U.S. patent application number 13/014702 was filed with the patent office on 2011-07-28 for methods and devices for denervation.
Invention is credited to Michael A. EVANS, Emily A. STEIN, Kondapavulur T. VENKATESWARA-RAO.
Application Number | 20110184337 13/014702 |
Document ID | / |
Family ID | 43735722 |
Filed Date | 2011-07-28 |
United States Patent
Application |
20110184337 |
Kind Code |
A1 |
EVANS; Michael A. ; et
al. |
July 28, 2011 |
Methods and devices for denervation
Abstract
Various delivery devices are described to deliver an agent
locally to the renal nerves. The delivery devices are positioned in
the renal artery and penetrate into the wall of the renal artery to
deliver the agent to the renal nerves. The delivery devices may be
used to deliver the agent according to longitudinal position,
radial position, and depth of the renal nerves relative to the
renal artery. In addition, various methods are described to
denervate, modulate, or otherwise affect the renal nerves and other
neural tissue. Also, various agents are described to denerve,
modulate, or otherwise affect the renal nerves and other neural
tissue.
Inventors: |
EVANS; Michael A.; (Palo
Alto, CA) ; VENKATESWARA-RAO; Kondapavulur T.; (San
Jose, CA) ; STEIN; Emily A.; (Redwood City,
CA) |
Family ID: |
43735722 |
Appl. No.: |
13/014702 |
Filed: |
January 26, 2011 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
|
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61336838 |
Jan 26, 2010 |
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Current U.S.
Class: |
604/22 ;
604/103.02; 604/506; 604/523 |
Current CPC
Class: |
A61B 5/4094 20130101;
A61P 9/12 20180101; A61K 31/198 20130101; A61K 45/06 20130101; A61K
31/7048 20130101; A61B 2017/22054 20130101; A61K 31/55 20130101;
A61M 25/04 20130101; A61B 2017/22067 20130101; A61M 2025/1047
20130101; A61B 5/0215 20130101; A61M 25/0084 20130101; A61P 9/06
20180101; A61P 25/00 20180101; A61M 2025/0087 20130101; A61P 43/00
20180101; A61B 2017/22061 20130101; A61B 2090/378 20160201; A61B
2090/3784 20160201; A61B 5/4839 20130101; A61M 2025/0086 20130101;
A61P 9/04 20180101; A61K 31/7048 20130101; A61K 2300/00 20130101;
A61K 31/198 20130101; A61K 2300/00 20130101; A61K 31/55 20130101;
A61K 2300/00 20130101 |
Class at
Publication: |
604/22 ; 604/523;
604/103.02; 604/506 |
International
Class: |
A61M 37/00 20060101
A61M037/00; A61M 25/00 20060101 A61M025/00; A61M 25/10 20060101
A61M025/10 |
Claims
1. A device for targeted delivery of an agent to a plurality of
renal nerve target sites within a wall of a renal artery, the renal
nerve target sites being associated with (1) longitudinal positions
relative to an ostium of the renal artery, (2) radial positions
relative to a circumference of the renal artery, and (3) depths
relative to an inner wall of the renal artery, the device
comprising: a catheter; and a delivery element slidably coupled to
the catheter, the delivery element configured to be at least
partially positioned within the renal artery, the delivery element
including a plurality of delivery points coupled to the delivery
element, the delivery element having a stowed configuration wherein
the delivery points are stowed, the delivery element having a
deployed configuration wherein the delivery points are capable of
penetrating the inner wall of the renal artery and delivering the
agent substantially simultaneously to the renal nerve target sites;
wherein the delivery points are configured in a pattern
corresponding to the longitudinal positions, radial positions, and
depths of the renal nerve target sites.
2. The device of claim 1, wherein the delivery element is a
delivery tube, and the delivery points are coupled to an outside
surface of the delivery tube.
3. The device of claim 1, wherein the delivery element is a coil,
and the delivery points are coupled to an outward-facing surface of
the coil.
4. The device of claim 1, wherein the delivery element is a
balloon, and the delivery points are coupled to an outer surface of
the balloon.
5. The device of claim 1, wherein the delivery element is a
self-expanding structure, and the delivery points protrude from
openings in the self-expanding structure.
6. The device of claim 5, wherein the self-expanding structure is a
self-expanding mesh.
7. The device of claim 1, wherein the pattern is predetermined.
8. The device of claim 1, wherein the pattern is selected by a
user.
9. The device of claim 1, wherein the pattern is
non-circumferential.
10. The device of claim 1, wherein the delivery points are
configured to deliver very small amounts of the agent.
11. The device of claim 1, wherein each of the delivery points
includes a delivery lumen for delivering the agent, the delivery
lumens varying in size with distance from the ostium of the renal
artery, the delivery lumens delivering varying amounts of the agent
with distance from the ostium of the renal artery.
12. The device of claim 1, wherein one or more of the delivery
points is solid and coated the agent.
13. The device of claim 1, wherein the catheter defines a flush
port capable of delivering a flush agent into the renal artery,
wherein the flush agent is capable of neutralizing at least a
portion of any of the agent escaping from the renal nerve target
sites.
14. The device of claim 1, further comprising: an energy source
coupled to the delivery element, the energy source capable of
delivering an energy through the delivery point to enhance a
bioavailability of the agent.
15. The device of claim 14, wherein the energy source is an
ultrasonic energy source.
16. The device of claim 14, wherein the energy source is a thermal
energy source.
17. A method for targeted delivery of an agent to a plurality of
renal nerve target sites within a wall of a renal artery, the
method comprising: determining a location of the renal nerves;
selecting a plurality of renal nerve target sites based on the
location of the renal nerves, the renal nerve target sites being
associated with (1) longitudinal positions relative to an ostium of
the renal artery, (2) radial positions relative to a circumference
of the renal artery, and (3) depths relative to an inner wall of
the renal artery; selecting a delivery element, the delivery
element including a plurality of delivery points coupled to the
delivery element, the delivery points having a configuration
corresponding to the longitudinal positions, radial positions, and
depths of the renal nerve target sites; deploying the delivery
element in the renal artery; urging the delivery points into the
inner wall of the renal artery to penetrate the inner wall of the
renal artery; delivering the agent to the renal nerve target sites
through the delivery points.
18. The method of claim 17, further comprising: delivering a flush
agent through a flush port in the catheter into the renal artery,
wherein the flush agent is capable of neutralizing at least a
portion of any of the agent escaping from the renal nerve target
sites.
19. The method of claim 17, further comprising: using an ultrasonic
energy source coupled to the delivery element to deliver an
ultrasonic energy through the delivery point to enhance a
bioavailability of the agent.
20. The method of claim 17, wherein mapping the location includes
using an electrical mapping catheter.
Description
CROSS-REFERENCE TO RELATED APPLICATIONS
[0001] This application claims the benefit of U.S. provisional
application Ser. No. 61/336,838, filed Jan. 26, 2010, which is
incorporated by reference.
BACKGROUND
[0002] A blood vessel or other bodily passage may be used to access
parts of the body to deliver an agent to a target site in the wall
of the vessels. For example, the renal arteries may be used as
access pathways to deliver a therapeutic agent to the renal nerves,
which run within the wall of the renal arteries. However, it may be
difficult to deliver therapeutic agents with sufficient precision
to the renal nerves. One approach is to "flood" the entire region
about the circumference of the renal artery using the agent. This
approach uses more of the agent than is necessary and may be toxic
to the patient or surrounding tissues. Moreover, the toxicity
concerns can also significantly limit the selection of particular
therapeutic agents to kill nerves and the ability to provide
effective treatment.
[0003] What is needed is a way of locally delivering the amount of
an agent needed to effect a desired therapeutic response while
reducing injury or harm to surrounding tissue. What is also needed
is a way of delivering an agent to a target site within the wall of
a blood vessel with increased precision and a way of removing or
neutralizing excess amount of agents to reduce potential toxicity
effects or vascular trauma.
[0004] Nerve denervation may be used to manage hypertension,
congestive heart failure, endstage renal disease, and other
conditions. Radio frequency (RF) ablation of the renal nerves has
been practiced and often lacks fine control, and may cause
unintended damage to neighboring tissue such as the endothelium
lining blood vessels and smooth muscles that constitute blood
vessel walls, resulting in vessel injury or occlusion.
[0005] What is needed are methods, devices, and agents for renal
denervation which offer greater control over the denervation
process than RF ablation or bolus injection, and the appropriate
chemistry for controlled delivery and subsequent neutralization to
reduce vessel occlusion, spasm, or other tissue damage.
SUMMARY
[0006] A device for targeted delivery of an agent to a plurality of
renal nerve target sites is described. The renal nerve target sites
are within a wall of a renal artery. The renal nerve target sites
are associated with (1) longitudinal positions relative to an
ostium of the renal artery, (2) radial positions relative to a
circumference of the renal artery, and (3) depths relative to an
inner wall of the renal artery.
[0007] The device includes a catheter and a delivery element
slidably coupled to the catheter. The delivery element is
configured to be at least partially positioned within the renal
artery. The delivery element includes a plurality of delivery
points coupled to the delivery element. The delivery element has a
stowed configuration wherein the delivery points are stowed. The
delivery element has a deployed configuration wherein the delivery
points are capable of penetrating the inner wall of the renal
artery and delivering the agent substantially simultaneously to the
renal nerve target sites.
[0008] The delivery points are configured in a pattern
corresponding to the longitudinal positions, radial positions, and
depths of the renal nerve target sites.
BRIEF DESCRIPTION OF THE DRAWINGS
[0009] FIG. 1A shows a front view of an abdominal aorta, a renal
artery, renal nerves, and a kidney. FIG. 1B shows a cross-sectional
view of a renal artery RA and renal nerves RN.
[0010] FIGS. 2A-2H show various embodiments of a delivery
device.
[0011] FIGS. 3A-3G show various embodiments of a delivery
device.
[0012] FIG. 4A shows a delivery device with a radioopaque
marker.
[0013] FIG. 4B shows a delivery device with depth markings FIG. 4C
shows a delivery device with an ultrasound transducer. FIG. 4D
shows a delivery device with an ultrasound device. FIG. 4E shows a
delivery device with a visualization device. FIG. 4F shows a
delivery device with a depth control.
[0014] FIG. 5A shows a delivery device with flush ports. FIG. 5B
shows a delivery device with dual balloons.
