaturing the remaining tissue to discourage further restenosis at
the treatment site.
[0034] The stenotic material removal mechanism is positioned by
advancing the inner catheter so that the side aperture of the
housing is situated across the stenosis within the stent and
inflating the balloon to press the side aperture against the
stenotic material. Then, the cutter is actuated by rotating and/or
by axially advancing the cutter within the housing to remove
stenotic material from within the stent. A sensing means for
sensing the proximity or contact between the stenotic material
removal mechanism and the stent is positioned on the cutter and/or
the housing of the catheter. Again, the sensing means may be in the
form of one or more electrode wires which are positioned on the
cutter and/or the housing. If the stenotic material removal
mechanism operates by electrical or thermal heating or ablation,
the heating or ablation electrodes can also serve as the sensing
means electrodes for monitoring proximity or contact with the
stent. When the sensing means detects sufficient proximity or
contact between the cutter and the stent to indicate the desired
depth of cut, the cutter is deactivated and withdrawn or directed
to another part of the stenosis within the stented portion of the
vessel.
[0035] In a fifth illustrative embodiment of the apparatus, the
stenotic material removal mechanism has a rotating cutting head
attached to a hollow drive cable which is coaxially and rotatably
positioned over a guidewire. The rotating cutting head is typically
spherical or ovoid in shape and has cutting blades, teeth or
abrasive particles on its exterior surface. Optionally, the inner
catheter or guidewire may have a bend or a steering mechanism close
to its distal end for directing the cutting head against the
stenotic material within the stent. Alternatively or additionally,
the cutting head may also have control means for adjusting the
outer diameter of the cutting head. A sensing means for sensing the
proximity or contact between the cutting head and the stent is
positioned on the cutting head. The sensing means may be in the
form of one or more electrodes which are positioned on the cutting
head.
[0036] The stenotic material removal mechanism is operated by
advancing the inner catheter so that the cutting head is positioned
within the stenosis, then rotating the drive cable and the cutting
head to remove stenotic material from within the stent. The
rotating action of the cutting head may be accompanied by axially
advancing or withdrawing the cutting head through the stenosis. The
cutting blades, teeth or abrasive particles on the exterior surface
of the cutting head comminute or pulverize the stenotic material
into fine particles that will not cause embolization downstream of
the treatment site. The optional bend or steering mechanism of the
inner catheter or guidewire may be used for directing the cutting
head against the stenotic material within the stent. Alternatively,
the control means may be used for adjusting the diameter of the
cutting head to achieve effective recanalization of the stented
artery. When the sensing means indicates sufficient proximity or
contact between the cutting head and the stent, the cutting head is
deactivated and withdrawn or directed to another part of the
stenosis within the stented portion of the vessel.
[0037] Each embodiment of the apparatus of the present invention
will also include a monitoring means which couples to the sensor
means of the catheter system through a connection fitting at the
proximal end of the inner catheter. In one preferred embodiment,
the monitoring means includes a voltage source that generates a
direct or alternating current reference voltage which is applied to
a unipolar electrode or applied between two bipolar electrodes
positioned on the stenotic material removal mechanism, and an
electrical monitor for monitoring the electrical conditions at the
sensor electrode or electrodes. The electrical monitor may monitor
the current leakage at the unipolar or bipolar sensor electrode to
detect contact between the sensor electrode and a metallic stent
and/or monitor the complex impedance across bipolar electrodes to
detect proximity between the sensor electrodes and a metallic
stent. The monitoring means may optionally include control means
for deactivating the stenotic material removal mechanism when an
unsafe condition that might lead to stent damage is detected or
when the sensing means indicates an appropriate endpoint for the
stenotic material removal process has been reached.
[0038] In an alternative embodiment, the monitoring means may be an
optical sensor that includes an optical fiber which transmits a
reference beam to a distal end of the catheter and directs it at
the inner surface of the vessel close to the stenotic material
removal mechanism. A photodetector detects the intensity and/or the
wavelength of the light reflected back from the inner surface of
the vessel through the optical fiber. A difference in reflectivity
between the tissue of the vessel wall and the stent material allows
the photodetector to detect proximity and/or contact between the
stenotic material removal mechanism and the stent. In another
alternative embodiment, the monitoring means may be a nonimaging, A
mode ultrasonic scanner which generates a pulsed ultrasonic signal
in a transducer mounted on or near the stenotic material removal
mechanism. Differences in the acoustic impedance between the stent
material and the arterial tissue or stenosis will cause echoes of
the ultrasonic signal back to the transducer. The A mode ultrasonic
scanner analyzes the amplitude and timing of the echoes detected by
the ultrasonic transducer to measure the depth of the stent within
the vessel wall. These two alternative embodiments of the
monitoring means are useful for detection of both metallic and
nonmetallic stents.
[0039] Preferably, each embodiment of the apparatus of the present
invention will also include a motor drive unit which attaches at
the proximal end of the catheter system. The motor drive unit
houses a drive motor which is mechanically coupled to the inner
catheter or the drive cable of the various embodiments to rotate
and/or axially translate the stenotic material removal mechanism.
For use with the first four embodiments of the apparatus described
above, the drive motor is preferably a motor or gear motor which
operates at relatively low speed for rotating the various cutters
at a speed from 500 to 2000 rpm. For use with the fifth embodiment
of the apparatus described above, the drive motor is preferably a
high speed motor which rotates the cutting head at a speed from
2000 to 150000 rpm for effective comminution of the stenotic
material. Alternatively, the stenotic material removal mechanism
may be operated by hand.
[0040] Optionally, the apparatus of the present invention may
further comprise means for collecting and withdrawing the removed
stenotic material from the blood vessel. The means for collection
and withdrawal of the removed stenotic material may include an
irrigation and/or aspiration apparatus attached respectively to the
inner and outer catheters of the catheter assembly. Additionally,
embolic filters or occlusion balloons may be included in the
catheter system for placement upstream and/or downstream of the
treatment site. An embolic filters and other stenotic material
capture means are described for use in conjunction and/or in a
combined apparatus with the stenotic material removal
mechanism.
BRIEF DESCRIPTION OF THE DRAWINGS
[0041] FIG. 1 is a generalized schematic diagram of the apparatus
of the present invention showing the different components of the
catheter system.
[0042] FIG. 2 is a side view of the distal portion of a first
embodiment of the apparatus of the present invention having a
stenotic material removal mechanism having with a plurality of
longitudinally oriented cutting blades shown in the contracted
position.
[0043] FIG. 3 is a side view of the apparatus of FIG. 2 showing the
stenotic material removal mechanism in the expanded position.
[0044] FIG. 4 is a distal end view of the apparatus of FIG. 2 with
the stenotic material removal mechanism in the expanded
position.
[0045] FIG. 5 is a magnified cutaway view of a cutting blade of the
apparatus of FIG. 2 showing the sensor electrodes.
[0046] FIG. 6 is a cross section of the cutting blade of FIG.
5.
[0047] FIG. 7 is a side view of the distal portion of a second
embodiment of the apparatus of the present invention having a
stenotic material removal mechanism having with a plurality of
helically configured cutting blades shown in the expanded
position.
[0048] FIG. 8 is an enlarged distal end view of the apparatus of
FIG. 7 with the stenotic material removal mechanism in the expanded
position.
[0049] FIG. 9 is a magnified cutaway view of a cutting blade of the
apparatus of FIG. 7 showing the sensor electrodes.
[0050] FIG. 10 is a cross section of the cutting blade of FIG.
9.
[0051] FIG. 11 is a side view of the distal portion and the
proximal portion of a third embodiment of the apparatus of the
present invention having a stenotic material removal mechanism with
an extendible and retractable blade shown in the retracted
position.
