U.S. patent number 3,638,649 [Application Number 04/839,297] was granted by the patent office on 1972-02-01 for implantable prosthetic pass-through device.
This patent grant is currently assigned to The Regents of the University of Minnesota. Invention is credited to Robert A. Ersek.
United States Patent |
3,638,649 |
Ersek |
February 1, 1972 |
**Please see images for:
( Certificate of Correction ) ** |
IMPLANTABLE PROSTHETIC PASS-THROUGH DEVICE
Abstract
An implantable through-the-skin prosthetic device for the
permanent entry into the body for passage of liquid, conductors or
the like. The device includes a roughened synthetic resinous member
that courses through the skin and subcutaneous tissues and into the
body. This special roughening promotes tissue ingrowth and thus
effects a firm mechanical seal. Animal experimentation and clinical
success imply that the seal is also dry and germproof. One form of
such a device is an arteriovenous shunt for use in artificial
dialysis. A roughened plastic cannula passes through the skin into
the blood vessel itself. A ball joint fitting for connection to the
external circuits allows for one-handed operation by a trained
patient. A special reamer is provided for use with the shunt.
Inventors: |
Ersek; Robert A. (St. Louis
Park, MN) |
Assignee: |
The Regents of the University of
Minnesota (Minneapolis, MN)
|
Family
ID: |
25279353 |
Appl.
No.: |
04/839,297 |
Filed: |
July 7, 1969 |
Current U.S.
Class: |
604/8; 138/177;
604/175 |
Current CPC
Class: |
A61M
1/3655 (20130101); A61M 39/0247 (20130101); A61L
29/06 (20130101); A61L 29/06 (20130101); C08L
83/04 (20130101); A61M 2039/0261 (20130101) |
Current International
Class: |
A61L
29/00 (20060101); A61L 29/06 (20060101); A61M
1/00 (20060101); A61M 39/10 (20060101); A61M
39/00 (20060101); A61M 1/36 (20060101); A61m
005/00 (); A61m 025/00 () |
Field of
Search: |
;128/348-351,214,214.4
;138/177,178 ;15/104.3 |
References Cited
[Referenced By]
U.S. Patent Documents
Other References
mcDonald et al., Trans. Amer. Soc. Artif. Int. Organs., Vol. XIV
June 1968, pp. 176-180.
|
Primary Examiner: Truluck; Dalton L.
Claims
The embodiments of the invention in which an exclusive property or
privilege is claimed are defined as follows:
1. An implantable through-the-skin prosthetic cannula device for
making a firm dry germproof mechanical seal, said device
comprising:
A. a flexible inert nontoxic synthetic resinous tube of length and
subcutaneous tissue of a living being,
B. at least a portion of the length of said tube at least
sufficient to extend through said cutaneous and subcutaneous tissue
having a roughened outer surface,
C. said roughened surface consisting of a plurality of integral
closely spaced hairlike projecting fibers whereby tissue ingrowth
into and among said projecting fibers is promoted when said tube is
implanted into living body tissue.
2. A device according to claim 1 further characterized in that said
synthetic resinous tube is formed from polytetrafluoroethylene
resin.
3. A method of making a firm dry germproof mechanically sealed
passage through the skin of a living being which comprises
implanting a tubular device according to claim 1 extending through
the cutaneous and subcutaneous tissue of a living being and
maintaining therein by means of attachment between the body tissues
and roughened surface of the tube.
4. An arteriovenous shunt comprising:
A. a pair of cannula segments according to claim 1, each having a
roughened outer surface intermediate of their ends,
B. a distal arterial segment and a distal venous segment,
C. occlusion means connecting each of said distal segments with a
cannula segment, and
D. disengageable junction means between said distal segments.
5. An arteriovenous shunt according to claim 4 further
characterized in that said junction means comprises a bulbous male
member on one of said distal segments and a mating female socket
member on the other of said distal segments.
6. An arteriovenous shunt according to claim 4 further
characterized in that the outer surface of the tip of each of said
cannula segments opposite from said occlusion means is smooth and
tapered.
