# Patent

## Title
Devices, systems and methods for acute or chronic delivery of substances or apparatus to extravascular treatment sites

## Abstract

Methods and apparatus for delivery of substances or apparatus to target sites located outside blood vessels within the body of a human or animal patient. A vessel wall penetrating catheter is inserted into the vasculature, positioned and oriented within a blood vessel near the target extravascular site and a penetrator is advanced from the catheter so as to penetrate outwardly through the wall of the blood vessel in the direction of the target site. Thereafter, a delivery catheter is passed through a lumen of the penetrator to the target site. A desired substance or apparatus is then delivered to or obtained from the target site. In some applications, the penetrator may be retracted into the vessel wall penetrating catheter and the vessel wall penetrating catheter may be removed, leaving the delivery catheter in place for chronic or continuous delivery of substance(s) to and/or obtaining of information or samples from the target site. Alternatively, a delivery catheter having an occlusion member or balloon may be advanced into a vein or venule and the occlusion member or balloon may be used to occlude the lumen of the vein or venule during and after injection of a substance through the catheter, such that the substance will not be carried away by normal venous blood flow and will remain in the vein or venule for a sufficient period of time to have its intended effect (e.g. to enter adjacent tissues through capillary beds drained by that vein or venule).

## Background
RELATED APPLICATIONS
This patent application is a continuation of copending U.S. patent application Ser. No. 11/927,888 filed Oct. 30, 2007 and issued on Mar. 18, 2014 as U.S. Pat. No. 8,672,920, which is a division of U.S. patent application Ser. No. 10/466,622 filed Mar. 1, 2004 and issued on Apr. 15, 2008 as U.S. Pat. No. 7,357,794, which is a Section 371 national stage application based on PCT International Application No. PCT/US02/01168 filed Jan. 17, 2002, which claims priority to U.S. patent application Ser. No. 09/766,502 filed Jan. 17, 2001 and issued on Aug. 5, 2003 as U.S. Pat. No. 6,602,241, the entire disclosure of each such patent and application being expressly incorporated herein by reference.


BACKGROUND OF THE INVENTION
There exist many situations in which it is desirable to deliver substances (e.g., drugs, biological materials, etc) or apparatus (e.g., wires, sensors, etc.) to specific locations within tissues (i.e. an “interstitial target site”) of the body of a human or veterinary patient. Examples of the types of tissues wherein such target sites may be located include myocardial tissue, brain tissue or tumors.
Some catheters and drug delivery stents of the prior art have been purportedly useable to indirectly deliver drugs or substances to specific interstitial target locations by first dispensing the drug within the lumen of a nearby blood vessel or on the inner surface of a nearby blood vessel and then allowing the drug to migrate through the blood vessel wall or through a downstream capillary bed, to the desired interstitial target location.
The prior art has also included catheter devices that may be used for delivering substances or apparatus directly into interstitial target locations by guided advancement of a penetrating cannula or needle from a catheter located within the lumen of a nearby blood vessel, through the wall of the blood vessel and through any intervening tissue, to the interstitial target site. The desired substance or apparatus may then be infused or delivered directly into the target interstitial site without any need for transmural diffusion through the blood vessel wall or downstream transluminal flow to the selected capillary bed. Examples of these catheter devices useable for direct delivery of drugs or apparatus into interstitial target sites are described in PCT International Patent Publications No. PCT/US99/07115 and PCT/US99/07112.