[0015] FIG. 6 shows a delivery system with a closed-feedback
loop.
[0016] FIG. 7A shows a drug-eluting stent. FIG. 7B shows a
time-release agent.
[0017] FIGS. 8A-8H show one embodiment of a method for using
delivery device 100.
[0018] FIGS. 9A-9E show one embodiment of a method for using
delivery device 1000.
[0019] FIG. 10A shows the amount of cell death caused by several of
agents for a fixed amount of time.
[0020] FIG. 10B shows the amount of cell death caused by several
agents versus time.
DETAILED DESCRIPTION
[0021] Methods, apparatuses, agents, and methods of delivery to
provide temporary and permanent nerve blockage are described, to
denerve the nervous system at specific sites and kill nerve cells
to treat disease. Delivery systems and agents are described that
provide site-specific treatment and control so that the controlling
effects are localized and can be adjusted over time to interrupt or
modulate the neural response and up or down regulate organ
function. These agents are also formulated in such a way that they
target or have an affinity for neural matter. Agents may also be
delivered in a time-dependent release configuration that focuses
treatment in a sustained manner on the desired neural matter while
reducing negative effects on the surrounding tissue and related
function, and protecting the blood vessel linings and surrounding
tissues. Agents may also be delivered in combination or in sequence
to provide enhanced agent bioavailability or bioactivity on
targeted neural matter. Some neural modulation agents will have
greater effect when delivered by methods that use mechanical,
thermal, electric, magnetic, electromagnetic, cryogenic, or other
energy forms to provide greater energy input, bioavailability,
permeation, thermal, or chemical activity.
[0022] Various agents, chemicals, proteins and toxins have been
used to provide temporary nerve blockage. Some of these agents
include site 1 sodium channel blockers such as tetrodotoxin (TTX),
saxitoxin (STX), decarbamoyl saxitoxin, vanilloids, and
neosaxitoxin are used as local anesthetic formulations. Other
agents such as lidocaine may be used as temporary nerve blockage
agents, whereas conotoxins may also provide temporary nerve
blockade. Other agents not known to provide nerve blockade are
inotropic drugs such as cardiac glycosides, which have been used to
treat congestive heart failure and arrhythmias, and more recently
the hoiamides have been identified to display inotropic properties.
These agents are useful to achieve temporary nerve blockage, and in
excess or in combination with inotropic agents, achieve long-term
nerve blockade and potentiate nerve cell damage. Devices, agents
and/or control methods are required to achieve permanent nerve
blockage, denervation and/or neuromodulation to control bodily
functions such as heart rate, hypertension, metabolic function,
pain, arthritis, and the like. In addition, compounds or agents are
needed that can permanently impair the function of nerve cells or
specifically kill nerve cells and induce apoptosis, thus affecting
the neural conduction pathways. Examples of agents are neurotoxins
such as tetrodotoxin, serotoxin, .omega.-conotoxin; nerve agents
such as organophosphates, sarin, and others; antagonist antibodies
against nerve growth hormones such as nerve growth factor (NGF),
the prototypical member of the neurotropin family; excitatory amino
acids such as glutamate and domoic acid in excess or in combination
with inotropic drugs. Excess concentrations of or combinations of
more than one channel blocker such as lithium, carbamazepine, and
verapamil can be used to promote nerve cell death.
[0023] Devices to deliver site-specific denervation agents require
precise control of target location, tissue depth and location of
neural matter. Such methods and devices may include catheters
integrated with hollow injection ports or solid protrusions coated
with agents and positioning structures such as inflatable balloons
or self-expanding, spring-like structures employing standard
catheter-based delivery and deployment methods used in
minimally-invasive interventional procedures. In one method,
mechanically expanding, self expanding devices, or braided
structures formed from materials such as spring steel, nickel
titanium or the like, can be placed at the desired site and
activated or released in position to allow delivery of agents in
predetermined patterns at discrete, non-contiguous sites along the
arterial walls at specific depths from the luminal surface where
neural matter is resident or where neural signal pathways are
located. Such expanding device may allow for perfusion during
treatment and may also be utilized to provide a stop or indexing
mechanism to provide the user with a predetermined length of
treatment from the aortic ostium.
[0024] The devices may also be balloons with solid protrusions to
perfuse or inject agents into tissue or the wall of a vessel, or
tube and syringe delivery methods. A braided structure may be used
to anchor and assist in fixing a delivery catheter in a blood
vessel such as the renal artery and deliver agents to one or more
sites along the artery substantially simultaneously. The depth,
linear spacing, and circumferential spacing of the sites for
delivery is important to achieve the desired therapeutic effect
while preserving vessel structure (endothelial cells, intima, and
media) and function while reducing injury to the delicate vessel
lining caused by the application of thermal, RF, or other forms of
energy. Additionally, the braided structure may be constructed from
materials that conform to the vessels at low expansion pressures to
position the protrusions for agent delivery while reducing
endothelial denudation. The braided structure may also include
features for non-obstructive function (blood flow perfusion in the
case of renal arteries, or bile secretion in the liver) during
denervation.
[0025] Other delivery systems may include balloons and implantable
systems made from biodegradable or coated non-biodegradable devices
such as stents with protruding structures (solid protrusions or
tubes) to deliver nerve denervating drugs or molecules that affect
neural blockade and/or control nerve signaling while simultaneously
treating atherosclerotic disease and the like. Ultrasound or other
forms of mechanical agitation can be added to delivery systems to
further aid and enhance agent delivery, diffusion and activity into
the adventitia.
[0026] Other delivery methods may include localized treatment
packaging the agents in a delivery medium that can regulate the
delivery rate of agents or has an impact on the agent's half-life,
while reducing impact to surrounding tissue. Such configurations
may include time-release microspheres from biodegradable polymers
or hydrogels and fluids that have a specific decay rates and
delivery profiles. The potential for nerve fiber regeneration may
also be addressed by time-release systems that can continue to kill
or block nerve fibers that regenerate over time.
[0027] In order to more precisely locate target neural matter,
various diagnostic devices may be used in combination with delivery
systems to deliver therapy. Such imaging modalities include
computed tomography (CT), magnetic-resonance imaging (MRI),
fluoroscopy, or ultrasound. Ultrasound may be external or
internally guided, and may use various agents such as ultrasound
contrast or ultrasound microbubble agents to aid in imaging neural
matter, their location and sites for denervation. Ultrasound can
measure both vessel wall thickness and placement of delivery
devices to ensure accurate delivery. Unlike angiography, ultrasound
can also image plaque and help determine the depth of penetration
needed to reach the neural matter. For example, in healthy
arteries, the neurons that are present mostly in the adventitial
regions of the vessel wall are located about 2-3 millimeters from
the inner lumen of the blood vessel. When diseased, this distance
increases by the thickness of plaque. Atherosclerotic plaque is
often unevenly distributed along the circumference and length of
the vessel. Ultrasound guided imaging may help locate the target
location for denervation.
[0028] Electroanatomical mapping and MRI methods may also be used
to identify the target location and deliver agents. In
electroanatomical mapping, a mapping transducer in conjunction with
an external electromagnetic field is used to map the electrical
conduction pathways and neuron signal activity surrounding blood
vessels and tissue. External (coil magnets) and internal
(catheter-based coils) MRI imaging methods may also be used to map
the neural matter and neural signal activity.
[0029] Another aspect of delivery of these agents is to reduce
detrimental effects to surrounding tissue and organs. The delivery
systems and methods described may include a neutralizer flush
system to inactivate any agent that gets beyond the desired
delivery site or any agent that does not bind target neurons within
the target site. To provide this control and neutralizer function,
the delivery systems may include dual isolation balloons where
agent is delivered between balloons or systems that aspirate or
neutralize any excess material or fluids during or after agent
delivery. Polymer delivery systems may also incorporate materials
to deactivate or destroy residual agents in a predetermined manner
or time using coatings such as oxidizers or the like for programmed
deactivation or destruction. Alternatively, delivery agents may be
formulated in a time-release material that when deployed, the
unbound agent is flushed by the kidneys.
[0030] FIG. 1A shows a front view of an abdominal aorta AA, a renal
artery RA, renal nerves RN, and a kidney K. The renal nerves run
lengthwise within the wall of the renal artery. FIG. 1B shows a
cross-sectional view of a renal artery RA and renal nerves RN.
[0031] Various delivery devices are described for targeted delivery
of an agent locally to the renal nerves. The delivery devices are
positioned in the renal artery and penetrate into the walls of the
renal artery to deliver the agent to the renal nerves. The delivery
devices may be used to deliver the agent according to three
parameters:
[0032] (1) Longitudinal position. The renal nerves run lengthwise
along the renal artery. Instead of delivering an agent to the
nerves at just one longitudinal position, the delivery devices
described may be used to deliver an agent to the nerves at multiple
discrete (non-contiguous) longitudinal positions along a length of
the renal artery.
[0033] (2) Radial position. The renal nerves are located at varying
radial positions relative to a circumference of the renal artery.
Instead of delivering agents to just one radial position, the
delivery devices described may be used to simultaneously deliver
agents to multiple radial positions in the renal artery.
[0034] (3) Depth. The renal nerves are located at varying depths
relative to an inner wall of the renal artery. Instead of
delivering agents to a fixed depth or distance, the delivery
devices described may be used to deliver agents to a range of
desired depths or distances. The desired depths may vary along the
longitudinal axis of the delivery device to account for the
anatomical changes along the length of the renal artery.
[0035] The delivery devices described are capable of delivering the
agent at multiple points that are discrete and non-contiguous along
the length of the renal nerves, effectively increasing the amount
of the renal nerves that are treated or exposed to the agent. The
delivery devices described also allow for delivering small amounts
of the agent to be used, by delivering the agent in a more targeted
and precise manner.
[0036] FIG. 2A shows one embodiment of a delivery device 100.
Delivery device 100 includes a catheter 110 and a delivery tube 120
slidably coupled within catheter 110. Delivery tube 120 includes a
distal end 124 with a delivery point 126. Delivery tube 120 may
include a delivery lumen 125. Alternatively, delivery tube 120 may
be solid instead of hollow.