[0052] FIG. 12 is a side view of the apparatus of FIG. 11 showing
the stenotic material removal mechanism in the extended
position.
[0053] FIG. 13 is a magnified cross section of the cutting blade of
the apparatus of FIG. 11 showing the sensor electrodes.
[0054] FIG. 14 is a side view of the distal portion of a fourth
embodiment of the apparatus of the present invention showing a
directional stenotic material removal mechanism with the balloon in
the inflated position.
[0055] FIG. 15 is a top view of the apparatus of FIG. 14.
[0056] FIG. 16 is a side view of the distal portion and the
proximal portion of a fifth embodiment of the apparatus of the
present invention having an abrasive cutting head.
[0057] FIG. 17 is a magnified view of the cutting head of the
apparatus of FIG. 16 showing the sensor electrodes.
[0058] FIGS. 18, 19, 20 and 21 are a series of drawings
illustrating the method of the present invention using the
apparatus of FIG. 2.
[0059] FIGS. 22, 23, 24 and 25 are a series of drawings
illustrating an alternate method of the present invention using the
apparatus of FIG. 2.
[0060] FIGS. 26, 27, 28 and 29 are a series of drawings
illustrating another alternate method of the present invention
using the apparatus of FIG. 2.
[0061] FIGS. 30, 31 and 32 are a series of drawings illustrating
the operation of an optional embolic filter apparatus which may be
used in conjunction with the method of the present invention.
[0062] FIGS. 33, 34, 35 and 36 are a series of drawings
illustrating the operation of a combined stenotic material removal
mechanism and stenotic material capture mechanism according to the
present invention.
[0063] FIGS. 37, 38 and 39 are a series of drawings illustrating
the operation of an alternate combined stenotic material removal
mechanism and stenotic material capture mechanism according to the
present invention.
[0064] FIG. 40 illustrates a kit including a catheter, a package
and instructions for use according to the present invention.
DESCRIPTION OF THE SPECIFIC EMBODIMENTS
[0065] FIG. 1 is a generalized schematic diagram of the apparatus
of the present invention. The apparatus comprises a catheter system
designed to facilitate percutaneous removal of stenotic material
from within a previously stented region of the vasculature without
damaging or disrupting the implanted stent. In particular, the
catheter system includes an inner catheter shaft 50 having a
proximal end and a distal end, with a stenotic material removal
mechanism 52 mounted near the distal end of the inner catheter
shaft 50 and a sensing means 54 for sensing when the stenotic
material removal mechanism 52 is approaching or contacting the
stent within the vascular wall. The inner catheter shaft 50 will
preferably include a guidewire lumen for introduction of the
catheter system over a steerable guidewire 56. The inner catheter
shaft 50 may have additional lumens or actuating mechanisms
associated with the stenotic material removal mechanism 52. Various
embodiments of the stenotic material removal mechanism 52 will be
more fully described below. In embodiments where the stenotic
material removal mechanism 52 comprises resilient members which are
radially compressible, the catheter system may also include an
optional tubular sheath 58 which serves to maintain the stenotic
material removal mechanism 52 in a compressed state as it is
maneuvered to, and potentially across, the stenosis. The tubular
sheath 58 may be split or scored along its length so that is can be
easily removed from around the inner catheter shaft 50 and
discarded after the stenotic material removal mechanism 52 has been
maneuvered into place. The catheter system will usually further
include an outer catheter tube 60 having a proximal end, a distal
end and an inner lumen. The outer catheter tube will usually have a
hemostasis valve 62 and an aspiration port 64 near its proximal end
so that dislodged stenotic material can be aspirated from the
vasculature. The outer catheter tube 60 may optionally have
selective or subselective curves formed near the distal end of the
outer catheter tube 60 for directing and maneuvering the catheter
system through the vasculature to the site of the stenosis. In
addition, an outer guiding catheter 66, for example a coronary
guiding catheter, may be used for guiding the catheter system into
the desired part of the vasculature and supporting it during the
treatment. The guiding catheter 66 will have a Y-fitting with a
hemostasis valve 68 connected at its proximal end.
[0066] Typically, the outer catheter 60 will have an overall length
of approximately 60 cm to 120 cm, depending on the location of the
vessel to be treated in the patient's body and the point of entry
into the vasculature. For application in peripheral vessels or for
application in the coronary arteries via a brachial artery
insertion, the outer catheter 60 will typically have an overall
length of approximately 60 cm to 90 cm. For application in the
coronary arteries via a percutaneous femoral artery insertion, the
outer catheter 60 will typically have an overall length of
approximately 90 cm to 120 cm. The inner catheter 50 should have an
overall length somewhat longer than the outer catheter 60 so that
the stenotic material removal mechanism 52 can be extended out from
the distal end of the outer catheter 60. The inner catheter 50
should therefore have an overall length of approximately 80 cm to
150 cm so that it can be extended 20 cm to 30 cm beyond the distal
end of the outer catheter 60.
[0067] In a preferred embodiment, the catheter system includes a
motor drive unit 70 which attaches at the proximal end of the inner
catheter shaft 50. The motor drive unit 70 houses a drive motor 72
which is mechanically coupled to the inner catheter shaft 50 to
rotate and/or axially translate the stenotic material removal
mechanism 52 for removing stenotic material from within the stented
vessel. The drive motor 72 may be a low speed motor or gear motor
which operates at a speed from 500 to 2000 rpm or a high speed
motor or a turbine which operates at a speed from 2000 to 150000
rpm. The operating speed of the drive motor 72 will be chosen
according to the particular needs of the stenotic material removal
mechanism 52, as will be discussed in more detail below. In
alternative embodiments, the stenotic material removal mechanism 52
may be operated by hand.
[0068] The catheter system will also include a monitoring means 80
which couples to the sensor means 54 of the catheter system through
a connection fitting 82 on the proximal end of the inner catheter
shaft 50. Typically, the connection fitting 82 will electrically
couple to the monitoring means 80 through a commutator 84 which is
part of the motor drive unit 70. Alternatively, the monitoring
means 80 may be miniaturized and incorporated as an integral part
of the motor drive unit 70. The monitoring means 80 may include an
audible alarm 85 and a visual alarm 86 to indicate contact between
the stenotic material removal mechanism 52 and the stent and/or a
visual gauge 88 of the proximity of the stenotic material removal
mechanism 52 to the stent. The structure and function of the sensor
means 54 and the monitoring means 80 will be discussed in further
detail below.
[0069] Optionally, the catheter system may further include an
embolic filter 90 which may be coaxially deployed over the same
guidewire 56 as the rest of the catheter system. Alternatively,
embolic filters and/or occlusion balloons may be deployed on
separate catheters for placement upstream and/or downstream of the
treatment site.
[0070] The stenotic material removal mechanism which is disposed
near the distal end of the inner catheter shaft may take one of
several possible forms. The distal portion of a first illustrative
embodiment of an inner catheter according to the apparatus of the
present invention is depicted in FIGS. 2-6. In this embodiment, the
stenotic material removal mechanism is in the form of a cutting
head 100 having a plurality of longitudinally oriented cutting
blades 102 arranged radially about the central axis of the inner
catheter shaft 104. The cutting head 100 is shown in a contracted
position in FIG. 2 with the cutting blades 102 compressed closely
around the central axis of the inner catheter shaft 104. FIG. 3
shows the cutting head 100 in an expanded position with the cutting
blades 102 extending radially outward from the central axis of the
inner catheter shaft 104. FIG. 4 shows a distal end view of the
cutting head 100 in the expanded position. In variations of this
embodiment, there may be two, three, four or more longitudinally
oriented cutting blades 102. Each of the cutting blades 102 is
preferably shaped like a flattened wire with one or both lateral
edges 110, 112 of the wire sharpened into a cutting edge, as shown
in the cross section of FIG. 6. The wire-shaped cutting blades 102
are resilient so that they can expand radially outward from the
central axis of the inner catheter shaft 104. Preferably, the
wire-shaped cutting blades 102 maintain an approximately parallel
orientation to one another as they expand and contract in the
radial direction so that the overall configuration of the cutting
head 100 is roughly cylindrical. The cutting blades 102 are
preferably made of a strong and resilient biocompatible material
capable of holding a sharp cutting edge. Suitable materials for the
cutting blades 102 include metals, such as stainless steel,
titanium and nickel/titanium alloys, and cobalt alloys like Elgiloy
and MP35. Composite constructions are also possible for the cutting
blades 102.