Particular interest has developed in methods for controlled or targeted delivery of substances such as drugs (e.g., chemotherapeutic agents), gene therapy compositions (e.g., plasmids, viral vectors, genetically modified cells, naked DNA), biological factors (e.g., angiogenic factors, nerve growth factors, other cell growth factors, other proteins), monoclonal antibodies, or specific cell types (e.g., stem cells or other progenator cells, pancreatic islet cells, dopamine secreting neurons, endothelial cells, myocardial cells, other myocytes, etc) into interstitial target locations for the purpose of treating diseases such as myocardial ischemia, solid tumor types of cancer, parkansonism, diabetes, etc. Specifically, in the treatment of myocardial ischemia, research has indicated that introduction of certain angiogenic substances into ischemic areas of myocardium may result in “therapeutic angiogenesis” in patients who suffer from clinically significant coronary artery disease. Generally speaking, the term “angiogenesis” refers to the creation of new capillaries and/or blood vessels within the parenchyma of an organ, within a tumor or within an area of tissue (e.g., myocardium). Angiogenesis is believed to occur as a multistep process in which endothelial cells focally degrade and invade through their own basement membrane, migrate through interstitial stroma toward an angiogenic stimulus, proliferate proximal to the migrating tip, organize into blood vessels, and reattach to newly synthesized basement membrane. The term “therapeutic angiogenesis” involves the administration of angiogenic substances or treatments to promote one or more steps in the angiogenesis process thereby providing for the creation of new blood flow in tissue that previously lacked sufficient blood flow.
Various approaches have heretofore been used for delivery of angiogenic substances into the myocardium. One approach is the use a tissue penetrating device such as a laser to create penetration tracts or transmyocardial (TMR) channels which extend from either the epicardial (outer) surface or endocardial (inner) surface of the heart into the myocardium, and to then inject quantities of angiogenic substances into those TMR channels. Examples of this approach are described in U.S. Pat. No. 5,925,012 (Murphy-Chutorian, et al.), U.S. Pat. No. 5,999,678 (Murphy-Chutorian, et al.) And U.S. Pat. No. 6,106,520 (Laufer, et al.)
There remains a need in the art for the development of new apparatus and methods for delivering substances or apparatus to specific target sites within tissues, tumors or organs of the body with minimal trauma to the tissues and optimum control as to the precise location(s) at which the substances or apparatus are introduced.
SUMMARY OF THE INVENTION
The present invention provides transluminal methods, devices and systems for delivering substances (e.g., drugs or other therapeutic or diagnostic agents) or articles (e.g., devices, apparatus, wires, sensors, thermistors, etc.) to interstitial sites within the body of a human or veterinary patient.
In accordance with one aspect of the invention, there is provided a system comprising a) a penetrating catheter that is positionable within the vasculature (e.g., a blood vessel, vascular sinus or chamber of the heart) of a human or animal patient and which has a penetrator advanceable from the catheter in the direction of an extravascular target site and b) a delivery catheter that is advanceable from the penetrator to the target site. As used herein, the term “vessel wall” shall mean not only the wall of a blood vessel (i.e., artery or vein) but also the endocardium surrounding a chamber of the heart or any other wall of an anatomical structure in which the penetrating catheter is positioned and through which the penetrator advances to reach its intended position within adjacent tissue. The substance(s), article(s) or apparatus may then be delivered to the target site through the delivery catheter and/or samples of body fluid or other information may be obtained from the target site through the delivery catheter. In applications where it is desired to use the delivery catheter continuously or intermittently over an extended period of time (e.g., hours, days, weeks or months) the penetrator may be withdrawn into the vessel wall penetrating catheter and the vessel wall penetrating catheter may be removed, leaving just the delivery catheter in place (e.g., extending through the patients blood vessel(s), outwardly through the penetration formed in the blood vessel wall and to the target site.) Also, the substance or article(s) may be injected periodically or continuously as the delivery catheter is being advanced or retracted, so as to provide a continuous “trail” or series of deposition sites wherein the substance or article(s) is/are deposited.