[0037] Delivery tube 120 is outwardly biased from a longitudinal
axis of catheter 110. Delivery tube 120 may be made of a
shape-memory and super-elastic alloy such as nickel titanium,
stainless steel, or other suitable materials of sufficient strength
and toughness to achieve a desired depth of penetration. Delivery
tube 120 may be preshaped to a desired three-dimensional
configuration, using shape-memory or superleastic properties of
nickel-titanium or spring properties of steels or other alloys used
to make springs, so that once the catheter is retracted, delivery
tube 120 makes contact with and penetrates into wall W. Delivery
point 126 may be sharp. Delivery lumen 125 may have an inner
surface that is coated or treated with polyethylene or other
suitable material to reduce the loss or degradation of agents from
adhesion inside delivery lumen 125 while delivering the agent
[0038] Delivery tube 120 is delivered retracted inside catheter
110, with delivery point 126 unexposed. Delivery tube 120 is
positioned in a vessel V at the longitudinal position of a target
site T. Catheter 110 may also be rotated to position delivery point
126 at a radial position of target site T. Delivery tube 120 is
then extended from catheter 110 to expose delivery point 126 and
penetrate into wall W. Delivery tube 120 is extended until delivery
point 126 is positioned at a depth of target site T. Delivery tube
120 then delivers an agent through delivery lumen 125 to target
site T. Alternatively, delivery point 126 may be treated or coated
with an agent which is capable of being absorbed by target site
T.
[0039] FIG. 2B shows another embodiment of a delivery device 200.
Delivery device 200 is similar to delivery device 100, but includes
a plurality of delivery tubes 120. Delivery tubes 120 may each be
independently extended and retracted from catheter 110. Delivery
device 200 allows multiple target sites T at the same longitudinal
position to be treated at the same time.
[0040] FIG. 2C-2D show another embodiment of a delivery device 300.
FIG. 2C shows a side view of delivery device 300. FIG. 2D shows an
end view of delivery device 300. Delivery device 300 includes a
catheter 310 with a plurality of ports 316. Ports 316 are formed at
the same angle relative to a longitudinal axis of catheter 310.
Delivery device 300 also includes a plurality of delivery tubes 320
slidably coupled within catheter 310. Delivery tubes 320 may be
evenly or irregularly spaced. Delivery tubes 320 each include a
distal end 324 with a delivery point 326. Delivery tubes 320 may
each include a delivery lumen 325. Alternatively, one or more
delivery tubes 320 may be solid instead of hollow.
[0041] Delivery tubes 320 are outwardly biased from a longitudinal
axis of catheter 310. Delivery tubes 320 may be made of a
shape-memory alloy such as nickel titanium, or other suitable
material. Delivery tubes 320 may be preshaped to a desired
three-dimensional configuration, using shape-memory or superleastic
properties of nickel-titanium or spring properties of steels or
other alloys used to make springs, so that once the catheter is
retracted, delivery tubes 320 make contact with and penetrate into
wall W. Delivery points 326 may be sharp. Delivery lumens 325 may
have inner surfaces that are coated or treated with polyethylene or
other suitable material to reduce the loss or degradation of agents
from adhesion inside delivery lumens 325.
[0042] Delivery tubes 320 are delivered retracted inside catheter
310, with delivery points 326 unexposed. Delivery tubes 320 are
positioned in a vessel V at the longitudinal position of a target
site T. Catheter 310 may also be rotated to position delivery
points 326 at a radial position of target site T. Delivery tubes
320 are then extended from catheter 310 through ports 316 to expose
delivery points 326 and penetrate into wall W. Delivery tubes 320
may be extended until delivery points 326 are positioned at a depth
of target site T. Delivery tubes 320 then deliver an agent through
delivery lumens 325 to target site T. Alternatively, delivery
points 326 may be treated or coated with an agent which is capable
of being absorbed by target site T. Delivery device 300 allows a
longer target site T at a similar radial position to be treated at
the same time.
[0043] FIGS. 2E-2F show another embodiment of a delivery device
400. FIG. 2E shows a side view of delivery device 400. FIG. 2F
shows an end view of delivery device 400. Delivery device 400 is
similar to delivery device 300, but includes a plurality of ports
316 that are formed at different angles relative to a longitudinal
axis of catheter 310. Delivery tubes 320 thus extend at different
angles from catheter 310. Delivery device 400 allows longer target
sites T at multiple radial positions to be treated at the same
time.
[0044] FIG. 2G shows another embodiment of a delivery device 500.
Delivery device 500 includes a catheter 510 with a plurality of
ports 516, with each port 516 formed on a separate catheter section
518. Each catheter section 518 may be slidably disposed within the
catheter section 518 before it. Delivery device 500 also includes a
plurality of delivery tubes 520 slidably coupled within catheter
510. Delivery tubes 520 each include a distal end 524 with a
delivery point 526. Delivery tubes 520 may each include a delivery
lumen 525. Alternatively, one or more delivery tube 520 may be
solid instead of hollow.
[0045] Delivery tubes 520 are outwardly biased from a longitudinal
axis of catheter 510. Delivery tubes 520 may be made of a
shape-memory alloy such as nickel titanium, or other suitable
material. Delivery tubes 520 may be preshaped to a desired
three-dimensional configuration, using shape-memory or superleastic
properties of nickel-titanium or spring properties of steels or
other alloys used to make springs, so that once the catheter is
retracted, delivery tubes 520 make contact with and penetrate into
wall W. Delivery points 526 may be sharp. Delivery lumens 525 may
have inner surfaces that are coated or treated with polyethylene or
other suitable material to reduce the loss or degradation of agents
from adhesion inside delivery lumens 525.
[0046] Delivery tubes 520 are delivered retracted inside catheter
510, with delivery points 526 unexposed. Each catheter section 518
may be independently extended and refracted to position delivery
tubes 520 at the longitudinal positions of target sites T. Each
catheter section 518 may also be independently rotated to position
delivery points 526 at the radial positions of target sites T.
Delivery tubes 520 are then extended from catheter sections 518
through ports 516 to expose delivery points 526 and penetrate into
wall W. Delivery tubes 520 may each be independently extended until
delivery points 526 are positioned at the depths of target sites T.
Delivery tubes 520 then deliver an agent through delivery lumens
525 to target sites T. Alternatively, delivery points 526 may be
treated or coated with an agent which is capable of being absorbed
by target sites T. Delivery device 500 allows multiple target sites
with different longitudinal positions, radial positions, and depths
to be treated at the same time.
[0047] FIG. 2H shows another embodiment of a delivery device 600.
Delivery device 600 includes a catheter 610 with a coil 620 having
along its length one or more delivery points 626. Coil 620 also
includes a delivery lumen 625.
[0048] Coil 620 is self-expanding. Coil 620 may be made of a
shape-memory alloy such as nickel titanium, or any other suitable
material. Coil 620 may be preshaped to a desired three-dimensional
configuration, using shape-memory or superleastic properties of
nickel-titanium or spring properties of steels or other alloys used
to make springs, so that once the catheter is retracted, coil 620
expands and makes contact with and delivery points 626 penetrate
into wall W. Delivery points 626 may be sharp. Delivery lumen 625
may have an inner surface that is coated or treated with
polyethylene or other suitable material to reduce the loss or
degradation of agents from adhesion inside delivery lumen 625.
[0049] Coil 620 is delivered in an unexpanded configuration inside
catheter 610, with delivery points 626 unexposed. Coil 620 is
positioned in a vessel V at the longitudinal position of target
sites T. Catheter 610 is then pulled back to allow coil 620 to open
and expose delivery points 626 to penetrate into wall W. Coil 620
then delivers an agent through delivery lumen 625 to target sites
T. Alternatively, delivery points 626 may be treated or coated with
an agent which is capable of being absorbed by target sites T.
[0050] FIG. 3A shows another embodiment of a delivery device 700.
Delivery device 700 is similar to delivery device 100, but also
includes a balloon 130 coupled to a distal end 114 of catheter
110.
[0051] Balloon 130 may have a port 132 through which delivery tube
120 can pass. Balloon 130 may be inflated and deflated through an
inflation lumen 135. When inflated, balloon 130 may anchor distal
end 114 of catheter 110 within vessel V.
[0052] FIG. 3B shows another embodiment of a delivery device 800.
Delivery device 800 is similar to delivery device 200, but also
includes a balloon 130 coupled to a distal end 114 of catheter
110.
[0053] FIG. 3C shows another embodiment of a delivery device 900.
Delivery device 900 is similar to delivery device 400, but includes
a balloon 330 adjacent to each port 316.
[0054] FIG. 3D shows another embodiment of a delivery device 1000.
Delivery device 1000 includes a catheter 1010 with a balloon 1030.
A plurality of delivery points 1026 is coupled to the surface of
balloon 1030. Catheter 1010 includes a delivery lumen 1025 in fluid
communication with the delivery points 1026. Catheter 1010 also
includes an inflation lumen 1035 coupled to the balloon.
[0055] Delivery points 1026 may be sharp. Delivery lumen 1025 may
be coated or treated with polyethylene or other suitable material
to reduce the loss of agents from adhesion inside delivery lumen
1025.
[0056] Balloon 1030 is delivered in a deflated configuration inside
catheter 1010, with delivery points 1026 unexposed. Balloon 1030 is
positioned in a vessel V at the longitudinal position of target
sites T. Catheter 1010 is then pulled back and balloon 1030
inflated to expose delivery points 1026 to penetrate into wall W.
Delivery points 1026 then deliver an agent to target sites T.
[0057] FIG. 3E shows one embodiment of a delivery device 1100.
Delivery device 1100 includes a catheter 1110 and a plurality of
delivery tubes 1120 slidably coupled within catheter 1110. Delivery
tubes 1120 each include a distal end 1124 with a delivery point
1126. Delivery tubes 1120 may each include a delivery lumen 1125.
Alternatively, one or more delivery tubes 1120 may be solid instead
of hollow.
[0058] Delivery device 1100 also includes a balloon 1130 slidably
coupled within catheter 1110 at a center of delivery tubes 1120.
Balloon 1130 is not coupled to delivery tubes 1120. Balloon 1130
may be inflated and deflated through an inflation lumen 1135. When
inflated, balloon 1130 may anchor distal end 1114 of catheter 1110
within vessel V.
[0059] Delivery tubes 1120 may be made of a shape-memory and
super-elastic alloy such as nickel titanium, stainless steel, or
other suitable materials of sufficient strength and toughness to
achieve a desired depth of penetration. Delivery points 1126 may be
sharp. Delivery lumens 1125 may have inner surfaces that are coated
or treated with polyethylene or other suitable material to reduce
the loss or degradation of agents from adhesion inside delivery
lumens 1125.
