U.S. patent application number 10/987313 was filed with the patent office on 2005-06-16 for compliant blood vessel graft.
Invention is credited to Bezuidenhout, Deon, Bowles, Hellmut, Douk, Nareak, Franz, Thomas, Rafiee, Nasser, Wolf, Michael F., Yeoman, Mark Simpson, Zilla, Peter Paul.
Application Number | 20050131520 10/987313 |
Document ID | / |
Family ID | 46123837 |
Filed Date | 2005-06-16 |
United States Patent
Application |
20050131520 |
Kind Code |
A1 |
Zilla, Peter Paul ; et
al. |
June 16, 2005 |
Compliant blood vessel graft
Abstract
A graft for replacement of a section of an artery and methods of
making the graft. The graft comprises a flexible, resilient,
generally tubular external support and a blood vessel segment,
e.g., a vein segment, carried within and having an ablumenal
surface in contact with and supported by the tubular support, the
graft being capable of resilient radial expansion in a manner
mimicking the radial compliance properties of an artery.
Inventors: |
Zilla, Peter Paul; (Cape
Town, ZA) ; Rafiee, Nasser; (Andover, MA) ;
Bezuidenhout, Deon; (Cape Town, ZA) ; Franz,
Thomas; (Cape Town, ZA) ; Yeoman, Mark Simpson;
(Lingfield, GB) ; Bowles, Hellmut; (Bloubergrant,
ZA) ; Douk, Nareak; (Lowell, MA) ; Wolf,
Michael F.; (Golden Valley, MN) |
Correspondence
Address: |
INTELLECTUAL PROPERTY GROUP
FREDRIKSON & BYRON, P.A.
200 SOUTH SIXTH STREET
SUITE 4000
MINNEAPOLIS
MN
55402
US
|
Family ID: |
46123837 |
Appl. No.: |
10/987313 |
Filed: |
November 12, 2004 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
|
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10987313 |
Nov 12, 2004 |
|
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|
10834360 |
Apr 28, 2004 |
|
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|
60466226 |
Apr 28, 2003 |
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Current U.S.
Class: |
623/1.13 ;
623/1.41; 623/901 |
Current CPC
Class: |
A61F 2/06 20130101; A61F
2/90 20130101; A61L 27/3625 20130101; A61L 27/14 20130101 |
Class at
Publication: |
623/001.13 ;
623/001.41; 623/901 |
International
Class: |
A61F 002/06 |
Claims
1. A flexible, resilient, generally tubular external support within
which may be supported a vein segment to form a venous graft
mimicking the compliance properties of a healthy artery, the
tubular support being capable of resilient radial expansion in a
manner providing compliance in the range of 3 to 30%/100 mm Hg.
2. The tubular external support of claim 1 in which said support
comprises a knit wire mesh.
3. The tubular external support of claim 1 in which said support
comprises a braided wire mesh including an element for controlling
the degree of axial extension of the support.
4. The tubular external support of claim 3 in which said element
comprises a thread attached to and carried internally of the
support.
5. The tubular external support of claim 1 including a vein segment
carried within the support, the vein segment having an ablumenal
surface in contact with, and supported by, said tubular
support.
6. A venous graft for replacement of a section of an artery, the
graft comprising a flexible, resilient, generally tubular external
support and a vein segment carried within and having an ablumenal
surface in contact with and supported by the tubular support, the
venous graft being capable of resilient radial expansion in a
manner mimicking the compliance properties of an artery.
7. The venous graft of claim 6 wherein said tubular support is
capable of said resilient radial expansion without significant
axial dimensional changes.
8. The venous graft of claim 6 wherein the compliance of the graft
ranges from 3 to 30%/100 mm Hg.
9. The venous graft of claim 6 wherein the external support
comprises a generally tubular fiber mesh capable of expanding in
diameter through resilient movement of wires of the mesh to
accommodate radial expansion of the vein segment supported in it
sufficient to provide the graft with said compliance.
10. The venous graft of claim 6 wherein said external support
comprises a knit, tubular mesh capable of expanding radially to
accommodate radial expansion of the vein segment supported in it
within said compliance range.
11. The venous graft of claim 6 wherein said external support
comprises a braided fiber mesh so configured as to exhibit radial
expansion in said compliance range without significant reduction in
the axial length of the support.
12. The venous graft of claim 11 wherein said fiber mesh is made of
metal wire.
13. The venous graft of claim 12 wherein said metal wire is of
stainless steel or of a cobalt chrome alloy.
14. The venous graft of claim 11 wherein said metal wire is a shape
memory alloy.
15. The venous graft of claim 11 wherein said fiber mesh is
polymeric.
16. The venous graft of claim 6 wherein the ablumenal surface of
the vein segment is bonded to said tubular support.
17. The venous graft of claim 6 wherein the vein segment and the
tubular support are axially coextensive.
18. The venous graft of claim 10 wherein said knitted tubular fiber
mesh is made from crimped fibers.
19. The venous graft of claim 9 wherein said tubular fiber mesh is
made from fibers that are crimped after having been formed into
said tubular mesh.
20. A venous graft for replacement of a section of an artery, the
graft comprising a flexible, resilient, knit wire mesh configured
as a generally tubular external support and a vein segment carried
within and having an ablumenal surface in contact with and
supported by the tubular support, the support having resilient
radial expansion and contraction characteristics that provide the
venous graft with compliance properties mimicking those of an
artery.
21. The venous graft of claim 1 wherein the compliance of the
venous graft ranges from 3 to 30%/100 mm Hg.
22. Method of producing a venous graft for use in replacing a
section of an artery, comprising providing a segment of a vein and
sheathing the segment in a generally tubular support in supportive
contact with the ablumenal surface of the vein segment, the support
being sufficiently flexible and radially resilient as to provide
the graft with compliance properties mimicking the compliance
properties of an artery.
23. The method of claim 22 including the step of cutting said
venous graft from a longer section of vein sheathed in said tubular
support, the ends of the vein and tubular support of the venous
graft being coextensive.
24. The method of claim 22 including the step of supporting said
generally tubular support upon an exterior surface of an applicator
having an internal passage within which is positioned the vein
segment, and removing the applicator to permit the tubular support
to come into supportive contact with the ablumenal surface of the
vein segment.
25. The method of claim 22 including the step of supporting said
generally tubular support upon an exterior surface of an applicator
having an internal passage, and, while passing the vein segment
from within the applicator passage, drawing the tubular support
onto the surface of the vein segment.
26. The method of claim 22 wherein said generally tubular support
is chosen to be sufficiently radially resilient as to provide the
venous graft with a compliance ranging from 3 to 30%/100 mm Hg.
27. The method of claim 24 wherein said tubular support is axially
resilient, the method including the step of controlling axial
dimension changes of the tubular support as the support comes into
supportive contact with the vein segment to provide the venous
graft with said compliance properties.
28. The method of claim 27 including the step of providing the
tubular support with an axially extending, relatively inextensible
element that restrains the tubular support from unwanted axial
extension.
29. The method of claim 28 wherein said inextensible element
comprises a flexible fiber positioned within the tubular support
and between the tubular support and the ablumenal surface of the
vein segment.
30. The method of claim 28 wherein the flexible fiber is a wire
joined to the interior of the tubular support.
31. The method of claim 22 including the step of bonding the
ablumenal surface of the vein segment to the tubular support.
32. The tubular external support of claim 1 in which said a knit
wire mesh support comprises loops that alternate in size
circumferentially of the support.
33. The method of claim 22 including forming said tubular support
from a knit wire mesh, wherein said mesh is formed with loops that
alternate in size circumferentially of the support.
34. Method of producing a blood vessel graft comprising providing a
segment of a blood vessel and sheathing the segment in a generally
tubular support in supportive contact with the ablumenal surface of
the vessel segment, the support being sufficiently flexible and
radially resilient as to contribute to the compliance properties of
the graft.
35. The method of claim 34 including supporting the generally
tubular support on the exterior surface of an introducer tube,
sliding the introducer tube over the vessel segment, and removing
the introducer tube to enable the tubular support to contact the
ablumenal surface of the vessel.
36. The method of claim 34 including affixing a cord to one end of
the vessel segment, and maintaining tension on the vessel segment
during sheathing of the vessel segment within the tubular
support.
37. The method of claim 36 wherein the cord comprises a plug
frictionally received within the introducer tube, the method
including withdrawing the introducer tube from the vessel segment
and tubular support, friction between the tube and plug maintaining
the vessel in tension during such withdrawal.