In accordance with the invention, the use of a unicurvate or multicurvate penetrator (or a curved delivery catheter in combination with a straight, unicurvate or multicurvate penetrator) may serve to guide the delivery catheter on a path that is navigates around anatomical structures or avoid penetration into a cavity, organ or anatomical structure that the operator does not wish for the delivery catheter to enter. In this regard, the delivery catheter may be guided such that it advances on a path that is generally tangential to the wall or edge or a chamber of the heart or other cavity or anatomical structure that the operator does not wish to enter or penetrate. This ability to avoid penetration of a chamber, cavity or anatomical structure may allow a greater length of the delivery catheter to be advanced into the tissue than would have been otherwise possible. The advancement of a greater length of delivery catheter into the tissue may allow for deposition of a longer trail or a more lengthy series of depots of an injected material than would be possible if the delivery catheter were to have been advanced in the direction of or non-tangentially to the chamber of the heart or other cavity or anatomical structure that the operator does not wish to enter or penetrate. Also, the ability to provide a lengthy trail or series of deposition sites may be advantageous in certain applications of the invention. For example, the ability to deposit a tissue graft or cells (e.g., stem cells, myoblasts, etc.) in an elongate trail may allow for the cells to form an organized structure wherein the cells communicate with one another and/or form a connection between two spaced apart regions of an organ or tissue mass. In cases where angiogenic substances are being injected through the delivery catheter, the ability to lay down a trail of the angiogenic substance may permit the operator to define a line or elongate region of new blood vessel growth. Also, advancement of a more lengthy segment of the delivery catheter into the tissue may provide for deeper injection of substances with less potential for bleedback or regurgitation through the interstitial tract created by advancement of the penetrator and/or delivery catheter. Also, this capability of the system allows for the deposition of a series or network of elongate trails or tracts of a substance or article, or spaced apart interstitial deposits of a substance or article in a manner that allows the individual trails, tracts or deposits to form a network and to interact with one another in a desired manner.
The types of substances that may be delivered through the delivery catheter include drugs (thrombolytics, platelet inhibitors, anti-restenotic agents, beta blockers, ion channel antagonists, positive or negative ionotropic agents, anti-arrhythmics, antibiotics, analgesics, chemotherapeutic agents, other anti-neoplastic agents, etc.), natural or recombinant proteins (e.g., angiogenic proteins such as vascular endothelial growth factor (VEGF), fibroblast growth factors (FGF), epidermal growth factor (EGF), platelet-derived growth factor (PDGF) nerve cell growth factor (NGF) or hepatocyte growth factor (HGF)), cells or cellular preparations (e.g., stem cells, other progenetor cells, myocytes, myoblasts, pancreatic islet cells, dopamine secreting cells, etc), genes or gene therapy preparations (e.g., viral vectors containing genes for gene therapy applications, genetic material for electrophoretic transmission into cells, plasmids, viral vectors, genetically modified cells, naked DNA, etc.), contrast media or dyes for imaging, radio-labeled diagnostic materials or drugs or other traceable substances, mixtures of any of the above, alone, in solution or in combination with any delivery substance or matrix (e.g., polymer matrices used to inhibit or slow distribution or dissemination of a substance away from its original injection site), dialysis solutions or micro-dialysis solutions, or any other type of substances that may be introduced through the delivery catheter for any therapeutic, imaging, diagnostic or other purpose.
Further in accordance with the invention, the types of target tissues into which the delivery catheter of the above-described system may be placed include various organs (e.g., heart, brain, liver, pancreas), the walls of blood vessels (by injection directly into the vessel wall or by injection into a periadventital area outside of but close to the vessel so that the drug or substance will be distributed into the vessel wall), muscles (e.g., myocardium, skeletal muscle) or aberrant masses (e.g., tumors, cysts).
Still further in accordance with the invention, substances delivered through the delivery catheter may be of increased viscosity to deter their egress from the target area, may be adherent to tissues in the target area so as to deter egress of the substance from the target area and/or may harden or form a mass in situ after injection into the target area, thereby deterring egress of the substance from the target area.
Still further in accordance with the invention, the outlet port(s) of the delivery catheter may be configured such that substances injected through the delivery catheter will form high pressure jet sprays into the tissue surrounding the delivery catheter.