[0071] The cutting head 100 can be passively expandable, in which
case the resilient wire-shaped cutting blades 102 are treated by
coldworking or heat treatment to have an elastic memory that
predisposes them to expand outward when they are released from the
radial constraint of the tubular sheath 58 which was shown in FIG.
1. Alternatively, the cutting head 100 can be configured to be
actively and controllably expandable. In this case, the resilient
wire-shaped cutting blades 102 are attached on their proximal ends
to the inner catheter shaft 104 and on their distal ends to an
inner actuating member 106 which is coaxially slidably with respect
to the inner catheter shaft 104. When the inner actuating member
106 is moved proximally with respect to the inner catheter shaft
104, the cutting blades 102 expand radially outward from the
central axis of the inner catheter shaft 104, and when the inner
actuating member 106 is moved distally with respect to the inner
catheter shaft 104, the cutting blades 102 contract radially inward
toward the central axis of the inner catheter shaft 104. The
cutting blades 102 may be treated by coldworking or heat treatment
to have an elastic memory so that they are biased toward the
contracted position so that the cutting head 100 will contract
easily for advancing it across tight stenotic lesions, or toward a
fully expanded position so that the cutting head 100 will be easy
to deploy. Alternatively, the resilient wire-shaped cutting blades
102 may be treated so that they are biased toward an intermediate
position which corresponds with a nominal expanded diameter. The
inner actuating member 106 may be tubular, such as a polymer tube,
a hollow flexible cable or a flexible metallic tube, so that a
lumen 108 for a guidewire 56 can pass coaxially through the inner
actuating member 106. Alternatively, the inner actuating member may
be a thin wire which runs parallel to and alongside the guidewire
lumen.
[0072] The inner catheter shaft 104 is a tubular structure with an
inner lumen 114 for passing the guidewire 56 and, in some
embodiments, the inner actuating member 106 through. The inner
catheter shaft 104 may be a polymer tube, a braid reinforced
polymer tube, a hollow flexible cable, such as a multifilar wound
cable, or a flexible metallic tube. The inner catheter shaft 104
acts as a flexible drive shaft for transmitting rotation and torque
from the drive motor 72 (FIG. 1) to the cutting head 100. The
stenotic material removal mechanism is operated by rotating the
cutting head 100 to remove the stenotic material from within the
stent by the cutting action of the longitudinally oriented cutting
blades 102. The rotating action of the blades 102 may be
accompanied by axially advancing or withdrawing the cutting head
100 through the stenosis and/or by expanding the width or diameter
of the cutting head 100. The cutting head 100 should be expandable
over a range of approximately 2 mm to 5 mm for use in stented
coronary arteries or as high as 6 mm for use in stented vein grafts
and even larger for use in stented peripheral vessels and other
stented body structures. The cutting head 100 should contract to as
small a diameter as possible for passing through tightly stenotic
lesions, preferably to a diameter smaller than 2 mm, more
preferably to a diameter smaller than 1 mm. The effective cutting
length of the cutting head 100 is preferably within the range of
approximately 10 mm to 40 mm for use in stented coronary arteries
and can be longer for use in stented peripheral vessels.
[0073] One or more, or all, of the longitudinally oriented cutting
blades 102 includes a sensing means for sensing the proximity or
contact between the cutting blades 102 and the stent. In this
illustrative embodiment, the sensing means are provided in the form
of one or more electrode wires 116, 118 which are positioned on the
cutting blades, as best seen in FIGS. 5 and 6. The sensing
electrodes 116, 118 may extend the full length of the cutting
blades 102 or only a portion of it, or the sensing electrodes 116,
118 may be arranged to provide a plurality of sensing locations
along the length of the cutting blades 102. In a first
implementation of this embodiment, one or more open, exposed
electrodes 116, 118 are located on the surface of the cutting
blades 102. Alternatively, the cutting blades 102 themselves may
serve as the sensor electrodes. A direct or alternating current
reference voltage is applied to a unipolar electrode or applied
between two bipolar electrodes, and the current leakage of the
electrode or electrodes is monitored. When one or more of the
electrodes 116, 118 contacts the metallic stent, the leakage
current increases indicating that the stenotic material has been
removed down to the stent support members for effective
recanalization of the stenosis within that portion of the stent. A
second implementation of this embodiment involves two capacitively
coupled bipolar electrodes 116, 118 which are located on the
surface of the cutting blades 102. An alternating current reference
voltage is applied between the bipolar electrodes 116, 118, and the
complex impedance between the electrodes is monitored. As the
electrodes 116, 118 approach the metallic stent, the capacitive and
inductive characteristics of the electrode circuit change, which
can be detected as a change in the complex impedance between the
electrodes. When the complex impedance between the electrodes has
changed a sufficient amount to indicate effective recanalization of
the stenosis within that portion of the stent, the stenotic
material removal mechanism may be deactivated or advanced along the
stenosis as appropriate. These two implementations can be combined
by applying an alternating current reference voltage between two
exposed bipolar electrodes 116, 118, and monitoring the complex
impedance between the electrodes to indicate when the stenotic
material removal mechanism is approaching the metallic stent, then
when one or more of the electrodes contacts the metallic stent, it
will ground to the stent which can be detected as an extreme change
in the complex impedance or as a rise in the leakage current. Thus,
the sensing means can be used to separately indicate proximity and
contact between the cutting blades 102 and the stent. The sensing
means can operate with very low voltage and current that will not
create any adverse physiological effects on the vascular wall or
the tissues and nerve pathways of the heart.
[0074] The distal portion of a second illustrative embodiment of an
inner catheter according to the apparatus of the present invention
is depicted in FIGS. 7-10. In this embodiment, the stenotic
material removal mechanism is in the form of a cutting head 120
having a plurality of helically configured cutting blades 122
arranged radially about the central axis of the inner catheter
shaft 124, as shown in FIG. 7. FIG. 8 shows an enlarged distal end
view of the cutting head 120 in the expanded position. In
variations of this embodiment, there may be two, three, four or
more helically configured cutting blades 122. Preferably, each of
the cutting blades 122 is shaped like a flattened wire with one or
both lateral edges 130, 132 of the wire sharpened into a cutting
edge, as shown in the cross section of FIG. 10. Preferably, the
helically configured cutting blades 122 maintain an approximately
parallel orientation to one another as they expand and contract in
the radial direction so that the overall configuration of the
cutting head 120 is roughly cylindrical. The cutting blades 122 are
made of a strong and resilient biocompatible material capable of
holding a sharp cutting edge, such as stainless steel, titanium and
nickel/titanium alloys, and cobalt alloys like Elgiloy and MP35, or
a composite construction.
[0075] As with the first embodiment, the cutting head 120 can be
passively expandable or actively and controllably expandable. In
the latter case, the helically configured cutting blades 122 are
attached on their proximal ends to the inner catheter shaft 124 and
on their distal ends to an inner actuating member 126 which slides
proximally and distally with respect to the inner catheter shaft
124 to expand and contract diameter of the cutting head 120,
respectively. The cutting blades 122 may be treated by coldworking
or heat treatment to have an elastic memory so that they are biased
toward the contracted position, the expanded position or an
intermediate position. The inner actuating member 126 may be
tubular, such as a polymer tube, a hollow flexible cable or a
flexible metallic tube, so that a lumen 128 for a guidewire 56 can
pass coaxially through the inner actuating member 126.