[0060] Delivery tubes 1120 are delivered retracted inside catheter
1110, with delivery points 1126 unexposed. Delivery tubes 1120 are
positioned in a vessel V at the longitudinal position of a target
site T. Catheter 1110 may also be rotated to position delivery
points 1126 at a radial position of target site T. Delivery tubes
1120 are then extended from catheter 1110 to expose delivery points
1126. Balloon 1130 is then extended from catheter 1110 distally to
delivery tubes 1120, and inflated through inflation lumen 1135 to
urge delivery points 1126 toward wall W. Delivery tubes 1120 may
continue to be extended to further urge delivery toward wall W and
into wall W. Delivery tubes 1120 are extended until delivery points
1126 are positioned at depths of target sites T. Delivery tubes
1120 then deliver an agent through delivery lumens 1125 to target
sites T. Alternatively, delivery points 1126 may be treated or
coated with an agent which is capable of being absorbed by target
sites T.
[0061] FIG. 3F shows one embodiment of a delivery device 1200.
Delivery device 1200 is similar to delivery device 1110, but also
includes a plurality of delivery tubes 1120 both proximally and
distally to balloon 1130.
[0062] FIG. 3G shows one embodiment of a delivery device 1300.
Delivery device 1300 includes a catheter 1310 and a plurality of
delivery tubes 1320 slidably coupled within catheter 1310. Delivery
tubes 1320 each include a distal end 1324 with a delivery point
1326. Delivery tubes 1320 may each include a delivery lumen 1325.
Alternatively, one or more delivery tubes 1320 may be solid instead
of hollow.
[0063] Delivery device 1300 also includes a positioning device 1330
slidably coupled within catheter 1310. Positioning device 1330 may
be a self-expanding structure with an open mesh-like
architecture.
[0064] Delivery tubes 1320 may be made of a shape-memory and
super-elastic alloy such as nickel titanium, stainless steel, or
other suitable materials of sufficient strength and toughness to
achieve a desired depth of penetration. Delivery points 1326 may be
sharp. Delivery lumens 1325 may have inner surfaces that are coated
or treated with polyethylene or other suitable material to reduce
the loss or degradation of agents from adhesion inside delivery
lumens 1325.
[0065] Delivery tubes 1320 are delivered retracted inside catheter
1310, with delivery points 1326 unexposed. Delivery tubes 1320 are
positioned in a vessel V at the longitudinal position of a target
site T. Catheter 1310 may also be rotated to position delivery
points 1326 at a radial position of target site T. Positioning
structure 1330 is delivered in an unexpanded state inside catheter
1310. Positioning structure 1330 is extended from catheter 1310 and
allowed to expand, anchoring distal end 1314 of catheter 1310
within vessel V. Delivery tubes 1320 are then extended from
catheter 1310 to expose delivery points 1326 and pass through
positioning structure 1330 to penetrate into wall W. Delivery tubes
1320 are extended until delivery points 1326 are positioned at
depths of target sites T. Delivery tubes 1320 then deliver an agent
through delivery lumens 1325 to target sites T. Alternatively,
delivery points 1326 may be treated or coated with an agent which
is capable of being absorbed by target sites T.
[0066] Positioning device 1330 and delivery points 1326 may be
retracted, advanced further and repositioned inside the artery for
additional delivery of agent along several locations along the
renal artery.
[0067] FIG. 4A shows delivery device 100 with a radioopaque marker
140 coupled to distal end 114 of catheter 110. Radioopaque marker
140 acts as an aid in positioning delivery tube 120. Radioopaque
marker 140 may be made of gold, platinum, platinum iridium alloys,
or other suitable material.
[0068] FIG. 4B shows delivery device 100 with radioopaque depth
markings 150 on delivery tube 120. Depth markings 150 aid in
measuring the depth of penetration while guiding delivery point 126
of delivery tube 120 to target site T. Delivery tube 120 may also
house a strain gage or other suitable force transducer or sensor to
monitor contact with wall W and depth of penetration.
[0069] FIG. 4C shows delivery device 100 with an ultrasound
transducer 160 coupled to distal end 114 of catheter 110.
Ultrasound transducer 160 allows imaging of the location and
monitoring of the location and depth of delivery tube 120, as well
as the volume of agent delivered. Ultrasound-based imaging of the
target location may be enhanced by the use of contrast media
(contrast-enhanced ultrasound) such as gas-filled microbubbles that
are administered intravenously to the systemic circulation prior to
the procedure. Further, these gas-filled microbubbles may also be
targeted with ligands that bind certain molecular markers that are
expressed by the area of imaging interest. Contrast media is
injected systemically in a small bolus and detection of bound
microbubbles show the area of interest or identify particular cells
in the area of interest.
[0070] FIG. 4D shows delivery device 100 with an ultrasound device
170 coupled to a proximal end 122 of delivery tube 120. Ultrasound
device 170 transmits ultrasound energy through delivery tube 120 to
delivery point 126, which may enhance the bioavailability of the
agent.
[0071] FIG. 4E shows delivery device 100 with a visualization
device 180 coupled to distal end 114 of catheter 110. Visualization
device 180 allows direct visualization of delivery tube 120 and
wall W. Visualization device 180 may be electromagnetic transducer,
magnetic-resonance imaging (MRI) transducer, angioscope, camera, or
other suitable device.
[0072] Visualization device 180 may be an electromagnetic
transducer, including one or more electrode pairs, coupled to
distal end 114 of catheter 110. The electromagnetic transducer
works in conjunction with a low-level magnetic field
(5.times.10.sup.-6 to 5.times.10.sup.-5 Tesla) generated by
electromagnetic coils placed on the operating table beneath the
patient. The electromagnetic transducer can be moved along the
vessel to record and map the electrical activity along the entire
surface of the renal artery. These electrical signals map the
neuron activity or electrical conduction pathways of the peripheral
nervous system surrounding the renal arteries, and aid in
identifying the target location for delivering the agent.
[0073] Visualization device 180 may be a magnetic-resonance imaging
(MRI) transducer coupled to distal end 114 of catheter 110. The MRI
transducer works in conjunction with a specific contrast agent
delivered, as a bolus, to the patient to assist in imaging the
electrical conduction of the peripheral nervous system surrounding
the renal arteries, and to help in identifying the target site for
denervation.
[0074] FIG. 4F shows delivery device 100 with a depth control 190
coupled to proximal end 112 of catheter 110 and proximal end 122 of
delivery tube 120. Depth control 190 includes marks which indicate
how far delivery tube 120 has been extended.
[0075] FIG. 4G shows delivery device 100 with a separate luminal
port in the catheter to inject radioopaque contrast agents to image
the location of the catheter and the target site using X-ray
fluoroscopy or angiography during the procedure.
[0076] FIG. 5A shows delivery device 100 having a catheter 110 with
flush ports 117. Flush ports 117 may introduce a neutralizing
substance into vessel V which neutralizes at least some of the
agent delivered by delivery tube 120 which leaks back into vessel
V.
[0077] FIG. 5B shows one embodiment of a delivery device 1400.
Delivery device 1400 includes a catheter 1410 with a delivery tube
port 1416 and an aspiration port 1417. Delivery device 1400 also
includes a delivery tube 1420 slidably coupled within catheter
1410. Delivery tube 1420 includes a distal end 1424 with a delivery
point 1426. Delivery tube 1420 may also include a delivery lumen
1425. Alternatively, delivery tube 1420 may be solid instead of
hollow. Delivery device 1400 also includes balloons 1430 coupled to
catheter 1410 both proximally and distally to delivery tube port
1416 and aspiration port 1417. Catheter 1410 includes perfusion
ports 1419 distal and proximal to balloons 1430.
[0078] Delivery tube 1420 is outwardly biased from a longitudinal
axis of catheter 1410. Delivery tube 1420 may be made of a
shape-memory alloy such as nickel titanium, or other suitable
material. Delivery tube 1420 may be preshaped to a desired
three-dimensional configuration, using shape-memory or superleastic
properties of nickel-titanium or spring properties of steels or
other alloys used to make springs, so that once the catheter is
retracted, delivery tube 1420 makes contact with and penetrates
into wall W. Delivery point 1426 may be sharp. Delivery lumen 1425
may have an inner surface that is coated or treated with
polyethylene or other suitable material to reduce the loss or
degradation of agents from adhesion inside delivery lumen 1425.
[0079] Delivery tube 1420 is delivered retracted inside catheter
1410, with delivery point 1426 unexposed. Delivery tube 1420 is
positioned in a vessel V at the longitudinal position of a target
site T. Catheter 1410 may also be rotated to position delivery
point 1426 at a radial position of target site T. Balloons 1430 are
inflated to anchor the catheter in vessel V and to isolate a
portion of vessel V. Delivery tube 1420 is then extended from
catheter 1410 through delivery tube port 1416 to expose delivery
point 1426 and penetrate into wall W. Delivery tube 1420 is
extended until delivery point 1426 is positioned at a depth of
target site T. Delivery tube 1420 then delivers an agent through
delivery lumen 1425 to target site T. Alternatively, delivery point
1426 may be treated or coated with an agent which is capable of
being absorbed by target site T. Excess agent which returns into
vessel V is isolated by balloons 1430 and may be vented out through
aspiration port 1417. Perfusion ports 1419 allow fluid flow through
vessel V to continue even when balloons 1430 are inflated.
[0080] FIG. 6 shows one embodiment of a delivery device 1500.
Delivery device 1500 includes a sensor 1510 coupled to a pump 1520
and a catheter 1530. Sensor 1510 is configured to measure a
physiological parameter. Pump 1520 includes control software and an
agent. Catheter 1530 is implanted in a suitable location within the
body. Pump 1520 receives data from sensor 1510, and responds by
using control software to determine an amount of the agent to
deliver through catheter 1530. For example, sensor 1510 may be used
to measure blood pressure, which pump 1520 uses to determine an
amount of a denerving agent to deliver through the catheter 1530,
which is implanted to deliver the agent to the renal nerves.
Delivery device 1500 thus uses a closed feedback loop to control a
physiological parameter such as blood pressure.
[0081] FIG. 7A shows a drug-eluting stent 1600 which may be
implanted in a renal artery. FIG. 7B shows a polymer-encapsulated
time-release agent 1700.
[0082] FIG. 8A-8B show one embodiment of a method of using a
delivery device 100.