7. An arteriovenous shunt according to claim 4 further
characterized in that:
A. said occlusion means comprises a length of flexible tubing
extending telescopically over the ends of the cannula segments and
distal segments connected thereby,
B. the ends of said cannula segments and distal segments telescoped
within the ends of the occlusion means are provided with a cuff of
enlarged exterior diameter, and
C. means are provided to secure the ends of said occlusion means to
the ends of said cannula segments and distal segments spaced
inwardly from said cuffs.
8. An arteriovenous shunt according to claim 4 further
characterized in that said cannula segments and said distal
segments are formed from polytetrafluoroethylene resin.
9. An arteriovenous shunt according to claim 4 further
characterized in that said occlusion means is formed from silicone
rubber tubing.
10. An arteriovenous shunt according to claim 5 further
characterized in that:
A. said mating male and female members are relatively thin
walled,
B. said male member mates with a close sealing fit in said female
member, and
C. the open end of said female member is of diameter less than the
outer diameter of the bulbous male member such that slight
deformation of said members occurs during engagement and
disengagement of the members.
11. An arteriovenous shunt comprising:
A. a semirigid tubular arterial cannula segment and a semirigid
tubular venous cannula segment formed from polytetrafluoroethylene
resin,
B. a roughened outer surface composed of a plurality of closely
spaced hairlike projecting fibers intermediate of the ends of each
of said cannula segments,
C. a smooth and tapered outer surface intravascular tip on each of
said cannula segments,
D. a distal arterial segment and a distal venous segment formed
from polytetrafluoroethylene resin,
E. tubular silicone rubber occlusion means extending telescopically
over the ends of each of said respective cannula segments and
distal segments connecting the same, and
F. disengageable junction means between said distal segments
comprising a bulbous male member on one of said segments and a
mating female socket member on the other of said segments.
Description
This invention relates to device for the permanent entry into the
body for passage of liquids, conductors, or the like where a
permanent firm mechanical dry and germproof seal with the skin and
subcutaneous tissues is desired. Such devices are useful, for
example, in artificial dialysis where a shunt is inserted into a
vein in the arm or leg of the patient and maintained for long
periods of time. Other devices such as heart pacemakers, bladder
stimulators, blood pumps, and the like, which are externally
powered require conducting cables or wires to extend through the
skin. These have been a source of irritation and infection since,
prior to the present invention, no safe dry and germproof
mechanical seal through the skin was possible. The invention is
described with particular reference to an implantable tubular
arteriovenous shunt for use by patients suffering from renal
failure and undergoing artificial dialysis, although it must be
understood that the invention is not so limited.
There are approximately 50,000 Americans contracting renal failure
each year. Of these, some 10,000 are qualified for dialysis or
transplantation. Each year as patients are saved by these
modalities, additional facilities are needed to accommodate the new
patients as well as those previously helped. Thus, there is an
expanding need for improvement in the treatment of renal
failure.
Since the demonstration of the feasibility of artificial dialysis
by Kolff, in the mid 1940's, great efforts have been directed to
the improvement of methods for gaining access to the bloodstream.
In 1960, Quinton and Scribner (Quinton, W., Dillard, D. H. and
Scribner, B. H., Cannulation of blood vessels for prolonged
hemodialysis. Trans. Am. Soc. for Artif. Int. Organs, 6: 104,
1960.) described a Teflon shunt system that allowed long term
implantation and repeated dialysis. Although many minor variations
have been brought forth, the basic device remains similar to the
original design except that silicone rubber tubing is used for the
subcutaneous and exterior sections. Successful cannulations have
been reported for as long as 5 years.
In 1961, Quinton and Scribner (Quinton, W. E., Dillard, D. d.,
Cole, J. J. and Scribner, B. H. Possible improvements in the
technique of long term cannulation of blood vessels. Trans, Am.
Soc. for Artif. Int. Organs, 7: 60, 1960.) defined the ideal
cannula as having 10 major properties. They are: (1) The inner
surface should minimize clotting; (2) The exterior surface should
give minimal tissue reaction; (3) The exterior surface should allow
some attachment to the tissues in order to anchor the cannula
firmly in place; (4) The skin at the exit site should surround the
cannula so that a seal is formed and weeping and granulation tissue
are absent., (5) Cannula material should be elastic and move freely
with the tissue as the arm is rotated; (6) Cannula should be able
to withstand extended trauma without permanent damage., (7) Cannula
should not occlude vessels at the cannulation site; (8) Cannula
should have an easily replaceable tip to facilitate fitting any
size vessel; (9) A simple clamp or method of attachment to the
external circuit is needed; and (10) The cannula should lie close
to the skin.