Alternatively, the inner actuating member may be a thin wire which
runs parallel to and alongside the guidewire lumen.
[0076] The inner catheter shaft 124 is a tubular structure with an
inner lumen 134 for passing the guidewire 56 and, in some cases,
the inner actuating member 126 through. The inner catheter shaft
124 may be a polymer tube, a braid reinforced polymer tube, a
hollow flexible cable, such as a multifilar wound cable, or a
flexible metallic tube that serves as a flexible drive shaft for
transmitting rotation and torque from the drive motor 72 (FIG. 1)
to the cutting head 120. The stenotic material removal mechanism is
operated by rotating the cutting head 120 to remove the stenotic
material from within the stent by the cutting action of the
helically configured cutting blades 122. The rotating action of the
blades 122 may be accompanied by axially advancing or withdrawing
the cutting head 120 through the stenosis and/or by expanding the
width or diameter of the cutting head 120. The cutting head 120
should be expandable over a range of approximately 2 mm to 5 mm for
use in stented coronary arteries or as high as 6 mm for use in
stented vein grafts and even larger for use in stented peripheral
vessels and other stented body structures. The cutting head 120
should contract to as small a diameter as possible for passing
through tightly stenotic lesions, preferably to a diameter smaller
than 2 mm, more preferably to a diameter smaller than 1 mm. The
effective cutting length of the cutting head 120 is preferably
within the range of approximately 10 mm to 40 mm for use in stented
coronary arteries and can be longer for use in stented peripheral
vessels.
[0077] One or more, or all, of the helically configured cutting
blades 122 includes a sensing means for sensing the proximity or
contact between the cutting blades 122 and the stent. As shown in
FIGS. 9 and 10, the sensing means may be in the form of one or more
electrode wires 136, 138 which are positioned on the surface of the
cutting blades 122. The sensing electrodes 136, 138 may extend the
full length of the cutting blades 122 or only a portion of it, or
the sensing electrodes 136, 138 may be arranged to provide a
plurality of sensing locations along the length of the cutting
blades 122. As in the first embodiment described above, the
electrodes 136, 138 may be exposed or insulated and unipolar or
bipolar. Alternatively, the cutting blades 122 themselves may serve
as the sensor electrodes. Contact and/or proximity between the
cutting blades 122 and the stent can be monitored by sensing the
leakage current and/or the complex impedance of the sensor
electrode circuit. When the sensing means detects sufficient
proximity or contact between the cutting blades 122 and the stent
to indicate effective recanalization of the stenosis within that
portion of the stent, the cutting head 120 may be deactivated or
advanced along the stenosis as appropriate.
[0078] The distal portion and the proximal portion of a third
illustrative embodiment of an inner catheter according to the
apparatus of the present invention is depicted in FIGS. 11-13. In
this embodiment, the stenotic material removal mechanism is in the
form of a blade 140 which is extendible and retractable from within
a cavity 142 located near the distal end of the inner catheter
shaft 144. The blade 140 is actuated to extend radially from the
inner catheter shaft 144 by advancing an actuating member 146 which
extends through an inner lumen 148 of the catheter to an
advancement knob 152 which is located on a handle assembly 150 near
the proximal end of the inner catheter shaft 144. FIG. 11 is a side
view of the inner catheter with the blade 140 on the distal portion
of the inner catheter shaft 144 and the advancement knob 152 on the
proximal handle assembly 150 in the retracted position. FIG. 12 is
a side view of the inner catheter with the blade 140 and the
advancement knob 152 in the extended position. Preferably, the
blade 140 maintains an approximately parallel orientation to the
inner catheter shaft 144 as it extends and retracts in the radial
direction. The blade 140 may be treated by coldworking or heat
treatment to have an elastic memory so that it is biased toward the
retracted position, in which case the blade 140 will be extended by
a compression force applied to the actuating member 146 by the
advancement knob 152 on the handle assembly 150. Alternatively, the
blade 140 may be treated to be biased toward the extended position,
in which case the blade 140 will be self-extending and will be
retracted by a tensile force applied to the actuating member 146 by
the advancement knob 152. Accordingly, the actuating member 146 may
be a thin wire, a flexible cable, or a thin tensile filament.
[0079] The inner catheter shaft 144 is a tubular structure with an
inner lumen 162 which extends to the distal end for passing a
guidewire 56 through for directing the catheter into and across a
stented region in an artery. The inner catheter shaft 144 may be a
polymer tube, a braid reinforced polymer tube, a hollow flexible
cable, such as a multifilar wound cable, or a flexible metallic
tube. Preferably, the inner catheter shaft 144 has sufficient
torsional rigidity to serve as a flexible drive shaft for
transmitting rotation and torque from the proximal handle assembly
150 to the blade 140 on the distal end of the inner catheter shaft
144. The torque may be applied to the proximal handle assembly 150
manually by the operator or the proximal handle assembly 150 may
include a drive motor 72, as in FIG. 1.
[0080] The stenotic material removal mechanism is operated by
advancing the actuating member 146 to extend the blade 140 radially
from the inner catheter shaft 144, then rotating the catheter shaft
144 about its longitudinal axis to remove the stenotic material
from within the stent. The rotating action of the blade 140 may be
accompanied by axially advancing or withdrawing the inner catheter
through the stenosis. In one preferred embodiment, the stenotic
material removal mechanism of the inner catheter operates by
cutting action, in which case the blade 140 is preferably shaped
like a flattened wire with one or both lateral edges 154, 156 of
the wire sharpened into a cutting edge, as shown in the magnified
cross section of the cutting blade in FIG. 13. The cutting blade
140 is made of a strong and resilient biocompatible material
capable of holding a sharp cutting edge, such as stainless steel,
titanium and nickel/titanium alloys, and cobalt alloys like Elgiloy
and MP35, or a composite construction. The cutting blade 140
includes a sensing means for sensing the proximity or contact
between the cutting blade 140 and the stent. As shown in FIG. 13,
the sensing means may be in the form of one or more electrode wires
158, 160 which are positioned on the surface of the cutting blade
140. The electrodes 158, 160 may be exposed or insulated and
unipolar or bipolar. Alternatively, the cutting blade 140 itself
may serve as a unipolar sensor electrode. Contact and/or proximity
between the cutting blade 140 and the stent can be monitored by
sensing the leakage current and/or the complex impedance of the
sensor electrode circuit. When the sensing means detects sufficient
proximity or contact between the cutting blade 140 and the stent to
indicate effective recanalization of the stenosis within that
portion of the stent, the cutting head 120 may be deactivated or
advanced along the stenosis as appropriate.
[0081] Additionally or alternatively, energy, such as electrical,
ultrasonic or thermal energy may be applied through the blade 140
to assist in removal of the stenotic material and/or for denaturing
the remaining tissue to discourage further restenosis at the
treatment site. In this case, electrodes used for heating or
ablation can also serve as the sensing means electrodes for
monitoring proximity or contact with the stent. If the device
relies principally on ablation as the stenotic material removal
technique, the blade 140 need not be sharpened as shown, but may
instead be flat, round or any convenient shape.
