# Patent

## Title
Expandable catheter system for vessel wall injection and muscle and nerve fiber ablation

## Abstract

A vascular nerve ablation (denervation) system includes a multiplicity of expandable needles which open around a central axis to engage the wall of a blood vessel allowing the injection of a cytotoxic or neurotoxic solution for ablating conducting tissue in and near the vessel wall of a renal artery or pulmonary vein. The expandable needles are formed of self-expanding materials and include structures which limit the distance of penetration of the injection needles into the tissue of the wall of the blood vessel.

## Background
FIELD OF USE
This invention is in the field of devices to ablate muscle cells and nerve fibers for the treatment of cardiac arrhythmias and/or hypertension.
BACKGROUND OF THE INVENTION
At the present time, physicians often treat patients with atrial fibrillation (AF) using radiofrequency (RF) catheter systems to ablate conducting tissue in the wall of the left atrium of the heart around the ostium of the pulmonary veins. Similar technology, using radiofrequency energy, has been used inside the renal arteries to ablate sympathetic and other nerve fibers that run in the outer wall of the renal arteries, in order to treat high blood pressure. In both cases these are elaborate and expensive catheter systems that can cause thermal, cryoablative, or other injury to surrounding tissue. Many of these systems also require significant capital outlays for the reusable equipment that lies outside of the body, including RF generation systems and the fluid handling systems for cryoablative catheters.
Because of the similarities of anatomy, for the purposes of this disclosure, the term target vessel ostial wall will refer here to either the wall of the pulmonary vein near the left atrium for AF ablation applications or the wall of the renal artery near the aorta for hypertension therapy applications. It is anticipated that ablation of nerve fibers for renal sympathetic denervation could be performed more distally as well.
In the case of atrial fibrillation ablation, the ablation of tissue surrounding multiple pulmonary veins can be technically challenging and very time consuming. This is particularly so if one uses RF catheters that can only ablate one focus at a time. There is also a failure rate using these types of catheters for atrial fibrillation ablation. The failures of the current approaches are related to the challenges in creating reproducible circumferential ablation of tissue around the ostium (peri-ostial) of a pulmonary vein. There are also significant safety issues with current technologies related to very long fluoroscopy and procedure times that lead to high levels of radiation exposure to both the patient and the operator, and may increase stroke risk in atrial fibrillation ablation.
There are also potential risks using the current technologies for RF ablation to create sympathetic nerve denervation inside the renal artery for the treatment of hypertension. The short-term complications and the long-term sequelae of applying RF energy inside the renal artery itself are not well defined. This type of energy applied within the renal artery may lead to late restenosis, thrombosis, embolization of debris into the renal parenchyma, or other problems inside the renal artery. There may also be uneven or incomplete sympathetic nerve ablation, particularly if there are anatomic abnormalities, or atherosclerotic or fibrotic disease inside the renal artery, such that there is non-homogeneous delivery of RF energy. This could lead to treatment failures, or the need for additional and dangerous levels of RF energy to ablate the nerves that run along the adventitial plane of the renal artery.
The Bullfrog® micro infusion catheter described by Seward et al in U.S. Pat. Nos. 6,547,803 and 7,666,163 which uses an inflatable elastic balloon to expand a single needle against the wall of a blood vessel could be used for alcohol injection but it would require multiple uses as it cannot deliver an ablative substance around the entire circumference of the vessel. The most number of needles shown by Seward is two and the two needle version of the Bullfrog® would be hard to make small enough to fit through a guiding catheter into a renal artery. If only one needle is used, accurate rotation of any device at the end of a catheter is difficult at best and could be risky if the subsequent injections are not evenly spaced if the rotation is off. Another limitation of the Bullfrog® is that inflation of a balloon within the renal artery can induce restenosis due to balloon injury as well as the removal of the protective layer of endothelial cells. Finally, while injection of ethanol as an ablative substance is well known and used within the heart and other parts of the body, there has been no development of an ethanol injection system specifically designed for the circumferential ablation of sympathetic nerve fibers around the renal arteries.
SUMMARY OF THE INVENTION
The present invention Vascular Nerve Ablation System (VNAS) is capable of producing damage in the nerve tissue that in or near the wall of a blood vessel in a relatively short period of time using a disposable catheter and requiring no additional capital equipment. The primary focus of use of VNAS is in the treatment of cardiac arrhythmias and hypertension.
Specifically, there is a definite need for such a catheter system that is capable of highly efficient, and reproducible ablation of the nerves surrounding the renal artery near, or distal to the ostium into the aorta in order to damage the sympathetic nerve fibers that track from the peri-ostial aortic wall into the renal arteries, and thus improve the control and treatment of hypertension.
This type of system may also have major advantages over other current technologies by allowing highly efficient, and reproducible circumferential ablation of the muscle fibers and conductive tissue in the wall of the pulmonary veins near the ostium into the Left Artium which could interrupt atrial fibrillation (AF) and other cardiac arrhythmias. Other potential applications of this approach may evolve.
The present invention is a catheter which includes multiple expandable injector tubes arranged circumferentially around the body of the VNAS near its distal end. Each tube includes an injector needle at its distal end. There is a penetration limiting member proximal to the distal end of each needle so that the needles will only penetrate into the tissue of the wall of the target blood vessel to a preset distance. This will reduce the likelihood of perforation of the vessel wall and will optimize the depth of injection for each application. The injector needles are in fluid communication with an injection lumen in the catheter body, which is in fluid communication with an injection port at the proximal end of the VNAS. Such an injection port would typically include a standard connector such as a Luer connector used to connect to a source of ablative fluid.
The expandable injector tubes may be self-expanding made of a springy material, a memory metal such as NITINOL or they may be made of a metal or plastic and expandable by other mechanical means. For example, the expandable legs with distal injection needles could be mounted to the outside of an expandable balloon whose diameter is controllable by the pressure used to inflate the balloon. There should be at least 2 injector tubes but 3 to 8 tubes are more appropriate, depending on the diameter of the vessel to be treated. For example, in a 5 mm diameter renal artery, only 3 or 4 needles may be needed while in an 8 mm diameter renal one might need 6 needles.
The entire VNAS is designed to include a fixed distal guide wire or be advanced over a guide wire in either an over the wire configuration where the guide wire lumen runs the entire length of the VNAS or a rapid exchange configuration where the guide wire exits the catheter body at least 10 cm distal to the proximal end of the VNAS and runs outside of the catheter shaft for its proximal section.
The VNAS would also be typically packaged inside a tubular sheath that constrains the self-expanding legs prior to deployment and for removal from the body. The sheath also allows the distal end of the VNAS to be inserted into the proximal end of a guiding catheter or introducer sheath. The sheath also serves to protect the operator(s) from possible needle sticks and exposure to blood borne pathogens at the end of the procedure when the VNAS is removed from the patient's body.
It is also envisioned that the injection needles could be formed from a radiopaque material such as tantalum or tungsten or coated with a radiopaque material such as gold or platinum so as to make them clearly visible using fluoroscopy.
It is also envisioned that one or more of the injector needles could be electrically connected to the proximal end of the VNAS so as to also act as a diagnostic electrode(s) for evaluation of the electrical activity in the area of the vessel wall.
It is also envisioned that one could attach 2 or more of the expandable legs to an electrical or RF source to deliver electric current or RF energy around the circumference of a target vessel to the ostial wall to perform tissue ablation.
For use in the treatment of hypertension the present invention VNAS would be used with the following steps:

    
    
        1. Engage a first renal artery with a guiding catheter placed through the femoral artery.
        2. Advance the distal end of the VNAS with a fixed distal guidewire into, and advance the VNAS through the guiding catheter, until the distal end of the injector needles are passed beyond the distal end of the guiding catheter and into the renal artery.
        3. Pull back the sheath allowing the expandable tubes to open up until the distal ends of the injector needles press outward against the inside wall of the renal artery.
        4. With the injector tubes having an outward curve or angle, the entire VNAS is then moved in the distal direction allowing the sharpened ends of the injector needles to penetrate the wall of the renal artery.
        5. The penetration limiting members will allow the needles only to penetrate a preset distance (typically between 0.3. and 2 mm but preferably about 0.5 mm) into the vessel wall of the renal artery.
        6. Attach a syringe or injection system to the injection connector at the VNAS proximal end.
        7. Inject an appropriate volume of ethanol (ethyl alcohol) or other appropriate cytotoxic fluid from the syringe or injection system through the catheter and out of the needles into the vessel wall. A typical injection would be 1-10 ml. This should produce a multiplicity of ablation zones (one for each needle) that will intersect to form an ablative ring around the circumference of the target vessel. Contrast could be added to the injection to allow x-ray visualization of the ablation area.
        8. Once the injection is complete, retract the VNAS in the proximal direction while holding the sheath steady, and then advance the sheath over the needles. This will collapse the needles back under the sheath. The entire VNAS can the be pulled back into the guiding catheter.
        9. In some cases, one may rotate the VNAS 20-90 degrees and then repeat the injection if needed to make an even more definitive ring of ablation.
        10. The same methods as per prior steps can be repeated to ablate tissue in the contralateral renal artery.
        11. Remove the VNAS from the guiding catheter completely.
        12. Remove all remaining apparatus from the body.
        13. A similar approach can be used with the VNAS, via transeptal access into the left atrium to treat AF, via ablation of tissue in the vessel wall of one or more pulmonary veins. When indicated, advance appropriate diagnostic electrophysiology catheters to confirm that the ablation (in the case of atrial fibrillation) has been successful
    
