# Patent

## Title
Endovascular devices and methods

## Abstract

Devices and methods for the treatment of chronic total occlusions are provided. One disclosed embodiment comprises a method of facilitating treatment via a vascular wall defining a vascular lumen containing an occlusion therein. The method includes providing an intravascular device having a distal portion with a side port, inserting the device into the vascular lumen, positioning the distal portion in the vascular wall, directing the distal portion within the vascular wall such that the distal portion moves at least partially laterally, and directing the side port towards the vascular lumen.

## Background
CROSS REFERENCE TO RELATED APPLICATIONS
This application claims the benefit of U.S. Provisional Application No. 60/716,287, filed Sep. 12, 2005, under 35 U.S.C. §119(e). In addition, this application also claims the benefit of U.S. Provisional Application No. 60/717,726, filed Sep. 15, 2005, under 35 U.S.C. § 119(e). In addition, the application also claims the benefit of U.S. Provisional Application No. 60/727,819, filed Oct. 18, 2005, under 35 U.S.C. §119(e). The entire disclosure of each of the above-referenced applications is incorporated by reference herein.


FIELD OF THE INVENTION
The inventions described herein relate to devices and associated methods for the treatment of chronic total occlusions. More particularly, the inventions described herein relate  to devices and methods for crossing chronic total occlusions and subsequently performing balloon angioplasty, stenting, atherectomy, or other endovascular methods for opening occluded blood vessels.
BACKGROUND OF THE INVENTION
Due to age, high cholesterol and other contributing factors, a large percentage of the population has arterial atherosclerosis that totally occludes portions of the patient's vasculature and presents significant risks to patient health. For example, in the case of a total occlusion of a coronary artery, the result may be painful angina, loss of cardiac tissue or patient death. In another example, complete occlusion of the femoral and/or popliteal arteries in the leg may result in limb threatening ischemia and limb amputation.
Commonly known endovascular devices and techniques are either inefficient (time consuming procedure), have a high risk of perforating a vessel (poor safety) or fail to cross the occlusion (poor efficacy). Physicians currently have difficulty visualizing the native vessel lumen, can not accurately direct endovascular devices toward visualized lumen, or fail to advance devices through the lesion. Bypass surgery is often the preferred treatment for patients with chronic total occlusions, but less invasive techniques would be preferred.
SUMMARY OF THE INVENTION
To address this and other unmet needs, the present invention provides, in exemplary non-limiting embodiments, devices and methods for the treatment of chronic total occlusions. The disclosed methods and devices are particularly beneficial in crossing coronary total occlusions but may also be useful in other vessels including peripheral arteries and veins. In exemplary embodiments, total occlusions are crossed using methods and devices intended to provide a physician the ability to place a device within the subintimal space, delaminate the connective tissues between layers within the lesion or vessel wall, or remove tissues from the chronic total occlusion or surrounding vessel.
In an aspect of the disclosure, a subintimal device may be used to guide conventional devices (for example guide wires, stents, lasers, ultrasonic energy, mechanical dissection, or atherectomy) within the vessel lumen. Additionally, a subintimal device may be used to delaminate vessel wall layers and also may be used to remove tissue from the occlusive lesion or surrounding vessel wall. In one example, the positioning of a subintimal device or the establishment of a delamination plane between intima and medial layers is achieved through the use of a mechanical device that has the ability to infuse a fluid (for example saline). Fluid infusion may serve to apply a hydraulic pressure to the tissues and aid in layer delamination and may also serve to protect the vessel wall from the tip of the subintimal device and reduce the chance of vessel perforation. The infusion of fluid may be controlled by pressure or by volume.
Subintimal device placement may be achieved with a subintimal device directing catheter. The catheter may orient a subintimal device so that it passes along the natural delamination plane between intima and media. The catheter may orient the subintimal device in various geometries with respect to the vessel. For example, the subintimal device may be directed substantially parallel with respect to the vessel lumen or in a helical pattern such that the subintimal device encircles the vessel lumen in a coaxial fashion. The subintimal device directing catheter may be an inflatable balloon catheter having proximal and distal ends with two wire lumens. One lumen may accept a conventional guide wire while the second lumen may accept the subintimal device. In an alternative embodiment, the wire directing catheter may be a guide catheter with distal geometry that steers the subintimal device with the appropriate orientation to enter the subintimal space.
In an additional disclosure, a subintimal device intended to mechanically delaminate tissue layers may use a device that is inserted into the subintimal space in a first collapsed configuration and is released or actuated into a second expanded configuration. The device may then be withdrawn or manipulated to propagate the area of delamination.
An additional aspect of the disclosure may allow the physician to remove tissues from the lesion or vessel wall. In one embodiment, a subintimal device is circumferentially collapsed around the total occlusion. Tissue removal is performed through simple device withdrawal or through a procedure that first cuts connective tissues (i.e. the intimal layer proximal and distal of the lesion) and then removes the targeted tissue. In another embodiment, a tissue removal device is passed through the lesion within the native vessel lumen. The targeted tissues may be mechanically engaged and removed through device withdrawal.