[0082] The distal portion of a fourth illustrative embodiment of an
inner catheter according to the apparatus of the present invention
is depicted in FIGS. 14-15. In this embodiment, the stenotic
material removal mechanism 170 has a cutter 172 positioned within a
housing 174. The housing 174 has a side aperture 176 which exposes
the cutter 172 and an inflatable balloon 180 located on the back of
the housing 174 opposite the side aperture 176. The balloon 180 can
be inflated with fluid injected through a balloon lumen 182 to
increase the width or diameter of the stenotic material removal
mechanism 170 and thereby to control the depth of cut and the
diameter of the blood flow channel created. The balloon 180 may be
made of polyethylene, polyester, nylon or other polymeric
materials. The cutter 172 may be a cup-shaped rotating blade, a
rotating linear or helical blade, a rotating abrasive burr or an
axially movable cutting blade, which is rotated and/or translated
by a drive shaft 178 that extends proximally through a lumen 186
within the catheter shaft 184. Additionally or alternatively,
medications, chemicals, ionizing radiation or energy, such as
electrical, magnetic, ultrasonic, hydraulic, pulsed hydraulic,
laser or thermal energy may be applied through the cutter 172 to
assist in removal of the stenotic material and/or for denaturing
the remaining tissue to discourage further restenosis at the
treatment site.
[0083] The catheter shaft 184 is a tubular structure which includes
the balloon lumen 182 and the drive shaft lumen 186. The catheter
shaft 184 may be a polymer tube, a braid reinforced polymer tube, a
hollow flexible cable, such as a multifilar wound cable, or a
flexible metallic tube. Preferably, the catheter shaft 184 has
sufficient torsional rigidity to rotate the housing 174 on the
distal end of the catheter by rotating the proximal end of the
catheter shaft 184. The drive shaft 178 may be a hollow tube with a
guidewire lumen 190 which extends to the distal end for passing a
guidewire 56 through for directing the catheter into and across a
stented region in an artery. The drive shaft 178 may be a polymer
tube, a braid reinforced polymer tube, a hollow flexible cable,
such as a multifilar wound cable, or a flexible metallic tube.
Alternatively, the drive shaft 178 may be a solid wire, in which
case the guidewire lumen 190 could be a separate lumen within the
catheter shaft 184.
[0084] In operation, the stenotic material removal mechanism 170 is
positioned by advancing and rotating the inner catheter so that the
side aperture 176 of the housing 174 is situated across the
stenosis within the stent and inflating the balloon 180 to press
the side aperture 176 against the stenotic material. Then, the
cutter 172 is actuated by rotating and/or by axially advancing the
cutter 172 within the housing 174 to remove stenotic material from
within the stent. A sensing means 188, 188' for sensing the
proximity or contact between the stenotic material removal
mechanism 170 and the stent is positioned on the cutter 172 and/or
the housing 174 of the catheter. Again, the sensing means 188, 188'
may be in the form of one or more electrode wires which are
positioned on the cutter 172 and/or the housing 174. If the
stenotic material removal mechanism 170 operates by electrical or
thermal heating or ablation, the heating or ablation electrodes can
also serve as the sensing means electrodes for monitoring proximity
or contact with the stent. When the sensing means detects
sufficient proximity or contact between the cutter 172 and the
stent to indicate the desired depth of cut, the cutter 172 is
deactivated and withdrawn or directed to another part of the
stenosis within the stented portion of the vessel.
[0085] The distal portion of a fifth illustrative embodiment of an
inner catheter according to the apparatus of the present invention
is depicted in FIGS. 16-17. In this embodiment, the stenotic
material removal mechanism is rotatably and slidably received
within an inner lumen 212 of the inner catheter shaft 210. The
stenotic material removal mechanism has a rotating cutting head 200
attached to a hollow drive cable 202 which is coaxially and
rotatably positioned over a guidewire 204. The rotating cutting
head 200 is typically spherical or ovoid in shape and has cutting
blades, teeth or abrasive particles 206 on its exterior surface. In
one preferred embodiment, the cutting head 200 has minute diamond
abrasive particles 206 embedded on its exterior surface. The hollow
drive cable 202 is preferably a multifilar wound cable, but
alternatively may be a polymer tube, a braid reinforced polymer
tube, a hollow flexible cable or a flexible metallic tube.
Optionally, the inner catheter shaft 210 and/or the guidewire 204
may have a bend 214, 216 or other steering mechanism close to its
distal end for directing the cutting head 200 against the stenotic
material within the stent. Alternatively or additionally, the
cutting head 200 may also have control means for adjusting the
outer diameter of the cutting head 200. Suitable cutting head
diameter control means are described in U.S. Pat. Nos. 5,217,474
and 5,308,354, the specifications of which are hereby incorporated
by reference in their entirety.
[0086] A sensing means for sensing the proximity or contact between
the cutting head 200 and the stent is positioned on the cutting
head 200. The sensing means may be in the form of one or more
electrodes 218, 220 which are positioned on the cutting head 200.
One or more electrode lead wires 222, 224 may be incorporated into
the multifilar hollow drive cable 202. The electrodes 218, 220 may
be exposed or insulated and unipolar or bipolar. Alternatively, the
cutting head 200 itself may serve as a unipolar sensor electrode
and the multifilar hollow drive cable 202 may serve as a single
electrode lead wire.
[0087] The stenotic material removal mechanism is operated by
advancing the inner catheter so that the cutting head 200 is
positioned within the stenosis, then rotating the drive cable 202
and the cutting head 200 to remove stenotic material from within
the stent. Preferably, the cutting head 200 is rotated with a high
speed motor or turbine which rotates the cutting head at a speed
from 2000 to 150000 rpm. The rotating action of the cutting head
200 may be accompanied by axially advancing or withdrawing the
cutting head 200 through the stenosis. The cutting blades, teeth or
abrasive particles 206 on the exterior surface of the cutting head
200 comminute, or pulverize, the stenotic material into fine
particles that will not cause embolization downstream of the
treatment site. The optional bend 214, 216 or steering mechanism of
the inner catheter 210 or guidewire 204 may be used for directing
the cutting head 200 against the stenotic material within the
stent. Alternatively, the control means may be used for adjusting
the diameter of the cutting head 200 to achieve effective
recanalization of the stented artery. When the sensing means
indicates sufficient proximity or contact between the cutting head
200 and the stent, the cutting head 200 is deactivated and
withdrawn or advanced and directed to another part of the stenosis
within the stented portion of the vessel.
[0088] The function of the monitoring means 80 of the catheter
system, shown generically in FIG. 1, will be more fully appreciated
in light of the foregoing descriptions of the various embodiments
of the stenotic material removal mechanism and their related
sensing means. In one preferred embodiment, the monitoring means
includes a voltage source that generates a direct or alternating
current reference voltage which is applied to a unipolar electrode
or applied between two bipolar electrodes positioned on the
stenotic material removal mechanism, and an electrical monitor for
monitoring the electrical conditions at the sensor electrode or
electrodes. The electrical monitor may monitor the current leakage
at the unipolar or bipolar sensor electrode to detect contact
between the sensor electrode and a metallic stent and/or monitor
the complex impedance across bipolar electrodes to detect proximity
between the sensor electrodes and a metallic stent. The monitoring
means may optionally include control means for deactivating the
stenotic material removal mechanism when an unsafe condition that
might lead to stent damage is detected or when the sensing means
indicates that an appropriate endpoint for the stenotic material
removal process has been reached.
[0089] In cases where the sensing means provides separate sensing
electrodes on the different blades of the stenotic material removal
mechanism or where a plurality of sensing locations are provided
along the length of the stenotic material removal mechanism, the
monitoring means 80 can be designed to monitor each of the multiple
electrodes or sensing locations simultaneously, or it can be
designed to have an appropriate sampling rate for alternately
monitoring each of the electrodes or sensing locations in
sequence.
[0090] In an alternative embodiment, the monitoring means may be an
optical sensor that includes an optical fiber which transmits a
reference beam to a distal end of the catheter and directs it at
the inner surface of the vessel close to the stenotic material
removal mechanism. A photodetector detects the intensity and/or the
wavelength of the light reflected back from the inner surface of
the vessel through the optical fiber. A difference in reflectivity
between the tissue of the vessel wall and the stent material allows
the photodetector to detect proximity and/or contact between the
stenotic material removal mechanism and the stent.