    


It is also envisioned that two or more of the legs/injector tubes may be connected to an electrical or RF field source to allow for electrical discharge or RF ablation to enable tissue ablation of the tissue in the vessel wall.
It is also envisioned that one could mount injector tubes with needles on the outer surface of an expandable balloon on the VNAS in order to deliver 2 or more needles into the vessel wall of a target vessel to inject ablative fluid.
Although the main embodiment of this invention utilizes two or more needle injection sites to circumferentially administer alcohol or other neuro-toxic fluid to the wall of the renal artery for sympathetic nerve ablation, it is also envisioned that other modifications of this concept could also be utilized to achieve the same result. In one case it is envisioned that circumferential fluid based (ethanol or other ablative fluid) could be administered in a circumferential fashion to a “ring segment” of the renal artery by injecting the fluid into a space between two inflated balloons. Thus, after inflating a proximal occlusive balloon and a distal occlusive balloon, the ablative fluid would be injected into the space between the two balloons and allowed to dwell for a short period of time allowing the fluid, such as ethanol to penetrate through the arterial wall and reach the adventitial layer, thus disrupting and ablating the sympathetic nerves running in this space. After the dwell period the space could be flushed with saline and the balloons deflated.
Similarly, a single balloon with a smaller diameter near the middle of the balloon could function in the same way, as the ethanol is injected in the “saddle-like” space in the central part of the balloon that is not touching the arterial wall.
It is also envisioned that another embodiment may include a circumferential band of polymer, hydrogel or other carrier, on the central portion of an inflatable balloon with the carrier containing the neurotoxic agent, such as alcohol, guenethidine, phenol, etc. The balloon would be inflated at relatively low pressure to oppose the intimal surface of the renal arterial wall, and inflated for a dwell time to allow penetration of the neurotoxic agent, circumferentially, into a “ring segment” of the renal artery and allow ablation of the sympathetic nerve fibers running near or in the adventitial plane.
Another embodiment may include two or more pores, or small metallic (very short) needle like projections on the outer surface of the central portion of an inflatable balloon, that would be in fluid communication with an injection lumen to allow injection into the wall of the renal artery and allow circumferential delivery of a neurotoxic agent. Given these teachings an embodiment descriptions, other similar techniques could be envisioned to allow other variations upon this concept of a balloon expandable, circumferential ablation system for renal artery sympathetic nerve ablation.
Thus it is an object of the present invention VNAS is to have a percutaneously delivered catheter that can be used to treat atrial fibrillation with a one, or more injections of an ablative fluid into the vessel walls of the pulmonary veins near the ostium into the left atrium of the heart.
Another object of the present invention VNAS is to have a percutaneously delivered catheter that can be used to treat hypertension with one, or more injections of an ablative fluid into the vessel walls of the renal arteries.
Still another object of the present invention VNAS is to have a percutaneously delivered catheter that includes a multiplicity of circumferentially expandable injector tubes, each tube having a needle at its distal end for injection of an ablative fluid into the wall of a target vessel.
Another object of the invention is to have a penetration limiting member or means attached just proximal to the distal end of each injector needle in order to limit the depth of needle penetration into the vessel wall.
Yet another object of the present invention VNAS is to have one or more of the injector needles act as diagnostic electrodes for measurement of electrical activity within the wall of the target vessel.
These and other objects and advantages of this invention will become obvious to a person of ordinary skill in this art upon reading of the detailed description of this invention including the associated drawings.