BRIEF DESCRIPTION OF THE DRAWINGS
It is to be understood that both the foregoing summary and the following detailed description are exemplary. Together with the following detailed description, the drawings illustrate exemplary embodiments and serve to explain certain principles. In the drawings,
FIG. 1 shows an illustration of a heart showing a coronary artery that contains a chronic total occlusion;
FIG. 2 is a schematic representation of a coronary artery showing the intimal, medial and adventitial layers;
FIG. 3 is a partial sectional view of a subintimal device directing balloon catheter embodiment with fluid infusion through the subintimal device lumen within the device directing catheter;
FIG. 4 is a partial sectional view of a subintimal device directing balloon catheter embodiment with fluid infusion through the subintimal device;
FIG. 5 is a partial sectional view of an additional subintimal device directing guiding catheter embodiment with fluid infusion through the subintimal device;
FIGS. 6A and B are partial sectional views of a expandable delamination catheter;
FIGS. 7 A-D are partial sectional views of a circumferential subintimal tissue removal device;
FIGS. 8A-C are an example of subintimal device construction;
FIGS. 9A and B are partial sectional views of an intraluminal rotational engagement tissue removal device;
FIG. 10 is a schematic illustration of an alternative subintimal device;
FIGS. 11A and 11B are schematic illustrations of an alternative subintimal device with a re-entry port;
FIGS. 12A-12D are schematic illustrations of a re-entry method using a balloon catheter; and
FIGS. 13A and 13B are schematic illustrations of an alternative subintimal device and associated pumping system.