Still further in accordance with the invention, the vessel wall penetrator of the vessel wall penetrating catheter and/or the delivery catheter may be equipped with backflow deterrent for limiting or preventing fluid that is injected through the delivery catheter from bleeding back through the tissue tract through which the delivery catheter and/or penetrator was/were advanced. In chronic dosing applications wherein the delivery catheter remains indwelling, such backflow deterrent may comprise a balloon, annular rib or other barrier formed on the outer surface of the delivery catheter to block the backflow of fluid through the tract in which the delivery catheter resides. In acute dosing applications wherein the delivery catheter is extracted and removed immediately after injection of the substance, the backflow deterrent may comprise a) an embolizing member such as a detachable blocker, balloon, clot, fibrin, bead of polyvinyl alcohol, etc. that is deployed into the tissue tract as the delivery catheter and/or penetrator is/are retracted, b) a substance such as a cyanoacrylate, polyethylene glycol, hydrogel, fibrin glue or other material is injected to embolize, seal or close the tract through which the delivery catheter and/or penetrator was/were advanced or c) a tissue fusing device, such as a radio-frequency emitting electrode, for welding or fusing adjacent tissue in a way that effectively closes the tract through which the delivery catheter and/or penetrator was/were advanced.
Still further in accordance with the invention, the delivery catheter of the above-described system may be used for aspiration of samples of blood or body fluid from the target site and/or may include one or more interactive members, such as emitters, detectors, electrodes, sensors, etc. for a) facilitating the delivery catheter's penetration through tissue, b) facilitating the distribution of an injected substance into surrounding tissues (e.g., by iontophoresis), c) creating a pocket into which a substance may be injected or d) sensing the position of the delivery catheter or some content or variable (e.g., ECG, contractility, force of contraction, pressure, local ECG amplitude, local protein levels, local antibody levels, pO2, pCO2, oxygen saturation, blood flow rate, pH, local lactate levels, etc.) of the adjacent tissue.
Still further in accordance with the invention, the delivery catheter may be used to continuously or intermittently monitor physiological parameters or variables (e.g., rate of blood flow away from the site) or pharmacokinetic or biodistributive parameters or variables (e.g., the rate at which a substance will distribute away from the target site, how long the injected substance may be expected to remain at the target site, the rate at which the injected substance may be inactivated or metabolized at the target site and/or other parameters/variables relating to the activity of the substance after it has been injected at the site). Such information may then be used to verify that the delivery catheter is suitably placed for optimal or desired therapeutic effect of an injected substance or apparatus delivered to the site. If it is determined that an injected substance is likely to distribute away from the target site too quickly, or remain at the target site for too long, or become inactivated too quickly or not quickly enough, the delivery catheter may be reposition to a site that is more desirable. Similarly, if it is determined that the site is too vascularized or not vascularized enough for the desired therapeutic or diagnostic activity of the delivered substance or apparatus, the delivery catheter may be repositioned to a new target site that is suitably vascularized, before continuing with delivery of the substance or apparatus through the delivery catheter. One example of a manner in which this type of site monitoring may be accomplished is to deliver radio-opaque dye, a radio-labeled substance or other traceable material through the delivery catheter and to the location adjacent the outlet port(s) of the delivery catheter (i.e., the target site to which the therapeutic or diagnostic substance is being or will be delivered) Thereafter, the rate at which that traceable substance distributes away from that site (or the rate at which it becomes inactivated, degraded or metabolized) may be measured by appropriate means such as x-ray (when radio-opaque traceable material is used) or radio-scanning (when radio-labeled traceable material is used). If the site is deemed to be acceptable, the therapeutic or diagnostic substance or apparatus may be delivered to the site. If the site is deemed to be unacceptable (or less than optimal) the delivery catheter may be repositioned and the test may be repeated. In some applications, the delivery catheter may have multiple lumens such that a therapeutic or diagnostic substance or apparatus may be delivered through one lumen and a traceable substance useable for site monitoring/verification may be delivered through another lumen.
Still further in accordance with the invention, the delivery catheter of the above-described system may include anti-obstruction apparatus (e.g., a mandrel, stylet, inflatable member or semi-permeable barrier) that allows the desired substances or apparatus to be introduced in the distal direction through the delivery catheter but prevents cellular ingrowth or other matter from invading and obstructing the lumen and/or outlet port(s) of the delivery catheter. In this manner, the delivery catheter remains patent, even when it has been indwelling within tissue for an extended period of weeks or months.