In spite of many refinements, several problems have remained
unsolved in the prior art shunts. The exit sites of the silicone
rubber cannula are usually long sinus tracts that must be
meticulously cleaned and are a constant septic threat to the
patient. The junction means for connection to the external circuits
are cumbersome, undependable, and require at least two hands to
manipulate. The many turned lumen prevents easy reaming of those
shunts should an occlusion occur. The newly developed shunt which
is the subject of the present invention is directed toward solving
these problems.
The arteriovenous shunt, according to the present invention, is
illustrated in the accompanying drawings in which:
FIG. 1 is a schematic plan view showing the shunt in place in the
arm of a patient;
FIG. 2 is an enlarged schematic illustration of the arterial
portion of the shunt showing details of construction and showing
the arterial cannula implanted in the body tissue;
FIG. 3 is a section on a somewhat enlarged scale on the line 3--3
of FIG. 2; and
FIG. 4 is an illustration of the reaming device used with the
shunt.
Referring now to the drawings, the shunt, including an implantable
through-the-skin seal device, according to the present invention,
indicated generally at 10 in FIG. 1 and shown in place in a forearm
11, comprises an arterial cannula 12 extending into the artery 13,
a flexible occlusion member 14, a distal arterial segment 15
connected through a disengageable junction means 16 to a distal
venous segment 17 connected by means of an occlusion member 18 to a
venous cannula 19 inserted through the skin into a vein 20. As is
well understood, the shunt remains in place in the arm (or leg) of
the patient between treatments, the blood flowing from the artery
through one cannula through the shunt to the other cannula and back
into the vein. During his periodic dialysis treatments, the
junction means 16 is disengaged and the distal arterial segment 15
and distal venous segment 17 of the shunt are connected to the
dialysis apparatus, the so-called "artificial kidney."
As best seen in FIG. 2, the semirigid arterial cannula 12 extends
through an opening 21 in the skin 22 through the subcutaneous
tissue 23 and into the end of severed artery 13. The interior of
the cannula is smooth throughout. The intravascular tip portion 24
of the cannula is smooth and slightly tapered to facilitate
insertion into the vessel. The intermediate portion 25 of the
cannula from adjacent the tapered smooth tip 24 to beyond its point
of exit through the skin is roughened to create a myriad of hairy
projections to enable an attachment to be achieved between the body
tissue and the cannula. A portion of the roughened surface extends
into the vessel 13 to anchor the cannula and keep the vessel sealed
around it.
After the cannula exits the skin, it is again smooth and is fitted
to a collapsibly deformable tubular occlusion member 14 which can
be squeezed closed by any suitable clamp during attachment of the
shunt device to and release from the dialysis apparatus. The
cannula-occlusion member junction can be made in the standard
fashion using a steel crimp ring 27, or a suture, or similar means.
Desirably, however, the smooth end 26 of the cannula is provided
with a cuff 28 in the form of an externally thickened ring in order
to assure a positive strong grip between the cannula and occlusion
tubing. The distal arterial segment 15 is similarly connected to
the opposite end of the occlusion tubing 14. The junctions are
permanent, leakproof and pressureproof.
The disengageable junction means 16 connecting the distal arterial
and venous segments 15 and 16, respectively, is in the form of a
ball joint. One of the distal segments has a bulbous male end 29.
The other segment is provided with mating bulbous socket 30 having
a slightly outwardly flaring mouth forming the female end of the
ball joint. This ball joint junction means allows rapid and certain
engagement and disengagement. The ball joint junction members are
relatively thin walled such that they may be deformed slightly when
fit together so that the narrowest part of the mouth of the socket
may have a slightly lesser diameter than the greatest diameter of
the male member. Any pressure within the lumen tends to force the
outer walls of the smaller male fitting 29 against the inner walls
of the slightly larger female fitting 30, thus increasing the
leakproofness and better seating the seal. The inner blood path
remains nearly uniform through such a connection. It is possible to
disengage and reengage the ball joint with just one hand, allowing
for self-dialysis by a trained patient. Apart from the male-female
ball joint members, the venous portion of the shunt essentially
duplicates the arterial portion already described in detail.