DETAILED DESCRIPTION OF EXEMPLARY EMBODIMENTS
The following detailed description should be read with reference to the drawings in which similar elements in different drawings are numbered the same. The drawings, which are not necessarily to scale, depict illustrative embodiments and are not intended to limit the scope of the invention.
Referring to FIG. 1, a diseased heart 100 includes a chronic total occlusion 101 of a coronary artery 102. FIG. 2 shows coronary artery 102 with intimal layer 200 (for sake of clarity, the multi layer intima is shown as a single homogenous layer). Concentrically outward of the intima is the medial layer 201 (which also is comprised of more than one layer but is shown as a single layer). The transition between the external most portion of the intima and the internal most portion of the media is referred to as the subintimal space. The outermost layer of the artery is the adventitia 202.
In an aspect of the disclosure, a subintimal device may be used to guide conventional devices (for example guide wires, stents, lasers, ultrasonic energy, mechanical dissection, or atherectomy) within the vessel lumen. Additionally, a subintimal device may be used to delaminate vessel wall layers and also may be used to remove tissue from the occlusive lesion or surrounding vessel wall. In one embodiment, FIG. 3 shows a subintimal device directing catheter is 300 with its distal balloon 301 that has been advanced over a conventional guide wire 302 and inflated proximal to chronic total occlusion 101. For the sake of clarity, FIG. 4 shows a subintimal device path that is substantially parallel to the vessel lumen, but other orientations (i.e. helical) may also be considered. Subintimal device lumen 303 is positioned adjacent to the intimal layer 200 and subintimal device 304 has been advanced as to perforate the subintimal layer. A fluid source (i.e. syringe) 305 is in fluid communication with subintimal device lumen 303 through infusion lumen 306. Fluid may flow from the fluid source 305 through the subintimal device lumen 303 under a controlled pressure or a controlled volume. The infused fluid may enter the subintimal space 307 directly from the subintimal device lumen 303 or from the volume 308 defined by the distal end of the balloon 301 and the proximal edge of the lesion 101. FIG. 4 shows an alternative fluid infusion path where fluid source 305 is in fluid communication with a lumen within the subintimal device 304. FIG. 5 shows an alternative subintimal device directing guide catheter 500 where the distal end 501 has a predefined shape or the distal end has an actuating element that allows manipulation by the physician intra-operatively.
Another aspect of the disclosure may place a subintimal device within the subintimal space in a first collapsed configuration and releases or actuated the subintimal device to a second expanded configuration. The device may then be withdrawn or manipulated to propagate the subintimal dissection. In one embodiment, FIG. 6A shows a subintimal device with internal expandable element 600 that contains one or more expanding elements contained in exterior sheath 602. FIG. 6B shows exterior sheath in a retracted position allowing expanding elements 601 to elastically expand. The subintimal device is intended to be delivered through the aforementioned subintimal device delivery catheters.
An additional aspect of the disclosure may allow the physician to remove tissues from the lesion or vessel wall. FIG. 7A shows an embodiment where subintimal device directing balloon catheter is inflated within coronary artery 102 just proximal to chronic total occlusion 101. Subintimal device 304 is partially delivered around chronic total occlusion 102 coaxially outside the intimal layer 200 and coaxially inside medial layer 201 in a helical pattern. FIG. 7B shows a subintimal device capture catheter 702 positioned across the chronic total occlusion 101 over conventional guide wire 703 and within subintimal device 304. The distal 704 and proximal 705 ends of the subintimal device have been captured and rotated as to reduce the subintimal device outside diameter and contain the lesion 101 and intima 200 within the coils internal diameter. The device may be withdrawn through the use of a cutting element. For example, FIGS. C and D show the advancement of a cutting element 706 in two stages of advancement showing the cutting of intima 200 proximal of the occlusion 707 and intimal distal of the occlusion 708.
An additional aspect of the subintimal device is the construction of the device body. The flexibility and torquability of the device body can affect the physician's ability to achieve a subintimal path. The subintimal device body may be constructed in part or in to total of a single layer coil with geometric features along the coil length that allow adjacent coils to engage (for example mechanical engagement similar to the teeth of a gear). FIG. 8A shows coil 801 closely wound such that the multitude of teeth 802 along the coil edges are in contact such that the peaks of one coil falls within the valleys of the adjacent coil. A conventional coil reacts to an applied torsional load by diametrically expanding or contracting, thus forcing the wire surfaces within a turn of the coil to translate with respect to its neighboring turn. The construction of coil 801 resists the translation of wire surfaces within the coil thus resisting the diametric expansion or contraction (coil deformation). An increased resistance to coil deformation increases the torsional resistance of the device body while the coiled construction provides axial flexibility. An exemplary construction may include a metallic tube where the coil pattern 801 and teeth 802 are cut from the tube diameter using a laser beam. FIG. 8B shows subintimal device body 804 that is for example a continuous metallic tube with distal laser cut coil segment 801 and proximal solid tube 803. Tube materials include but are not limited to stainless steel and nickel titanium. Alternatively, the coil may be wound from a continuous wire. The wire has a cross section that for example has been mechanically deformed (stamped) to form the teeth and allow coil engagement. FIG. 8C shows an example of a laser cut tooth pattern from the circumference of a tube that has been shown in a flat configuration for purposes of illustration.
In another embodiment, a tissue removal device may be passed through the lesion within the native vessel lumen. FIG. 9A shows corkscrew device 900 with exterior sheath 902 engaging occlusion after delamination of the intimal layer 901 has been performed by the aforementioned methods and devices. FIG. 9B shows removal of the occlusion and a portion of the intimal layer through axial withdrawal of the corkscrew device.