38. A blood vessel graft comprising a flexible, fiber mesh
configured as a generally tubular external support and a blood
vessel segment carried within and having an ablumenal surface in
contact with and supported by the tubular support, the support
having resilient radial expansion and contraction characteristics
contributing to the compliance properties of the graft.
39. The graft of claim 38 including an adhesive adhering the
tubular support to the ablumenal surface of the vessel to resist
collapse of the vessel within the support.
40. The graft of claim 38 including an adhesive tape positioned
around a portion of the tubular support, the tape including an
adhesive that extends through the fiber mesh support and into
adhesive contact with the ablumenal surface of the vessel.
41. The graft of claim 39 wherein said adhesive at least partially
embeds said fiber mesh and adhesively contacts the ablumenal
surface of the vessel.
42. The graft of claim 39 wherein said adhesive is formed as a
coating on the fibers of the fiber mesh.
43. Method of attachment of the graft of claim 40 to another blood
vessel, comprising cutting said portion of the graft bearing said
adhesive tape to conform to the wall of the other blood vessel, the
adhesive tape maintaining the cut end of the graft open and
preventing fraying of the cut end.
44. The method of claim 43 wherein the graft is cut on the
bias.
45. Method of applying an adhesive tape to the exterior surface of
a vessel graft that includes a vessel segment supported within a
flexible, elastic fiber mesh tubular support, the method comprising
compressing the graft between lengths of adhesive tape having an
adhesive that penetrates the mesh to adhesively contact the
ablumenal surface of the vessel, and allowing the graft to resume
its tubular configuration.
46. The method of claim 45 including positioning the tape lengths
in a deformable clip, inserting a segment of the stent in the clip
between the tape lengths, deforming the clip to compress and
flatten the stent, and removing the clip.
47. The graft of claim 37 wherein said vessel is of porcine or
bovine origin.
48. A graft for replacement of a section of an artery, the graft
comprising a flexible, resilient, knit wire mesh configured as a
generally tubular external support and a blood vessel segment
carried within and having an ablumenal surface in contact with and
supported by the tubular support, the support having resilient
radial expansion and contraction characteristics that provide the
graft with compliance properties mimicking those of an artery.
Description
CROSS REFERENCE
[0001] This application is a continuation-in-part of U.S. patent
application Ser. No. 10/834,360, filed Apr. 28, 2004, which claims
priority from U.S. Provisional Application Ser. No. 60/466,226
filed Apr. 28, 2003, both of which applications are incorporated
herein by reference in their entireties.
FIELD OF THE INVENTION
[0002] This invention involves a graft involving a blood vessel
segment and a supportive sheath chosen to provide the graft with
mechanical compliance properties which resemble those of a healthy
native artery.
BACKGROUND OF THE INVENTION
[0003] Various types of vascular prostheses are known or available.
Commercially available synthetic vascular grafts in use are
commonly made from expanded polytetrafluoroethylene (e-PTFE), or
woven, knitted, or velour design polyethylene terephthalate (PET)
or Dacron.RTM.. These prosthetic vascular grafts may have various
drawbacks. When used for repairing or replacing smaller diameter
arteries, these grafts may fail due to occlusion by thrombosis or
kinking, or due to an anastomotic or neointimal hyperplasia
(exuberant cell growth at the interface between artery and graft).
Another problem may involve expansion and contraction mismatches
between the host artery and the synthetic vascular prosthesis,
which may result in anastomotic rupture, stimulated exuberant cell
responses, and disturbed flow patterns and increased stresses
leading to graft failure.
[0004] Problems also exist with the use of autologous saphenous
vein grafts in these applications. Use of autologous saphenous vein
grafts to bypass blockages in coronary arteries has become a
well-established procedure. However, their success in the long term
has been limited. In the coronary position, the literature reports
a low (45-63%) patency of vein grafts after 10-12 years. It is
believed that these failures result from remodeling of the
implanted vein in response to greatly increased internal pressure,
that is, as the vein is required to function as an artery. In
general, arteries have substantial musculature and, although able
to expand diametrically in response to increased internal pressure,
are capable of withstanding normal arterial pressure variances.
Veins, on the other hand, are not required to withstand arterial
pressure variances and are relatively incapable of withstanding the
higher arterial pressures without substantial bulging. In this
regard, the nominal venous diameter seen under nominal venous
pressure is seen to approximately double upon exposure to arterial
pressure.
[0005] Increases in lumenal diameter of these magnitudes in vein
segment implants are accompanied by increases in tangential stress.
Tangential stress has been shown to be proportional to the lumenal
radius-wall thickness ratio. In healthy arteries, this ratio
remains constant across multiple species. However, this does not
occur in veins. It is believed that a vein's smooth muscle cells
increase their growth rate and secrete extra-cellular matrix
components in response to such increases in tangential stress. This
becomes a remodeling response, and is likely an attempt by the vein
to reduce the lumenal radius-wall thickness ratio, and consequently
the tangential stress. However, it appears that these reactions
overcompensate in the veins, resulting in the phenomenon of
neointimal hyperplasia yielding grossly thickened and stiff graft
walls. As the dilation of the vein segment continues, the resulting
mismatch between the vein and artery diameters may lead to
disturbance of flow patterns, which may also favor the formation of
thrombi.
[0006] Problems also exist when tubular prostheses are used as
exteriorly accessible shunts to facilitate access to the
circulatory system for, e.g., the administration of medicines and
nourishment and for dialysis procedures.
SUMMARY OF THE INVENTION
[0007] It has now been found that a blood vessel segment such as a
vein segment, if externally supported by an appropriate, flexible,
radially-resiliently tubular support, can provide a valuable
tubular prosthesis. A vein segment so supported can function in
much the same fashion as the artery that is to be replaced. That
is, it functions without undue bulging or aggravated mismatching
phenomena leading to graft failure. Unless otherwise indicated, the
term "compliance" means the ratio of the diameter change of a
vessel as it expands in the radial direction in response to a given
change in vessel pressure, and the values for compliance referred
to below result from dynamic, in vitro testing. As described in
greater detail below, the compliance of venous graft is largely
dependent upon the compliance of the external, radially resilient
support.
[0008] The invention in one embodiment, accordingly, relates to a
flexible, resilient, generally tubular external support within
which may be supported a blood vessel segment such as a vein
segment to form a graft. The tubular support is capable of
resilient radial expansion in a manner mimicking the compliance
properties of an artery, and compliance figures in the range of 3
to 30%/100 mm Hg are appropriate. The tubular support may be formed
of a knitted or woven fiber mesh that is so formed as to exhibit
the needed compliance properties.
[0009] The invention in certain embodiments provides a venous graft
for replacement of a section of an artery. The graft comprises a
flexible, resilient, generally tubular external support and a vein
segment carried within and having an ablumenal surface in contact
with and supported by the tubular support, the venous graft being
capable of resilient radial expansion in a manner mimicking the
compliance properties of an artery. Compliance figures in the range
of 3 to 30%/100 mm Hg are appropriate, although compliance values
ranging up to 50%/100 mm Hg may be desired in some instances. The
tubular support may take the form of a fiber mesh, such as a
knitted, braided or woven mesh, the fibers of which may, if
desired, be appropriately crimped to provide the required
resiliency and compliance.
[0010] In other embodiments, the invention relates to a method for
producing a venous graft for use, for example, in replacing a
section of an artery. A segment of a vessel is provided, and is
sheathed in a generally tubular support in supportive contact with
the ablumenal surface of the vein segment. The support is
sufficiently flexible and radially resilient as to provide the
resulting graft with compliance properties mimicking the compliance
properties of the artery to be replaced. Sheathing of the vessel
segment within the tubular support may be accomplished by
supporting the generally tubular support upon an exterior surface
of an applicator having an internal passage within which is
positioned the vessel segment, and removing the applicator to
permit the tubular support to come into supportive contact with the
ablumenal surface of the vessel segment. Axial dimensional changes
in the tubular support may be controlled as necessary to provide
the graft with the desired compliance properties mimicking arterial
compliance properties.
