Catheter having window and partial balloon covering for dissecting tissue planes and injecting treatment agent to coronary blood vessel

A method is provided including introducing a delivery device through a vessel wall to a treatment site within one of a peri-adventitial space or a pericardium adjacent a coronary blood vessel and delivering a treatment agent through the delivery device. The treatment agent is delivered through the delivery device according to conditions that hydraulically dissect tissue planes within the peri-adventitial space. A kit is provided including a delivery device having a needle to be advanced through one of an epicardium of a heart and a wall of a coronary blood vessel into a peri-adventitial space and a treatment agent comprising particles having an average diameter on the order of 15 microns or more to be delivered through the delivery device into the peri-adventitial space.

BACKGROUND

Field

Methods for delivering treatment agents to coronary vessels. In particular, methods and kits for delivering treatment agents to tissues or spaces adjacent to coronary vessels.

Background

Cardiovascular diseases of the heart or blood vessels continue to affect individuals within the United States and many Western countries at increasingly alarming rates. A major component of morbidity and mortality attributable to cardiovascular disease occurs as a consequence of the partial or complete blockage of vessels carrying blood in the coronary and/or peripheral vasculature caused by diseased vessels. When such vessels are partially occluded, lack of blood flow causes ischemia of the muscle tissues supplied by such vessel, consequently inhibiting muscle contraction and proper function. Total occlusion of blood flow causes necrosis of the vasculature and muscle tissues.

Myocardial infarction (MI) is one form of heart disease that often results from the sudden lack of supply of oxygen and other nutrients. The lack of blood supply is a result of closure of the coronary artery that nourishes a particular part of the heart muscle. The cause of this event is generally attributed to arteriosclerosis, “hardening of the arteries”, in coronary vessels.

Formerly, it was believed that an MI was caused from a slow procession of closure from, for example, 95 percent then to 100 percent but an MI can also be a result of minor blockages where, for example, there is rupture of the cholesterol plaque resulting in blood clotting within the artery. Thus, the flow of blood is blocked and downstream cellular damage occurs. This damage can cause irregular rhythms that can be fatal, even though the remaining muscle is strong enough to pump a sufficient amount of blood. As a result of this insult to the heart tissue, scar tissue tends to naturally form.

Blood vessel stenosis or occlusions are commonly treated by mechanically enhancing blood flow in the affected vessels. Such mechanical enhancements often employ surgical techniques that attach natural or synthetic conduits around the occlusion, thereby providing bypass grafts, or employ revascularization by various means to physically enlarge the vascular lumen at the site of occlusion. These revascularization procedures involve balloons, endovascular knives (atherectomy), and endovascular drills. Significant morbidity and even mortality frequently accompany surgical approaches, while, in many cases, recurrent stenoses complicate angioplasty-type processes.

Systemic, local or direct drug delivery techniques designed to treat damaged heart and vasculature tissues may accompany or replace mechanical techniques. Such techniques, however, can be problematic for a number of reasons. In particular, in systemic delivery techniques, the whole organism is treated therefore greater amounts of drugs must be supplied which are sometimes toxic to the organism. In local delivery techniques the therapeutic is typically injected into a blood stream at a point upstream from the treatment site or into an unperfused vessel region after first occluding the vessel region to inhibit blood flow. In either case, once blood flow is restored, as it must be to prevent further damage to the vessel, the therapeutic is washed away from the region where delivery is desired. Lastly, in direct delivery, typically, the drug is delivered through a vessel wall into dense tissues having few spaces for accommodating fluid uptake. Accordingly, administering an effective drug amount may require several injections to the region.

SUMMARY

A method is disclosed. In one embodiment the method includes introducing a delivery device to a treatment site within a peri-adventitial space surrounding a coronary blood vessel. At least 1.0 cubic centimeters (cc) of a treatment agent may be delivered through the delivery device to a region of the peri-adventitial space according to conditions that hydraulically dissect tissue planes within the peri-adventitial space. The term “hydraulic dissection” as used herein refers to the separation of tissue planes by delivering a fluid to a tissue at a pressure or flow rate sufficient to separate the tissue planes and create repositories between the tissue planes for accommodating a substance. The delivery device may be introduced to the treatment site by positioning the delivery device within a blood vessel and advancing the delivery device needle through a vessel wall. Alternatively, the delivery device may be introduced to the peri-adventitial space by positioning the delivery device adjacent the pericardium and advancing a delivery device needle through the pericardium and into the epicardium. The delivery conditions that hydraulically dissect tissue planes include delivering the treatment agent into the peri-adventitial space at a pressure or flow rate that creates a repository between the tissue planes for accommodating the treatment agent.

In another embodiment, a method includes introducing a delivery device to a site within a peri-adventitial space surrounding a coronary blood vessel. Tissue planes within the peri-adventitial space are hydraulically dissected by delivering the solution to the peri-adventitial space through the delivery device according to conditions that hydraulically dissect tissue planes within the space. Saline is a suitable solution. Applying negative pressure to the delivery device allows the solution to drain from the peri-adventitial space. After draining the solution, a treatment agent may be delivered into the peri-adventitial space through the device. Between 0.1 and 20 cc of treatment agent may be delivered into this space.

In another embodiment, a method includes introducing a delivery device to a treatment site within a peri-adventitial space surrounding a coronary blood vessel through an epicardial layer. A treatment agent is delivered through the delivery device under conditions that hydraulically dissect tissue planes within the peri-adventitial space.

Still another embodiment features a kit including a delivery device comprising a needle to be advanced through one of an epicardium of a heart or a wall of a coronary blood vessel into a peri-adventitial space. The kit further includes a treatment agent to be delivered into the peri-adventitial space through the delivery device. The treatment agent comprises particles having an average diameter on the order of 15 microns or more.

Other embodiments feature methods for introducing a delivery device to a treatment site within one of a peri-adventitial space or a pericardium adjacent a coronary blood vessel. The method further includes delivering a controlled release treatment agent at the treatment site.

As used herein, treatment agents include, but are not intended to be limited to, drugs, biologically active agents, chemically active agents, therapeutic agents, and the like, and pharmaceutical compositions thereof, which can be used to deliver a treatment agent to a treatment site as described herein. In some embodiments, the treatment agent may be an agent suitable for local treatment, regional treatment or a combination of agents suitable for local and regional treatment.

In some embodiments, the treatment agent may be a drug including, but not limited to, a high density lipoprotein (HDL) mimetic, an anti-inflammatory and an anti-proliferative. Alternatively, the treatment agent may be a non-living biologic including, but not limited to, an extra cellular matrix, urinary bladder matrix, small intestinal submucosa or a liver derived biomatrix. Still further, the treatment agent may be a living biologic including, but not limited to, bone marrow stem cells, mesenchymal cells and endothelial progenitor cells.

Treatment agent delivery can be solution-based, such as a microparticle or nanoparticle within a carrier. The carrier can include a property to control a release rate of the treatment agent. In other embodiments, the treatment agent may be within a gel.

DETAILED DESCRIPTION

The following description provides for techniques for locally treating regions of a blood vessel by delivering a treatment agent to a region adjacent the vessel. For example, in some embodiments, the treatment agent is delivered to a peri-adventitial space surrounding a coronary blood vessel. In some embodiments, the peri-adventitial space is hydraulically dissected during or prior to delivery of the treatment agent. The term “peri-adventitial space” as used herein refers to an anatomical confluence of tissue planes surrounding a blood vessel that are between an adventitial layer of the blood vessel wall and a fat layer overlying the blood vessel. As previously discussed, the term “hydraulic dissection” as used herein refers to the separation of tissue planes by delivering a fluid to the tissue at a pressure or flow rate sufficient to separate the tissue planes and create repositories between the tissue planes for accommodating a substance. Various devices are described herein for hydraulically dissecting the tissue planes and delivering the treatment agent. But other devices known in the art may be used.

Alternatively, a coronary vessel may be treated by delivering a treatment agent to a region of a pericardium surrounding a heart and the blood vessels. In some embodiments, the treatment agent is delivered to a pericardial cavity having serous fluid therein. In other embodiments, the treatment agent is delivered to tissues of the pericardium.

Referring toFIG. 1, a simplistic view of a heart is shown to illustrate the vasculature and tissue layers enveloping it. Heart100includes various chambers, valves (not shown) and vessels for pumping and transporting blood throughout the body. A pericardium118envelopes heart100. Pericardium118is a multilayered sack having a superficial fibrous layer119and a deeper serous layer120. Serous layer120has a parietal layer120A and a visceral layer120B (seeFIG. 2). Visceral layer120B is the epicardium. A pericardial space or cavity which contains serous or pericardial fluid lies between parietal layer120A and epicardium120B. Epicardium120B contacts myocardium122on the side opposite the pericardial space. Blood vessels124lie between serous layer120and myocardium122.