[0091] In another alternative embodiment, the monitoring means may
be a nonimaging, A mode ultrasonic scanner which generates a pulsed
ultrasonic signal in a transducer mounted on or near the stenotic
material removal mechanism. Differences in the acoustic impedance
between the stent material and the arterial tissue or stenosis will
cause echoes of the ultrasonic signal back to the transducer. The A
mode ultrasonic scanner analyzes the amplitude and timing of the
echoes detected by the ultrasonic transducer to measure the depth
of the stent within the vessel wall. These two alternative
embodiments of the monitoring means are useful for detection of
both metallic and nonmetallic stents. A nonimaging, A mode
ultrasonic scanner of this type is much more economical than the
imaging ultrasonic scanners which have been described in
combination with various atherectomy devices. The high echogenicity
of the stent material will give a reliable measure of the depth of
the stent within the vessel wall without the need for expensive
imaging equipment.
[0092] FIGS. 18, 19, 20 and 21 are a series of drawings
illustrating the method of the present invention. The method is
illustrated and described using the apparatus of FIG. 1 with the
stenotic material removal mechanism of FIGS. 2-6 by way of example.
This method may be applied using any of the various apparatus
described above with minor modifications to the procedure. The
catheter system of FIG. 1 is introduced into the patient's vascular
system through a peripheral arterial access using the known
techniques of an arterial cutdown, the Seldinger technique and/or
an introducer sheath. The catheter system is maneuvered to the
vicinity of a restenosed region within a previously stented region
of the vasculature, for example within a coronary artery, using
manipulations of the optional guiding catheter 66 and the outer
catheter 60 of the catheter system. The inner catheter 50 carrying
the stenotic material removal mechanism 52 is positioned on one
side of the restenosed stented region and the steerable guidewire
56 is maneuvered across the stenosis.
[0093] Referring now to FIG. 18, the cutting head 100 of the
stenotic material removal mechanism is advanced from the inner
catheter in the contracted position and positioned across the
stenosis S within the stent T. The cutting head 100 is then
expanded within the stenosis S, as shown in FIG. 19. The expansion
may occur passively, by withdrawing the optional tubular sheath 58
(shown in FIG. 1) and allowing the resilient cutting blades 102 of
the cutting head 100 to expand outward. Alternatively, the
expansion may occur actively and controllably, by withdrawing the
inner actuating member 106 to expand the cutting blades 102 outward
and increase the width or diameter of the cutting head 100. The
stenotic material removal mechanism is then activated by rotating
the cutting head 100 to remove the stenotic material M from within
the stenosis S. The cutting head 100 may be manually rotated by the
operator or by a drive motor 72 within a motor drive unit 70, as
shown in FIG. 1. Medications, chemicals, ionizing radiation or
energy, such as electrical, magnetic, ultrasonic, hydraulic, pulsed
hydraulic, laser or thermal energy may be applied to assist in
removal of the stenotic material M and/or for denaturing the
remaining tissue to discourage further restenosis at the treatment
site. The stenotic material M that is removed may be aspirated out
through the aspiration port 64 of the outer catheter 60 (shown in
FIG. 1). The electrodes 116, 118 of the sensing means located on
the cutting blades 102 monitor the proximity or contact between the
cutting head 100 and the stent T. When the cutting blades 102 have
approached close enough to the stent T to indicate effective
recanalization of the stenosis S, as shown in FIG. 20, the stenotic
material removal mechanism is deactivated. The catheter system is
then withdrawn, leaving the stented region recanalized and open to
renewed blood flow, as shown in FIG. 21.
[0094] FIGS. 22, 23, 24 and 25 are a series of drawings
illustrating an alternate method of the present invention. As
above, the method is illustrated and described using the stenotic
material removal mechanism of FIGS. 2-6, but the method may be
applied using most of the various apparatus described above with
minor modifications to the procedure. In this alternative method,
the catheter carrying the stenotic material removal mechanism is
positioned on one side of the restenosed stented region. The
cutting head 100 of the stenotic material removal mechanism is
extended from the catheter and advanced part-way into the stent T
and the cutting blades 102 are expanded outward, as shown in FIG.
22. The electrodes 116, 118 of the sensing means located on the
cutting blades 102 monitor the proximity or contact between the
cutting head 100 and the stent T so that the diameter of the
cutting head 100 can be accommodated to the internal diameter of
the stent T. If the stenosis S does not extend all of the way to
the end of the stent T, the expansion step can be performed while
the cutting head 100 is stationary. However, if necessary, the
stenotic material removal mechanism can be activated by rotating
the cutting head 100 as the cutting blades 102 expand outward to
begin removing the stenotic material M while adjusting the diameter
of the cutting head 100 to the size of the stent T.
[0095] The stenotic material M is removed from within the stent T
by rotating the cutting head 100 and advancing it through the
stenosis S, as shown in FIGS. 23 and 24. The diameter of the
cutting head 100 can be held constant as it is advanced through the
stenosis S or it can be adjusted continuously based on feedback
from the sensing means. Medications, chemicals, ionizing radiation
or energy, such as electrical, magnetic, ultrasonic, hydraulic,
pulsed hydraulic, laser or thermal energy may be applied to assist
in removal of the stenotic material M and/or for denaturing the
remaining tissue to discourage further restenosis at the treatment
site. The stenotic material M that is removed may be aspirated out
through the aspiration port 64 of the outer catheter 60 (shown in
FIG. 1). When the cutting head 100 has passed all the way through
the stenosis S, the stenotic material removal mechanism is
deactivated and the catheter system is withdrawn, leaving the
stented region recanalized and open to renewed blood flow, as shown
in FIG. 25.
[0096] This method can be effectively performed in the reverse
direction, by advancing the cutting head 100 all the way across the
stenosis in a contracted or compressed state. The cutting head 100
is then expanded within the far end of the stenosis S or within the
vessel beyond the stenosis, using the sensing means to adjust the
diameter of the cutting head 100 to the size of the stent T. The
cutting head 100 is then rotated while withdrawing it toward the
catheter to advance it through the stenosis S.
[0097] FIGS. 26, 27, 28 and 29 are a series of drawings
illustrating another alternate method of the present invention.
Once again, the method is illustrated and described using the
stenotic material removal mechanism of FIGS. 2-6, but the method
may be applied using most of the various apparatus described above
with minor modifications to the procedure. In this alternative
method, the catheter carrying the stenotic material removal
mechanism is positioned on one side of the restenosed stented
region. The cutting head 100 of the stenotic material removal
mechanism is extended from the catheter and advanced part-way into
the stenosis S within the stent T, as shown in FIG. 26. The cutting
blades 102 are then expanded outward within the stenosis S, either
passively or actively and controllably as described above, to
increase the width or diameter of the cutting head 100. The
stenotic material removal mechanism is then activated by rotating
the cutting head 100 to begin removing the stenotic material M from
within the stenosis S, as shown in FIG. 27. Medications, chemicals,
ionizing radiation or energy, such as electrical, magnetic,
ultrasonic, hydraulic, pulsed hydraulic, laser or thermal energy
may be applied to assist in removal of the stenotic material M
and/or for denaturing the remaining tissue to discourage further
restenosis at the treatment site. The stenotic material M that is
removed may be aspirated out through the aspiration port 64 of the
outer catheter 60 (shown in FIG. 1). The electrodes 116, 118 of the
sensing means located on the cutting blades 102 monitor the
proximity or contact between the cutting head 100 and the stent T.