[0011] Other embodiments of the invention relate to vessel grafts
that include a flexible, resilient, generally tubular external
support formed of a shape memory alloy, and a vessel segment
carried within and having an ablumenal surface in contact with and
supported by the tubular support. The shape memory support may be
placed around a vessel segment when the shape memory material is in
a first enlarged configuration. The tubular support comes into
supportive contact with the ablumenal surface of the vessel when
the support is transformed, as by a temperature increase or upon
removal of an introducer tube over which the tubular support is
supported, into a second configuration different from the first
configuration. The shape memory support in its second configuration
may exhibit superelastic properties and in any event is
sufficiently flexible and resilient as to provide the venous graft
with compliance properties mimicking the compliance properties of,
for example, an artery. Compliance figures in the range of 3 to
30%/100 mm Hg are appropriate. The tubular support may take the
form of a wire mesh made of shape memory alloy, such as a knitted
or woven mesh, the wires of which may, if desired, be appropriately
crimped to provide the required resiliency and compliance.
[0012] The invention is described hereafter primarily with respect
to grafts that utilize veins that are received within a tubular
support and that can function as replacements for arterial segments
in, for example, coronary by-pass procedures, but the grafts of the
invention may also utilize other vessels such as arteries,
including treated vein and artery segments from donor animals such
as vessels of porcine and bovine origin.
BRIEF DESCRIPTION OF THE DRAWING
[0013] FIG. 1 is a pressure versus diameter graph typifying the
characteristics of a native vein, native artery, a non-compliant
stented vein, and a compliant stented vein;
[0014] FIG. 2 is a schematic cross-sectional view of an artery;
[0015] FIG. 3 is a representative pressure versus strain graph;
[0016] FIG. 4 is a pressure versus graft diameter graph;
[0017] FIG. 5 is a photograph of a tubular support in a first
configuration, shown in an axially compressed and radially expanded
configuration and supported on a plastic tube;
[0018] FIG. 6 is a photograph of the tubular support of FIG. 5 in
an axially elongated and radially reduced configuration to conform
to a vein outer diameter;
[0019] FIG. 7 is a side view of the graft of FIG. 6, showing a
length-governing element;
[0020] FIG. 8 is a schematic view of braided elements;
[0021] FIG. 9 is a perspective view of a braided tubular
support;
[0022] FIG. 10 is a schematic view of knitted elements;
[0023] FIG. 11 is a side view of a section of a knitted tubular
support;
[0024] FIG. 12 is a view of angular pre-braiding crimped
elements;
[0025] FIG. 13 is a perspective, schematic view of an angular
pre-braiding crimped tubular support;
[0026] FIG. 14 is a view of rounded pre-braiding crimped
elements;
[0027] FIG. 15 is a view of angular pre-knitting crimped
elements;
[0028] FIG. 16 is a view of rounded pre-knitting crimped
elements;
[0029] FIG. 17 is a broken-away, perspective view of a
post-braiding crimped tubular support;
[0030] FIG. 18 is a broken-away, perspective view of a venous graft
showing a portion with anti-fraying element;
[0031] FIG. 19 is a broken-away, perspective view of one embodiment
utilizing an applicator for assembling a venous graft;
[0032] FIG. 20 is a broken-away, perspective view of the use of a
modified applicator for assembling a venous graft;
[0033] FIG. 21 is a photographic, perspective view of a section of
a knit tubular support;
[0034] FIG. 22A is a schematic cross-sectional view of an assembly
device;
[0035] FIG. 22B is a schematic, prospective view of a step in the
assembly of a vessel graft;
[0036] FIG. 23 is a schematic, prospective view of another step in
the assembly of a vessel graft;
[0037] FIG. 24 is a schematic cross-section of an attachment of a
vessel to a tubular support;
[0038] FIG. 25 is a schematic cross-section of another attachment
of a vessel to a tubular support;
[0039] FIG. 26 is a schematic cross-section of yet another
attachment of a vessel to a tubular support;
[0040] FIG. 27 is a schematic cross-section of the attachment of a
vessel to a tubular support utilizing a sleeve;
[0041] FIG. 28 is a schematic cross-section of the attachment of a
vessel to a tubular support utilizing an adhesive tape;
[0042] FIG. 29A is a cross section of a clip bearing an adhesive
tape segment;
[0043] FIGS. 29B through D are schematic views showing stages in
the application of an adhesive tape segment to a vessel graft;
[0044] FIG. 30 is a schematic view showing severance on a bias of
the vessel graft also shown in FIG. 29D;
[0045] FIG. 31 is a schematic view of the attachment to an artery
of a segment shown in FIG. 30; and
[0046] FIG. 32 is a photograph of a portion of a bioprosthetic
access vessel graft.
DETAILED DESCRIPTION OF THE PRESENTLY PREFERRED EMBODIMENTS
[0047] Applicants have recognized that significant deficiencies
attend to the past methodologies and devices relating to the
increased pressures experienced by vein grafts utilized in arterial
positions. The increased pressures lead to excessive dilation of
vein grafts in arterial circulation, leading to the development of
intimal hyperplasia, which causes occlusion of the vessel.
[0048] Intimal hyperplasia is believed to be a primary reason for
vein graft failure. In this context it is known that intact
endothelium acts in a manner to protect against the proliferation
of underlying vascular smooth muscle cells, known as VSMC. The
intact endothelium also plays a role in VSMC contractile responses.
The VSMC have also been shown to release factors with long term
physiological effects on the endothelial cells, including
maintenance of a non-proliferative state. By comparison, the
pathogenesis of intimal hyperplasia in a vein graft may follow the
sequence of dilatation under arterial pressure; overstretching to
maximum capacity; disruption of borders of endothelial cells;
rupture of internal elastic membranes; migration of smooth muscle
cells into the intimal layer and resultant unbalanced
proliferation; atrophy of media and further consolidation of
stiffness; and graft arteriosclerosis with traumatic media necrosis
and atrophy, as well as pathological surface and wall stress and
strain. These phenomena may result in a decrease in vein graft
patency within six years. Intimal hyperplasia may be observed in
such grafts from about 16 months, while anastomotic intimal
hyperplasia may occur at about 18 months, and arteriosclerosis may
occur from about 45 months.
[0049] Others have attempted to overcome certain of these problems
by use of metallic or polymeric external structures designed to
arrest the dilation of the vein graft. FIG. 1 graphs blood pressure
against vessel diameter, with D.sub.O representing the vessel
diameter at zero pressure. As shown in this graph, lines 16, 18
represent the normal diastolic, i.e. low (80 mm Hg) and normal
systolic, i.e. high (120 mm Hg) physiological blood pressure range
for humans. Line 21 may represent the diameter of an artery
(D.sub.A) at 100 mmHg, and line 23 may represent the diameter of a
vein (D.sub.V) at the same pressure of 100 mmHg. An unstented
native artery reacts to pressure loading as shown at line 32, and
an unstented vein reacts to the same loading as shown at line 35.
The use of known stents with vein grafts results in movement of
line 35 in the direction shown by arrow 38, resulting in the
approximate profile indicated at line 42 showing the response of a
pressure loaded vein and non-compliant stent combination. Although
this prevents over-dilation, and some advantage accrues, this may
lead to further unhealthy sequelae. Also, to the extent that
vein-stent combination devices may be shown to limit some of the
dilation and intimal hyperplasia in the mid-graft region, they may
not be able to prevent intimal hyperplasia at the anastomoses. This
can be a significant problem for vein grafts that are transplanted
into the arterial circulation vasculature. Prior attempts to
resolve these problems fail to recognize the full implications of a
vein being used in these situations. Accordingly, factors in the
design of a vein-graft that may have a significant impact on its
long term patency may have been missed.
[0050] One important factor in proper remodeling is that of proper
cyclic stretch. Applicants are able to incorporate this concept
into vein-stent grafts of the invention. In similar manner, the
role of vascular endothelial growth factor (VEGF) in vascular
smooth muscle cells may be very important to the design of a
preferred arterial vein-stent graft. It is known that low
concentrations of VEGF may play a role in preserving and repairing
the arterial lumenal endothelial layer. Further, it is suggested
that activation of the VEGF receptor KDR is affected by cyclic
stretch. Applicants believe that the phenomenon of upregulation of
VEGF expression by physiological stretching of vascular smooth
muscle cells is one reason for redesigning a vein-stent graft which
has improved, controllable cyclic stretch features.
[0051] A further consideration is the influence of tensile
stress/strain on the structure and organization of smooth muscle
cells during development and remodeling, particularly as to the
orientation of such cells. In a larger topographical sense, this
may also relate to the role of blood flow in the formation of focal
intimal hyperplasia in known vein grafts, including inducement of
eddy blood flow at locations of graft-host diameter mismatch.