Blood vessels124are coronary arteries and veins surrounding heart100. About 10 centimeters (cm) to 15 cm of blood vessels124are exposed around the outer surface of heart100and beneath pericardium118. Coronary arteries have their walls fed by vasa vasorum. The vasa vasorum is a network of small arteries and veins that run roughly parallel to and down the outer surface of the artery with small branches around the artery that penetrate the artery wall. In arteries with plaques, especially metabolically active plaques like vulnerable plaques, growing plaques or plaques in the process of becoming vulnerable, the vasa vasorum grows larger and grows many more small feeding and branching arteries into the coronary artery wall and into the plaques themselves to support the increased metabolic activity. Treatment agents delivered and released within the pericardium (e.g. the pericardial space) and its adjacent regions (e.g., peri-advential space) will have a higher concentration in the vicinity of the vasa vasorum than that which would be found in the blood if the agent were delivered systemically or locally. It is, however, recognized that this concentration difference may vary depending upon factors of the treatment solution such as the clearance rate, the amount of the treatment agent and dissolution rate of the treatment agent. The high agent concentration outside the vasa vasorum will drive the treatment agent across the thin walls of the arteries of the vasa vasorum thereby feeding the plaques and transporting the treatment agent directly into the environment inside the plaque. The concentration difference will also drive the treatment agent into the coronary arterial blood via the arterial wall (i.e., via the vasa vasorum vessels) feeding other tissues of the heart. In this aspect, the tissues of the heart will be exposed to greater than systemic concentrations of the treatment agents. Thus, in the case of potent treatment agents with undesired systemic side effects, the concentration of the treatment agent may be kept at effective levels for the desired time of treatment in a target tissue of the heart, but at a low level systemically thereby limiting undesired systemic effects. Additionally the total amount of the treatment agent required will be less than that which would be required if applied using a systemic dosing method. This may be a benefit where the cost of the treatment agent is high. In addition, applying the treatment agent in a time release manner in the peri-adventitial space or pericardium assures the effective application of the treatment agent and doesn't rely on the often unreliable compliance of the patient.

FIG. 2illustrates a cross-section of heart100illustrated inFIG. 1.FIG. 2shows a right ventricle108and a left ventricle116bounded by myocardium122. Overlying myocardium122is epicardium120B, which is further enveloped by parietal layer120A and fibrous layer119. The figure illustrates pericardial space200between parietal layer120A and epicardium120B. Positioned along a back side of heart100are artery202and vein206, which are within peri-adventitial space210. Myocardium122and fat layer214bound peri-adventitial space210. Similarly, artery204and vein208lie along a front side of heart100. Artery204and vein208are within peri-adventitial space212which is bounded by myocardium122and a fat layer216.

Peri-adventitial space210,212is an anatomical confluence of tissue planes surrounding coronary blood vessels. As is apparent from the enlarged view of this region illustrated inFIG. 3, peri-adventitial space210,212refers to a region separate from the tissue layers making up the walls of the blood vessels. This aspect is illustrated inFIG. 3with respect to artery202. Artery202includes an arterial wall having a number of layers extending outwardly from lumen300. Innermost layer302represents the intimal layer that includes the endothelium, the subendothelial layer, and the internal elastic lamina. Medial layer304is concentrically outward from intimal layer302and bounded by external elastic lamina and an outermost adventitial layer306. There is no external elastic lamina in a vein. Medial layer304(in either an artery or vein) primarily consists of smooth muscle fibers and collagen. Beyond medial layer304and adventitial layer306lies the peri-adventitial space210. Areas radially outward from peri-adventitial space210include connective tissue, such as adipose tissue that is most likely located, in terms of areas around the heart, toward the epicardial surface of the heart, and myocardial tissue composed of muscle fibers.

FIG. 4is a flowchart detailing a method400for delivering a fluid substance to the peri-adventitial space using a delivery device. In one embodiment, a delivery device is introduced to a treatment site within a peri-adventitial space (block402). In one embodiment, the delivery device may be introduced to the treatment site by positioning the delivery device within a blood vessel lumen and advancing the device through a wall of the blood vessel. In this aspect, the device may include an assembly, for example, a needle, to pierce through the vessel wall and into the peri-adventitial space.

Alternatively, the delivery device may be introduced to the treatment site via a route outside of the blood vessel. In one embodiment, the delivery device may be introduced through the chest by, for example, a subxiphoid, sub-sternal or thoracascopic insertion route, and maneuvered to a region of the heart adjacent the treatment site. In another embodiment, the delivery device may be introduced directly to an exposed region of the heart. This technique may be particularly desirable, for example, where the patient is undergoing cardiac surgery and therefore their chest cavity is opened exposing the heart. Once in position, a needle, for example, of the delivery device, may be advanced through the various layers overlying the peri-adventitial space and into the tissues within this region. In still further embodiments, the delivery device may be introduced to the treatment site through the heart. For example, the delivery device may be advanced through a vessel terminating within the heart. A needle of the delivery device is then advanced through a wall of the heart to the desired treatment site, for example, the peri-adventitial space.

In some embodiments, the above described techniques are further used to introduce the delivery device into tissue regions of the pericardium enveloping the heart. For example, where the delivery device is positioned within a vessel, the device needle is advanced through the vessel wall, the peri-adventitial space and the epicardium until an outlet port of the needle is within the pericardial cavity. Accordingly, although delivery of the treatment agent to the peri-advential space using the techniques and devices referenced herein are described, it is further contemplated that the techniques and devices may further be used to introduce the treatment agent to tissues or spaces within the pericardium.

In some embodiments, a guidance device is used to position the delivery device within a desired treatment region. In some embodiments, the guidance device is a conventional imaging modality capable of allowing for visualization of the tissue layers or delivery device as the needle is advanced to the desired treatment region. Representative imaging modalities include optical coherence tomography, fiberoptic, ultrasonic, x-ray or magnetic resonance based imaging systems that image the tissue and/or the needle. For example, in the case of an ultrasonic imaging modality, a pointed (distal) end of the device needle is visualized during advancement through the tissue layers.

Where the needle is positioned within the peri-adventitial space, a fluid substance may be delivered through the delivery device according to conditions that hydraulically dissect tissue planes within the peri-adventitial space (block404). In their natural anatomical configuration, tissue planes of the peri-adventitial space are relatively compact without spaces and channels between them for fluid retention. For this reason, typically an effective volume amount of a fluid such as a treatment agent for treating a target region may not be accommodated within the peri-adventitial space. Moreover, since there are no spaces and channels between the tissue planes, there is only minimal diffusion of any fluids within the peri-advential space to tissue regions outside of the delivery point. Accordingly, if before or during delivery of a treatment agent the tissue planes become hydraulically dissected, larger volumes of the agent may be delivered to the site. In addition, the spaces between the planes allow the treatment agent to diffuse throughout a greater tissue region than when the tissues are not hydraulically dissected.

In one embodiment, a pressure sufficient to separate the tissue planes may be between approximately 30 mm Hg and 1000 mm Hg. In another embodiment, the pressure sufficient to separate the tissue planes may be between approximately 80 mm Hg and 200 mm Hg. Still further, the pressure sufficient to separate the tissue planes may be approximately 150 mm Hg. In one embodiment, a volumetric flow rate sufficient to separate tissue planes may be that which is less than a flow rate which disrupts or kills cells. In this aspect, a fluid may be delivered to the peri-adventitial space at a pressure and volumetric flow rate which keeps the fluid below a level that disrupts or kills cells.

A fluid volume suitable for hydraulically dissecting tissue planes within, for example, the peri-adventitial space may be at least 1.0 cc. It is recognized that due to the compact tissue layers of the peri-adventitial space, some of the fluid used for dissection of the space is lost around a delivery needle. Accordingly, in embodiments where the treatment agent is used as the fluid for hydraulically dissecting the tissue planes, generally, a higher fluid volume than that which is needed to effectively treat the desired region is delivered. In embodiments where the treatment agent is delivered after hydraulic dissection of the peri-adventitial space, a lower fluid volume that that which is needed for dissection of the tissue may be delivered.