BRIEF DESCRIPTION OF THE DRAWINGS
FIG. 1 is a longitudinal cross section drawing of the distal portion of the present invention Vascular Nerve Ablation System (VNAS) having a fixed guide wire at its distal end.
FIG. 2 is a schematic view of the distal portion of the VNAS in its closed position as it would be configured for delivery into the human body or to cover the injector needles during removal from the human body.
FIG. 3 is a schematic view of the distal portion of the VNAS in its open position as it would be configured for delivery of an ablative solution into the target vessel wall.
FIG. 4 is a longitudinal cross sectional drawing of the proximal end of the fixed wire embodiment of the VNAS of FIGS. 1 through 3.
FIG. 5A is a schematic view of the distal portion of the closed VNAS of FIG. 2 as it is first advanced out of a guiding catheter into a renal artery.
FIG. 5B is a schematic view of the distal portion of the closed VNAS as the sheath is being pulled back to allow the expandable tubes open against the wall of the renal artery distal to the ostium.
FIG. 5C is a schematic view of the distal portion of the fully open VNAS of FIG. 3 with needles fully embedded into the wall of the renal artery to allow the infusion of an ablative substance into the vessel wall.
FIG. 5D is a schematic view of the distal portion of the closed VNAS as the distal portion of the VNAS is being pulled back into the sheath to close the VNAS either for subsequent use in the other renal artery or for removal from the body.
FIG. 5E is a schematic view of the distal portion of the closed VNAS of FIG. 2 after it has been closed by retraction of the distal portion of the VNAS into the sheath either for subsequent use in the other renal artery or for removal from the body.
FIG. 6 is a longitudinal cross section drawing of the embodiment of the VNAS that is delivered over a separate guide wire.
FIG. 7 is a longitudinal cross sectional drawing of the proximal end of an over-the-wire embodiment of the VNAS of FIG. 6.