[0052] These considerations and deficiencies can be addressed with
the various structures and methodologies of the present invention
in which a vein graft is provided that exhibits compliance
properties mimicking those of healthy arteries. Radial expansion
and contraction of the graft is permitted in a manner that mimics
the radial expansion and contraction of an artery to at least
closely approach the desired result in which the vein graft, its
connections to adjacent arterial ends or stumps, and the adjacent
arterial portions tend to expand and contract in a similar manner,
to thereby substantially avoid anastomotic compliance mismatches.
This is accomplished through the use of a flexible, resilient,
generally tubular external support that engages the ablumenal
surface of a vein segment carried within the support, the support
being so fabricated as to functionally provide the graft with the
compliance properties of an artery.
[0053] Compliance Properties
[0054] As noted earlier, compliance is the ratio of the diameter
change of a vessel in the radial direction to a given change in
vessel pressure, and the values for compliance referred to below
result from dynamic, in vitro testing. Compliance values are
reported here as percentage changes in the internal diameter of a
vessel per a 100 mm Hg change in vessel pressure, as measured in
the range of normal blood pressures, that is, from about 80 mm Hg
to about 120 mm Hg. In the laboratory, it is convenient to measure
compliance through the use of an elongated balloon structure over
which a candidate tubular support is positioned. Distilled water at
about 37.degree. C. is pumped into the balloon to cause it to
inflate, and the pressure within the balloon is cycled between 0 mm
Hg and 140 mm Hg at a frequency of about 72 cycles per minute to
mimic a normal pulsatile blood flow. The change in internal volume
is measured between 0 mm Hg and 140 mm Hg to provide
pressure/volume data. From this data is subtracted the
pressure/volume data resulting from repeating the procedure with
the balloon alone, and from the resulting pressure/volume data the
percentage change in the internal diameter of the tubular support
between 80 and 120 mm Hg can be calculated. It is convenient to
express this radial compliance value as %/100 mm Hg.
[0055] The compliance of an implanted venous graft may be measured
in vivo through the use of ultrasound techniques in which the vein
graft is visualized in a cross-sectional view and the dimensional
change of the vessel with varying blood pressure is recorded for at
least one and usually a number of cardiac cycles. The
cross-sectional lumenal area of the vein graft is measured for the
smallest cross-sectional configuration and the largest
cross-sectional configuration for one cardiac cycle. The smallest
cross-sectional configuration of the vein graft lumen is associated
with diastolic blood pressure whereas the largest cross-sectional
configuration is associated with systolic pressure. The
cross-sectional lumenal area values for diastolic and systolic
blood pressure are used to calculate the lumenal diameter values
and the vein graft compliance. Compliance values of a venous graft
measured in vivo often are slightly larger that the compliance
values measured in the laboratory, and the compliance values
referred to herein are laboratory values resulting from the in
vitro measurements described above.
[0056] FIG. 2 is a sectional representation of vascular tissue
useful for illustrating the relation of the natural arterial
structure with the prosthetic venous graft structure of the
invention. The natural adventitial layer 95 of an artery 98 is
comprised of two main tissue types that contribute to the
mechanical properties of the natural artery, namely elastin and
collagen. The mechanical properties of these two soft tissue
components are described in Table I below:
1 TABLE I Soft Tissue Elastic Modulus (Pa) Max Strain (%) Elastin 4
.times. 10.sup.5 130 Collagen 1 .times. 10.sup.9 2-4
[0057] As shown in the above table, these two soft tissue types
have large differences in mechanical properties. Elastin is very
elastic, and collagen is very stiff in comparison. These two tissue
types are combined in the adventitial layer to produce a non-linear
elastic response. As shown in FIG. 3, the combined effect of the
characteristics of elastin 101 and collagen 104 (having a greater
role at higher strains) results in a non-linear response curve
(shown loading at 135 and un-loading at 137) within the
physiological pressure range of a natural artery between about
80-120 mm Hg. This characteristic of pulsatile expansion and
contraction of arteries requires fine mechanical compliance of any
prosthetic graft, i.e., a close mimicking by the prosthetic device
of the mechanics and timing of the natural artery distending and
reshaping under change in blood pressure.
[0058] From an engineering standpoint, the following relationships
may be helpful from a design standpoint in producing venous stent
grafts of the invention. 1 C d = D D diastolic P .times. 100
.times. 100 mmHg
[0059] in which C.sub.d is compliance, P is blood pressure,
.DELTA.P is the difference between systolic and diastolic blood
pressures, D is vessel diameter, and .DELTA.D represents the
diameter change between systolic and diastolic pressures.
[0060] The stiffness of blood vessels is stated as a stiffness
index (.beta.), and is a measure of the changes of curvature and
diameter, stated as: 2 = ln P systolic P diastolic D D diastolic =
D diastolic ln P systolic - ln P diastolic D
[0061] A related characteristic of blood vessels is that of elastic
modulus (K), which is considered a measure of stiffness, and is
stated as: 3 K = V diastolic P V D diastolic P D 1 C
[0062] in which C is compliance, V.sub.diastolic is the vessel
volume per unit length at diastole, and .DELTA.V is the difference
in unit volumes between systole and diastole. In terms of diametric
compliance, as an example, 4 K = D diastolic P systolic - P
diastolic D systolic - D diastolic = D diastolic P D
[0063] FIG. 4 shows that the Elastic Modulus (K), as defined in the
above equations, is proportional to the secant S.sub.1 of the
pressure-diameter curve PD.sub.1, plotted on a linear scale (left
y-axis in FIG. 4), between diastolic and systolic pressure. The
slope, (P.sub.syst-P.sub.diast)/(D.sub.syst-D.sub.diast), of the
secant S.sub.1 is a good approximation to the slope of the
pressure-diameter curve PD.sub.1 in that pressure range. From the
above equations for the Elastic Modulus (K) it can be appreciated
that the Elastic Modulus (K) is not equal to the slope of the
secant S.sub.1 but is proportional to the slope by a factor
D.sub.diastolic. Compliance (C.sub.d) is approximately proportional
to the Elastic Modulus (K) hence it is approximately proportional
to the inverse of the secant S.sub.1 of the pressure-diameter curve
PD.sub.1 between diastolic and systolic blood pressure.
[0064] The stiffness index (.beta.) is proportional to the secant
S.sub.2 of the pressure-diameter curve PD.sub.2 between diastolic
and systolic blood pressure when the pressure-diameter curve is
plotted on a logarithmic pressure scale (right y-axis in FIG. 4).
The slope of the secant S.sub.2 is (in P.sub.syst-1n
P.sub.diast)/(D.sub.syst-D.sub.diast) and is a good approximation
to the slope of the pressure-diameter curve PD.sub.2 in that
pressure range. It can be again appreciated, from the above
equations for the Stiffness Index (.beta.) that the Stiffness Index
(.beta.) is not equal to the slope of the secant S.sub.2 but is
proportional to the slope by a factor D.sub.diastolic.
[0065] Compliance data of natural human vessels is categorized by
vessel type and by age of the vessel (i.e., age of patient). For
example, a common carotid artery has about a 6.6%/100 mm Hg
compliance value. The values for a superficial femoral artery and a
femoral artery are 6-10%/100 mm Hg. A value for a saphenous vein,
however, is about 4.4%/100 mm Hg, while an aorta ranges generally
from about 20-50%/100 mm Hg, depending on the location. Also, the
lengths of grafts according to location in the body must be
considered, and substantial lengthwise variance in graft lengths is
not uncommon. It is also known that the diameter of various
arteries change over time, and this may have a significant impact
on overall compliance values. Returning to FIG. 1, line 80
represents the pressure-diameter data that certain embodiments of
venous grafts of the invention seek to emulate, wherein the
compliance properties of a native artery (line 32) is closely
mimicked.
[0066] Support Materials and Manufacture
[0067] The radially resilient support may be manufactured from any
biologically acceptable material that possesses the ability to be
shaped into a tubular structure having the required compliance.
Polymeric fibers may be employed, such as polyurethanes,
polyethylene terephthalate, polypropylene, and
polytetraflouroethylene, and good results may be obtained through
the use of wires of such metals as stainless steel and
cobalt-chromium alloys. Wires made of shape memory alloys such as
nitinol may be used to advantage. Shape memory elements or
filaments may be made of one or more shape memory materials as
exemplified in the following table, it being understood that this
is not to be considered an exhaustive list. Also, any metal or
metal alloy may be coated with a polymer for improved
biocompatibility, recognizing that the polymer may or may not be
biodegradable.