Delivery of a treatment agent to a hydraulically dissected peri-adventitial space or pericardial cavity as described herein may be useful in treating various cardiovascular diseases and in particular conditions affecting coronary arteries such as hyperplasia or vulnerable plaque. In addition, the methods described herein, may further be useful in regional therapies, cellular therapies and diffuse diseases. In particular, spaces between dissected tissues of the peri-adventitial space or within the pericardium serve as repositories for the treatment agent. Accordingly, the treatment agent is not washed away from the treatment site as is common in, for example, local delivery methods. Instead, the agents diffuse throughout the tissue spaces of, for example, the peri-adventitial space longitudinally along the underlying vessel walls. In addition, some of the treatment agent may diffuse through the fat layer overlying the vessel and peri-adventitial space and diffuse along the vessel wall. The treatment agent thus remains along the vessel and, over time, diffuses through the layers of the vessel wall treating the diseased or damaged vessel region.

Any suitable biocompatible substance or solution may be used to hydraulically dissect tissue planes of the peri-adventitial space. In some embodiments, a suitable solution may be a saline solution or a solution including a treatment agent. In this aspect, a volume of the solution (e.g., saline or treatment agent solution) may be delivered to the peri-adventitial space at a sufficient pressure or volumetric flow rate to dissect the tissue planes within the peri-adventitial space. In one embodiment, the solution may be delivered at a pressure or volumetric flow rate as previously discussed with respect to the treatment agent. In one embodiment, the solution may be delivered at a high pressure of least about 300 mm Hg. Once dissection of the tissue is achieved, in the case of a saline solution, the saline may be withdrawn from the tissue by applying a negative pressure. The tissue planes remain separated for a period of time before re-adhering to each other. During this period, a volume of the treatment agent may be delivered to the tissue. Representative volumes of treatment agent delivered to the tissue may be, for example, between 0.1 cc and 20 cc, and in some embodiments between 0.1 cc to 5 cc or between 0.1 cc to 0.2 cc.

The treatment agent may be any agent suitable for treating coronary vessel tissues and cardiac ailments. For example, in one embodiment, the treatment agent treats the progression of atherosclerosis. Representative atherosclerotic treatment agents include anti-inflammatory, statin, cholesterol acceptor and antioxidant agents. In other embodiments, the treatment agent treats coronary vascular dysfunction. Representative coronary vascular dysfunction treatment agents include nitric oxide donors or generators and adiponectin agents. Still further, the treatment agent treats fractures or thrombosis of vulnerable lesions. Representative vulnerable lesion treatment agents include inhibitors of tissue factor and metalloproteinase inhibitors. The treatment agent may further treat pericarditis, arrhythmia or cardiac metastases. Representative pericarditis, arrhythmia and cardiac metastases treatment agents include antibiotics, anti-arrhythmic and chemotherapeutic agents, respectively.

In one embodiment, the treatment agent may be a drug. Representative drugs include HDL mimetics, anti-inflammatory agents and anti-proliferative agents. Exemplary HDL mimetics include cyclodextrin. Exemplary anti-inflammatory agents include clobetasol, dexamethasone, prednisone, aspirin and cortisone. Exemplary anti-proliferative agents include taxol, everolomus, sirolomus, doxorubicin and other chemotherapeutic agents. Still further representative drugs include apolipoprotein A1 (APO A1).

In one embodiment, the treatment agent may be a non-living biologic. In one embodiment, the non-living biologic may include scaffolding such as an Extra Cellular Matrix (ECM). Representative non-living biologics may include Urinary Bladder Matrix (UBM), Small Intestinal Submucosa (SIS) and liver derived BioMatrix (LBM).

In another embodiment, the treatment agent may be a living biologic. The peri-adventitial space is particularly suitable for delivering living biologics. Representative living biologics include bone marrow stem cells, mesenchymal cells and endothelial progenitor cells.

In one embodiment, one or more of the above described agents can be encapsulated, suspended, disposed within or loaded into a biodegradable carrier. Examples of biodegradable carriers include, but are not limited to, a liposome, a polymerosome, a micelle, a particle and a gel. Examples of particles include, but are not limited to, microparticles and nanoparticles. In some embodiments, the biodegradable carrier is formulated such that it is bioerodable when present in physiological conditions.

In one embodiment, the biodegradable carrier for the treatment agent is a liposome. A “Liposome” is an artificial vesicle that is approximately spherical in shape and can be produced from natural phospholipids and cholesterol. In one method, phospholipids are mixed with cholesterol in chloroform. Suitable phospholipids include, but are not limited to, dimyristoyl phosphatidyl choline (DMPC) or dipalmitoyl ethanolamine. For hydrophobic treatment agents, the treatment agent can be added with an optional co-solvent, such as heptane or toluene. The liposomes can also be hydrophilically modified with an agent such as polyethylene glycol or dextran. After mixing, the solvent (and optional co-solvent) can be evaporated with heat or ambient temperature in a round bottom flask. Resultant lipids will be deposited on the glass surface. The deposited lipid film will be re-suspended in aqueous solution to form multilamellar vesicles, and extruded to prepare appropriate sized liposomes.

In another embodiment, the biodegradable carrier for the treatment agent is a polymerosome. A “Polymerosome” is a polymer vesicle formed from di-block or tri-block copolymers with blocks of differing solubility. Polymerosomes may be formed by methods such as film rehydration, electro-formation and double emulsion. In some methods, a similar manufacturing technique can be used as that of a liposome to form polymerosomes. For example, a polymerosome can be a di-block copolymer including a block which is hydrophobic, e.g., poly lactic acid, polycaprolactone, n-butyl acrylate, and another block which is hydrophilic, e.g., poly (ethylene glycol), poly(acrylic acid). A polymerosome can be in a range from between about 25 nm to about 2000 nm.

In another embodiment, the biodegradable carrier for the treatment agent is a micelle. A “micelle” is an aggregate of surfactant or polymer molecules dispersed in a liquid colloid. Micelles are often globular in shape, but other shapes are possible, including ellipsoids, cylinders, bilayers, and vesicles. The shape of a micelle is controlled largely by the molecular geometry of its surfactant or polymer molecules, but micelle shape also depends on conditions such as temperature or pH, and the type and concentration of any added salt.

Micelles can be formed from individual block copolymer molecules, each of which contains a hydrophobic block and a hydrophilic block. The amphiphilic nature of the block copolymers enables them to self-assemble to form nanosized aggregates of various morphologies in aqueous solution such that the hydrophobic blocks form the core of the micelle, which is surrounded by the hydrophilic blocks, which form the outer shell. The inner core of the micelle creates a hydrophobic microenvironment for a non-polar treatment agent, while the hydrophilic shell provides a stabilizing interface between the micelle core and an aqueous medium. Examples of polymers which can be used to form micelles include, but are not limited to, polycaprolactone polyethylene oxide blocks, polyethylene oxide-β-polypropylene oxide-β-polyethylene oxide triblock copolymer and copolymers which have a polypeptide or polylactic acid core-forming block and a polyethylene oxide block. A micelle can be in a range from between about 10 nm to about 100 nm.

In another embodiment, the biodegradable carrier for the treatment agent is a nanoparticle (e.g., nanosphere) or microparticle (e.g., microsphere). Various methods can be employed to formulate and infuse or load the particles with the treatment agent. Representatively, the particles are prepared by a water/oil/water (W/O/W) double emulsion method. In the W1phase, an aqueous phase containing treatment agent, is dispersed into the oil phase consisting of polymer dissolved in organic solvent (e.g., dichloromethane) using a high-speed homogenizer. Examples of polymers include, but are not limited to, poly(D,L-lactide-co-glycolide) (PLGA), poly(D,L-lactide) (PLA) or PLA-PEG co-polymers, poly-ester-amide co-polymers (PEA) and polyphosphazines. The primary water-in-oil (W/O) emulsion is then dispersed in an aqueous solution containing a polymeric surfactant, e.g., poly(vinyl alcohol) (PVA), and further homogenized to produce a W/O/W emulsion. After stirring for several hours, the particles are collected by filtration. A microparticle can be in a range from about 5 μm to about 200 μm, preferably 10 μm to 50 μm. A nanoparticle can be in a range from between about 10 nm to about 500 nm, preferably about 50 nm to about 300 nm.

In some embodiments, the carrier controls a release rate of the treatment agent. The carrier may allow for a slow or sustained release of the treatment agent. Representative sustained-release carriers include encapsulation polymers such as poly (L-lactide), poly (D,L-lactide), poly (glycolide), poly (lactide-co-glycolide), polycaprolactone, polyanhydride, polydioxanone, polyorthoester, polyamino acids, or poly (trimethylene carbonate), and combinations thereof. In this aspect, the polymer forming the carrier controls a release rate of the treatment agent. In some embodiments, the carrier allows for immediate-release or periodic-release of the treatment agent. For example, the carrier allows for periodic-release of a treatment agent such that the treatment agent is released for a short time at relatively regular intervals.