[0083] FIG. 8A shows mapping of vessel V and nerves using a mapping
catheter C. Mapping catheter C is introduced into vessel V and used
to locate and map the nerves surrounding vessel V. In this example,
vessel V is a renal artery and the nerves are renal nerves.
Alternatively, vessel V may be a renal vein or other vessel which
provides access to the renal nerves. Mapping catheter C may be an
electrical mapping catheter, an ultrasound catheter, a magnetic
resonance imaging (MRI) catheter, or other suitable catheter. An
electrical mapping catheter may be cardiac mapping catheter adapted
for use in the renal artery and renal nerves. An ultrasound
catheter may be used with contrast agents such as paramagnetic
(e.g., gadolinium, manganese) and superparamagnetic (e.g., iron
oxide) contrast agents, in the form of nanoparticles or other
suitable form. An MRI catheter may be used with fluorescent
nanospheres, fluorescent microspheres and other agents to enhance
imaging.
[0084] FIG. 8B shows introducing delivery device 100 into vessel V.
Catheter 110 may be moved along vessel V to place delivery point
126 of delivery tube 120 at the longitudinal position of target
site T. Catheter 110 is capable of being placed in the proximal
third of the renal artery beginning at the aorto-ostial junction of
the aorta and renal artery. Catheter 110 may be placed with the
assistance of radioopaque marker 140.
[0085] FIG. 8C shows rotating catheter 110 in vessel V to place
delivery tube 120 at the radial position of target site T.
[0086] FIG. 8D shows extending delivery tube 120 from catheter 110
to penetrate into wall W of vessel V. Delivery tube 120 is extended
until delivery point 126 is placed at the depth of target site T.
Delivery point 126 may be placed at target site T with the
assistance of depth markings 150, ultrasound transducer 160, or
other suitable features and devices. Depth control 190 may be used
to control delivery tube 120 and delivery point 126. In renal
arteries, the depth for healthy vessels may have a range of 1-10
mm, with a typical range of 2-3 mm. For diseased vessels, such as
those lined with atherosclerotic plaque, the depth may have a range
of 3-15 mm, with a typical range of 4-7 mm.
[0087] FIG. 8E shows delivering a preparatory agent to target site
T using delivery tube 120. Preparatory agent may be an anesthetic,
vasoconstrictor, vasodilator, neurotropic agent conjugated to a
traceable marker, steroid, or other suitable agent. Preparatory
agent serves to anesthesize, reduce uptake of delivered agents by
vessel V, and other purposes. The traceable marker may be a
lipophilic dye or fluorophore (e.g., nile red, long-chain
carbocyanines), a radioisotope (e.g., thallium 201Ti, technetium
99mTC, gallium 67Ga, lithium 6Li, lithium 7Li), metallic
nanoparticles (e.g., gadolinium, iron oxide, manganese), an enzyme,
contrast agents (e.g., godadiamide), and/or antibodies (e.g.,
antibodies against myelin oligodendrocyte glycoprotein, axonin-1,
neuronal cell adhesion molecule, neuroglial cell adhesion
molecule).
[0088] FIG. 8F shows delivering a priming agent to target site T
using delivery tube 120. Delivering a priming agent may be
performed at a controlled rate. A priming agent may be used as an
initial signal to activate or inactivate nerve intracellular
signaling, nerve cell action potential, or nerve cell membrane
repolarization.
[0089] Priming agent may be an inotropic drug (e.g., cardiac
glycoside, hoiamides), channel blocker (e.g., conotoxins,
amlodipine, diltiazem, verapamil), excitatory amino acid (e.g.,
glutamate, domoic acid), beta-blocker (e.g., propranolol),
bi-partite fusion construct, pro-apoptotic factor (e.g.,
staurosporine, tumor necrosis factor (TNF), antibody against nerve
growth factor receptor p75, glucocorticoid), neurotropic agent
conjugated to a neuroactive agent, or anti-manic agent (e.g.,
lithium).
[0090] Neurotropic agents may be an antibody against UCHL1, myelin
oligodendrocyte glycoprotein, axonin-1, neuronal cell adhesion
molecule, neuroglial cell adhesion molecule; nerve growth factor,
reovirus .sigma.1 protein, rabies spike glycoprotein, Theiler's
murine encephalomyelitis virus (TMEV), or other suitable agents
used to bind to the surface of nerve cells in a specific
manner.
[0091] Priming agent may also be a toxin or toxic peptide (e.g.,
conotoxin, tetrodotoxin, saxitoxin), alcohol (e.g., ethanol), an
enzyme (e.g., eosinophil cationic protein/RNase 3), phenol, or an
anti-convulsant (carbamazepine).
[0092] Priming agent may also be a neurotropic agent (e.g., ciliary
neurotropic factor (CNTF), brain derived neurotropic factor (BDNF),
glial derived nexin (GDN)).
[0093] Priming agent may also be batrachotoxin, neosaxitoxin,
gonyautoxins, aurotoxin, agitoxin, charybdotoxin, margaoxin,
slotoxin, scyllatoxin, hefutoxin, calciseptine, taicatoxin,
calcicludine, PhTx3, amphetamine, methamphetamine, or MDMA.
[0094] FIG. 8G shows an optional step of enhancing delivery of an
agent using ultrasound device 170. Alternatively, enhancing
delivery may be performed with mechanical, ultrasonic, thermal,
and/or other energy means.
[0095] FIG. 8H shows an optional step of delivering a neutralizing
agent using flush ports 117 in catheter 110. Neutralizing agent
deactivates at least some of any excess agent which may escape back
into vessel V or excess agent that remains unbound to nerve cells.
Neutralizing agent may be a dilutant such as saline, a neutralizing
antibody (e.g., digoxin immune Fab), an enzyme (e.g., glutamate
dehydrogenase), sodium bicarbonate (to neutralize phenol), a
chelating agent (e.g., EDTA, EGTA), a steroid, non-steroidal
anti-inflammatory drugs (e.g., aspirin, ibuprofen, sirolimus), or
other suitable agent.
[0096] FIG. 8I shows delivering a secondary agent to target site T
using delivery tube 120. Secondary agent may be delivered at a
controlled rate. Secondary agent may be delivered at the same time
as priming agent, or at some predetermined time after priming
agent. Priming agent and secondary agent may be different agents.
Priming agent and secondary agent may also be the same agent, in
the same or different volumes and/or concentrations. Priming agent
and secondary agent may be different agents and may be linked
together to form a bi-partite construct. Priming agent may also be
linked to two different secondary agents to form a tri-partite
construct. The function of sequential or combined delivery of
priming and secondary agents is to deliver multiple stimuli to the
nerve cell to promote or induce nerve cell death.
[0097] The use of a priming agent and a secondary agent may result
in a synergistic effect. This synergistic effect may result in (1)
smaller amounts of the agents needed than if either agent was used
by itself, (2) faster action than if either agent was used by
itself, and (3) greater effectiveness than if either agent was used
by itself
[0098] Some or all of the method may be repeated as desired. For
example, delivering a secondary agent may be followed by enhancing
delivery and delivering a neutralizing agent. As another example,
delivering a secondary agent may be followed by delivering another
secondary agent.
[0099] FIGS. 9A-9E show one embodiment of a method for using
delivery device 1000.
[0100] FIG. 9A shows mapping of vessel V and nerves using a mapping
catheter C. Mapping catheter C is introduced into vessel V and used
to locate and map the nerves surrounding vessel V. In this example,
vessel V is a renal artery and the nerves are renal nerves.
Alternatively, vessel V may be a renal vein or other vessel which
provides access to the renal nerves. Mapping catheter C may be an
electrical mapping catheter, an ultrasound catheter, a magnetic
resonance imaging (MRI) catheter, or other suitable catheter.
[0101] FIG. 9B shows introducing delivery device 1000 into vessel
V. Catheter 1010 may be moved along vessel V to place distal end
1014 at the longitudinal position of target sites T. Catheter 1010
is capable of being placed in the proximal third of the renal
artery beginning at the aorto-ostial junction of the aorta and
renal artery. Catheter 1010 may be placed with the assistance of a
positioning element 1011 such as a balloon or self-expanding
structure. Positioning element 1011 is coupled to catheter 1010 at
a fixed or known distance from distal end 1014. Positioning element
1011 may be configured to fit at the ostium of the renal
artery.
[0102] FIG. 9C shows deploying balloon 1030 from catheter 1010.
Positioning element 1011 is fully expanded, and may be seated at
the ostium of the renal artery, thus positioning distal end 1014
and balloon 1030 at a fixed or known distance from the ostium of
the renal artery.
[0103] FIG. 9D shows rotating balloon 1030 in vessel V to place
delivery points 1026 of balloon 1030 at the radial positions of
target sites T.
[0104] FIG. 9E shows expanding balloon 1030 in vessel V to urge
delivery points 1026 into wall W of vessel V. Delivery points 1026
are of a known length, and penetrate a known distance into wall W
to reach target sites T. Delivery points 1026 may have different
lengths and configurations. For example, delivery points 1026 may
become have lengths that become shorter with distance from the
ostium of the renal artery. As another example, delivery points
1026 may have delivery lumens 1025 that become smaller and deliver
less agent with distance from the ostium of the renal artery.
[0105] Delivery points 1026 may be arranged in a predetermined
configuration or pattern. The configuration or pattern of delivery
points 1026 may be selected to maximize the probability they will
be positioned on or near the renal nerves in the renal artery,
based on distribution data for the renal nerves. Several different
preconfigured patterns may be available, with selection based on
results of mapping of the renal nerves. The configuration or
pattern of delivery points 1026 may also be selected to be
non-circumferential to reduce the effects of any swelling or
stenosis. For example, the configuration or pattern may be a
helical or spiral pattern, as opposed to one or more
circumferential rings.
[0106] Delivery points 1026 are capable of creating noncontiguous
or discrete delivery areas. Delivery points 1026 are capable of
delivering very small quantities of agents. The ability to deliver
very small quantities in a very focused and targeted manner allows
for a greater selection of very toxic agents to be used.
[0107] FIG. 9F shows delivering an agent to target sites T. Agent
may be one or more agents, delivered sequentially or substantially
simultaneously.