DETAILED DESCRIPTION OF THE DRAWINGS
FIG. 1 is a longitudinal cross section drawing of the distal portion of the present invention Vascular Nerve Ablation System (VNAS) 10 having a fixed guide wire 25 with tip 28 at its distal end. FIG. 1 shows the VNAS 10 in its fully open position with the self-expanding injector tubes 15 with distal ends sharpened to form injection needles 19 open to their maximum diameter. Flexible cords 13 with adhesive 14 that attaches the cords 13 to the injector tubes 15 act as a penetration limiting member to prevent the distal tip of the needles 19 from penetrating more than a maximum distance L into a vessel wall. The injector tubes can be made from any springy material with the preferred material being NITINOL. A separate spring or inflatable balloon could be placed inside of the injector tubes if the tubes are self-expanding to achieve the same objective. A balloon while increasing the diameter of the system would be able to push the needles with great force into the vessel wall.
A sheath 12 with radiopaque marker 27 is shown in FIG. 1 in its position where it has been pulled back to allow full expansion of the injector tubes 15. There are 4 injector tubes 15 in this embodiment of the VNAS 10 although as few as 2 and as many as 12 are envisioned. The distance L can be between 0.2 and 2 mm with the optimal being about 1 mm.
The distal section 20 of the VNAS 10 includes the distal wire 25, tapered flexible tip 26, radiopaque maker 24 and sheath engagement section 22 that assures that the distal portion of the VNAS 10 will properly pull back into the sheath 12 following use of the VNAS 10 to ablate tissue in a vessel of the human body. The VNAS 10 is fully closed when the two radiopaque markers 27 and 24 are next to each other. This provides a visual indication during fluoroscopy.
The proximal end of the injector tubes 15 are held by a manifold 17 that is attached inside the distal end of the outer tube 16 and the core wire 11. The proximal end of the outer tube 16 is attached to a hypotube 18 that continues to the proximal end of the VNAS 10. The hypotube 18 is typically made from a metal like 316 Stainless steel and the outer tube 16 is made from a plastic or metal reinforced plastic so that it is flexible enough to allow the VNAS to easily be advanced and retracted around the bend in a typical guiding catheter such as that used for angioplasty or stenting of the renal arteries. The outer tube 16 would typically be between 5 and 30 cm long although it is also envisioned that the VNAS 10 could be designed without a hypotube 18 and only a plastic or metal reinforced plastic outer tube 16 running to the proximal end.
The core wire 11 is attached to the inside of the hypotube 18 at junction point 23. This attachment could for example be by adhesive means, welding or brazing. Spot welding is the preferred method. In this way, the core wire 11 that supports the fixed wire 25 cannot be easily detached form the VNAS 10. The injector lumen 21 inside of the hypotube 18 connects to the lumen of the outer tube 16 which is in fluid communication with the injector tube lumens 29 of each of the expandable tubes 15 allowing an ablative substance or solution to flow from the proximal end of the VNAS 10 through the hypotube 18, through the outer tube 16, through the expandable injector tubes 15 and out of the sharpened injector needles 19 into a vessel wall.
FIG. 2 is a schematic view of the distal portion of the VNAS 10′ in its closed position as it would be configured for delivery into the human body or to cover the injection needles 19 during removal from the human body. The VNAS 10′ includes fixed wire 25 with tip 28, core wire 11, outer tube 16 and sheath 12. In this configuration the two radiopaque markers 27 and 24 are adjacent to each other with the sheath 12 being advanced to it fully distal position.
FIG. 3 is a schematic view of the distal portion of the present invention Vascular Nerve Ablation System (VNAS) 10 in its fully open position having a fixed guide wire 25 with tip 28 at its distal end. FIG. 3 shows the VNAS 10 in its fully open position with the self-expanding injector tubes 15 with distal ends sharpened to form injection needles 19 open to their maximum diameter.
Flexible cords 13 with adhesive 14 that attaches the cords 13 to the injector tubes 15 act as a penetration limiting member to prevent the distal tip of the needles 19 from penetrating more than a maximum distance L shown in FIGS. 1 and 3 into a vessel wall.
A sheath 12 with radiopaque marker 27 is shown in FIG. 3 in its position where it has been pulled back to allow full expansion of the injector tubes 15. There are 4 injector tubes 15 in this embodiment of the VNAS. The distal section 20 of the VNAS 10 includes the fixed distal wire 25, tapered flexible tip 26, radiopaque maker 24 and sheath engagement section 22 that assures that the distal portion will properly pull back into the sheath 12 following use of the VNAS 10 to ablate tissue in a vessel of the human body. Also shown in FIG. 3 are the outer tube 16 with injection lumen 21 and core wire 11.
FIG. 4 is a longitudinal cross sectional drawing of the proximal end of the fixed wire embodiment of the VNAS 10 of FIGS. 1 through 3. The hypotube 18 with injection lumen 21 also shown in FIG. 1, has a Luer fitting 35 with lumen 36 attached to its proximal end allowing a source of an ablative substance of solution to be injected through the lumen 36 of the Luer fitting 35 into the lumen 21 of the hypotube 18 and subsequently out of the injection needles 19 of FIGS. 1 through 3. The proximal end of the sheath 12 is attached to the distal end of the Tuohy-Borst fitting 30 with handle, 36, inner hub 33 washer 39 and O-Ring 43. As the handle 36 is tightened by screwing it down over the inner hub 33, the O-Ring will compress sealing the Tuohy-Borst fitting 30 against the hypotube 18. A side tube 31 with Luer fitting 32 having a lumen 34 is designed to allow the lumen 38 between the inside of the sheath 12 and hypotube 18 to be flushed with saline before insertion of the VNAS 10 into a human body. Before insertion into the body, the Tuohy-Borst fitting 30 is tightened onto the hypotube 18 with the sheath 12 in its most distal position and the VNAS 10′ closed as is shown in FIG. 2. When in the distal end of the VNAS 10′ is properly positioned in one of the renal arteries, the Tuohy-Borst fitting is loosened and the handle 36 is pulled in the proximal direction while the Luer fitting 35 his held in place. This will open the VNAS 10 and allow the injector tubes 15 of FIG. 1 to expand outward in the vessel.
FIG. 5A is a schematic view of the distal portion of the closed VNAS 10′ of FIG. 2 as it is first advanced out of a guiding catheter 80 into a renal artery just distal to the ostium with the aorta. The VNAS 10′ is advanced until the marker band 24 distal to the distal end of the guiding catheter 80. It is anticipated that an optimal distance of 5 to 15 mm distal would work best although shorter and longer distances are possible depending on the geometry of the renal artery and the distance of penetration of the guiding catheter 80 into the ostium of the renal artery.
FIG. 5B is a schematic view of the distal portion of the closed VNAS 10′′ as the sheath 12 is being pulled back to allow the expandable tubes 15 open against the wall of the renal artery just distal to the ostium into the aorta. After the sheath 12 is pulled back so it no longer constrains the expandable injector tubes 15, the VNAS 10′′ is then pushed in the distal direction allowing the injector tubes 15 to continue their outward expansion as the injection needles 19 penetrate into the wall of the renal artery. The penetration will stop when the cords 13 engage the wall of the renal artery limiting the penetration of the needles 19.
FIG. 5C is a schematic view of the distal portion of the fully open VNAS 10 of FIG. 3 with needles 19 fully embedded into the wall of the renal artery to allow the infusion of an ablative substance into the vessel wall. Although FIG. 5C show the cords 13 fully expanded, it would be typical for them to be slightly less in diameter than their maximum diameter when they engage the wall of the renal artery to limit the penetration of the needles 19. Preferably, the maximum diameter of the VNAS 10 system selected for the procedure should be at least 2 to 4 mm greater than the inside diameter of the renal artery. For example, if the renal artery diameter at the desired ablation site is 5 mm in diameter, then a VNAS 10 with maximum diameter of 7 to 9 mm should be selected. In the configuration of FIG. 5C, the ablative substance is injected through the needles 19 into the wall of the renal artery. The preferred ablative substance is ethyl alcohol (ethanol), which has historically been used to ablate tissue, particularly nerve tissue in the cardiovascular system. Other agents such as phenol, guenethidine or other cytotoxic and/or neurotoxic agents are also anticipated as possible injectates.
FIG. 5D is a schematic view of the distal portion of the closed VNAS 10′′ as its distal portion is being pulled back into the sheath 12 to close the VNAS 10′′ either for subsequent use in the other renal artery or for removal from the body. A shaded area shows the ablated region 100 where the tissue in the wall of the renal artery has been ablated.
FIG. 5E is a schematic view of the distal portion of the closed VNAS 10′ of FIG. 2 after it has been closed by retraction of the distal portion of the VNAS into the sheath 12 either for subsequent use in the other renal artery or for removal from the body.
For this embodiment of the VNAS 10, the method of use for hypertension would be the following steps:

    
    
        1. Remove the sterilized VNAS 10 from its packaging in a sterile field, flush the lumen 38 between the outer tube 12 and hypotube 18 with saline.
        2. Advance the sheath 12 until the VNAS 10′ is in its close position.
        3. Lock the Tuohy-Borst fitting 30 down onto the hypotube 18 of FIG. 4.
        4. Access the aorta via a femoral artery, typically with the insertion of an introducer sheath.
        5. Using a guiding catheter 80 of FIGS. 5A through 5E or a guiding sheath with a shaped distal end, engage the first targeted renal artery through the aorta. This can be confirmed with contrast injections as needed.
        6. Place the distal end of the VNAS 10 in its closed position of FIG. 2 into the proximal end of the guiding catheter 80. There is typically a Tuohy-Borst fitting attached to the distal end of a guiding catheter 80 to constrain blood loss.
        7. The closed VNAS 10 can be pushed through the opened Tuohy-Borst fitting into the guiding catheter 80.
        8. Advance the VNAS 10 through the guiding catheter, until the marker band 24 is distal to the distal end of the guiding catheter within the renal artery as shown in FIG. 5A.
        9. Pull the sheath 12 back in the proximal direction while holding the Luer fitting 35 and hypotube 18 the proximal end of the VNAS 10 fixed. This will allow expansion of the injector tubes 15 against the wall of the renal artery as shown in FIG. 5B.
        10. Lock the Tuohy-Borst fitting 30 down on the hypotube 18.
        11. With the Tuohy-Borst fitting at the proximal end of the guiding catheter 80 loosened advance the sheath 12 and hypotube 18 locked together pushing the sharpened needles 19 into the wall of the renal artery as the self-expanding injector tubes 15 continue to expand outward. The injector tubes 15 will stop penetration when the cords 13 engage the wall of the renal artery limiting the penetration of the needles 19.
        12. Attach a syringe or injection system to the Luer fitting 35 of FIG. 4 that provides ablative fluid that will be injected into the wall of the renal artery
        13. Inject an appropriate volume of ethanol (ethyl alcohol) or other appropriate cytotoxic fluid from the syringe or injection system through the lumen 36 and out of the needles 19 into the wall of the renal artery. A typical injection would be 1-10 ml. This should produce a multiplicity of intersecting volumes of ablation (one for each needle) that should create a torroid of ablated tissue around the circumference of the renal artery as shown as the ablated regions shown in FIGS. 5D and 5E.
        14. Loosen the Tuohy-Borst fitting 30 and while holding the Tuohy-Borst fitting 30 and sheath 12 fixed, pull the Luer 35 with hypotube 18 in the proximal direction until the expandable tubes 15 with needles 19 are fully retracted back into the distal end of the sheath 12 and the marker bands 27 and 25 are next to one another. This is shown in FIGS. 5D and 5E.
        15. In some cases, one may advance the VNAS 10 again into the renal artery, rotate it between 20-90 degrees and then repeat the injection to make an even more definitive volume of ablation. This would be advantageous if the VNAS 10 has fewer than 4 injector tubes and should not be needed with the 4 injector tubes shown in herein.
        16. The same methods as per steps 8-15 can be repeated to ablate tissue around the other renal artery during the same procedure.
        17. Remove the VNAS 10 in its closed position from the guiding catheter. Being in the closed position, the needles 19 are enclosed and cannot harm the health care workers, or expose them to blood borne pathogens.
        18. Remove all remaining apparatus from the body.
    