In still further embodiments, a coating may be applied to the treatment agent or the carrier to control a release rate of the treatment agent. In some embodiments, the coating may be a bio-degradable coating such as a gel which decreases a dissolution rate of the treatment agent or carrier within the body. For example, the treatment agent encapsulated within, for example, a microparticle or a nanoparticle, may be dipped into a dilute gelatin solution to provide a gel coating around the microparticle or nanoparticle encapsulated treatment agent. It is further contemplated that both the treatment agent carrier and a coating applied to the carrier modify a release rate of the encapsulated treatment agent.

In some embodiments, the release rate of the treatment agent is tailored to accommodate the ailment to be treated. For example, a carrier encapsulating an antibiotic used to treat an infection can have an intermediate release rate so that the treatment agent is released for a period just long enough to treat an infection whereas a carrier encapsulating a nitric oxide generating treatment agent used to compensate for endothelial dysfunction can have a sustained-release rate so that the treatment agent is released as long as possible. Alternatively, a carrier encapsulating a treatment agent for preventing vulnerable plaques can have a periodic release rate which releases the treatment agent for a short time at regular intervals. Vulnerable plaques result when macrophage activity is heightened to the point that the inside of the plaque is broken down more rapidly than recruited migrating smooth muscle cells can lay down a reinforcing fibrotic matrix. Temporary depression of macrophage activity may allow sufficient recruitment of smooth muscle cells and the laying down of matrix to prevent or delay a vulnerable plaque fibrous cap from becoming too thin and rupturing for long enough to allow the plaque to revert back to a stable plaque when the, as yet unknown, cause of the heightened macrophage activity is gone. It is likely that a slight modification of the balance between the smooth muscle cells laying down matrix and the macrophages breaking down the matrix by a bio-active substance, may prevent a vulnerable plaque rupture.

Since the treatment agent is delivered to peri-adventitial space210or the pericardium, the particle size is not limited to the intraluminal dimensions of the blood vessels. In this aspect, the particles may have an average diameter less than 1000 μm. In other embodiments, the average diameter of the particle may be less than 5 μm. Still further, the average diameter of the particle may be between 15 μm and 1000 μm.

The treatment agents may further be delivered in a gel. Representative gels may be one or more component gels including but not limited to, alginate gels, PEG-gels and other suitable hydrogels. Such gels may be suitable for delivery of a treatment agent alone and/or within the above-described carriers. The living biologics may further be co-delivered within a matrix gel or drug loaded particles.

Hydraulic dissection and delivery of the above described treatment agents and solutions may be accomplished by any of the methods and devices which will now be described with reference toFIGS. 5-12.FIGS. 5-12illustrate various embodiments of a delivery device capable of dissecting tissue planes and delivering treatment agents. In general, the delivery devices provide a system for delivering a substance, such as a treatment agent or a combination of treatment agents adjacent a desired area of a blood vessel to treat a localized area of the blood vessel or to treat a localized area of tissue possibly located adjacent to the blood vessel.

FIG. 5, illustrates a simplified cross-sectional view of an embodiment of an intraluminal delivery device. The delivery device is similar in certain respects to the delivery apparatus described in commonly-owned, U.S. Pat. No. 6,692,466 issued Feb. 17, 2004, titled “Directional Needle Injection Drug Delivery Device”, of Chow, et al. The delivery apparatus is further similar in certain respects to the delivery apparatus described in commonly-owned, U.S. Pat. No. 6,702,744 issued Mar. 9, 2004 titled “Agents That Stimulate Therapeutic Angiogenesis and Techniques and Devices That Enable These Devices”, of Evgenia Mandrusov et al. and U.S. patent application Ser. No. 10/792,960 filed as a continuation in part of U.S. Pat. No. 6,702,744 on Mar. 3, 2004 titled “Agents That Stimulate Therapeutic Angiogenesis and/or Angiomyogenesis and Techniques and Devices That Enable Delivery”, of Evgenia Mandrusov and U.S. patent application Ser. No. 10/781,984 filed as a divisional of U.S. Pat. No. 6,702,744 on Feb. 18, 2004 titled “Agents That Stimulate Therapeutic Angiogenesis and Techniques and Devices That Enable These Devices”, of Evgenia Mandrusov et al. The delivery apparatus includes a catheter assembly500, which is intended to broadly include any medical device designed for insertion into a blood vessel or physiological lumen to permit injection and/or withdrawal of fluids, to maintain the potency of the lumen, or for any other purpose.

In one embodiment, catheter assembly500is defined by elongated catheter body (cannula)512having proximal end513and distal end514. In one embodiment, catheter assembly500includes catheter body512extending from proximal end513to distal end514. In this example, guidewire cannula516is formed within catheter body512for allowing catheter assembly500to be fed and maneuvered over guidewire518(shown at this point within guidewire cannula516).

Balloon520attaches at distal end514of catheter assembly500and is in fluid communication with inflation lumen522formed within catheter body512. Balloon520includes balloon wall or membrane530, which is selectively inflatable to expand from a collapsed configuration to a desired and controlled expanded configuration. Balloon520can be selectively expanded by supplying a fluid into inflation cannula522at a predetermined rate of pressure through inflation port523. Balloon wall530is selectively deflatable, after inflation, to return to the collapsed configuration or a deflated profile. In one embodiment, balloon wall530can be defined by three sections, distal taper wall532, medial working length534, and proximal taper wall536. In one embodiment, proximal taper wall536can taper at any suitable angle θ, typically between about 10° to less than about 90°, when balloon520is in the expanded configuration.

Distal taper wall532, medial working length534, and proximal taper wall536may be bound together by seams or be made out of a single, seamless material. Balloon520may be made from any suitable material, including polymers and copolymers of polyolefins, polyamides, polyesters and the like. The specific material employed must be mutually compatible with the fluids employed in conjunction with balloon520and must be able to stand the pressures that are developed within balloon520. Balloon wall530may have any suitable thickness so long as the thickness does not compromise properties that are critical for achieving optimum performance. Such properties include high burst strength, low compliance, good flexibility, high resistance to fatigue, the ability to fold, the ability to cross and re-cross a desired region of treatment or an occluded region in a lumen, and low susceptibility to defect caused by handling. By way of example, and not limitation, the thickness may be in the range of about 10 microns to about 30 microns, the diameter of balloon520in the expanded configuration may be in the range of about 2 mm to about 10 mm, and the length may be in the range of about 3 mm to about 40 mm, the specific specifications depending on the procedure for which balloon520is to be used and the anatomy and size of the target lumen in which balloon520is to be inserted.

Balloon520may be inflated by the introduction of the liquid into inflation lumen522. Liquids containing treatment or diagnostic agents may also be used to inflate balloon520. In one embodiment, balloon520may be made of a material that is permeable to such therapeutic and/or diagnostic liquids. To inflate balloon520, the fluid may be supplied into inflation lumen522at a predetermined pressure, for example, between about one and 20 atmospheres.

Catheter assembly500also includes substance delivery assembly538A for injecting a treatment agent into a tissue of a physiological passageway. In one embodiment, delivery assembly538A includes needle546A having a lumen with a diameter of, for example, 0.004 inches (0.010 cm) to 0.012 inches (0.030 cm). Needle546A is movably disposed within delivery lumen540A formed in catheter body512. Delivery assembly538B includes needle546B movably disposed within delivery lumen540B. Delivery lumen540A and delivery lumen540B each extend between distal end514and proximal end513. Delivery lumen540A and delivery lumen540B may be made from any suitable material, such as polymers and copolymers of polyamides, polyolefins, polyurethanes, and the like. Access to the proximal end of delivery lumen540A or delivery lumen540B for insertion of needle546A or546B, respectively is provided through hub551.

One or both of delivery lumen540A and delivery lumen540B may be used to deliver a treatment agent to a treatment site (e.g., through needle546A and/or needle546B). Alternatively, one delivery lumen (e.g., delivery lumen540A via needle546A) may be used to deliver a treatment agent (e.g., anti-inflammatory treatment agent) while the other delivery lumen (e.g., delivery lumen540B via needle546B) may be used to deliver a therapeutic substance other than an anti-inflammatory substance.