With reference to FIG. 10, an alternative subintimal device 1000 is shown schematically. Subintimal device 1000 is similar to the device shown and described with reference to FIGS. 8A-8C, and may include any of the variants described previously, such as distal atraumatic tip configurations, fluidic dissection mechanisms, etc. Subintimal device 1000 may be sized and shaped for intravascular navigation and includes an elongate tubular shaft 1004, at least a distal portion of which includes a helical interlocking gear 1006 and a helical wire coil 1008 disposed thereon. A helically shaped inner mandrel or tube 1010 may be disposed in the tubular shaft 1004 such that the shaft 1004 rotates freely thereon. The shaft 1004 may have a linear or straight configuration in a relaxed state and a helical configuration (shown) when the helically shaped inner member 1010 is disposed therein. The device 1000 may be disposed in a constraining sheath (not shown) and navigated to the intravascular site, such as the site of an occlusion. When the device 1000 is advanced distally out the end of the constraining sheath or when the sheath is pulled proximally relative thereto, the distal portion of the device 1000 assumes a helical shape as shown. The shaft 1004 may be rotated relative to the inner member 1010 to cause rotation of the helical wire threads 1008, which may be used to engage the vessel wall and advance around an occlusion in a subintimal path as described previously. A bearing (not shown) may be disposed on the inner member 1010 to engage the proximal or distal end of the shaft 1004 to enable the shaft 1004 and the inner member 1010 to be advanced in unison.
With reference to FIGS. 11A and 11B, an alternative subintimal device 1100 is shown schematically. Subintimal device 1100 may be similar to device 1000 described previously, with the helical interlocking gear and helical wire coil eliminated for sake of illustration. Subintimal device 1100 includes an elongate tubular shaft 1102 having a lumen extending therethrough and a re-entry port 1106 disposed distally in the region of the helical shape. In this embodiment, the distal portion of the shaft 1102 may have a helical shape in its relaxed state such that the re-entry port 1106 is always oriented toward the center of the helix as shown in FIG. 11A. With this arrangement, a re-entry device 1110 such as a guide wire or flexible stylet with a tissue penetrating tip may be advanced through the lumen 1104 of the shaft 1102 to exit the re-entry port 1106 as shown in FIG. 11B. This arrangement may be used to establish re-entry of the native lumen of a vessel once the device 1100 traverses an occlusion in the subintimal space.
With reference to FIGS. 12A-12D, an alternative re-entry method is schematically shown. In this method, a subintimal device such as guide wire 1210 is advanced into the subintimal space 1202 across an occlusion 1200 in a manner similar to the methods described previously, for example. As shown in FIG. 12A, the guide wire 1210 extends across an occlusion 1200 disposed in subintimal space 1202 between intimal/medial layers 1204 and adventitial layer 1206, where re-entry of the native lumen 1208 distal of the occlusion 1200 is desired. A balloon catheter 1220 is then advanced over the guide wire 1210 until the balloon portion is disposed adjacent the distal end of the occlusion as shown in FIGS. 12B and 12C. The guide wire 1210 is pulled proximally and balloon is then inflated causing radial displacement of the distal end of the balloon catheter 1220 as shown in FIG. 12C. Inflating the balloon of the balloon catheter 1220 orients the tip of the catheter toward the intimal/medial layers 1204. The guide wire 1210 may be removed from the balloon catheter 1220 and a sharpened stylet 1230 or the like may be advanced through the guide wire lumen of the catheter 1220 until the distal end of the stylet 1230 penetrates the intimal/medial layers 1204 as shown in FIG. 12D, thus establishing re-entry from the subintimal path 1202 and into the native lumen 1208.
With reference to FIGS. 13A and 13B, an alternative fluidic subintimal system 1300 with subintimal device 1310 and associated pumping system 1320 is shown schematically. The fluidic system 1300 is similar in certain aspects to the arrangements described with reference to FIGS. 3, 4 and 5, the various aspects of which may be combined or used in the alternative as will be appreciated by those skilled in the art. System 1300 includes a subintimal device 1310 which may comprise any of the tubular subintimal devices described herein. Generally, subintimal device 1310 includes a tubular shaft 1312 having a proximal end connected to a pumping mechanism 1320. A plunger rod 1314 is slidingly disposed in the tubular shaft 1312 as shown in FIG. 13B and its proximal end is connected to a linear actuator 1322 of the pumping mechanism as shown in FIG. 13A. As seen in FIG. 13B, a ring seal 1315 is disposed in the lumen of shaft 1312 around the rod 1314. The rod 1314 extends through the tubular shaft 1312 to a point proximal of the distal end thereof to define a pumping chamber 1316. A source of liquid 1330 (e.g., saline bag) is connected to the proximal end of the subintimal device 1310 via a fluid line 1332 and optional valve 1334 to supply liquid to the annular lumen between the rod 1314 and the inner wall of the tubular shaft 1312. As the linear actuator moves the rod 1314 back and forth in the tubular shaft 1312, liquid is caused to be expelled out of the chamber 1316 in a pulsatile fashion, which may be used to hydraulically dissect tissues to define a subintimal path as described previously, for example. The stroke length, stroke rate and stroke volume may be adjusted to achieve the desired effect. For example, the stroke volume of the chamber 1316 may be relatively small (0.01 cc-1.0 cc, for example) such that liquid exits the chamber 1316 with high energy that dissipates quickly to minimize trauma to tissues as they are dissected.
From the foregoing, it will be apparent to those skilled in the art that the present invention provides, in exemplary non-limiting embodiments, devices and methods for the treatment of chronic total occlusions. Further, those skilled in the art will recognize that the present invention may be manifested in a variety of forms other than the specific embodiments described and contemplated herein. Accordingly, departures in form and detail may be made without departing from the scope and spirit of the present invention as described in the appended claims.