[0108] Other methods may be used to deliver agents. For example,
agents may be delivered with a drug-eluting stent. The stent may be
configured to fit inside the renal artery, and may be
bioabsorbable. The stent may be configured to deliver a priming
agent during a first period of time, and a secondary agent during a
second period of time. As another example, agents may be delivered
in time-release formulations, such as encapsulated in polymers. The
time-release formulations may be configured to release a priming
agent during a first period of time, and a secondary agent during a
second period of time. As yet another example, agents may be
delivered with microbubbles having a diameter of approximately 1-10
micrometers, used in combination with focused ultrasound. These
microbubbles may temporarily permeabilize the vessel wall in a
localized area to permit the passage of neuroactive or neurotoxic
agents through the vasculature and to the surrounding interstitial
tissue near a nerve cell.
[0109] Agents may be transiently housed within or complexed with
liposomes. The liposomes may contain nerve growth factor (NGF) on
the outer leaflet of the liposomal membrane or may contain one or
more other neurotropic agent (e.g., ciliary neurotropic factor
(CNTF), brain derived neurotropic factor (BDNF), glial derived
nexin (GDN)).
[0110] Glutamate or domoic acid (0.00005-700 mM) can be
administered as a denerving agent singly or in combination.
Excessive stimulation of neurons by glutamate initiates a cascade
of ion fluxes, cellular swelling and death in nerve cells.
Additionally, fibroblasts expressing human NR1a/2A or NR1a/2B NMDA
receptors are hypersensitive to glutamate receptor-mediated
toxicity and NR1a/2B NMDA receptors are expressed in tissues
outside of the brain (kidney, adrenal cortex, pancreas, heart and
others) in low amounts.
[0111] L-glutamate is the major excitatory neurotransmitter in the
central nervous system and activates both inotropic and
metabotropic glutamate receptors. Glutamatergic neurotransmission
is involved in most aspects of normal brain function and can be
perturbed in many neuropathologic conditions. The metabotropic
glutamate receptors are a family of G protein-coupled receptors
that have been divided into 3 groups on the basis of sequence
homology, putative signal transduction mechanisms, and
pharmacologic properties. Group I includes GRM1 and GRM5 and these
receptors have been shown to activate phospholipase C. Group II
includes GRM2 and GRM3 while Group III includes GRM4, GRM6, GRM7
and GRM8.
[0112] Group II and III receptors are linked to the inhibition of
the cyclic AMP cascade but differ in their agonist selectivities.
The canonical alpha isoform of the metabotropic glutamate receptor
1 gene is a disulfide-linked homodimer whose activity is mediated
by a G-protein-coupled phosphatidylinositol calcium second
messenger system. GRM receptor expression is not exclusive to
neurons and has been determined to be present in kidney, liver,
heart, lungs, thyroid and other organs.
[0113] Cardiac glycosides are inotropic drugs that specifically
inhibit Na+,K(+) ATPase activity. Cardiac glycoside binding to the
alpha subunit of the Na+,K(+) ATPase induces intracellular ion
flux. Extended inhibition of Na+,K(+) ATPase function can induce
apoptosis in nerve cells. Additionally, brief exposure (5 to 10
minutes) to high concentrations of cardiac glycoside (1-10 mM) is
toxic to nerve cells.
[0114] A combination of an amino acid and an inotropic drug can be
administered to potentiate nerve cell blockade, sensitivity, damage
or death. Exposure to cardiac glycoside (0.01-1 mM) prior to
exposure of a nerve cell to glutamate produces supersensitivity in
a nerve cell and induces glutamate excitotoxicity.
[0115] Ziconotide is a synthetic peptide derived from a toxin
produced by the marine snail, Conus magus. Ziconotide selectively
targets N-type voltage-gated calcium channels. Additionally, other
members of the cysteine-rich conotoxin superfamily can be used to
target nerve cells. Conotoxins and peptides derived from conotoxins
(conopeptides) have also shown efficacy in clinical applications.
Targeted administration of a high concentration of toxic peptide
can induce nerve cell damage and death.
[0116] Hoiamide B(2) is a cyclic depsipeptide produced by marine
cyanobacteria. The linear lipopeptide, hoiamide C(3) is also
produced by marine cyanobacteria. Both metabolites possess the
unique hoiamide structural class, characterized by an acetate
extended and S-adenosyl methionine modified isoleucine, a central
tri-heterocyclic core of two alpha-methylated thiazolines and one
thiazole, and a highly oxygenated and methylated C-15 polyketide
unit. Hoiamides have been demonstrated to induce sodium influx and
suppress calcium oscillations.
[0117] Eosinophil cationic protein/RNase 3 can induce
neurotoxicity, consistent with apoptosis, in a dose-dependent
manner. Upon binding to the nerve cell surface, an increase in free
cytosolic calcium flux, induction of caspase-3, -8, and -9 can be
observed.
[0118] The bi-partite fusion construct contains (i) a neurotropic
agent that has high affinity to one or more receptors on the
surface of a nerve cell, and is linked by a flexible linker to (ii)
a neuroactive agent that alters a nerve cell. In one example, the
neurotropic agent is the .beta.-subunit of nerve growth factor
(NGF). NGF is internalized into the neurons following binding to
cognate receptors located on nerve cells.
[0119] A bi-partite neurotropic fusion construct may be used to
mark nerve cells and nerve bundles. The neurotropic agent can be a
protein, peptide or other ligand for a receptor located on the
surface of nerve cell. The neurotropic agent is linked by a
hydrolysable or flexible linker (protein, PEGylated crosslinker, or
other) to a traceable marker. The traceable marker can be a
fluorophore, radioisotope, metallic nanoparticles, enzyme, antibody
or other and can be detected by conventional methods. Binding of
the neurotropic agent delivers the traceable marker to the nerve
cell. The binding of the fusion construct labels the outside and
inside of the nerve (upon internalization).
[0120] A bi-partite neurotropic fusion construct to generate nerve
cell blockade, damage or death. The neurotropic agent can be a
protein, peptide or other ligand for a receptor located on the
surface of nerve cell. The neurotropic agent is linked by a
hydrolysable or flexible linker (protein, PEGylated crosslinker, or
other) to a neuroactive agent. The neuroactive agent can be a
toxin, drug, hoiamide, antibody or other and can interrupt nerve
cell homeostasis. Binding of the neurotropic agent delivers the
neuroactive agent to the nerve cell. The binding of both agents
potentiates the action of the neuroactive agent.
[0121] MDMA, also known as ecstasy, is an amphetamine-like
stimulant known to induce apoptotic damage of serotonergic
nerves.
[0122] Calcium channel blockers block voltage-gated calcium
channels to decrease the electrical conductance of a nerve cell and
are used as anti-epileptic drugs. Targeted administration of a high
concentration of calcium channel blocker can induce nerve cell
damage and death.
[0123] Potassium channel blockers block potassium channels to
prolong repolarization of the nerve cell and are used as
anti-arrhythmic drugs. Targeted administration of a high
concentration of potassium channel blocker can induce nerve cell
damage and death.
[0124] Pro-apoptotic factors activate the caspase signaling
cascade, leading to a "quiet" programmed cell death characterized
by blebbing, loss of cell membrane asymmetry and attachment, cell
shrinkage, nuclear fragmentation, chromatin condensation, and
chromosomal DNA fragmentation. This is separate from necrosis,
which is traumatic cell death that results from physical,
electrical or chemical trauma and is pro-inflammatory.
EXAMPLE 1
[0125] A vasoconstrictor (antidiuretic hormone (ADH or vasopressin)
or tetrahydrozoline) is first administered to vessels surrounding
the target site to minimize leakage of the priming or secondary
agents.
[0126] A priming agent of digoxin at a concentration of 0.0001-10
mM in a volume of 0.05-2 cc is then administered at a nerve
proximal site to prime the neurons by inhibiting the transport of
potassium and sodium across the nerve cell membrane and
subsequently inducing an intracellular calcium flux.
[0127] Approximately 0.1-20 minutes later, a secondary agent of
glutamate at a concentration of 0.1-700 mM in a volume of 0.05-2 cc
is then administered at a nerve proximal site to induce neuronal
excitotoxicity.
[0128] Vasoconstriction results from the increased concentration of
calcium (Ca2+ ions) within vascular smooth muscle cells. However,
the specific mechanisms for generating an increased intracellular
concentration of calcium depends on the vasoconstrictor. Two common
stimuli for eliciting smooth muscle contraction are circulating
epinephrine and activation of the sympathetic nervous system
(through release of norepinephrine) that directly innervates the
muscle. These compounds interact with cell surface adrenergic
receptors. Such stimuli result in a signal transduction cascade
that leads to increased intracellular calcium from the sarcoplasmic
reticulum (SR) through IP3 mediated calcium release, as well as
enhanced calcium entry across the sarcolemma through calcium
channels. The rise in intracellular calcium complexes with
calmodulin, which in turn activates myosin light chain kinase. This
enzyme is responsible for phosphorylating the light chain of myosin
to stimulate cross bridge cycling.
[0129] Cardiac glycosides are used therapeutically mainly in the
treatment of congestive heart failure. These effects are caused by
the ability to increase cardiac output by increasing the force of
contraction by increasing intracellular calcium as described below,
increasing calcium-induced calcium release and thus contraction.
Drugs such as ouabain and digoxin are cardiac glycosides.
[0130] Normally, sodium-potassium pumps in the membrane of cells
(in this case, cardiac myocytes) pump potassium ions in and sodium
ions out. Cardiac glycosides inhibit this pump by stabilizing it in
the E2-P transition state, so that sodium cannot be extruded,
therefore increasing intracellular sodium concentration. A second
membrane ion exchanger, NCX, is responsible for "pumping" calcium
ions out of the cell and sodium ions in (3Na/Ca). Raised
intracellular sodium levels inhibit this pump, so calcium ions are
not extruded and will also begin to build up inside the cell.
[0131] Increased cytoplasmic calcium concentrations cause increased
calcium uptake into the sarcoplasmic reticulum via the SERCA2
transporter. Raised calcium stores in the SR allow for greater
calcium release on stimulation, so the myocyte can achieve faster
and more powerful contraction by cross-bridge cycling. The
refractory period of the AV node is increased, so cardiac
glycosides also function to regulate heart rate.
[0132] Binding of cardiac glycoside to Na--K ATPase is slow, and
also, after binding, intracellular calcium increases gradually.
This can be seen in the delayed action of digitalis, even on IV
injection.
[0133] Raised extracellular potassium decreases binding of cardiac
glycoside to Na--K ATPase, resulting in increased toxicity of these
drugs in the presence of hypokalemia.