In one embodiment, delivery lumen540A and delivery lumen540B conform to the outer dimensions of cannula body512and balloon520. In this aspect, delivery lumen540A and delivery lumen540B include bend regions at which distal sections of delivery lumen540A and delivery lumen540B are capable of bending (or generally rotating) about pivotal point with respect to a proximal section. Thus, for example, in response to the inflation of balloon520, distal section542of delivery lumen540A moves relative to proximal section544to form the bend region. In one embodiment, section542may move from a substantially longitudinal position to a substantially perpendicular position. Thus, the angle θ of the bend region may vary between 0° and 90°. In one example, after inflation of balloon520, angle θ may range from between about 10° and 90°, for example, 45°.

Needles546A and546B may be slidably or movably disposed in delivery lumen540A and540B respectively. Each of needles546A and546B may include a tissue-piercing tip having a dispensing port. The dispensing port is in fluid communication with a lumen (not shown) of the needle. In one embodiment, the lumen of, for example, needle546A may be pre-filled with a measured amount of a treatment agent. The lumen of needle546A connects the dispensing port with treatment agent injection port559, which is configured to be coupled to various substance-dispensing means of the sort well known in the art, for example, a syringe or fluid pump. Injection port559allows for dispensing a measured treatment agent from the dispensing port as desired or on command.

Needle546A is coupled at proximal end513of catheter assembly500in a needle lock555. Needle lock555can be used to secure needle546A in position once needle546A has been either retracted or extended from delivery lumen540A. In one embodiment, an adjustment knob557sets the puncture distance of needle546A as it extends from delivery lumen540A and into the wall of the physiological lumen. For example, adjustment knob557may have calibrations such that each revolution from one calibrated mark to another represents a fixed distance of travel for needle546A. The portion of needle546A protruding from delivery lumen540can be of any predetermined length; the specific length depending on the desired penetration depth and the procedure for which delivery assembly538A is to be used. In one embodiment, the protruding length of needle546A is that which is sufficient to advance the dispensing port through the vessel wall and into the peri-adventitial space. In one aspect, the protruding length of needle546A may be approximately nine millimeters (mm) or less. It is appreciated that other mechanisms for securing needle546A at a retracted or extended position may alternatively be used, including the incorporation of a mechanical stop optionally including a signaling (e.g., electrical signaling) device as described in commonly-owned U.S. Pat. No. 6,692,466 issued Feb. 17, 2004, titled “Directional Needle Injection Drug Delivery Device.”

Needle546A is slidably disposed in delivery lumen540A, so that it can move between retracted and extended positions. In its retracted position, the tissue-piercing tip lies inboard of the distal surface of catheter body512, so as to avoid damaging tissue during deployment of catheter assembly500. In its extended position, the tissue-piercing tip lies outboard of the distal surface of catheter body512, so as to permit the needle tip to penetrate the tissue surrounding the physiological passageway and extend into, for example, the peri-adventitial or pericardial space.

FIG. 6illustrates the introduction of catheter assembly500into a left coronary artery network. In this simplified example, vasculature600includes left anterior descending artery (LAD)602, left circumflex artery (LCX)604and right coronary artery (RCA)606. Site608represents a region within the peri-adventitial space. Occlusion610is shown in LCX604. Occlusion610limits the amount of oxygenated blood flow through LCX604. Accordingly, the treatment site within the peri-adventitial space is shown adjacent the occluded region.

To improve the function of the artery network, it is generally desired to remove occlusion610(for example through an angioplasty procedure), bypass occlusion610, or induce therapeutic angiogenesis to makeup for the constriction and provide blood flow to the ischemic region (e.g., the region downstream of occlusion610). Additionally, a treatment agent may be introduced to the diseased region. In the illustrated embodiment, guidewire518is introduced into the arterial system600of the patient (e.g., through the femoral artery) until the distal end of guidewire518is upstream of a narrowed lumen of the blood vessel (e.g., upstream of occlusion610). Alternatively, guidewire518may be introduced into the venous system of the patient. Catheter assembly500connects to the proximal end of guidewire518and advances over the guidewire518until catheter assembly500is positioned as desired.FIG. 6shows the catheter assembly510positioned so that balloon520and delivery lumen540A are upstream of the narrowed lumen of LCX604. Angiographic, fluoroscopic or other guidance techniques as previously discussed may be used to position catheter assembly500. Once balloon520is placed and subject to low inflation pressure, guidewire518is removed and replaced in one embodiment with an optical fiber (not shown). For example, an imaging portion of an imaging device (e.g., OCT, ultrasonic, etc.) may be within an imaging lumen as the catheter is positioned. Once positioned, in this case upstream of occlusion610, the imaging assembly may be used to view the blood vessel and identify its various layers. The imaging assembly may provide viewable information about the thickness of the various layers of the blood vessel wall of LCX604. In this aspect, a treatment site within a peri-adventitial space608adjacent to LCX604may be identified.

In one embodiment, for example, delivering a liquid or gas to balloon520through inflation lumen522expands the balloon520. The inflation of balloon520causes delivery lumen540A to move proximate to or contact the blood vessel wall adjacent to the treatment site. Needle546A is then advanced a distance. The thickness of the blood vessel wall and the proximity of the exit of delivery lumen540A to the blood vessel wall determine this distance. Once the needle advances this distance, its dispensing port lies within peri-adventitial space608. A real time image may be used to advance needle546A. Alternatively, the advancement may be based on a measurement of the blood vessel wall or layer boundary derived from an optical image. Adjustment knob557(SeeFIG. 5) may be used to accurately locate needle tip546A in the desired peri-adventitial region608. Once in position, a treatment agent may be introduced through needle546A to the treatment site (e.g., peri-adventitial site608or a pericardial space).

A volume of the treatment agent or solution within injection port559is dispensed from the dispensing port at a pressure sufficient to hydraulically dissect tissue planes within the space. In some embodiments, a saline solution hydraulically dissects the tissue planes. In this aspect, once the solution dissects the tissues, a negative pressure may then drain the saline from the space through catheter assembly500. Once drained, a volume of the treatment agent may be loaded within injection port559and delivered from the dispensing port and into the hydraulically dissected tissue.

Dissecting the tissue planes allows a greater volume of treatment agent to be delivered to the treatment site within the peri-adventitial space at one time than not dissecting the tissue planes. In this aspect, a volume of the treatment agent delivered to the peri-adventitial space at one time may be greater than approximately 5 cc. In other embodiments, the volume of fluid delivered may be between approximately 5 cc and 20 cc. Still further, the volume of fluid delivered may be between approximately 10 cc and 20 cc.

FIG. 7is a simplified cross-sectional view of another embodiment of a delivery device in the form of a catheter assembly having a balloon and needle assembly. In particular, in this embodiment, catheter assembly700is a “spiked” balloon catheter having a balloon728with needles722A,722B incorporated into its surface. Needles722A,722B may have dimensions substantially similar to those of the needles discussed in regard toFIG. 5. A proximal portion716of catheter assembly700may be external to a blood vessel702and to the patient while a distal portion714is within vessel702. Representatively, catheter assembly700may be inserted through a femoral artery and guided through, for example, a guide catheter704with a guidewire726to a location in the vessel. Alternatively, guidewire726may be introduced into the venous system of the patient.FIG. 7shows distal portion714of catheter assembly700positioned at a point within vessel702adjacent to a treatment site within peri-adventitial space724.

In one embodiment, catheter assembly700includes primary cannula704having a length that extends from proximal portion716(e.g. located external to a patient during a procedure) to connect with a proximal end or skirt of balloon728. Primary cannula704has a lumen therethrough that includes guidewire cannula706and delivery cannula708. Delivery cannula708may extend from proximal portion714of catheter assembly700to distal portion716. Delivery cannula708has a distal end that terminates within balloon728. In one embodiment, a fluid or treatment agent may be introduced through delivery cannula708to expand balloon728within vessel702.

Similar to the balloon illustrated inFIG. 5, balloon728includes a balloon wall or membrane which is selectively inflatable from a collapsed configuration to a desired and controlled expanded configuration. Balloon728may be selectively inflated by supplying a fluid into delivery cannula728or alternatively an inflation cannula (not shown) at a predetermined rate through an inflation port. The balloon is selectively deflatable to return to the collapsed configuration or a deflated profile. The balloon wall may be made of any suitable material, including polymers, copolymers of polyolefins, polyamides, polyesters and the like. Balloon728may have any suitable thickness so long as the thickness does not compromise properties that are critical for optimum performance. By way of example, and not limitation, the thickness may be about 10 microns to about 30 microns, the expanded diameter of balloon728may be about 2 mm) to about 10 mm, and the length may be about 3 mm to about 40 mm. The specific specifications depend on the procedure that balloon728is to be used in and the anatomy and size of the target lumen in which balloon728is to be inserted.