    


A similar approach can be used with the VNAS 10, to treat atrial fibrillation through a guiding catheter inserted through the septum into the left atrium with the wall of the target vessel being the wall of one of the pulmonary veins.
FIG. 6 is a longitudinal cross section drawing of the distal portion of another embodiment the present invention Vascular Nerve Ablation System (VNAS) 40 that is delivered over a separate guide wire 60. FIG. 6 shows the VNAS 40 in its fully open position with the self-expanding injector tubes 45 with distal ends sharpened to form injection needles 49 open to their maximum diameter. Flexible cords 43 connect the injector tube 45 and act as a penetration limiting member to prevent the distal tip of the needles 49 from penetrating more than a maximum distance D into a vessel wall. Unlike the cord 13 of FIG. 1, the cords 43 are fed though holes 57 in the sides of each injector tube 45 a distance D from the distal end. A drop of adhesive (not shown) can be used to seal the holes and prevent leakage of the ablative substance or solution during injection into a vessel wall.
A sheath 42 is shown in its position where it has been pulled back to allow full expansion of the injector tubes 45. There are 4 injector tubes 45 in this embodiment of the VNAS 40 although as few as 2 and as many as 12 are envisioned. The distance D can be between 0.2 and 2 mm with the optimal being about 0.5-1 mm.
The proximal end of the injector tubes 45 are held by a manifold 47 that is attached inside the distal end of the outer tube 46 and the inner tube 48. An injection lumen 51 lies between the inner tube 48 and outer tube 46 proximal to the manifold 47. Ablative material injected through the injection lumen 51 will flow into the proximal ends of the injector tubes 45 and then out of the injection needles 49 into a vessel wall.
The distal section 50 of the VNAS 40 that is coaxially attached to the distal section of the inner tube 48 includes the tapered flexible tip 56, radiopaque maker 55 and sheath engagement section 54 that assures that the distal portion of the VNAS 40 will properly pull back into the sheath 42 following use of the VNAS 40 to ablate tissue in a vessel of the human body. The guide wire 60 can be advance and retracted in the longitudinal direction inside of the guide wire lumen 41 that lies inside of the inner tube 48. The VNAS 40 can be configured either as an over-the-wire or a rapid exchange device. If over-the-wire, the guide wire lumen 41 inside of the inner tube 48 runs all the way to the proximal end of the VNAS 40 as is shown in FIG. 7. If a rapid exchange configuration is used then the guide wire would exit from the VNAS 40 and run external to the outside of the VNAS 40 for some portion of the length of the VNAS 40. If a rapid exchange is used then a slot will be needed in the sheath 42 to allow for the sheath 42 to move longitudinally with respect to the rest of the VNAS 40. The proximal end of the rapid exchange configuration would be identical to that of the fixed wire VNAS 10 of FIG. 4. The guide wire would typically run outside of the body of the VNAS 40 for at least the most proximal 10 cm with the preferred embodiment having the guide wire exit through the side of the outer tube 46 and sheath 42 between 5 and 15 cm from the distal end of the VNAS 40.
FIG. 7 is a longitudinal cross sectional drawing of the proximal end 70 of an over-the-wire embodiment of the VNAS 40 of FIG. 6. The inner tube 48 has a Luer fitting 78 attached to its proximal end. The guide wire 60 can be advanced through the guide wire lumen 41 inside of the inner tube 48. The proximal end of the outer tube 46 is attached to the hub 79 that is sealed against the inner tube 48, forming the injection lumen 51 between the inner tube 48 and outer tube 46. A side tube 74 with lumen 76 connects into the hub 79 with a Luer fitting 75 attached to the proximal end of the side tube 74. A syringe or other injection device can be attached to the Luer fitting 75 to inject an ablative substance or solution through the lumen 76 into the injection lumen 51 into the injector tube 45 of FIG. 6 and out of the ends of the injection needles 49 into a vessel wall. The proximal end of the sheath 42 connects to the hub 77 that acts as a handle to slide the sheath 42 coaxially over the outer tube 46 to open and close the VNAS 40 of FIG. 6. A side tube 72 with lumen 73 connects into the hub 77. A Luer fitting 71 it attached to the proximal end of the side tube 72 to allow the lumen 62 between the sheath 42 and the outer tube 46 to be flushed with saline solution before introduction of the VNAS 40 in to the human body. While the hub 77 shown here is a plastic member, it is envisioned that a Tuohy-Borst fitting such as the Tuohy-Borst fitting 30 of FIG. 4 could be used here and could be advantageous as it would allow one to lock the sheath 42 in position onto the outer tube 46 during insertion and removal from the body so that the distal end of the sheath 42 would remain in its most distal position protecting the injection needles 49 and protecting health care workers from exposure to needle stick injury.
Various other modifications, adaptations, and alternative designs are of course possible in light of the above teachings. Therefore, it should be understood at this time that within the scope of the appended claims the invention may be practiced otherwise than as specifically described herein.