[0134] Digoxin binds to a site on the extracellular aspect of the
.alpha.-subunit of the Na+/K+ ATPase pump in the membranes of heart
cells (myocytes) and decreases its function. This causes an
increase in the level of sodium ions in the myocytes, which leads
to a rise in the level of intracellular calcium ions. This occurs
because of a sodium/calcium exchanger on the plasma membrane, which
depends on a constant inward sodium gradient to pump out calcium.
Digoxin decreases sodium concentration gradient and the subsequent
calcium outflow, thus raising the calcium concentration in
myocardiocytes and pacemaker cells.
[0135] Increased intracellular calcium lengthens Phase 4 and Phase
0 of the cardiac action potential, which leads to a decrease in
heart rate. Increased amounts of Ca2+ also leads to increased
storage of calcium in the sarcoplasmic reticulum, causing a
corresponding increase in the release of calcium during each action
potential. This leads to increased contractility, the force of
contraction, of the heart.
[0136] There is also evidence that digoxin increases vagal
activity, thereby decreasing heart rate by slowing depolarization
of pacemaker cells in the AV node. This negative chronotropic
effect would therefore be synergistic with the direct effect on
cardiac pacemaker cells. Digoxin is used widely in the treatment of
various arrhythmias. Glutamate is the most abundant excitatory
neurotransmitter in the vertebrate nervous system. At chemical
synapses, glutamate is stored in vesicles. Nerve impulses trigger
release of glutamate from the pre-synaptic cell. In the opposing
post-synaptic cell, glutamate receptors, such as the NMDA receptor,
bind glutamate and are activated. Because of its role in synaptic
plasticity, glutamate is involved in cognitive functions like
learning and memory in the brain. The form of plasticity known as
long-term potentiation takes place at glutamatergic synapses in the
hippocampus, neocortex, and other parts of the brain. Glutamate
works not only as a point-to-point transmitter but also through
spill-over synaptic crosstalk between synapses in which summation
of glutamate released from a neighboring synapse creates
extrasynaptic signaling/volume transmission.
[0137] Glutamate transporters are found in neuronal and glial
membranes. They rapidly remove glutamate from the extracellular
space. In brain injury or disease, they can work in reverse, and
excess glutamate can accumulate outside cells. This process causes
calcium ions to enter cells via NMDA receptor channels, leading to
neuronal damage and eventual cell death, and is called
excitotoxicity. The mechanisms of cell death include damage to
mitochondria from excessively high intracellular Ca2+, and
Glu/Ca2+-mediated promotion of transcription factors for
pro-apoptotic genes, or downregulation of transcription factors for
anti-apoptotic genes.
[0138] Excitotoxicity due to glutamate occurs as part of the
ischemic cascade and is associated with stroke and diseases like
amyotrophic lateral sclerosis, lathyrism, autism, some forms of
mental retardation, and Alzheimer's disease.
[0139] Glutamic acid has been implicated in epileptic seizures.
Microinjection of glutamic acid into neurons produces spontaneous
depolarizations around one second apart, and this firing pattern is
similar to what is known as paroxysmal depolarizing shift in
epileptic attacks. This change in the resting membrane potential at
seizure foci could cause spontaneous opening of voltage-activated
calcium channels, leading to glutamic acid release and further
depolarization.
EXAMPLE 2
[0140] A vasoconstrictor (antidiuretic hormone (ADH or vasopressin)
or tetrahydrozoline) is first administered to vessels surrounding
the target site to minimize leakage of the priming or secondary
agents.
[0141] A priming agent of proscillaridin at a concentration of
0.0001-10 mM in a volume of 0.05-2 cc is then administered at a
nerve proximal site to prime the neurons by inhibiting the
transport of potassium and sodium across the nerve cell membrane
and subsequently inducing an intracellular calcium flux.
[0142] Approximately 0.1-20 minutes later, a secondary agent of
domoic acid at a concentration of 0.00005-0.005 mM in a volume of
0.05-2 cc is then administered at a nerve proximal site to induce
neuronal excitotoxicity.
[0143] Proscillaridin binds to a site on the extracellular aspect
of the .alpha.-subunit of the Na+/K+ ATPase pump in the membranes
of heart cells (myocytes) and decreases its function. This causes
an increase in the level of sodium ions in the myocytes, which
leads to a rise in the level of intracellular calcium ions. This
occurs because of a sodium/calcium exchanger on the plasma
membrane, which depends on a constant inward sodium gradient to
pump out calcium. Proscillaridin decreases sodium concentration
gradient and the subsequent calcium outflow, thus raising the
calcium concentration in myocardiocytes and pacemaker cells.
[0144] Increased intracellular calcium lengthens Phase 4 and Phase
0 of the cardiac action potential, which leads to a decrease in
heart rate. Increased amounts of Ca2+ also leads to increased
storage of calcium in the sarcoplasmic reticulum, causing a
corresponding increase in the release of calcium during each action
potential. This leads to increased contractility, the force of
contraction, of the heart.
[0145] There is also evidence that proscillaridin increases vagal
activity, thereby decreasing heart rate by slowing depolarization
of pacemaker cells in the AV node. This negative chronotropic
effect would therefore be synergistic with the direct effect on
cardiac pacemaker cells. Proscillaridin and other bufadienolides
are not used widely in the United States, but are used in Europe to
treatment of various arrhythmias.
[0146] Domoic acid can bioaccumulate in marine organisms such as
shellfish, anchovies, and sardines that feed on the phytoplankton
known to produce this toxin. DA can accumulate in high
concentrations in the tissues of these plankton feeders when the
toxic phytoplankton itself is high in concentration in the
surrounding waters. In mammals, including humans, domoic acid acts
as a neurotoxin, causing short-term memory loss, brain damage and,
in severe cases, death. DA-producing algal blooms are associated
with the phenomenon of amnesic shellfish poisoning (ASP).
[0147] In marine mammals, domoic acid typically causes seizures and
tremors. In the brain, domoic acid especially damages the
hippocampus and amygdaloid nucleus. It damages the neurons by
activating AMPA and kainate receptors, causing an influx of
calcium. Although calcium flowing into cells is a normal event, the
uncontrolled increase of calcium causes the cell to degenerate.
Because the hippocampus may be severely damaged, short-term memory
loss occurs.
EXAMPLE 3
[0148] A vasoconstrictor (antidiuretic hormone (ADH or vasopressin)
or tetrahydrozoline) is first administered to vessels surrounding
the target site to minimize leakage of the priming or secondary
agents.
[0149] A priming agent of N-Methyl-D-aspartic acid (NMDA) at a
concentration of 0.01-300 mM in a volume of 0.05-2 cc is then
administered at a nerve proximal site to prime the neurons by
inducing excitatory intracellular signaling.
[0150] Approximately 0.1-20 minutes later, a secondary agent of
digoxin at a concentration of 0.0001-10 mM in a volume of 0.05-2 cc
is then administered at a nerve proximal site to inhibit the
transport of potassium and sodium across the nerve cell membrane
and subsequently induce high levels of intracellular calcium to
mediate pro-apoptotic signaling and neuronal toxicity.
[0151] N-Methyl-D-aspartic acid (NMDA) is an amino acid derivative,
which acts as a specific agonist at the NMDA receptor mimicking the
action of glutamate, the neurotransmitter, which normally acts at
that receptor. Unlike glutamate, NMDA only binds to and regulates
the NMDA receptor and has no effect on other glutamate receptors
(such as those for AMPA and kainate). NMDA receptors are
particularly important when they become overactive during
withdrawal from alcohol as this causes symptoms such as agitation
and, sometimes, epileptiform seizures.
[0152] NMDA is a water-soluble synthetic substance that is not
normally found in biological tissue. NMDA is an excitotoxin; this
trait has applications in behavioral neuroscience research. The
body of work utilizing this technique falls under the term "lesion
studies." Researchers apply NMDA to specific regions of an (animal)
subject's brain or spinal cord and subsequently test for the
behavior of interest, such as operant behavior. If the behavior is
compromised, it suggests the destroyed tissue was part of a brain
region that made an important contribution to the normal expression
of that behavior. However, in lower quantities NMDA is not
neurotoxic. Therefore the action of glutamate specifically through
NMDA receptors can be investigated by injecting small quantities of
NMDA into a certain region in the brain: for example, injection of
NMDA in a brainstem region induces involuntary locomotion in cats
and rats.
EXAMPLE 4
[0153] A vasoconstrictor (antidiuretic hormone (ADH or vasopressin)
or tetrahydrozoline) is first administered to vessels surrounding
the target site to minimize leakage of the priming or secondary
agents.
[0154] A priming agent of verapamil at a concentration of 0.1-600
mM in a volume of 0.05-2 cc is then administered at a nerve
proximal site to interrupt potassium and sodium transport across
the nerve cell membrane and prime the neurons by blocking calcium
channels and inducing an intracellular signaling.
[0155] Approximately 0.1-20 minutes later, a secondary agent of
carbamazepine at a concentration of 10-500 mM or lithium at a
concentration of 0.5-400 mM in a volume of 0.05-2 cc is then
administered at a nerve proximal site to interrupt potassium and
sodium transport across the nerve cell membrane and induce neuronal
toxicity.
[0156] Verapamil (brand names: Isoptin, Verelan, Verelan PM, Calan,
Bosoptin, Covera-HS) is an L-type calcium channel blocker of the
phenylalkylamine class. It has been used in the treatment of
hypertension, angina pectoris, cardiac arrhythmia, and most
recently, cluster headaches. It is also an effective preventive
medication for migraine. Verapamil has also been used as a
vasodilator during cryopreservation of blood vessels. It is a class
4 anti-arrhythmic, more effective than digoxin in controlling
ventricular rate. Verapamil's mechanism in all cases is to block
voltage-dependent calcium channels.
[0157] In cardiac pharmacology, calcium channel blockers are
considered class IV anti-arrhythmic agents. Since calcium channels
are especially concentrated in the sinoatrial and atrio-ventricular
nodes, these agents can be used to decrease impulse conduction
through the AV node, thus protecting the ventricles from atrial
tachy arrhythmias.
[0158] Calcium channels are also present in the smooth muscle that
lines blood vessels. By relaxing the tone of this smooth muscle,
calcium-channel blockers dilate the blood vessels. This has led to
their use in treating hypertension and angina pectoris. The pain of
angina is caused by a deficit in oxygen supply to the heart.