FIG. 7shows first needle722A and second needle722B on a surface of balloon728. Any number of needles may be located along the surface of balloon728. The needle may be connected to the surface of balloon728by, for example, an adhesive such as cyanoacrylate. Needle722A may include hollow shaft730and tip732having an outlet port. Needle722A connects to delivery cannula708to permit delivery of a treatment agent through the outlet port of needle722A. Needle722B is substantially the same as needle722A. In other embodiments, catheter assembly700may include a separate inflation lumen and a number of delivery cannulas equal to that of the needles. In this aspect, each needle may connect with a separate delivery cannula so as to allow each needle to deliver different fluids simultaneously while the inflation lumen is used to inflate balloon728.

In one embodiment, any of the solutions or treatment agent previously discussed may be delivered through delivery cannula708to balloon728. The solution or treatment agent may be used to expand balloon728causing needle722A to move in a substantially perpendicular direction, relative to a longitudinal axis of balloon728, and pierce the vessel wall into peri-adventitial space724. Needle722A may then deliver the solution or treatment agent into peri-adventitial space724. In some embodiments, needle722A is advanced through peri-adventitial space724and into the pericardial space as previously discussed for delivery of the treatment agent to this region.

In one embodiment, fluid volume, pressure and flow rate are controlled manually via a syringe. In another embodiment, fluid pressure is controlled by a pressurized reservoir, such as a pressurized IV bag. In another embodiment, flow rate may be controlled by an IV pump. In still further embodiments, the delivery device may have a pressure gauge or relief valve to aid in manual control or pressure.

Various techniques are used to prevent needles722A and722B from piercing the vessel wall during advancement and withdrawal of catheter assembly700through the vessel. In one embodiment, balloon728is deflated and needles722A and722B are positioned between folds of balloon728. Folds of balloon728may be set in a heat forming process to hold the folds during catheter delivery and to cause the balloon to re-fold in the same manner when the balloon is deflated. Representatively, the deflated balloon cross-section at the needles may look like an “H” and the needles may be positioned between the “I” portions of the “H”. Away from the needles the balloon folds may be wrapped to produce distal and proximal bevels to aid in atraumatic catheter movement.

In other embodiments, needles722A and722B are positioned along deflated balloon728parallel to a longitudinal axis of catheter assembly700. For example, a partially deflated balloon728is positioned within the vessel and then withdrawn slightly to ensure needle disengagement from the vessel wall. A guidewire or wire-like device is then advanced through a cannula in communication with a lumen of needles722A and722B. The wire-like device includes a stiff portion that is advanced into the base of needles722A and722B causing a polymer cannula with elastomeric properties that would normally direct needles722A and722B toward the wall to be straightened. This, in turn, causes needles722A and722B to lay down parallel to the longitudinal axis of catheter assembly700during the completion of balloon deflation so that the folds of balloon728cover needles722A and722B. Such a wire-like device includes mechanical interferences with the needle and cannula and dimensions, such that it can only be advanced to position part of the stiff portion in a distal portion of the polymer and the proximal portion of needles722A and722B to effect the straightening. Such a wire-like device can also be configured to be completely withdrawn from the catheter to allow injection through needles722A and722B or dimensioned such that it need only be withdrawn a short distance (i.e., a major portion of the wire remains inside the catheter) while still leaving enough space in the cannula for an injection to be performed. If the design allows a partial wire-like device withdrawal, a rotating hemostasis valve type device (e.g., a hemostasis valve with side-arm) can be used to facilitate longitudinal motion of the wire-like device, sealing around the wire-like device and injection (via the side-arm).

In still further embodiments, a sheath or portion of a sheath is advanced over balloon728causing needles722A and722B to lie down along a surface of balloon728during insertion and withdrawal of catheter assembly700within the vessel. The sheath is removed once catheter assembly700is positioned at the desired location within the vessel to allow for delivery of a treatment agent as previously described.

Catheter assembly700may be an over the wire (OTW) configuration wherein guidewire cannula706extends from a proximal end (external to a patient during a procedure) to a distal end of catheter assembly700. Guidewire cannula710may also be used for systemic delivery of a treatment agent. In another embodiment, catheter assembly700is a rapid-exchange-type (RX-type) catheter assembly, and only a portion of catheter assembly700(a distal portion714including balloon728) advances over guidewire726. In an RX-type catheter assembly, typically, the guidewire cannula and lumen extends from the proximal end of the catheter assembly. The proximal guidewire port is typically spaced a substantial distance from the proximal end of the catheter assembly.

FIG. 8Ais a simplified cross-sectional view of another embodiment of an intraluminal delivery device in the form of a catheter assembly including an imaging assembly for imaging vessel features to locate a desired treatment site. In this embodiment, the imaging assembly is positioned within a modified atherectomy device similar in certain respects to the delivery apparatus described in commonly-owned, U.S. Pat. No. 5,865,748 issued Feb. 2, 1999, titled “Guided Directional Coronary Atherectomy Distal Linear Encoder.”

Catheter assembly800includes a proximal end828and a distal end826. Proximal end828of catheter assembly800is external to blood vessel802and to the patient while distal end826is within vessel802. Representatively, catheter assembly800is inserted through a femoral artery and guided through, for example, primary cannula804with guidewire824to a location within the vessel. Alternatively, guidewire824is introduced into the venous system of the patient. In still further embodiments, a sheath (not shown), may be inserted into the brachial or femoral artery and advanced in a well known manner through the vasculature toward the heart. Alternatively, the sheath may be introduced into the venous system. Catheter assembly800may then be inserted into a proximal end of the sheath and guided through the arteries by fluoroscopy to a position in blood vessel802adjacent a treatment site within peri-adventitial space830.FIG. 8Ashows distal end826of catheter assembly800positioned at a point within vessel802adjacent to a treatment site within peri-adventitial space830.

Cable816includes a duplex spring to facilitate rotation of imaging assembly820. A duplex spring is a spring inside a spring and usually multi-filar (more than one wire used to construct each spring), a very miniature coaxial cable or other electrical cable(s) having a polymer sheath or impregnating polymer on its outer diameter. The outer winding (spring) of the duplex spring is open wound (there is a gap between the filars/wires of the outer spring) and the coaxial cable or other electrical cable(s) is placed/wound into this gap and held in place by the sheath/impregnation. In some embodiments, cable816is a single insulated conductor and the stainless steel duplex spring acts as the other conductor. At their distal ends the two conductors are electrically connected to transducer818and at their proximal ends to electrical connections (brushes or slip ring-like surfaces)844a844bof electro-mechanical connector846. Electro-mechanical connector846is attached to the proximal end of a stiffened section848of cable816.

The proximal end of cable816has a stiffened section848that allows cable816to be manually advanced or retracted by thumb lever850. In some embodiments, stiffened section848is a stainless steel hypotube-like component attached to the duplex spring or outer diameter of the sheath on cable816. Thumb lever850mechanically engages (engagement features not shown) stiffened section848such that stiffened section848may rotate, but not translate longitudinally relative to thumb lever850. Stiffened section848, is positioned such that it completely fills proximal hub852(i.e., there is no flexible cable816section in the hub852) with thumb lever850in its most proximal position to prevent cable816buckling in hub852. Thumb lever850may be rotated slightly to engage (or disengage) the housing of the catheter interface unit832with a frictional/interference to lock (unlock) the position of the thumb lever850when desired.

Proximal hub852is an RHV-like (Rotating Hemostasis Valve) device attached to primary cannula804. It contains a seal or seal assembly854that forms a seal around an outer diameter of stiffened section848such that when fluid is injected into flush port856, flow is directed into annular space between the outer diameter of cable816and an inner diameter of primary cannula804and not out of the proximal end of hub852. The proximal end of the hub852is configured to be an interference fit connection858that retains hub852in catheter interface unit832. Proximal hub852also includes a seal and features (not shown) that allow interference fit connection858to rotate relative to the rest of proximal hub852.

Catheter interface unit832(a hand held unit) and electro-mechanical connector846having raised portions845engage such that catheter interface unit832applies rotation to the connector846in a manner that allows cable816to be moved longitudinally proximal or distal by moving thumb lever850. Additionally, it contains electrical connections (electrical brushes and slip rings and/or slip ring-like surfaces) that provide electrical connection access to transducer818. On the proximal end of connector846are thumb wheel860and port834. Port834enables access to the open inner diameter/lumen that runs continuously through thumb wheel860, connector846, cable816and support mechanism838. Guidewire824is shown occupying that lumen. In another embodiment, the device800is a fixed guidewire device, such that a guidewire-like tip is attached to the distal end of nosecone808and thus, needle842may reside in the lumen (in a retracted position) during catheter positioning/imaging or inserted at another time in the procedure prior to injection. In some embodiments, port834and/or the housing of catheter interface unit832may be configured to releasably attach to a needle advancement control device (not shown). Thumbwheel860allows the operator to manually rotate the cable816to rotationally orient the support mechanism838/imaging assembly820in the desired direction for needle842advancement. The thumbwheel860and/or the catheter interface unit832may contain elements (not shown) to only allow thumbwheel860(and thus cable816and other components) rotation in the preferred direction.