2 ALLOYS POLYMERS Ag--Cd Two component system based on
oligo(.SIGMA.-caprolactone)dimethacrylate and N-butyl acrylate
Au--Cd Polyurethanes Cu--Al--Ni Polynorborenes Cu--Sn Poly(ether
ester)s consisting of poly(ethylene oxide) and poly(ethylene
terephthalate) (EOET copolymers) Cu--Zn Ethylene vinyl acetate
copolymers Cu--Zn--Si Polystyrene polybutadiene copolymer
Cu--Zn--Sn Cu--Zn--Al In--Ti Ni--Al Ni--Ti Fe--Pt Mn--Cu
Fe--Mn--Si
[0068] With respect to shape memory alloys, other design
considerations include temperatures, different diameters and radial
compliance, shape transformation dimensional changes, and wire
thicknesses. Generally, shape memory alloys and shape memory
polymers may have transformation temperatures which are below
physiological temperatures, i.e., 37.degree. C., to ensure
self-righting responses. Preferably, transformation temperatures
will also be above room temperature to ensure that the shape memory
material reinforcing does not need to be refrigerated for storage
purposes. Thus, the ideal shape memory transformation temperatures
will likely be between 21.degree. and 37.degree. C. This transition
may either be a two-way or a one-way directional transition, with a
currently preferred embodiment including a two-way directional
transition. The transition temperature range can either be a short,
i.e. 0.5.degree. C., or a long transition temperature range, i.e.
10.degree. C., where the shape is proportionally regained over this
temperature range. For example, for a desired temperature
transition to be 100% complete at 25.degree. C. but with it
starting at 20.degree. C., then this would yield a temperature
range of 5.degree. C. The changes in radial diameter due to the
shape memory material experiencing transformation dimensional
changes is preferably in a range of from 5% to 30%.
[0069] An embodiment of a tubular support utilizing a shape memory
alloy is illustrated in FIGS. 5 and 6. FIG. 5 shows an arterial
reinforcement tubular support 77 formed of one or more shape memory
material elements 165. These elements are braided, but may also be
knitted or woven, into a generally tubular structure designed for
placement around a portion of a vein to produce an arterial graft.
In this example, a shape memory alloy is employed because of its
so-called "superelastic" properties rather than its ability to
undergo temperature-induced phase changes, although some phase
change from austenite to stress-induced martensite may occur. In
FIG. 5, the braided tube is positioned on a hollow plastic straw as
representing a vein segment, and has been compressed axially to
produce an increase in diameter. By extending the braided tube
axially, as shown in FIG. 6, the tube becomes reduced in diameter
to provide support to the vein segment.
[0070] The shape memory braided material shown in FIGS. 5 and 6, if
used also for its phase transformation properties, may be supplied
in a first configuration (which may be in the martensite phase)
which can be easily manipulated to receive a vein segment 86 within
the structure, and a second configuration (shown in FIG. 6, which
may be in the higher temperature austenite phase) which has a
"remembered" narrower diameter configuration to provide support to
the vein segment. The contact of inner surfaces 170 of the
structure with ablumenal surfaces 175 of the vein segment 86 is
shown also in FIG. 7. The resilience of shape memory materials can
be controlled by altering compositions, tempering procedures, wire
diameters, etc., so that a tubular support fashioned from this
material may mimic (when combined with the minimal mechanical
values of a vein segment) the compliance values of a host artery in
order to optimize the venous graft-artery interaction. This aspect
of compliance mimicking has components of expansion, recoil,
timing, and tissue remodeling. In this example, the vein-stent
compliance values are chosen to closely mimic those of a healthy
native artery. Whereas the shape memory wires are shown as braided
in FIGS. 5, 6 and 7, they may also be knit, and in fact the knit
configuration appears to offer certain advantages.
[0071] Radially resilient tubular supports may be knit from metal
wire, such as stainless steel and cobalt-chromium alloys. Metal
wires ranging in diameter from about 25 to 150 micrometers are
appropriate for knit supports with diameters in the range of 35 to
50 micrometers being particularly useful, although larger or
smaller diameters may be employed as desired. For braided tubular
supports, metal wires ranging in diameter from about 37 to about
170 micrometers are appropriate, although larger or smaller
diameters may be employed.
[0072] Knitting procedures may be performed by known methods using,
for example, a LX96 knitting machine manufactured by the Lamb
Knitting Machine Corporation. Favorable radial compliance and
tubular dimensional properties may result from knitting the tubular
structure in a manner providing loops that alternate in the
circumferential direction between larger and smaller loops, as
shown in FIG. 21. In this Figure, smaller loops 250 are shown
alternating circumferentially with larger loops 251. Such
alternating loop sizes typically present themselves visually as
longitudinal stripes extending axially along the tubular support,
as the adjacent loops of each size align in the longitudinal axis.
Each closed end of the loop may be either rounded or generally
square-shaped or variations in between, and, the sides of the loop
may turn outward, be parallel, or turn inward. The latter design
has shown some advantage in acting like a spring and assisting in
the stability of the overall dimensions of the tubular structure,
and maintaining its compliance characteristics.
[0073] The knitted or braided tubular support may then be subjected
to crimping to provide crimps extending, for example, about the
circumference of the tubular support (that is, in the manner shown
in FIG. 17). One way of doing this is through the use of an axially
fluted mandrel that is inserted into the tube and is pressed
outwardly against a wall of the tube to force the wall against a
complementary shaped outer female mold to bend the knitted or
braided wires and to form a circumferential crimp, the crimp
resulting from each flute or raised ridge of the mandrel extending
axially of the support.
[0074] A compliant venous graft using various metals or polymers
for the tubular support may be provided in several ways.
Embodiments may be advantageously provided in knitted form. FIGS. 8
and 9 show material 165 in a braided configuration, and FIGS. 10
and 11 show material 165 in a knitted configuration. Mechanical
characteristics of the tubular support may be enabled by the type
of shaping and relational structures formed on the elements making
up the knit or braided structures. It is contemplated that a
technique involving crimping of the material 165 to achieve angular
crimps (shown in FIGS. 12 and 13), formed prior to the braid or
knit construction, and rounded crimps (shown in FIG. 14) may
provide acceptable results. Crimping techniques that may be
appropriate with pre-knit configurations are shown in FIG. 15
(angular crimps) and FIG. 16 (rounded crimps). Another technique
for achieving certain performance characteristics of braided or
knitted shape memory materials 165 is to perform crimping after
braiding or knitting, i.e. post-braiding or post-knitting. FIG. 17
shows one embodiment of material 165 formed in a braided
configuration and having a post-braided crimping operation applied
to form a crowned pattern to achieve desired crimp
characteristics.
[0075] Crimp angle and pitch density may be important variables in
certain embodiments of the current design of the tubular supports.
It is understood, however, that certain advantages of this
invention may still be achieved without use of crimping. Ranges of
crimp angle are preferably from about 10.degree. to 85.degree. to
the line of lay of the reinforcing wire or braid. The crimp size
may vary from 0.01 to 5 mm in length. It is desired that the braid
or helical wires have a pitch angle that may vary from about
5-85.degree. to the axial length of the vein graft.
[0076] Applicants have identified certain crimping techniques that
relate to crimping either before or after braiding or knitting. For
example, in post-braid crimping the material braids are produced
according to existing techniques, after which macroscopic
longitudinal crimping is imparted to the tubular mesh using a
post-braid crimping tool. However, according to the material and
specific configuration of the stent, if the post-braid crimping of
braided tubes does not achieve sufficient compliance then alternate
methods are possible. One example is to effect pre-braid crimping,
thereby setting the memory of a shape memory material in a crimped
configuration and subsequently straightening the material before
braiding. The crimp is thus induced upon exposure to physiological
temperatures.
[0077] In certain embodiments, it is appropriate to provide for
"jump" grafts, or "skip" grafts to communicate a stented graft with
another vessel. To accommodate such grafts, an opening is made in
the resilient, external tubular support of a compliant graft of the
invention so that a portion of the vessel wall itself is exposed
through the opening to enable a jump graft to be attached at that
location. It is desirable to provide for such openings in the
support wall prior to assembly of the compliant graft. When the
tubular support is made of a shape memory alloy, such as nitinol,
an opening in the mesh may be made by supporting the mesh on an
appropriately shaped mandrel and gently moving the fibers forming
the mesh away from what is to be the center of the opening. A pin
or other support is placed in the opening to keep it open, the pin
being held and supported by the mandrel. The tubular support,
constrained in this shape, is subjected to a heat treatment, e.g.,
in the 500.degree. C. range, tor a short period of time and then
cooled. The resulting tubular support, in its austenite phase,
exhibits the usual super elasticity associated with nitinol and
other shape memory alloys, and the opening thus provided in the
wall of the tubular support remains open and accessible for
formation of a jump graft. By selection of an appropriately shaped
and sized tubular support with a pre-formed access opening, a
surgeon may produce a graft prosthesis having an opening in the
wall of the tubular support positioned where desired for formation
of a jump graft.