Still further in accordance with the invention, the efficacy of substances injected through the delivery catheter may in some applications be enhanced by limiting the rate at which the substance distributes away from the site or otherwise altering the biodistribution and/or pharmacokinetics of the substance after it has been introduced into the body. This may be accomplished by introducing the substance in the form of a solid, dry pellet, implant, filament or gel. Alternatively, this may be accomplished by micro-encapsulating or mixing the substance with a polymer matrix, oil or other drug delivery matrix or material that is prepared before injection or formed in situ or by forming liposomes or colloidal suspensions containing the substance, etc. Another way in which this may be achieved is by causing the substance to promptly enter cells rather than allowing the substance to remain disposed in intercellular fluids or intercellular spaces from which the substance my quickly distribute or disseminate away from the injection site (e.g., by driving the substance into adjacent cells by electrophoretic means or chemical means, by modifying the properties (e.g., solubility, polarity, pH) of the substance in a manner which will facilitate its transport into cells, by atomizing or spraying the substance as it exits the catheter, or by causing the substance to exit the catheter at increased velocity or force.
The invention together with additional features and advantages thereof may best be understood by reference to the following description taken in connection with the accompanying illustrated drawings.



BRIEF DESCRIPTION OF THE DRAWINGS
FIG. 1 is a schematic showing of a human patient who is undergoing a procedure for transvenous placement of a delivery cannula for ongoing delivery of drugs or apparatus to an ischemic region of the patient's myocardium.
FIG. 2 is a broken, side view of one embodiment of a catheter system of the present invention.
FIG. 2A is an enlarged, cut-away view of section 2a of FIG. 2.
FIGS. 2B-2D show, in step-by-step fashion, the manner in which the catheter system of FIG. 2 may be used to accomplish transluminal placement of a delivery catheter for delivery of substances or apparatus to an extravascular target location.
FIG. 3A shows an embodiment of a delivery catheter of the present invention which incorporates a subcutaneous injection port for periodic infusion of fluids through the delivery catheter.
FIG. 3B shows an embodiment of a delivery catheter of the present invention which incorporates an exteriorized Luer fitting for attachment of a syringe to the delivery catheter for periodic infusion of fluids through the delivery catheter.
FIG. 4 is a partial perspective view of a delivery catheter of the present invention having a plurality of side apertures for disseminated outflow of fluid therefrom and a balloon for preventing injected fluid from backflowing through the tract through which the delivery catheter extends.
FIG. 5 is a partial perspective view of a delivery catheter of the present invention having a plurality of side apertures for disseminated outflow of fluid therefrom and a stylet member that is insertable into the lumen of the delivery catheter to block the side apertures at times when no fluid is being infused through the delivery catheter.
FIG. 6A is a partial perspective view of a delivery catheter of the present invention having a plurality of side apertures for disseminated outflow of fluid therefrom and any inflatable obturator position within the lumen of the delivery catheter in an inflated state wherein the obturator blocks the side apertures at times when no fluid is being infused through the delivery catheter.
FIG. 6B is a partial perspective view of the delivery catheter of FIG. 6 wherein the obturator is in a deflated state such that fluid may be infused through the lumen of the delivery catheter and out of the side apertures.
FIG. 7 is a partial longitudinal sectional view of a delivery catheter the present invention having a plurality of side aperture is for disseminated outflow of fluid therefrom and a semi-permeable diffusion barrier mounted about the catheter such that fluid infused through the lumen of the delivery catheter and out of the side apertures will collect within the diffusion barrier and will subsequently diffuse outwardly through the barrier while the diffusion barrier prevents cellular matter or other material from invading and obstructing the side apertures or lumen of the delivery catheter.
FIG. 8A is a partial longitudinal sectional view of a delivery catheter the present invention having an open distal end and a spring mounted tip member having a fluid outlet channel formed therein, such tip member being in a retracted position wherein the fluid outlet channel is fully covered by the catheter body and cellular matter or other material is prevented from invading and obstructing the fluid outlet channel.