In one embodiment, catheter assembly includes primary cannula804having a length that extends from proximal end828(e.g. located external to the patient) to connect with a proximal end of balloon822. Delivery cannula812extends from distal end826of catheter assembly800to proximal end828. A distal end of delivery cannula812terminates within balloon822. Delivery cannula812is a part of or attached to primary cannula804(e.g., by capturing both cannulas inside a heat shrinkable tube (not shown)). In some embodiments, delivery cannula812is attached to an outer diameter of primary cannula804. Delivery cannula812can be spiraled around primary cannula804outer diameter.

In one embodiment, a fluid (usually a fluoroscopic contrast agent solution) is introduced through delivery cannula812to expand balloon822within vessel802.

Catheter assembly800further includes imaging assembly820so that an image of vessel802can be viewed to identify a desired treatment region. Since the wall of vessel802and the adjacent anatomy can be viewed by a user prior to injection, injection into adjacent vessels, the pericardial sac and/or muscle tissue can be avoided. In addition, it is recognized that vessel wall thickness varies with vessel size and disease state. Therefore imaging assembly820is further used to facilitate measuring of the vessel wall thickness and in turn a depth a needle must penetrate the vessel wall to enter peri-adventitial space830. In this aspect, catheter assembly800provides a stable platform from which to advance a needle through the wall of vessel802and have it reliably penetrate into peri-adventitial space830.

Cable816is connected to imaging assembly820at one end and catheter interface unit832at another end to facilitate rotation of imaging assembly820. Cable816includes a lumen therethrough to accommodate guidewire824inserted through port834. Guidewire824can be advanced through catheter assembly800by inserting guidewire824through port834and advancing it through the lumen of cable816and imaging assembly820.

Imaging assembly820includes a transducer818attached to a support mechanism838. Support mechanism838is attached to an end of cable816and has an opening therethrough to accommodate guidewire824. Support mechanism838can be any size and shape capable of being rotated and translated within housing806and can be of any material suitable for supporting transducer818. Transducer818generates a series of ultrasonic pulses which are transmitted outward from transducer818. Echo pulses reflected from the wall of blood vessel802are received by transducer818between transmitted pulses of transducer818and collected by a control imaging system (not shown) connected to catheter800via the catheter interface unit832, electrical cable862proximal patient interface unit840and electrical cable866to be displayed as a cross-sectional ultrasonic image of blood vessel802.

To facilitate imaging, imaging assembly820is positioned within housing806having window836formed therein. In one embodiment, housing806is a cylindrically shaped body attached at one end to nose cone808and primary cannula804at another end. In one embodiment, nosecone808and the distal end of primary cannula804will contain features (not shown) that limit the longitudinal motion (proximal and distal) of the imaging assembly820. Nose cone808is a substantially cone shaped structure having openings at both ends to allow guidewire824to pass through it. Nose cone808provides a flexible tapered tip to catheter assembly800to facilitate advancement of catheter assembly800through vessel802. In addition, in some embodiments, support mechanism838includes a cutting edge on its distal outer diameter for removing an atheroma of vessel802when imaging assembly820is rotated and advanced distally. In this aspect, nose cone808provides a storage space for the cut atheroma tissue. Housing806may be made of any material suitable to support the inflated balloon822in the vessel without deformations that impede the motion of the imaging assembly820. Representative materials include a polymer such as polyetheretherketone (PEEK) or a metal such as stainless steel. Window836is formed in the surface of housing806at an approximately 120 degree angle or smaller (but large enough to accommodate the needle outer diameter) with respect to the housing's center axis. Imaging assembly820is rotated as illustrated by arrows inFIG. 8Awithin housing806to achieve a section image of the wall of blood vessel802and the adjacent anatomy through window836. To achieve additional views, primary cannula804may be rotated by an attending physician to rotate window836to obtain a views of other portions of blood vessel802and the adjacent anatomy. Housing806may include encoder structures (not shown) adjacent window836for indicating movement of transducer818along a linear axis of housing806through window836. During operation, the encoder structures return one of the echo pulses in response to transducer transmitted pulses to indicate angles of revolution thus defining linear movement of transducer818through the area of window836. This information is than transmitted to the control imaging apparatus via cable816for analysis. In another embodiment, the longitudinal position of the transducer818and associated components may be detected in the catheter interface unit832, preferably by detecting the position of thumb lever850using conventional methods/components (not shown).

A patient interface unit840is connected to catheter interface unit832to facilitate the transmission of ultrasonic pulses, echo signals and the rotation and translation of imaging assembly820. In this aspect, patient interface unit840includes a motor or other type of apparatus for rotating imaging assembly820via cable816and circuitry which generates or transmits pulses at predetermined degrees of rotation of proximal end of cable816or of the motor (not shown) for enabling transducer818to generate an ultrasonic pulse. In some embodiments, imaging assembly820is mechanically rotated by cable816due to the mechanical rotation provided by the motor (not shown) located in the patient interface unit840and provided to the catheter interface unit832via a torque cable assembly864. In one embodiment, the functions of the catheter interface unit832and the patient interface unit840are combined into a single unit.

A balloon822is mounted on a bottom of housing806to hold catheter assembly800in place once a desired vessel region is identified and the balloon822is inflated. Balloon822is substantially the same as the balloons previously described herein however is mounted to only a portion of housing806such that it does not cover window836. Balloon822is deflated to facilitate rotation and/or translation of catheter assembly800within the vessel802. Balloon822is inflated by delivering a fluid through delivery cannula812to balloon822. Inflation of balloon822presses window836of housing806against the desired vessel region.

FIG. 8Bshows the distal end of catheter assembly800with guidewire824removed. When a desired vessel region is identified, a fluid is delivered to balloon822via delivery cannula812to inflate balloon822and hold catheter assembly800in place. Guidewire824is then removed as shown to allow for insertion of a needle through cable816. Imaging assembly820is further withdrawn proximally from window836to a proximal end of housing806prior to needle842advancement out of imaging assembly820. In another embodiment, the needle842exits proximal of or from a proximal portion of the imaging assembly820and imaging assembly820is advanced distal of the window836to a distal end of housing806prior to needle842advancement.

FIG. 8Cshows the distal end of catheter assembly800having a needle842inserted as previously described and advanced through window836and into a desired vessel region. Needle842may be a curved end needle having an outer diameter (OD) near that of a 0.014″ OD guidewire. In some embodiments, needle842is made out of a shape memory and/or superelastic alloy such as nickel-titanium (NiTi). In this aspect, needle842may be substantially straightened during advancement through catheter assembly800and then return to its curved shape once it exits the lumen of support mechanism838. In a fixed guidewire type design, the needle842is preferred to be substantially straight and the lumen of support mechanism838curved to cause the needle842to exit it at an angle to the housing806centerline. It is therefore contemplated that housing806can include additional features such as a hole(s) or indent(s) that allow transducer818to be turned toward that feature by turning thumb wheel860and observing the image produced. For example, in some embodiments, a hole is formed in the proximal portion of the housing806. When imaging assembly820is retracted into housing806and turned using thumb wheel860(prior to needle advancement into the vessel wall), the image seen when the transducer818is oriented toward this hole will be very different from the image seen when transducer818is orientated toward the wall of housing806. Thus the orientation of the support mechanism838relative to the window836may be known/controlled.

In addition, features (e.g. holes or indents) (not shown) between imaging assembly820(support mechanism838) and/or the lumen of cable816and needle842can be included to orient the distal end of needle842relative to imaging assembly820/support mechanism838during its advancement. With proper attention to the design, when the hole, indent or other feature is seen in the image, the curve or exit angle of needle842will be aimed toward window836(e.g., by a mechanical interference such as by the shapes of the outer diameter of the needle842and the inner diameter of the cable or imaging assembly, and/or a tang on an outer surface of needle842engaging a slot or groove in the inner diameter of cable816or imaging assembly820while advancing it or in order to advance it).