[0078] The external tubular support adjusts the mechanical and
geometrical properties of the vein graft to match or mimic healthy
arterial properties and therefore adapt to the arterial pressure of
the host artery. Accordingly, this results in substantial matching
of the lumen of the vein graft and the host artery, the substantial
matching of compliance of the vein graft and the host artery, and
substantial matching of the radius to wall thickness ratio (r/wt)
of the vein graft to the host artery. As noted above, optimization
of the vein-stent compliance should ensure that the vein-stent
graft mimics the behavior of arteries regarding the non-linear
stiffening with increasing diameter due to elevated blood pressure,
"locking" at a maximum pressure, and then demonstrating dynamic
recoil in a timely manner.
[0079] When venous grafts utilizing knit or braided tubular
supports are cut at angles suitable for end-to-end anastomoses,
either at generally right angles or in scallop-like shape, the ends
of the supports may experience fraying (see, for example, FIG. 17).
Certain methods and structure are helpful to eliminate such
fraying. In one embodiment, adjustable rings 210 of bioabsorbable
or biodegradable material are placed generally circumferentially
around a portion of the material 165, and in contact with external
surfaces 217, as shown in FIG. 18. The number of rings may be
varied as needed. The location of the rings may be adjusted to the
position of anastomoses where vein and tubular support need to be
cut. The cut or suture may be carried out through the ring, and the
ring may be absorbed or degraded over a predetermined time, as
desired.
[0080] Another embodiment of a structure to prevent fraying of a
knit or braided tubular support when it is cut is the use of
polymer coating for the fiber mesh. This feature may also provide
the benefit of preventing gluing of joints and contact zones of
elements of the stent. However, use of the radially compliant
tubular support as a reinforcing structure may advantageously
involve bonding of the ablumenal surface of a vein segment to
confronting internal surfaces of the support. This attachment or
connection may be accomplished through the use of a glue or other
material having adhesive or connecting characteristics. In one
embodiment, a fibrin glue or other material having adhesive or
connective characteristics may be sprayed on designated portions of
the vein (as exemplified at 283 in FIG. 20) and/or the tubular
support. Another embodiment includes placement of a material on
designated portions of the lumenal surfaces of the tubular support
so as to provide the characteristics of contact adhesion and/or
bonding when these portions contact the vein. However, the glue or
other material must not inhibit the function of the tubular
support. It is desirable that the contact of the tubular support
with the ablumenal vein segment surface be reasonably uniform along
the length of the support, and that regions of much higher force of
the support against the ablumenal wall of the vein be avoided.
[0081] Performing the anastomoses of small-diameter unsupported
vein grafts in the coronary position is complicated by the tendency
of the free end of the vein to collapse on itself, thereby
obscuring the lumen and making it difficult for the surgeon to
identify a suitable position for the placement of sutures. The
application of an external tubular support (referred to sometimes
herein as a stent) on a vein graft potentially further complicates
the suturing, as the collapsed vein is situated inside (and at
least partially obscured by) the non-collapsed stent material. By
attachment of the ablumenal surface of the vein to the lumenal
surface of the stent, however, the stent offers support to the vein
to prevent it from collapsing, and this is particularly the case
when stents formed from shape memory alloys are employed. As noted
above, adjustable rings 210 and various adhesives may be employed
to bond the confronting surfaces of the vessel and the supporting
tubular structure together.
[0082] Attachment of the vessel surface to the tubular support
stent can be achieved in various ways. In one embodiment, a
covering gel is employed that attaches to the vessel wall and
surrounds and entraps the stent wires, thereby attaching the stent
to the vessel, this embodiment being schematically depicted in FIG.
24, the tubular support fibers being shown at 320, the vessel wall
at 322 and the gel at 324. Examples of such gels are synthetic gels
(such as modified polyethylene glycol, polyvinyl alcohol, acrylic
gels, etc) and biological gels (such as fibrin, gelatin, and
albumin glues). In another embodiment shown schematically in FIG.
25, an adhesive glue 326 such as a cyanoacrylate attaches the stent
to the vessel ablumenal wall, the glue adhering to both the vessel
and the stent.
[0083] In another embodiment, shown schematically in FIG. 26,
individual fibers 320 of the stent are coated with an adhesive
material 328 containing groups reactive to the vessel tissue. This
material may be either directly applied on the metal wires (FIG.
26) or on a polymeric coating with which the wires are pre-coated.
This material coating, applied optionally over a polymer coating on
the wires, may also be employed in other embodiments, for example,
those shown in FIGS. 24, 25, 27 and 28.
[0084] In a preferred embodiment, a sleeve is placed over the
assembled stented vessel. As schematically depicted in FIG. 27, the
sleeve 330 may primarily offer mechanical support for the stent to
prevent fraying of cut edges, in the manner discussed above in
connection with FIG. 18, while having minimal if any effect on the
mechanical properties of the assembly, such as compliance.
Referring to FIG. 28, a sleeve may comprise an adhesive tape 332
having an elastic backing material 334 bearing an adhesive material
336 having a consistency enabling it to penetrate between fibers of
the tubular mesh and adhesively contact the ablumenal surface of
the vessel. The adhesive may have the consistency of a gel. The
elastic material may be a fabric, and may be formed from a variety
of materials that are inherently elastic (e.g. polyurethane
elastomers) or materials that are not elastic by themselves, but
may act in an elastic fashion due to the fact that they are coated
with or entrapped in an elastic gel-like material that constitutes
the adhesive portion of the tape. Crimped fibers made from
polyesters (PET) or degradable materials such polylactic acid (PLA)
or polyglycolic acid (PGA) or copolymers thereof may also be used
for the elastic material.
[0085] The adhesive material 336 should be of sufficient cohesive
strength and adhesive strength to the vessel wall by virtue of
mechanical interlocking and/or covalent chemical binding to attach
the stent to the vessel during normal handling during implantation.
As the vessel tissue contains both nucleophilic (amino, thiol and
hydroxyl groups) and electrophilic (carboxyl) groups, the adhesive
may employ a number of chemical groups capable of reacting with the
vessel wall. Aldehydes, acyl chlorides, activated esters,
isocyanates or carboxylic acids (plus activators such as
carbodiimides) are examples of compounds capable of reacting with
nucleophilic groups on the tissue, and alcohols and amines may be
employed to react with the electrophilic carboxylic acid groups on
the tissue (in the presence of an activator, e.g. a
carbodiimide).
[0086] In general, the adhesive may be composed of synthetic
polymers, in their swollen or unswollen states. Gel-like
characteristics may be imparted by the adhesive material itself, or
by swelling the material with a solvent or a plasticizing agent,
such as water. Gels offer the advantages of having viscoelastic
properties that may simulate the mechanics of vessels to some
extent, and of being capable of deforming to facilitate contact and
binding of the gel to the tissue through the gaps in the stents. In
addition, gels may contribute to the strength of the bond between
the vessel wall and the stent by mechanical interlocking. Adhesives
may be non-degradable cross-linked materials such as polyethylene
glycols, polyimines, polyacrylates (e.g., polyacrylic acid,
polyacrylamides, poly(hydroxyethyl methacrylate), and
co-polyacrylates. Degradable and/or resorbable adhesives may
include multifunctional polyethylene glycols containing degradable
end groups and/or crosslinked with degradable crosslinkers, and
non-crosslinked or lightly crosslinked polyvinyl alcohol.
[0087] As noted above, the adhesive material desirably is
functionalized with groups capable of reacting with the vessel
tissue. For example, an adhesive may comprise crosslinked
polyacrylic acid gels functionalized with aldehyde groups (e.g.,
via a diamine bridge) capable of reaction with tissue amines. As
another example, a polyvinyl alcohol, the degree of hydrolysis,
molecular mass and tacticity (and thus crystallinity) have been
adjusted to render the adhesive slowely dissolvable in vivo can be
appropriately functionalized with groups reactive toward tissue
groups.