## Claims

1. A method of facilitating treatment of a blood vessel having a vascular wall, an innermost surface of the vascular wall defining a vascular lumen that contains an occlusion therein, the vascular wall having an outermost surface furthest from the lumen, the method comprising:
inserting an intravascular device into the vascular lumen, the intravascular device configured to be associated with a re-entry device having a distal portion, the intravascular device having a first balloon portion located on a first side of the intravascular device and a second balloon portion located on a second side of the intravascular device, the first and second balloon portions being located at a same axial location of the intravascular device, the first balloon portion being configured to extend radially outward in a first direction, the second balloon portion being configured to extend radially outward in a second direction opposite the first direction;
positioning the first and second balloon portions in the vascular wall such that a distal portion of the intravascular device is parallel to the vascular lumen when the first and second balloon portions are in an uninflated state, the distal portion of the intravascular device having an opening; and
inflating the first and second balloon portions to rotate the opening of the intravascular device toward the vascular lumen while all surfaces of the first and second balloon portions are outside of the vascular lumen and radially inward from the outermost surface of the vascular wall.

2. The method of claim 1, wherein inflating the first and second balloon portions distends a portion of tissue along the vascular wall.

3. The method of claim 1, wherein the re-entry device includes a tissue penetrating tip, and the method further comprising advancing the re-entry device to penetrate tissue of the vascular wall such that the re-entry device enters a location of the vascular lumen distally beyond the occlusion.

4. The method of claim 1, wherein the intravascular device defines an internal lumen and an opening fluidly communicating with the internal lumen, and the method further comprises advancing the re-entry device through the internal lumen and through the distal opening.

5. The method of claim 4, wherein inflating the first and second balloon portions distends a portion of tissue along the vascular wall, wherein the re-entry device includes a tissue penetrating tip, and the method further comprising advancing the re-entry device to penetrate distended tissue of the vascular wall such that the re-entry device enters a location of the vascular lumen distally beyond the occlusion.

6. The method of claim 1, wherein positioning the first and second balloon portions in the vascular wall comprises inserting a guidewire into subintimal space within the vascular wall, past the occlusion, and advancing the intravascular device over the guidewire.

7. The method of claim 6, further comprising removing the guidewire.

8. The method of claim 1, wherein positioning the first and second balloon portions in the vascular wall comprises advancing the balloon distally of the occlusion.

9. The method of claim 8, wherein advancing the first and second balloon portions distally of the occlusion occurs prior to inflating the first and second balloon portions within the vascular wall.

10. The method of claim 8, wherein advancing the first and second balloon portions distally of the occlusion includes advancing all of the first and second balloon portions distally of the occlusion.

11. The method of claim 1, further including positioning the distal portion of the re-entry device adjacent the first and second balloon portions within the vascular wall.

12. The method of claim 1, wherein the first and second balloon portions each has a proximal end, and wherein positioning the first and second balloon portions in the vascular wall comprises advancing the proximal ends of the first and second balloon portions within the vascular wall.

13. The method of claim 12, further comprising advancing the proximal ends of the first and second balloon portions beyond the occlusion.

14. The method of claim 1, further comprising advancing the re-entry device to penetrate tissue of the vascular wall such that the re-entry device enters a location of the vascular lumen distally beyond the occlusion after inflating the first and second balloon portions.

15. The method of claim 1, further comprising directing a tissue penetrating tip of the re-entry device toward the vascular lumen.

16. The method of claim 15, further comprising advancing the tissue penetrating tip of the re-entry device into the vascular lumen.

17. The method of claim 15, wherein the tissue penetrating tip of the re-entry device is directed toward the vascular lumen when the tissue penetrating tip is advanced through an opening defined by the intravascular device.

18. The method of claim 15, wherein advancing the tissue penetrating tip of the re-entry device through an opening defined by the intravascular device directs the tissue penetrating tip toward the vascular lumen.

19. The method of claim 1, further comprising directing a tissue penetrating tip of the re-entry device toward an intimal layer of the vascular wall.

20. The method of claim 19, further comprising advancing the tissue penetrating tip of the re-entry device through the intimal layer of the vascular wall.