The cannula segments and distal segments of the shunt are
preferably formed from polytetrafluoroethylene (Teflon) which has
the requisite properties of inertness, chemical resistance,
compatibility with body tissues, workability, strength, and the
like. Other suitable materials, though less desirable, include
nylon, acetal resin (Delrin), polycarbonate resin (Leaxan),
polyvinylchloride, polyvinylidenechloride, and the like, compounded
so as to have the requisite semirigidity to form a noncollapsible
tube. Similarly, medical grade silicone rubber (Siliastic) is the
preferred material for the occlusion members although other
flexible natural and synthetic rubber or rubberlike materials
having the required properties of inertness chemical resistance,
etc., may be used.
The desired roughness of the intermediate portion of the cannula
segments which transverse the blood vessel lumen and the
subcutaneous tract was achieved by turning the tubing on a lathe
and applying a roughening tool. The tube is inserted over a steel
mandrel to prevent deformation of the tubing, the lathe was rotated
at about 600 r.p.m. and the machining tool was made from a hacksaw
blade and piece of brass stock. The teeth of the hacksaw blade are
allowed to very carefully gouge just the outer few thousandths of
an inch of the tubing. As the tubing spins in contact with the
roughening tool, thousands of roughened hairy projections are
created. As is apparent, the hairy projections are integral with
the body of the tubing. Great care, of course, is exercised in
order that the lumen is not entered or the tubing deformed.
The cuff 28 at the ends of the cannula and distal segments can be
formed by forcing the tubing back on itself while being heated and
placed within a forming jig.
The shunt may be reamed by use of a flexible elongated wire, as
shown in FIG. 4. The reamer 35 comprises an elongated central
flexible wire core 36, which may be a single-strand or a
multiple-strand cable. The core 36 is wrapped along its length by a
coil spring 37 of small diameter. The reamer has a smooth bulbous
termination 38 at one end and a manipulative device in the form of
a small ball configuration 39 at the other end. The first end has a
permanent slightly angled bend 40 deviating by about 40.degree. to
50.degree. from the longitudinal axis of the cable and spaced
inwardly about 1 to 3 inches from the bulbous end. The reamer
ranges in length from about 2 to 3 feet. The remotely angled bend
can be controlled from the opposite end by manipulation of the ball
element 39. By pushing the reamer into the lumen of the shunt and
flexing and straightening the ball end, any turns can be followed
and the smooth finish of he reamer protects the inner lumen from
scratches.
In order to assess the efficacy of the pass through design, animal
experiments were conducted to determine if the connective tissue
would grow into and become attached to the roughened cannula
(Teflon) surface, if sepsis could be avoided, and if strength could
be expected from such a seal. In the initial series, a single
U-shaped piece of Teflon tubing with one limb of the U roughened
and the other smooth, was implanted beneath the skin of two dogs.
The skin was completely closed over the tubing, since previous
tests were thwarted by the dogs removing the device, no matter what
steps were taken to restrain them. A single U-shaped piece of
Teflon was employed in order that the very same piece of stock
would be used and thus serve as its own control, and so that
photomicrographs could be taken of the two limbs of the U.
When the skin and subcutaneous tissue containing the tubes were
removed, a firm grip of the roughened segment was noted and no grip
of the smooth area was seen. Photomicrographs of the two ends of
the same U-shaped piece of tubing show connective tissue
tenaciously involved with the roughened portion and the smooth
portion remaining discretely uninvolved.
In a second series of experiments 10 guinea pigs were used and a
roughened and a smooth Teflon tube was implanted into the dorsal
surface thereof through a small skin puncture into the underlying
tissue. Two percent Xylocaine was infiltrated into the area for
anesthesia and each animal received five drops of a mixture of 1
million units penicillin and 1 gram streptomycin orally. These
devices were then removed after 14 to 20 days for inspection. The
skin and underlying connective tissue grew into the roughened tube
but all smooth segments fell out spontaneously, even though a
circumferential bandage was applied in order to prevent the
dislodgment by the guinea pigs, and the roughened tubes just a few
millimeters away remained intact.