[0088] Although the adhesive tape 332 may be applied as desired to
the stented vessel, a preferred method involving particular stented
vessels having a supportive tubular structure derived from a shape
memory material utilizes a pre-assembled clip comprising a
disposable elastic metal clip and a segment of the adhesive tape,
as schematically depicted in FIGS. 29 A through D. Referring to
FIG. 29A, the metal clip 340 is shaped to provide an opening for
reception of the stented vessel, and may, for example, be generally
"C" shaped. The clip contains within it a section of the adhesive
tape 332, the adhesive surface 336 facing the interior of the clip
and the elastic backing adjacent the inside surface of the clip. As
desired, the assembled clip may be positioned within the jaws of a
pliers-like applicator 342 (FIG. 29B). In use, a section 344 of a
stented vessel is inserted into the opening of the clip as shown in
FIG. 29B. The jaws of the applicator 342 are closed on each other,
the stented vessel becoming temporarily flattened as shown in FIG.
29C and the adhesive penetrating between fibers of the stent to
adhesively contact the ablumenal surface of the vessel. The jaws of
the applicator are opened, enabling the section of the stented
vessel to resume its substantially circular cross-sectional
configuration. The metal clip is removed, and excess tape is
removed from the edges to provide the stented tube structure
schematically shown in FIG. 29D.
[0089] An alternative method involves the employment of a tape
dispenser that contains a continuous roll of the tape, sections of
the tape being severed from the roll and applied to the stented
vessel by hand.
[0090] The application of the tape to the stented vessel can be
performed at a position required by the surgeon according to the
implant position. FIG. 30 shows how a taped section 350 of a
stented vessel may be cut to provide a biased opening that may be
sutured to, for example, a coronary artery. The taped section is
cut so that the resulting open end is configured to conform
generally to the ablumenal surface of an artery or other vessel to
which the stented vessel is to be attached. FIG. 30 shows a cut
being made generally along the dashed lines to provide segments
352, 354. FIG. 31 shows how the bias-cut taped end of the segment
352 may be sutured to a length of artery 356, and it will be
understood that the artery has a surgically prepared, axially
extending slit (not shown) providing an opening through its wall
about which the segment 352 is sutured to communicate the graft
with the artery.
[0091] By appropriately cutting the taped portion, the end of the
segment can be shaped to conform as needed to the external contour
of various vessels to which it is to be attached. For example, a
graft may be shaped to make an appropriately angled (e.g., 45
degrees) juncture with a coronary artery, the artery and the
stented graft segment lying generally in the same plane. In another
example, the stented graft may cross over a vessel to which it is
to be attached. In this "cross-overjump" configuration, slit-like
openings are provided in the taped section of the graft segment and
the vessel, and the taped section and the vessel are sutured
together about their confronting openings and to establish fluid
communication through the openings. The slit-like openings may be
made such that they are approximately parallel as they confront
each other. In yet another example, the stented graft and a vessel
may be positioned substantially parallel and in contact with each
other. In this "longitudinal jump" configuration, slit-like,
desirably axially extending openings are made in the taped section
of the stented graft and in the vessel, and suturing is performed
as above.
[0092] Applicants have further recognized the need for a device to
facilitate assembly of the radially compliant tubular support and a
vein segment. It is desirable that such an applicator should not
obscure the stent lumen, and that it should allow for easy
insertion of the vein. It is further recognized that a design
whereby diameter is increased by length compression, as in a
braided configuration, would allow easy slipping of the tubular
support over a vein. FIG. 19 illustrates this concept in
combination with an applicator 279 to apply the braided support 284
to a vein 86. This longitudinal braid contraction phenomena (shown
earlier in FIGS. 5 and 6), and which must be carefully managed at
the time of joining the vein to the stent, is likely quite useful
to achieving the goals of an applicator 279, as noted above. This
applicator may also facilitate placement of anti-fraying rings 210.
In one embodiment, the method of using the applicator comprises the
steps of: providing the means of longitudinally contracting a
stent; holding the stent in the contracted position with increased
stent diameter resulting; inserting a vein into the stent lumen;
and distending the stent longitudinally while the vein is inserted
simultaneously until the stent is slipped over the desired portion
of the vein. Further design considerations must ensure that the
stent will not be fixed to the vein in a longitudinally
over-distended or contracted state, so as to ensure that the
predetermined mechanical stent properties remain viable.
[0093] FIG. 20 shows an embodiment in which a tubular support 185
is received along the outer surface of an applicator 281 having an
internal passage, and, while passing the vein segment 86 from
within the applicator passage, the tubular support is drawn onto
the ablumenal surface of the vein segment. The applicator here may
be a thin walled tube resembling a soda straw.
[0094] FIGS. 22A and B show the end of a syringe 300 having a
mechanism 302 for engaging and immobilizing the end of a blood
vessel and the surrounding tubular support. The mechanism may be
any mechanism adapted to connect to the ends of open tubes, and one
such mechanism may include an outer tubular portion 301 within
which is received an end portion 304 of a blood vessel, the
mechanism including an axially movable internal tapered mandrel 305
that is inserted in the vessel. Axial movement of the mandrel (to
the left in FIG. 22) pinches and captures the end of the blood
vessel between the mandrel and an introducer sheath carrying a
tubular support, the sheath and tubular support together being
shown in FIG. 22A as 303.
[0095] Referring to FIG. 22B and 23, in one assembly method, the
distal end 304 of the vessel is supported by the mechanism 302 with
the proximal end of the vessel being attached to a cord 306. The
tubular support 308 (FIG. 23) is carried exteriorly of and is
supported by an introducer tube 310. A plug 312 sized to engage the
interior wall of the introducer tube is attached to the proximal
end of the vessel. The introducer tube 310, bearing on its outer
surface the tubular support 308, is drawn over the cord 306, the
plug and the vessel segment, the cord being maintained under
tension to facilitate sliding the introducer tube over the vessel.
The end of the tubular support is gripped by the mechanism 302
(FIG. 22A). Thereafter, the introducer tube is withdrawn proximally
away from the mechanism 302. By frictionally engaging the interior
surface of the introducer tube, the plug 312 exerts a gentle
longitudinal tension on the proximal end of the vessel, causing the
vessel to shrink somewhat in diameter. As the introducer tube is
withdrawn, the tubular support 308 comes into contact with the
ablumenal surface of the vessel. Once the introducer tube has been
completely withdrawn, the gentle longitudinal tension on the vessel
is relaxed and the vessel itself seeks to return to its original
larger diameter to thereby more closely contact the tubular
support.
[0096] The plug may be made of any appropriate material that
frictionally engages the interior wall of the introducer tube as it
is withdrawn, and a soft urethane rubber plug, for example, may be
employed.
[0097] Although assembly of the stented graft has been described as
occurring away from the vein or artery to which it will eventually
become attached, in practice, such assembly can be affected by
attaching one end of the harvested vessel segment to the artery or
vein with a cord attached to its other end. The mesh tubular
support is then urged gently over the ablumenal surface of the
vessel while maintaining gentle tension on the cord until the
support is positioned where desired.
[0098] It is desired that the support be applied to a vein at a
predetermined length which is associated with a particular desired
compliance. A length-defining support feature or system should
ensure a predetermined support length. This is particularly true
with respect to braided supports, and perhaps less important with
knit supports in which radial resilience is less dependent upon the
amount to which the support is extended axially.
[0099] In a braided support, and to a much lesser extend in a knit
support, compliance and related mechanical properties are linked to
the support length through the pitch angle. Imparting a change in
length results in a change in pitch angle and compliance. However,
the compliance of the support is a mandatory characteristic which
is optimized, as noted above, to mimic the compliance of a normal
healthy host artery. When applying a support to a vein segment, it
is important to accurately accommodate the predetermined tubular
support length, even after longitudinal contraction of the support
for the attachment of the support to the vein.
[0100] With braided, and to a much lesser extent knit supports,
axial support length may be controlled, for example, through the
use of an axially extending, relatively inextensible element, (as
for example the thread 78 in FIG. 7), that restrains the tubular
support from unwanted axial extension. The thread may be woven
through the support mesh and may be fastened, as by welding, to the
various wires that the thread encounters along the length of the
support so that as the support is stretched axially, the extent of
axial elongation is controlled by the thread as the thread is drawn
taut. Moreover, this feature may enable a length of the tubular
support to be divided into portions of appropriate length, with the
permitted axial extension of each portion controlled by the section
of thread within it. As presently envisioned, a vein segment may be
sheathed in a tubular support as discussed in detail above, with
the intent of cutting out a smaller segment of the resulting venous
graft for use in the surgical replacement of an artery, and the
venous graft that is thus used will have vein and tubular support
ends that are coextensive.