During operation of catheter assembly800, needle842is inserted into cable816through port834. Needle842is advanced through cable816and out an end of support mechanism838of imaging assembly820. Once needle842reaches window836it curves and extends through window836and into the wall of vessel802. Needle842can be advanced or retracted through catheter assembly800until it penetrates vessel802to a desired depth, e.g. within peri-adventitial space830. Fluids may then be delivered through needle842to peri-adventitial space830to hydraulically dissect and deliver a desired treatment agent as previously described.

In the above described intraluminal embodiments for hydraulically dissecting tissues of the peri-adventitial space and locating a treatment agent within the peri-adventitial space, it is appreciated that an opening is made in or through the blood vessel. In some instances, it may be desirable to plug or fill the opening following delivery of the treatment agent. This may be accomplished by introducing through a catheter lumen cyanoacrylate or similar material that will harden on contact with blood.

FIG. 9schematically illustrates an epicardial access system in relation to the heart. In general, the delivery device provides a system for delivering a substance, such as a treatment agent or a combination of treatment agents optionally, from outside of the heart to treat a localized area of the blood vessel or to treat a localized area of tissue located adjacent to the blood vessel. The delivery apparatus ofFIG. 9is similar in certain respects to the delivery apparatus described in commonly-owned, U.S. patent application Ser. No. 11/159,705, filed on Jun. 23, 2005, titled “Method and System for Accessing A Pericardial Space”, of Peter L. Callas, et al.

FIG. 9is a general illustration of an epicardial access device902in relation to a heart900. As shown in greater detail inFIG. 10, device902is positioned adjacent a pericardium of heart900. As previously discussed, a pericardialspace1002lies between visceral layer1004A and epicardium1004B of the pericardium. Fibrous layer1000of the pericardium overlays visceral layer1004A. Myocardium1006is adjacent a side of epicardium1004B opposite that of pericardial space1002. A vein or artery1008having an overlying fat layer1005lies between epicardium1004B and myocardium1006. Surrounding vein1008beneath fat layer1005is peri-adventitial space1010.

In one embodiment, epicardial access device902includes a shaft1012and a needle1014fixed in relation to a longitudinal axis of shaft1012(i.e. needle1014is prevented from moving longitudinally with shaft1012). Shaft1012extends from a proximal end (not shown) to a distal end1016and is provided with an atraumatic tip1018. Shaft1012is sized so that distal end1016can be brought into proximity with pericardium1000while the proximal end is accessible from outside of the chest cavity. Shaft1012includes a cavity or recessed region1020having a depth, d, disposed near distal end1016, preferably somewhat proximal relative to distal tip1018of shaft1012. A suction lumen1022extends from a proximal port (not shown) near the proximal end of the shaft adapted for connecting to a source of negative pressure to a suction port1024disposed at recessed region1020of shaft1012. In other embodiments, the cavity or region1020includes a plurality of ports distributed at various locations to optimize the suction force applied to the pericardium (i.e., fibrous layer1000, visceral layer1004A and epicardium1004B). In one embodiment, cavity1020is defined by a substantially concave cavity wall. In other embodiments, cavity1020is other shapes and configurations.

Needle1014may be a hollow tubular structure defining an inner bore1026and having a sharp distal tip1028. Needle tip1028protrudes into recessed region1020of shaft1012a fixed distance and, in one embodiment, angles downwardly, or towards pericardium1000. However, needle1014extends downwardly no further than depth, d, of cavity1020. This prevents needle tip1028from snagging on tissue as device902is advanced to heart900. Needle1012includes an access port1030in fluid communication with needle bore1026. Access port1030is located near needle tip1028and is positioned within cavity1020of shaft1012. Needle bore1026and access port1030are adapted for slidably receiving medical instruments, for example, guidewires, or fluids or gases. In one embodiment, needle1014extends from about 0.5 to about 3 mm into cavity1020. In one embodiment, needle1014extends downwardly toward heart900at an angle of from about 15 to about 60 degrees with respect to a longitudinal access of shaft1012.

As illustrated inFIG. 10, suction lumen1022encompasses generally the entire interior of shaft1012, and needle1014lies within suction lumen1022. In other embodiments, shaft1012includes a secondary lumen separate from suction lumen1022for receiving needle1014. Alternatively, needle1014may be integrally formed within shaft1012.

In one embodiment, epicardial access device902may enter into the chest by, for example, a subxiphoid insertion route, and advance along a surface of heart900so that recessed region1020lies along fibrous layer1000adjacent a target blood vessel region. Alternatively, a sub-sternal or thoracascopic insertion route may be used in positioning device902along fibrous layer1000. Suction or negative pressure is applied to suction port1024via suction lumen1022, drawing fibrous layer1000, visceral layer1004A, epicardium1004B and fat layer1005into recessed region1020. The negative pressure is sufficient to cause the underlying fibrous layer1000, visceral layer1004A, epicardium1004B and fat layer1005to engage the stationary and protruding needle tip1028, such that needle tip1028penetrates the layers. Depth, d, of cavity1020is such that when fibrous layer1000, visceral layer1004A, epicardium1004B and fat layer1005are drawn upwardly, needle tip1028penetrates through the layers and into peri-adventitial space1010. Alternatively, only fibrous layer1000and visceral layer1004A are drawn upwardly such that needle tip1028penetrates through the layers and into pericardial space1002.

A fluid, such as saline or a treatment agent, may be delivered through access port1030and into peri-adventitial space1010to hydraulically dissect tissue planes within peri-adventitial space1010.

In one embodiment, fluid volume, pressure and flow rate are controlled manually via a syringe. In another embodiment, fluid pressure is controlled by a pressurized reservoir, such as a pressurized IV bag. In another embodiment, flow rate may be controlled by an IV pump. In still further embodiments, the delivery device may have a pressure gauge or relief valve to aid in manual control or pressure.

In other embodiments, a delivery device may be introduced directly to the peri-adventitial space during a medical procedure wherein the heart is exposed. In this aspect, a direct delivery device may be introduced to the epicardium during, for example, cardiac surgery such as valve surgery or coronary bypass surgery.FIG. 11schematically illustrates an embodiment of such a direct access system. In one embodiment, a delivery device1100is a syringe. In one embodiment, syringe1100may be any syringe assembly suitable for delivering a fluid substance to a vasculature of the heart. Syringe1100includes a plunger1102fitted to a barrel1104, which includes a small aperture1106on one end. Needle1108extends from barrel1104and may be secured within aperture1106. Needle1108may be made of materials including, for example, micropolymers, metals and metal alloys. Needle1108may have dimensions similar to the needles described in regard toFIG. 5. In some embodiments, needle1108may be a blunt tipped needle so as to prevent accidental perforation of a coronary artery or vein. Needle1108may be of a sufficient length to extend through the tissue and fat layers overlying the heart surface and into the peri-adventitial space surrounding the underlying vasculature as previously described in reference toFIG. 10. A representative needle1108length may be between about 3 mm and about 30 mm.

FIG. 12schematically illustrates another embodiment of a syringe direct delivery device having a stop feature. Similar to the syringe ofFIG. 11, syringe1200includes plunger1102fitted to barrel1104having a small aperture1106on one end. Needle1108extends from barrel1104and may be secured within aperture1106. Syringe1200further includes a stop feature1202secured to needle1108. Stop feature1202sets the penetration depth of needle1108within the tissue. In this aspect, stop feature1202lies at a distance from a tip1110of needle1108so that needle tip1110may be advanced through fibrous layer1000, visceral layer1004A, epicardium1004B and fat layer1005and into peri-adventitial space1010surrounding blood vessel1008as illustrated inFIG. 12. Alternatively, needle tip1110is only advanced through fibrous layer1000and visceral layer1004A such that needle tip1110penetrates through the layers and is positioned within pericardial space1002. Syringe1100may include multiple needles, which may be used for delivery of the same or different substances simultaneously to peri-adventitial space1010.

A volume of fluid, such as a treatment agent or saline solution, may be loaded into barrel1104. Needle1108may be advanced through fibrous layer1000, visceral layer1004A, epicardium1004B and fat layer1005adjacent a treatment site within peri-adventitial space1010so that a dispensing port of needle1108is within peri-adventitial space1010. The fluid may then be delivered to peri-adventitial space1010at a pressure sufficient to hydraulically dissect the tissue planes. As previously discussed, a sufficient pressure, may be, for example, approximately 30 mmHg. The volume of fluid delivered may be, in one embodiment, between approximately 0.1 cc and 20 cc, preferably at least 1.0 cc. In an embodiment, where the fluid is saline or other biocompatible solution, the fluid is drained and then the treatment agent is delivered.