When the cutting blades 102 have approached close enough to the
stent T to indicate effective recanalization of that portion of the
stenosis S, the cutting head 100 is advanced farther into the
stenosis S, as shown in FIG. 28. The stenotic material removal
mechanism may be deactivated and advanced step-wise into the
stenosis S by contracting or compressing the cutting head 100,
advancing it a short distance and expanding it again in a new
portion of the stent T. Otherwise, the cutting head 100 may be
advanced continuously, relying on either the resiliency of the
cutting blades 102 or active control for adjusting the width or
diameter of the cutting head 100 as it advances. When the sensing
means indicates that the new portion of the stent T has been
effectively recanalized, the cutting head 100 is advanced again
along the stenosis S until the entire stented region has been
recanalized, as shown in FIG. 29.
[0098] This method can be effectively performed in the reverse
direction, by advancing the cutting head 100 all the way across the
stenosis in a contracted or compressed state. The cutting head 100
is then expanded within the far end of the stenosis S or within the
vessel beyond the stenosis, either passively or actively and
controllably as described above, to increase the width or diameter
of the cutting head 100. The cutting head 100 is then rotated while
withdrawing it toward the catheter to advance it through the
stenosis in either a step-wise or continuous fashion. Medications,
chemicals, ionizing radiation or energy, such as electrical,
magnetic, ultrasonic, hydraulic, pulsed hydraulic, laser or thermal
energy may be applied to assist in removal of the stenotic material
and/or for denaturing the remaining tissue to discourage further
restenosis at the treatment site. The sensing means is used to
monitor the proximity or contact between the cutting head 100 and
the stent T in order to control the diameter and/or the rate of
advancement of the cutting head 100 for effective recanalization of
the stenosis S within the stent T.
[0099] The methods of the present invention will optionally further
comprise collecting and withdrawing the removed stenotic material
from the blood vessel. FIGS. 30, 31 and 32 are a series of drawings
illustrating the operation of an optional embolic filter apparatus
90 which may be used in conjunction with the method of the present
invention. The embolic filter apparatus 90 may be arranged
coaxially as part of the catheter system as shown in FIG. 1 and
introduced through a single vascular access point and positioned
distally to the treatment site. Alternatively, embolic filter
apparatus 90 may be arranged on a separate catheter which is
introduced through a different vascular access point and positioned
proximally or distally to the treatment site.
[0100] In FIG. 30, the embolic filter 90 is shown in its compacted
position within a tubular sheath 92 as it is first introduced into
the vasculature and advanced to or across the stenosis. In coaxial
arrangements, the tubular sheath 92 may be the same as the tubular
sheath 58 or the inner catheter 50 of the catheter system of FIG.
1. The embolic filter 90 may be delivered coaxially over a separate
guidewire 56, or it may be built integrally with a guidewire 56
constructed especially for the purpose. Once the embolic filter 90
is in position, the tubular sheath 92 is withdrawn and the embolic
filter 90 is allowed to expand to the full diameter of the vessel,
as shown in FIG. 31. The expansion can occur passively, or an
actuation member 94 may be used to actively expand the embolic
filter 90. The embolic filter 90 should be expandable over a range
of approximately 2 mm to 5 mm for use in stented coronary arteries
or as high as 6 mm for use in stented vein grafts and even larger
for use in stented peripheral vessels and other stented body
structures. The embolic filter 90 should contract to as small a
diameter as possible for passing through tightly stenotic lesions,
preferably to a diameter smaller than 2 mm, more preferably to a
diameter smaller than 1 mm. The embolic filter 90 has a plurality
of structural members 96, which enclose and support a
nonthrombogenic expandable filter medium 98. The structural members
96 can be made of a metallic or polymeric material, and may be
biased radially outward to assist in expansion of the embolic
filter 90. The expandable filter medium 98 may be a porous foam
material or it may be a fibrous filter medium such as polyester
fiber, which, in its expanded state, has a pore size appropriate
for capturing significant emboli which may be dislodged during the
stenotic material removal process. The pore size of the expandable
filter medium 98 may advantageously be in the range of 0.01 to 0.2
mm to capture potential emboli. Once the stenotic material removal
procedure has been completed, the embolic filter 90 is compressed
slightly, by passive or active means, and withdrawn into an outer
catheter 99, to capture the emboli without releasing them, as shown
in FIG. 32. In coaxial arrangements, the outer catheter 99 may be
the inner catheter 50 or outer catheter 60 of the catheter system
of FIG. 1. The outer catheter 99 and the embolic filter 90 are then
withdrawn from the patient's vasculature. In other alternative
methods, embolic filters and/or occlusion balloons may be placed
upstream and downstream of the treatment site to isolate or capture
potential emboli.
[0101] FIGS. 33, 34, 35 and 36 are a series of drawings
illustrating a method and an apparatus according to the present
invention that combine a stenotic material removal mechanism with
an embolic filter for capturing stenotic material M which is
removed from within the stent T. The apparatus has a cutting head
300 which is mounted on the distal end of an inner catheter shaft
302. The cutting head 300 has a cutting portion 304 and a filtering
or material capturing portion 306. In this illustrative embodiment,
the cutting portion 304 is centrally located on the cutting head
300 and the material capturing portion 306 is located distal to it.
The cutting head 300 should be expandable over a range of
approximately 2 mm to 5 mm for use in stented coronary arteries or
as high as 6 mm for use in stented vein grafts and even larger for
use in stented peripheral vessels and other stented body
structures. The cutting head 300 should contract to as small a
diameter as possible for passing through tightly stenotic lesions,
preferably to a diameter smaller than 2 mm, more preferably to a
diameter smaller than 1 mm. The effective cutting length of the
cutting portion 304 is preferably within the range of approximately
10 mm to 40 mm for use in stented coronary arteries and can be
longer for use in stented peripheral vessels. Additionally or
alternatively, the cutting head 300 may also include a second
material capturing portion 306' located proximally to the cutting
portion 304. Alternatively, the material capturing portion 306 may
occupy the entire length of the cutting head 300. The cutting
portion 304 of the cutting head 300 may take any one of the
different forms described herein in connection with the various
embodiments of the invention. For illustrative purposes, the
cutting portion 304 is shown having a plurality of longitudinally
oriented cutting blades 308, similar to those shown in FIGS. 2-6.
Alternatively, the cutting blades may be laterally or
circumferentially oriented or helically configured, similar to
those shown in FIGS. 7-10, or any convenient geometry. The cutting
blades 308 of the cutting head 300 may be either passively or
actively expandable, as described above.
[0102] The material capturing portion 306 preferably contains a
nonthrombogenic expandable filter medium 310. The expandable filter
medium 310 may be a porous foam material or it may be a fibrous
filter medium such as polyester fiber, which, in its expanded
state, has a pore size appropriate for capturing significant emboli
which may be dislodged during the stenotic material removal
process. The pore size of the expandable filter medium 310 may
advantageously be in the range of 0.01 to 0.2 mm to capture
potential emboli. The expandable filter medium 310 is enclosed and
supported by the cutting blades 308 of the cutting head 300.
Additionally or alternatively, the expandable filter medium 310 may
include a membranous filter material that is attached to and
suspended between the cutting blades 308 of the cutting head 300.
Suitable membranous filter materials include flexible woven,
nonwoven or knitted filtration fabrics. The expandable filter
medium 310 occupies a distal portion 306 and/or a proximal portion
306' of the cutting head 300. Alternatively, the expandable filter
medium 310 may occupy the entire length of the cutting head
300.