[0101] Various generally tubular external wire mesh supports were
fabricated from metal wires by braiding and by knitting, some being
crimped and others not, and the diametrical compliance of each was
measured using the in vitro diametrical compliance testing outlined
above. The measured compliance values were dependent upon many
variables, including wire size, tightness of braid or knit, etc.
The following values were obtained:
3 Compliance Design %/100 mmHg A Braided Non-crimped 0.9 B Braided
Crimped 5.6 C Braided Crimped 1.8 D Knitted Non-crimped 3.4 E
Knitted Crimped 7.9 F Knitted Crimped 8.0 G Knitted Non-crimped
10-21 H Knitted Non-crimped 9-21 I Knitted Non-crimped 16->30 J
Knitted Non-crimped >30 K Knitted Non-crimped 10-16 L Knitted
Non-crimped 21-29 M Knitted Non-crimped 22-28 N Knitted Non-crimped
>30 O Knitted Non-crimped 10-15 P Knitted Non-crimped 9-11 Q
Knitted Non-crimped 13-24 R Knitted Non-crimped >30
[0102] A surgical procedure is proposed for use of the graft
disclosed herein. This procedure, which may also be viewed as a
simple method for placement of a venous reinforcement structure,
includes, in this example, application of the compliant external
tubular support during the procedure of vein excision. In many
instances, vein excision is considered a standard part of a
surgical operation, which is usually done by an assistant at a time
when the surgeon is still in the preparatory phase of the
operation. When an autologous blood vessel such as a segment of the
saphenous vein is harvested for use in accordance with the
invention, it may contain side branches that need to be removed
before the vein is enclosed within the tubular support. Closure of
the opening that remains after removal of a side branch can be
accomplished in several ways. Surgically placed sutures or small
clips such as Liga clips may be used to ligate small sections of
branches. However, when a branch has been removed flush with the
ablumenal Surface of the vessel, it is desirable to close the
resulting opening in the vessel by suturing to reduce interference
with the tubular support. Purse string sutures are appropriate. To
avoid undue narrowing of the lumen of the vessel when a purse
string suture is pulled tight, the ends of the purse string suture
are preferably tightened by pulling them in the longitudinal
direction, i.e., axially of the vessel, rather than in a direction
transverse to the longitudinal direction of the vein.
[0103] In one embodiment, an initial step includes dissection and
freeing of a saphenous vein. The saphenous vein is dissected free
in a standard way, leaving it in situ while ligating and cutting
off its branches as discussed above. The second step involves
testing for potential wall leaks of the vein. In order to test the
isolated saphenous vein for potential leaks, it is normally
cannulated distally and cold heparinised blood is injected while
the proximal end is occluded. This inflation of the vein (using old
techniques) with a syringe creates pressures of up to 350 mm of Hg
and is often a main reason for traumatic damage of the vein wall.
Therefore, a pressure limiting mechanism may be positioned between
the vein cannula and the syringe. The external tubular support
cannot be applied yet because leaks in the vein wall need to be
freely accessible for repair. Therefore, no over-distention
protection is placed around the vein yet, necessitating the
limitation of the inflation pressure to a level suitable for
detecting any leaks of concern but less than a level deemed to
cause unacceptable damage, such as, for example, in one embodiment,
15 mm of Hg, the pre-maximal dilatation pressure for veins. The
tissue remodeling functions of applicants' invention become more
critical in view of the importance of leak testing and the reality
of possible damage to the intimal layer in the vein during even the
most carefully performed leak testing.
[0104] The next step involves assembling the harvested vein segment
and an external tubular support of this invention. In this step,
the tubular support (typified here as a knit support) is mounted on
a tube or straw-like applicator within which is positioned the vein
segment. See FIG. 20. The straw is then removed axially, leaving
the support and vein in contact to form the venous graft.
Over-extension of the tubular support is prevented using a
length-limiting central thread or other means, as described above.
As required, the vein segment is then inflated under arterial blood
pressures of 120 mm of Hg, causing it to contact the tubular
support inner lumenal surfaces. In certain embodiments, an adhesive
securing the tubular support to the vein will ensure that the vein
does not collapse during the surgical procedure when no internal
pressure is applied. Again, it should be recognized (without
limitation) that this is one of several ways to accomplish the
above objectives.
[0105] The following sequence may occur at this or another time
during the procedure. One of the external anti-fraying rings or
cuffs is slid to the end of the vein, and a typical
double-S-cutting line is used to prepare the end for the first
anastomoses. The thin cuff prevents fraying of the tubular support
and also gives the vein tissue and tubular support a uniformity
which makes the surgical process of stitching the vein to the host
artery in an end-to-side fashion much easier. Another thin
anti-fraying ring is then slid down from the applicator to a
position where either a side-to-side anastomoses for a sequential
graft is being performed, or where the vein is being cut at an
appropriate graft length. The half of the sliding cuff which
remains on the original vein will make the process of the
anastomoses to the proximal host artery much easier. In the case of
a coronary artery bypass graft, for example, the end of the
remaining vein protected by the other half of the cuff is used for
the next distal graft anastomoses.
[0106] Although the invention has been described primarily in
connection with the use of autologous blood vessels to form a
stented graft as a replacement for diseased vessels, the invention
has other uses as well. External stent structures can be used to
allow repeated access to the vascular system for administration of
medicines or nourishment or the administration of dialysis
procedures. Exterior access grafts may be subject to frequent
penetration by hypodermic needles, and it is desirable not only
that the vessel walls of the graft retain their capacity to be
punctured many times, but also that the wounds thus formed in the
vessel wall self-seal to a large extent.
[0107] In accordance with the invention, an external stent
structure 360 as shown in FIG. 32 may be produced from a blood
vessel segment harvested from human or non-human animals, such as
segments of bovine or porcine arteries, the vessels having been
treated, as by known aldehyde fixing or decellularization. A
flexible, resilient tubular support of the type described herein
may be placed over the resulting venous or arterial vessel segment
to provide a bioprosthetic access graft to enable ready access to
the cardiovascular system. For this purpose, one may form a
bioprosthetic device utilizing a suitably treated bovine or porcine
artery or vein segment by placing the segment within an elastic,
resilient tubular support sized to contact and squeeze against the
ablumenal surface of the vessel when the vessel is filled with
blood, as when it is being used as a shunt between an artery and a
vein of a patient. In this manner, once a hypodermic needle has
been inserted and withdrawn from the wall of the vessel, the
elastic, resilient tubular support tends to exert a squeezing force
on the vessel, forcing the edges of the wound to close upon one
another.
[0108] FIG. 32 is a photograph showing an access graft formed from
a decellularized porcine artery segment 362 contained within a
knitted, resilient tubular support 364. This figure illustrates a
puncture wound 366 formed by a syringe 368. The edges of the wound
are brought together by the squeezing action imparted by the
knitted support. It may be noted that the knitted support, or
braided support if desired, may be made with loops or openings 370
that are sized to receive a hypodermic needle of the desired
diameter. For hypodermic needles commonly used for dialysis
procedures, for example, needle sizes, and hence the size of
openings between fibers of the tubular support, may be in the range
of about 1.8 and 2.1 mm.
[0109] As structures have become increasingly complex, not only in
design but also in the range of material use, pure analytical
methods have begun to fail in describing the behavior of such
structures. Due to the scientific challenge of closely matching a
vascular graft of the type described herein to a host, analytical
methods are rendered somewhat obsolete. Development of a prosthetic
vascular graft which mimics the mechanical requirements and dynamic
compliance of a normal healthy artery is made possible, however,
with certain old tools, particularly cut and try methods in which
incremental changes are made to the material or structure of the
tubular support to modify its compliance properties, and the
resulting properties are used to guide further changes. Empirical
data or constitutive equations and mathematical analyses may be
used for certain features. Alternatively, the use of numerical
modeling with such tools as, for example, Finite Element Models and
Methods, relying on continuum mechanics, along with certain other
tools makes this level of customization feasible.
[0110] While the embodiments of the invention described herein are
presently preferred, various modifications and improvements can be
made without departing from the spirit and scope of the invention.
The scope of the invention is indicated by the appended claims, and
all changes that fall within the meaning and range of equivalents
are intended to be embraced therein.
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