FIG. 8B is a partial longitudinal sectional view of the delivery catheter of FIG. 8A, wherein fluid is being infused in the distal direction through the lumen of the delivery catheter and the pressure of the fluid has advanced the distal tip member to an extended position wherein the fluid outlet channel uncovered and fluid is permitted to flow from the lumen of the delivery catheter, outwardly through the fluid outlet channel.
FIG. 9A is a partial perspective view of a delivery catheter the present invention having an open distal end and a coil spring mounted tip member mounted thereon, such tip member being in a retracted position wherein the convolutions of the coil spring are contracted into abutting contact with each other, thereby closing the lumen of the delivery catheter and preventing cellular matter or other material from invading and obstructing the lumen of the delivery catheter.
FIG. 9B is a partial perspective view of the delivery catheter of FIG. 9A wherein fluid is being infused in the distal direction through the lumen of the delivery catheter and the pressure of the fluid has advanced the distal tip member to an extended position wherein the convolutions of the coil spring are spaced apart and fluid is permitted to flow from the lumen of the delivery catheter, outwardly through the spaces between the convolutions of the coil spring.
FIG. 10 is a diagram of a human heart showing the manner in which a delivery catheter of the present invention may be transvenously implanted within an interstitial target site of the myocardium.
FIG. 10A is an enlarged, cut-away view of a portion of FIG. 10, showing the manner in which the delivery catheter extends through the wall of a coronary vein and in generally tangential relationship to the adjacent left ventricle of the heart.
FIG. 11 is a diagram of a human heart showing the manner in which a delivery catheter of the present invention having a backflow preventing balloon thereon may be positioned within a coronary vein to deliver a substance to a target region of the myocardium by selective, retrograde infusion through the coronary vein.
FIG. 12 is an enlarged, cut-away view of a portion of FIG. 11, showing the backflow preventing balloon in an inflated state and a substance being infused through the delivery catheter and through the coronary vein in the retrograde direction.
FIG. 13 is a partial, side view of a vessel wall penetrating catheter of the present invention showing the varying angles at which the vessel wall penetrating member may be deployed, relative to the longitudinal axis of the catheter body, depending on the extent to which the vessel wall penetrating member has been advanced.
FIG. 14 is a partial perspective view of another tissue penetrating catheter system of the present invention.
FIG. 15 is a diagram of the catheter system of FIG. 14 positioned within a chamber of a human heart and being used to deliver a substance into the myocardial wall via an endocardial approach.
FIG. 16 is a diagram of a modified catheter system of FIG. 14 having a corkscrew penetrator positioned within a chamber of a human heart and being used to deliver a substance into the myocardial wall via an endocardial approach.
FIG. 16A is a schematic diagram illustrating the manner in which the catheter system of FIG. 16 may be used to deposit a series or radially arranged elongate tracts or trails of a substance within a mass of tissue creating a “wagon wheel” pattern of substance deposition within the tissue.
FIG. 17 is a diagram of a catheter system comprising a tissue penetrating catheter having a laterally deployable penetrator combination with an optional guide catheter, positioned within a chamber of a human heart and being used to deliver a substance into the myocardial wall via an endocardial approach.
FIG. 18 is a perspective view of a human heart having an area of necrotic myocardium do to a prior infarct, wherein a penetrating catheter of the present invention has been advanced into a coronary vein and the penetrator and delivery catheter are being used to deliver a therapeutic substance into the necrotic area of myocardium.
FIG. 18A is an enlarged view of region 18A of FIG. 18.
FIG. 19 is a cross sectional view through line 19-19 of FIG. 18.



DETAILED DESCRIPTION OF PREFERRED EMBODIMENTS
The following detailed description, and the drawings to which it refers, are provided for the purpose of describing and illustrating certain examples or embodiments of the invention only and are not intended to exhaustively describe or show all possible embodiments or examples of the invention.