Calcium channel blockers like verapamil will dilate blood vessels,
which increases the supply of blood and oxygen to the heart. This
controls chest pain, but only when used regularly. It does not stop
chest pain once it starts. A more powerful vasodilator such as
nitroglycerin may be needed to control pain once it starts.
Verapamil is also used intra-arterially to treat cerebral vasospasm
and cluster headaches.
[0159] Carbamazepine exhibits autoinduction: it induces the
expression of the hepatic microsomal enzyme system CYP3A4, which
metabolizes carbamazepine itself. Upon initiation of carbamazepine
therapy, concentrations are predictable and follow their respective
baseline clearance/half-life values that have been established for
the specific patient. However, after enough carbamazepine has been
presented to the liver tissue, the CYP3A4 activity increases,
speeding up drug clearance and shortening the half-life.
Auto-induction will continue with subsequent increases in dose but
will usually reach a plateau within 5-7 days of a maintenance dose.
Increases in dose at a rate of 200 mg every 1-2 weeks may be
required to achieve a stable seizure threshold. Stable
carbamazepine concentrations occur usually within 2-3 weeks after
initiation of therapy. The mechanism of action of carbamazepine and
its derivatives is relatively well understood. Voltage-gated sodium
channels are the molecular pores that allow brain cells (neurons)
to generate action potentials, the electrical events that allow
neurons to communicate over long distances. After the sodium
channels open to start the action potential, they inactivate,
essentially closing the channel. Carbamazepine stabilizes the
inactivated state of sodium channels, meaning that fewer of these
channels are available to subsequently open, making brain cells
less excitable (less likely to fire). Carbamazepine has also been
shown to potentiate GABA receptors made up of alpha1, beta2, gamma2
subunits.
[0160] Lithium salts such as lithium carbonate (Li2CO3), lithium
citrate, and lithium orotate are mood stabilizers. They are used in
the treatment of bipolar disorder since, unlike most other mood
altering drugs, they counteract both depression and mania (though
more effective for the latter). Lithium continues to be the gold
standard for the treatment of bipolar disorder. It is also helpful
for related diagnoses, such as schizoaffective disorder and cyclic
major depression. In addition to watching out for the well-known
complications of lithium treatment--hypothyroidism and decreased
renal function--health care providers should be aware of
hyperparathyroidism. Lithium can also be used to augment
antidepressants. Because of lithium's nephrogenic diabetes
insipidus effects, it can be used to help treat the syndrome of
inappropriate antidiuretic hormone hypersecretion (SIADH). It was
also sometimes prescribed as a preventive treatment for migraine
disease and cluster headaches.
[0161] The active principle in these salts is the lithium ion Li+.
Although this ion has a smaller diameter than either Na+ or K+, in
a watery environment like the cytoplasmic fluid, Li+ binds to the
oxygen atoms of water, making it effectively larger than either Na+
or K+ ions. How Li+ works in the central nervous system is still a
matter of debate. Li+ elevates brain levels of tryptophan, 5-HT
(serotonin), and 5-HIAA (a serotonin metabolite). Serotonin is
related to mood stability. Li+ also reduces catecholamine activity
in the brain (associated with brain activation and mania), by
enhancing reuptake and reducing release. Therapeutically useful
amounts of lithium (1.0 to 1.2 mmol/L) are only slightly lower than
toxic amounts (>1.5 mmol/L), so the blood levels of lithium must
be carefully monitored during treatment to avoid toxicity.
EXAMPLE 5
[0162] A vasoconstrictor (antidiuretic hormone (ADH or vasopressin)
or tetrahydrozoline) is first administered to vessels surrounding
the target site to minimize leakage of the priming or secondary
agents.
[0163] A priming agent of digoxin at a concentration of 0.0001-10
mM in a volume of 0.05-2 cc is then administered at a nerve
proximal site to prime the neurons by inducing an intracellular
calcium flux.
[0164] Approximately 0.1-20 minutes later, a secondary agent of
tetrodotoxin, hoiamide, or .omega.-conotoxin, each at a
concentration of 0.00005-0.001 mM, in a volume of 0.05-0.5 cc is
then administered at a nerve proximal site to block ion channels
and induce neuronal toxicity.
[0165] Tetrodotoxin has been isolated from widely differing animal
species, including western newts of the genus Taricha (where it was
termed "tarichatoxin"), pufferfish, toads of the genus Atelopus,
several species of blue-ringed octopodes of the genus Hapalochlaena
(where it was called "maculotoxin"), several sea stars, certain
angelfish, a polyclad flatworm, several species of Chaetognatha
(arrow worms), several nemerteans (ribbonworms) and several species
of xanthid crabs. The toxin is variously used as a defensive
biotoxin to ward off predation, or as both a defensive and
predatory venom (the octopodes, chaetognaths and ribbonworms).
Tarichatoxin and maculotoxin were shown to be identical to
tetrodotoxin in 1964 and 1978, respectively. Recent evidence has
shown the toxin to be produced by bacteria within blue-ringed
octopuses. The most common source of bacteria associated with TTX
production is Vibrio bacteria, with Vibrio alginolyticus being the
most common species. Pufferfish, chaetognaths, and nemerteans have
been shown to contain Vibrio alginolyticus and TTX.
[0166] Tetrodotoxin binds to what is known as site 1 of the fast
voltage-gated sodium channel. Site 1 is located at the
extracellular pore opening of the ion channel. The binding of any
molecules to this site will temporarily disable the function of the
ion channel. Saxitoxin and several of the conotoxins also bind the
same site. The use of this toxin as a biochemical probe has
elucidated two distinct types of voltage-gated sodium channels
present in humans: the tetrodotoxin-sensitive voltage-gated sodium
channel (TTX-s Na+ channel) and the tetrodotoxin-resistant
voltage-gated sodium channel (TTX-r Na+ channel). Tetrodotoxin
binds to TTX-s Na+ channels with a binding affinity of 5-15
nanomolar, while the TTX-r Na+ channels bind TTX with low
micromolar affinity. Nerve cells containing TTX-r Na+ channels are
located primarily in cardiac tissue, while nerve cells containing
TTX-s Na+ channels dominate the rest of the body. The prevalence of
TTX-s Na+ channels in the central nervous system makes tetrodotoxin
a valuable agent for the silencing of neural activity within a cell
culture.
[0167] The toxin blocks the fast Na+ current in human myocytes (the
contractile cells of the muscles), thereby inhibiting their
contraction. By contrast, the sodium channels in pacemaker cells of
the heart are of the slow variety, so action potentials in the
cardiac nodes are not inhibited by the compound. The myocytes in
the atrium, which surround the main cardiac pacemaker, do express
this fast Na+ current and therefore the electrical activity is
blocked and the heart fails to beat.
[0168] A conotoxin is one of a group of neurotoxic peptides
isolated from the venom of the marine cone snail, genus Conus.
Conotoxins, which are peptides consisting of 10 to 30 amino acid
residues, typically have one or more disulfide bonds. Conotoxins
have a variety of mechanisms of actions, most of which have not
been determined. Many of these peptides modulate the activity of
ion channels.
[0169] .omega.-conotoxins have a knotting or inhibitor cysteine
knot scaffold. The knotting scaffold is a very special
disulfide-through-disulfide knot, in which the III-VI disulfide
bond crosses the macrocycle formed by two other disulfide bonds
(I-IV and II-V) and the interconnecting backbone segments, where
I-VI indicates the six-cysteine residues starting from the
N-terminus. The cysteine arrangements are the same for omega, delta
and kappa families, even though omega conotoxins are calcium
channel blockers, whereas delta conotoxins delay the inactivation
of sodium channels, and kappa conotoxins are potassium channel
blockers. Ziconotide is derived from the toxin of the cone snail
species Conus magus.
[0170] The following table lists agents and examples of
concentrations for which they may be used for denervation at a
volume of approximately 2 cc.
TABLE-US-00001 CAS CONCENTRATION AGENT NUMBER MW RANGE Digoxin
20830-75-5 780.94 g/mol 0.01-10 microM Staurosporine 62996-74-1
466.54 g/mol 0.1-100 microM Amlodipine 88150-42-9 408.88 g/mol
0.25-250 microM Verapamil 52-53-9 454.60 g/mol 0.1-500 microM
Cymarin 508-77-0 548.66 g/mol 0.1-10 microM Digitoxin 71-63-6
764.94 g/mol 0.1-10 microM Proscillaridin 466-06-8 530.65 g/mol
0.1-10 microM Ouabain 630-60-4 584.65 g/mol 0.01-10 microM
Veratridine 71-62-5 673.79 g/mol 10-100 microM Glutamate 617-65-2
147.13 g/mol 0.1-800 microM Domoic acid 14277-97-5 311.33 g/mol
0.01-100 microM Oleandrin 465-16-7 576.72 g/mol 0.01-10 microM
Carbamazepine 298-46-4 236.27 g/mol 1-900 microM
[0171] FIG. 10A shows the amount of cell death caused by several of
agents for a fixed amount of time. Primary nerve cell death was
measured using percent trypan blue positive. Primary nerve cells
were incubated in the presence of the agents for 15 minutes, washed
with fresh media, and incubated for 30 minutes at 37.degree. C.
prior to trypan blue scoring. Cell death was assessed by the
percentage of cells in the field that were trypan blue positive.
Three hundred cells per condition (100 cells per well, 3 wells per
condition) were counted using a light microscope.
[0172] FIG. 10B shows the amount of cell death caused by several
agents versus time. Primary nerve cells were incubated at
37.degree. C. in the presence of the agents for 5, 10, 30, and 60
minutes, washed with fresh media, and evaluated by trypan blue
scoring. Cell death was assessed by the percent of cells in the
field that were trypan blue positive. Three hundred cells per
condition (100 cells per well, 3 wells per condition) were counted
using a light microscope.
[0173] The description and examples given above describe the
denervation of renal nerves surrounding the renal arteries to
control hypertension. However, the described devices, methods,
agents and delivery methods may be used to treat other diseases.
These include and are not limited to diabetes (insulin production
levels), fibromyalgia, pain management, and obesity.
[0174] While the foregoing has been with reference to particular
embodiments of the invention, it will be appreciated by those
skilled in the art that changes in these embodiments may be made
without departing from the principles and spirit of the
invention.
* * * * *