In other experiments 10 guinea pigs received a roughened Teflon
tube but herein were allowed 21 days to become embedded and a 2by 4
inch circle of skin was removed and pressure applied by pneumatic
piston to determine what force was needed to disrupt the
skin-Teflon seal. The 21-day implanted rough Teflon segments were
disrupted by pressure calculated at 720 mm. Hg. The skin Teflon
seal was watertight until the bursting pressure was attained.
Shunts incorporating the roughened Teflon cannula were then
implanted in three uremic patients. The shunt in one patient
remained clot free for more than 8 weeks. In the first case the
shunt clotted several times after 1 day and 1 night, and was
replaced by a prior art shunt, which also clotted several times.
The patient went on to recovery of his acute tubular necrosis in 24
days. The second patient, a 45-year-old white female with acute
tubular necrosis following pancreatitis was placed on dialysis
acutely and after 4 weeks began to have urine output and her uremia
slowly receded. Her shunt remained patent through this course and
the skin ans subcutaneous tissue became well involved within the
roughened surface of the shunt. Photomicrographs show that a good
junction was formed between the epithelial layers of the skin and
the exit site of the cannula. There was never any pain associated
with this shunt and the patient remained afebrile with a dry exit
site throughout her hospital course. No infection was noted in
either of these two, even though the second patient forgot about
her shunt and completely submerged the arm in her bath water during
the sixth week.
The leak pressure of the ball joint was tested by placing a closed
ball joint seal in series with a mercury manometer and pumping the
system full of fluid and measuring the pressure on the mercury
manometer. Five ball joints were subjected to 300 mm. HG pressure
without leak or bursting.
The use of all Teflon members to transverse the vessel lumen and
the subcutaneous tract enables an attachment to be achieved between
the tissue and the prosthesis if the Teflon has been roughened. The
seal obtained appears to be a mechanical seal but a tight one, as
evidenced by the tests. This is a logical result if we examine the
basic processes of wound healing by secondary intention whereby new
cells are added to the advancing wound edge, thus the roughened
surface presents many facets, angles and geometric projections for
the advancing connective tissue cells to become entangled in and
mechanically intertwine.
As the cells multiply at the circular wound edge, the potential
defect herein occupied by the prosthesis becomes smaller and
smaller, until pressure exerted by advancing cells exceeds that
pressure under which they can continue to proliferate. By that time
a firm mechanical seal is effected. The strength of the seal is
related to the number of surface grooves and projections on the
rough Teflon surface and the strength of the fibrous tissue that
embraces them. The guinea pig skin accepting the roughened tube is
a measure of the affinity for implantation, since all the smooth
tubes fell out of the guinea pig's skin. To withstand pressures
without leaks points out the intimacy of the seal as is further
implied in photomicrographs where a close juxtaposition of the
tissues and the Teflon is shown.
The slight taper and smooth leading edge of the intravascular
portion of the cannula facilitates its insertion, since the
roughened surface requires some force for sliding but follows the
few smooth millimeter at its tip with ease. The skin itself grows
into the roughened surface and forms a seal. Study of the
photomicrographs, in addition to showing the mechanical
interdigitation between the tissue and the Teflon, points out the
germproof nature of this seal since the cells adjacent to the
Teflon seem to be mostly fibroblasts without significant
inflammation or foreign body reaction. The short (2 to 3 cm.)
subcutaneous path and gentle turns of this shunt decrease the
tissue damage and scar formation at a given shunt site, and hence
allows greater number of shunt sites per limb. This is especially
important in the chronic uremic whose life is dependent on the
availability of shunt sites.
The new arteriovenous shunt, according to this invention, meets the
10-point criteria outlined by Scribner as well as current materials
will allow. Since there are fewer parts than other designs, and
since mass production can be simple, significant cost reduction can
be effected.
In the case of a lead-through for electrical conductors, as for a
cardiac pacemaker or the like, the prosthetic device may be made in
tubular form, as a cannula. Then, after implantation of the
roughened tubular member through the skin and subcutaneous tract,
the conductors may be mechanically sealed within the tubular
passage. The device may be utilized whenever a permanent or
semipermanent sealed passage through the skin is desirable or
necessary.
* * * * *