Generally, one method of the present invention may carried out by first inserting a vessel wall penetrating catheter into the vasculature of a human or veterinary patient, advancing the vessel wall penetrating catheter through the vasculature to a location within a blood vessel that is adjacent or near a target location at which a substance (e.g. a drug, biological or therapeutic agent) or apparatus (e.g. a sensor) is to be delivered and thereafter advancing a vessel wall penetrator from the catheter, transmurally through the wall of the blood vessel, in the direction of the target location. In some embodiments, the vessel wall penetrator itself may comprise a tubular member through which a substance or apparatus may be passed. In those embodiments, the penetrator will be advanced all the way to the target location(s) and the substance or apparatus will then be infused or delivered through the lumen of the penetrator. In other embodiments, a separate delivery catheter will be advanced through the vessel wall penetrator to the target location and, thereafter, the vessel wall penetrator may be withdrawn and removed (along with the entire vessel wall penetrating catheter) leaving only the delivery catheter in place. This secondary catheter may then remain indwelling for whatever period of time is desired, to allow samples to be withdrawn from the target location or to allow therapeutic agents and/or apparatus (e.g. wires or sensors) to be introduced to the target location at desired intervals or on a desired schedule.
A. Transluminally Deployable Catheter System for Acute or Chronic Delivery of Substances or Apparatus to Interstitial Target Sites:
FIGS. 2-2D show an example of a catheter system 10 of the present invention. This system 10 comprises the combination of a vessel wall penetrating catheter 11 and a delivery catheter 12. FIG. 1 shows this catheter system 10 in use on a human patient.
Vessel Wall Penetrating Catheter
In the embodiment illustrated, the vessel wall penetrating catheter 11 includes an elongated catheter body 13 having a proximal end 15, a distal end 17, a handle 19 and a hub 21 coupled to the proximal end of the catheter body and to the handle. The handle 19 may also serve as a controller for use in advancing and retracting the vessel wall penetrator 85, as described more fully below.
The vessel wall penetrating catheter body 13 includes a relatively rigid proximal section 23 shown in FIGS. 2 and 3A which may be constructed, for example, of a metal hypo tube and an elongated flexible distal section or region 25 suitably joined to the proximal section. At least the distal section 25 is sized to be received within a coronary artery, and therefore can be received within either a coronary artery or a coronary vein. The catheter body section 13 has a penetrator lumen 27 which terminates distally at an exit location or exit port 29 that is located on a peripheral wall 31 of the catheter body. A vessel wall penetrator 85, such as a hollow NiTi needle as shown in FIGS. 2a (phantom lines), 2B and 2C, is disposed within the penetrator lumen 27 and is advanceable out of the side exit port 29 as seen in FIGS. 2A-2C. The exit port 29 is preferably located a short distance proximally of the distal end 17. A radiopaque marker 33 may be mounted on the lumen 27 adjacent the exit port 29 to facilitate placement and positioning of the vessel wall penetrating catheter 11. The penetrator 85 may be a single hollow member or may consist of a series of hollow members which advance through one another or telescope in a desired manner. In embodiments where the penetrator consists of a plurality of hollow members which advance through one another or telescope, the individual members may have differing curvatures or differing shapes to allow the penetrator or follow a multicurvate path of advancement. This may be useful in applications where the penetrator is required to advance around a prohibited zone or anatomical structure that the operator does not whish to penetrate.
The catheter body 13 also has a guidewire lumen 35 (FIG. 3A) which extends to the distal end 17 of the catheter body 15. In this embodiment, the guidewire lumen 35 extends proximally to an inlet port 37 at the peripheral wall 31 closely adjacent the proximal section 23.
A major section of the catheter body 13 terminates distally in a distal opening 53, and the catheter body includes a distal tip section 55 of soft, flexible, biocompatible material (FIGS. 3A and 3B). A proximal portion 56 of the distal tip section 55 is received in the distal opening 53 and a distal portion of the distal tip section extends distally to the distal end 17. The distal portion of the distal tip section 55, i.e. the portion of the distal tip section 55 which extends beyond the distal end of the major section is of smaller cross sectional area than the adjacent region of the major section to thereby define an annular shoulder 57 on the catheter body 13. The exit port 29 is spaced slightly proximally of the shoulder 57.