## Claims

1. A vascular nerve ablation system for ablating tissue in or near the vessel wall of a target vessel comprising:
a catheter body having a central axis extending in a longitudinal direction and a fluid injection lumen;
at least two self-expanding injector tubes, each of said injector tubes having an injector tube lumen in fluid communication with the catheter body fluid injection lumen, the distal end of each of said injector tubes being an injector needle with injector needle lumen, and the injector needle lumen being in fluid communication with the injector tube lumen;
a single penetration limiting member directly attached to all of said injector tubes, the single penetration limiting member located at a predetermined distance from the distal end of each injector needle, wherein the single penetration limiting member is configured to simultaneously limit the penetration of each injector needle; and,
an external source of ablative fluid in fluid communication with each of said injector tube lumens.

2. The vascular nerve ablation system as recited in claim 1 where said catheter body includes a fixed guide wire attached to its distal end.

3. The vascular nerve ablation system as recited in claim 1 configured to be advanced coaxially over a separate guide wire.

4. The vascular nerve ablation system of claim 3 having an over-the-wire configuration where the guide wire lumen runs the entire length of the catheter body.

5. The vascular nerve ablation system of claim 3 having a rapid exchange configuration where the proximal end of the guide wire lumen exits from the catheter body at a location at least 10 cm distal to the proximal end of the catheter body.

6. The vascular nerve ablation system as recited in claim 1 further including a sheath that when retracted to its most proximal open position allows the expandable injector tubes to expand outward.

7. The vascular nerve ablation system as recited in claim 1 further including a sheath that includes a radiopaque marker at its distal end.

8. The vascular nerve ablation system as recited in claim 1 further including a sheath that includes a Tuohy-Borst adapter at its proximal end, the Tuohy-Borst adapter when tightened preventing the sheath from moving in the longitudinal direction with respect to the remainder of the vascular nerve ablation system.

9. The vascular nerve ablation system of claim 8 where said sheath has a distal closed position and a proximal open position, where the sheath in the closed position extends in the distal direction so as to completely cover the injector needles.

10. The vascular nerve ablation system as recited in claim 1 where said single penetration limiting member is a cord fixedly attached to each of said injector tubes.

11. The vascular nerve ablation system as recited in claim 1 where said injector tubes are formed from NITINOL.

12. The vascular nerve ablation system as recited in claim 1 where said ablative fluid is an ethanol composition.

13. The vascular nerve ablation system as recited in claim 1 where said single penetration limiting member is located at least 0.5 mm proximal to the distal end of said injector needles.

14. A vascular nerve ablation system for ablating tissue in or near the vessel wall of a target vessel comprising:
a catheter body having a central axis extending in a longitudinal direction and a fluid injection lumen;
at least two self-expanding injector tubes, each of said injector tubes having an injector tube lumen in fluid communication with the catheter body fluid injection lumen, the distal end of each of said injector tubes being an injector needle with injector needle lumen, and the injector needle lumen being in fluid communication with the injector tube lumen;
a single penetration limiting member directly attached to all of said injector tubes, the single penetration limiting member configured to provide uniform penetration and angular spread of the injector needles; and,
an external source of ablative fluid in fluid communication with each of said injector tube lumens.

15. The vascular nerve ablation system as recited in claim 14 further including a sheath that when retracted allows the expandable injector tubes to expand outward.

16. The vascular nerve ablation system as recited in claim 14 where said injector tubes are formed from NITINOL.

17. A vascular nerve ablation system for ablating tissue in or near the vessel wall of a target vessel comprising:
a catheter body having a central axis extending in a longitudinal direction and a fluid injection lumen;
at least two self-expanding injector tubes, each of said injector tubes having an injector tube lumen in fluid communication with the catheter body fluid injection lumen, the distal end of each of said injector tubes being an injector needle with injector needle lumen, and the injector needle lumen being in fluid communication with the injector tube lumen;
a single penetration limiting member directly attached to all of said injector tubes, wherein said at least two injector tubes are configured to move longitudinally and expand simultaneously, wherein the single penetration limiting member is configured to limit the penetration of each of said injector needles into the tissue; and,
an external source of ablative fluid in fluid communication with each of said injector tube lumens.

18. The vascular nerve ablation system as recited in claim 17 further including a sheath that when retracted allows the expandable injector tubes to expand outward.

19. The vascular nerve ablation system as recited in claim 17 where said injector tubes are formed from NITINOL.