[0103] In use, the catheter carrying the stenotic material removal
mechanism is positioned on one side of the restenosed stented
region. The cutting head 300 is extended from the catheter and
advanced across the stenosis S in the contracted position, as shown
in FIG. 33. The expandable filter medium 310 is compressed within
the cutting head 300. The cutting head 300 is then expanded within
the stenosis S, as shown in FIG. 34. The expansion may occur
passively, by withdrawing a surrounding tubular sheath 58 (shown in
FIG. 1) and allowing the resilient cutting blades 308 of the
cutting head 300 to expand outward. Alternatively, the expansion
may occur actively and controllably, by operating an actuating
mechanism to expand the cutting blades 308 outward and increase the
width or diameter of the cutting head 300, as described above in
connection with FIGS. 2-6. Preferably, the filter medium 310 within
the material capturing portion 306 of the cutting head 300 expands
to a diameter at least as large or larger than the expanded
diameter of the cutting portion 304 of the cutting head 300. The
stenotic material removal mechanism is then activated by rotating
the cutting head 300 to remove the stenotic material M from within
the stenosis S. The cutting head 300 may be rotated manually by the
operator or by a drive motor 72 within a -motor drive unit 70, as
shown in FIG. 1. Medications, chemicals, ionizing radiation or
energy, such as electrical, magnetic, ultrasonic, hydraulic, pulsed
hydraulic, laser or thermal energy may be applied to assist in
removal of the stenotic material M and/or for denaturing the
remaining tissue to discourage further restenosis at the treatment
site. The stenotic material M that is removed is captured by the
filter medium 310 within the material capturing portion 306 of the
cutting head 300, as shown in FIG. 35.
[0104] Preferably, the cutting head 300 includes a sensing means,
such as the sensor electrodes 116, 118 described above in
connection with FIGS. 5 and 6, for sensing the proximity or contact
between the cutting blades 308 of the cutting head 300 and the
stent T. When the cutting blades 308 have approached close enough
to the stent T to indicate effective recanalization of the stenosis
S, as shown in FIG. 35, the stenotic material removal mechanism is
deactivated. The cutting head 300 and all of the stenotic material
M captured by the filter medium 310 within the material capturing
portion 306 of the cutting head 300 are then withdrawn into the
outer catheter 60, as shown in FIG. 36. The catheter system is then
withdrawn from the patient, leaving the stented region recanalized
and open to renewed blood flow.
[0105] Alternatively, this cutting head 300 with a combined
stenotic material removal mechanism and stenotic material capture
mechanism may be operated as a simple shearing body without a
sensing means. In this alternative method, the cutting head 300 may
be rotated and/or translated within the stenosis S to dislodge
stenotic material M from within an interface envelope defined by
the stent T embedded within the vessel wall, as shown in FIG. 34.
The cutting head 300 may be expanded passively or actively to
remove all of the stenotic material M from within the stent T. The
stenotic material M that is removed is captured by the filter
medium 310 within the material capturing portion 306 of the cutting
head 300, as shown in FIG. 35. The cutting head 300 and all of the
stenotic material M captured by the filter medium 310 within the
material capturing portion 306 of the cutting head 300 are then
withdrawn into the outer catheter 60, as shown in FIG. 36.
[0106] FIGS. 37, 38 and 39 are a series of drawings illustrating an
alternate method and apparatus according to the present invention
that also combine a stenotic material removal mechanism with a
means for capturing the stenotic material M that is removed from
within the stent T. The apparatus has a head 350 which is mounted
on the distal end of an inner catheter shaft 352. The head 350 is a
cage-like structure of counterwound or interwoven helical elements
356. The helical elements 356 may comprise round filaments, ribbon
filaments, or the like, made of a metallic or polymeric material.
The helical elements 356 are attached to a distal ring 358 and to a
proximal ring 360 which is free to slide over the inner catheter
shaft 352. The helical elements 356 may be treated by coldworking
or heat treatment to have an elastic memory so that they are biased
toward the expanded position, allowing the head 350 to be passively
expanded. Alternatively, the proximal ring 360 may optionally be
attached to a rod, sleeve, or other means 362 for axially
translating the proximal ring 360 to actively and controllably
adjust the radius of the head 350. The cage-like structure of
counterwound or interwoven helical elements 356 serves to capture
dislodged stenotic material M that passes through the interstices
between the helical elements 356.
[0107] In use, the catheter 60 carrying the stenotic material
removal mechanism is positioned on one side of the restenosed
stented region. The head 350 is extended from the catheter and
advanced across the stenosis S in a contracted position, as shown
in FIG. 37. The head 350 is then expanded within the stenosis S,
either passively or actively and controllably as described above.
The stenotic material removal mechanism is then activated by
rotating and/or translating the head 350 within the stenosis S to
remove stenotic material M from within the stent T, as shown in
FIG. 38. The head 350 may be rotated manually by the operator or by
a drive motor 72 within a motor drive unit 70, as shown in FIG. 1.
The head 350 may operate by cutting action, abrasive action or
shearing action. Alternatively or additionally, medications,
chemicals, ionizing radiation or energy, such as electrical,
magnetic, ultrasonic, hydraulic, pulsed hydraulic, laser or thermal
energy may be applied to assist in removal of the stenotic material
M and/or for denaturing the remaining tissue to discourage further
restenosis at the treatment site. The stenotic material M that is
dislodged passes through the interstices between the helical
elements 356 and is captured within the cage-like structure of the
head 350.
[0108] Preferably, the head 350 includes a sensing means for
sensing the proximity or contact between the helical elements 356
of the head 350 and the stent T. As shown in FIG. 38, the sensing
means may take the form of one or more sensor electrode wires 366,
368 interwoven among the helical elements 356 of the head 350.
Alternatively, the helical elements 356 of the head 350 may serve
as sensor electrodes themselves. When the helical elements 356 of
the head 350 have approached close enough to the stent T to
indicate effective recanalization of the stenosis S, as shown in
FIG. 38, the stenotic material removal mechanism is deactivated.
The head 350 and all of the stenotic material M captured within the
cage-like structure of the helical elements 356 are then withdrawn
into the outer catheter 60, as shown in FIG. 39. The interstices
between the helical elements 356 of the head 350 contract as the
head 350 is drawn into the catheter 60, helping to assure that the
particles of dislodged stenotic material M remain captured within
the catheter. The catheter system is then withdrawn from the
patient, leaving the stented region recanalized and open to renewed
blood flow.
[0109] Alternatively, the head 350 of this apparatus may be
operated as a simple shearing body without a sensing means. In this
alternative method, the head 350 may be rotated and/or translated
within the stenosis S to dislodge stenotic material M from within
an interface envelope defined by the stent T embedded within the
vessel wall, as shown in FIG. 38. The head 350 may be expanded
passively or actively to remove all of the stenotic material M from
within the stent T. The stenotic material M that is dislodged
passes through the interstices between the helical elements 356 and
is captured within the cage-like structure of the head 350. The
head 350 and all of the stenotic material M captured within it are
then withdrawn into the outer catheter 60, as shown in FIG. 39.
[0110] Referring now to FIG. 40, a catheter kit according to the
present invention comprises a catheter or catheter system 370,
often mounted on a board or in a tray 372, instructions for use
(IFU) 374, and a pouch 376 or other conventional package. A motor
drive unit 70 (FIG. 1) may be packaged together with the catheter
kit or separately. The instructions for use (IFU) 374 are typically
part of a separate sheet or booklet which together with the
catheter 370, is packaged within the pouch 376 or other packaging
material. The packaging and its contents will preferably be sterile
or sterilizable. The instructions for use (IFU) 374 will set forth
method steps comprising the method(s) as described above.
[0111] Although the method of the present invention has been
described using the example of revascularizing restenosed coronary
arteries, it should be noted that the methods and apparatus
disclosed may be used for reopening any previously stented body
passage which has been subject to restenosis or reclosure. Other
body passages where these methods and apparatus may apply include
the peripheral blood vessels, the urinary tract, the digestive
tract and the respiratory tract.
* * * * *