21. The method of claim 19, wherein the tissue penetrating tip of the re-entry device is directed toward the intimal layer when the tissue penetrating tip is advanced through an opening defined by the intravascular device.

22. The method of claim 19, wherein advancing the tissue penetrating tip of the re-entry device through an opening defined by the intravascular device directs the tissue penetrating tip toward the intimal layer.

23. The method of claim 1, further comprising advancing a guidewire into subintimal space within the vascular wall.

24. The method of claim 23, wherein advancing the guidewire into subintimal space within the vascular wall comprises advancing a distal end of the guidewire distally of the occlusion.

25. The method of claim 24, further comprising withdrawing the guidewire from the vascular lumen.

26. The method of claim 1, wherein the opening is located on a distal face of the intravascular device.

27. The method of claim 1, wherein the first and second balloon portions are part of a single balloon.

28. A method of facilitating treatment of a blood vessel having a vascular wall, an innermost surface of the vascular wall defining a vascular lumen that contains an occlusion therein, the vascular wall having an outermost surface furthest from the lumen, the method comprising:
positioning a distal portion of a guidewire within the vascular wall and distally of the occlusion;
positioning a catheter relative to the guidewire, the catheter having a first balloon portion located on a first side of the catheter and a second balloon portion located on a second side of the catheter, the first and second balloon portions being located at a same axial location of the catheter, the first balloon portion being configured to extend radially outward in a first direction, the second balloon portion configured to extend radially outward in a second direction opposite the first direction;
advancing the first and second balloon portions in the vascular wall via the guidewire such that a distal portion of the catheter is parallel to the vascular lumen when the first and second balloon portions are in an uninflated state, the distal portion of the catheter having an opening;
rotating the opening of the catheter relative to the vascular lumen by inflating the first and second balloon portions while all surfaces of the first and second balloon portions are outside of the vascular lumen and radially inward from the outermost surface of the vascular wall;
replacing the guidewire with a re-entry device; and
positioning a distal portion of the re-entry device adjacent the first and second balloon portions within the vascular wall.

29. The method of claim 28, wherein replacing the guidewire with the re-entry device comprises withdrawing the guidewire from a guidewire lumen of the catheter and advancing the re-entry device into the guidewire lumen of the catheter.

30. The method of claim 28, wherein positioning the first and second balloon portions relative to the guidewire includes positioning the first and second balloon portions over the guidewire.

31. The method of claim 28, wherein the first and second balloon portions each has a proximal end, and wherein advancing the first and second balloon portions in the vascular wall comprises advancing the proximal ends of the first and second balloon portions within the vascular wall.

32. The method of claim 28, wherein orienting the catheter includes orienting a distal tip of the catheter.

33. The method of claim 28, further comprising advancing the re-entry device to penetrate tissue of the vascular wall such that the re-entry device enters a location of the vascular lumen distally beyond the occlusion after inflating the first and second balloon portions.

34. The method of claim 28, further comprising removing the guidewire from the subintimal space prior to positioning the distal portion of the re-entry device.

35. The method of claim 28, wherein the opening is located on a distal face of the catheter.

36. The method of claim 28, wherein the first and second balloon portions are part of a single balloon.

37. A method of facilitating treatment of a blood vessel having a vascular wall, an innermost surface of the vascular wall defining a vascular lumen that contains an occlusion therein, the vascular wall having an outermost surface furthest from the lumen, the method comprising:
advancing a catheter along a guidewire that has been previously positioned to extend into the vascular wall, the catheter having a first balloon portion located on a first side of the catheter and a second balloon portion located on a second side of the catheter, the first and second balloon portions being located at a same axial location of the catheter, the first balloon portion being configured to extend radially outward in a first direction, the second balloon portion configured to extend radially outward in a second direction opposite the first direction;
positioning the first and second balloon portions of the catheter in the vascular wall such that a distal portion of the catheter is parallel to the vascular lumen when the first and second balloon portions are in an uninflated state, the distal portion of the catheter having an opening; and
rotating the opening of the catheter relative to the vascular lumen by inflating the first and second balloon portions while all surfaces of the first and second balloon portions are outside of the vascular lumen and radially inward from the outermost surface of the vascular wall.

38. The method of claim 37, further comprising providing a re-entry device having a distal portion, and advancing the distal portion of the re-entry device through the opening defined by the catheter.

39. The method of claim 37, wherein the catheter defines a longitudinal axis and the opening is distally facing transverse the longitudinal axis.

40. The method of claim 37, wherein the first and second balloon portions are part of a single balloon.