Guidance Elements
In many embodiments, it will be desirable for the vessel wall penetrating catheter 11 to include a guidance element for guiding the positioning and rotational orientation of the catheter 11 within the vasculature such that the vessel wall penetrator 85 will be properly aimed in the direction of the target site. Such guidance element may include marker(s), imaging apparatus, emitter(s), sensor(s) etc. In the particular embodiment shown in FIGS. 2a and 2b, the guidance element comprises the combination of an imaging transducer 81 and an imageable marker assembly 101. The imaging transducer 81 is fixedly mounted on the catheter 11, and in the embodiment illustrated in Fig. 3A, the imaging transducer is mounted on the distal tip section 55 just distally of the shoulder 57. In this embodiment, the imaging transducer 81 is a phased array transducer and is operative to image 360° about the vessel wall catheter 11. The imaging transducer 81 is coupled to a multiplex circuit which is within the major section of the catheter body 13 adjacent the shoulder 57, and the multiplex circuit is in turn coupled to leads 85 which extend through the lead lumen, through the handpiece 19 and are attached to a connector which allows the leads to be connected to a viewing instrument and screen. When activated, the imaging transducer emits ultrasound signals and receives back echoes or reflections which are representative of the nature of the surrounding environment. The imaging transducer provides an imaging signal from which an image of the surrounding structure can be created on a screen of the viewing instrument. In a preferred practice of this invention, the phased array transducer, the accompanying circuitry and the separate viewing instrument/screen may be obtained from Endosonics, Inc. of Rancho Cordova, Calif..
In an alternate embodiment of this invention, the imaging element may be formed of a single rotating crystal or transducer. In this embodiment the transducer would have a single lead out, would include a drive shaft which would run back to the proximal end of the catheter through the leads.
In the particular embodiment shown, an imageable marker 101 is fixedly mounted on the catheter body 13 in a known circumferential orientation relative to the exit port 29. This marker 101 may be in the form of a structure or cage, as shown, and the transducer 81 may be located within the marker cage or marker structure. In the embodiment shown, the marker cage comprises a plurality of longitudinal members disposed at circumferentially spaced apart locations about a hollow interior space 105. The hollow space 105 receives the distal tip section 55 and the transducer 81, and the transducer 81 is an onboard transducer in that it is inseparable from and not removable from the catheter body 13. One of the longitudinal members is located at a circumferential position that is axially aligned with the exit port 29 and consequently is also axially aligned with the path that will be followed by a tissue penetrator that is advanced from the catheter body 13 through the exit port. Thus, the imageable marker 101 forms on the image obtainable from the imaging signal from the imaging transducer a penetrator path indication that indicates the path that will be followed by the tissue penetrator when the tissue penetrator is advanced from the catheter. As an alternative to the use of a marker 101, the path that will be followed by the penetrator may be indicated on the image by electronic means or by the use of a computer program, thereby eliminating the need for a penetrator path indicating marker 101. In many embodiments, the marker 101, electronic penetrator path indicator or computer program for determination of the penetrator path may not only indicate the trajectory or path of the penetrator but may also indicate a stopping point at which advancement of the penetrator will stop or is intended to stop. By providing such an indication of the mandatory or intended stopping point of the penetrator advancement, the operator may case the penetrator to be optimally positioned at the intended site without advancing the penetrator too far as may result in missing of the intended delivery site or unwanted penetration of a blood vessel or other anatomical structure that lies beyond the site at which the penetrator is desired to stop.
With the construction described above, the imaging transducer 81 and the marker 101 are both mounted on the distal tip section 55 which has a smaller cross sectional area than does the adjacent region of the major section of the catheter body 13. Accordingly, the cross sectional area of the catheter body 13 at the region containing the imaging transducer 81 and the marker 101 can still be relatively small. Also, the exit location 29 is closely adjacent to the imaging transducer 81 and may be, for example, about 5 mm from the imaging transducer. This minimizes the likelihood of any significant torsional displacement of the exit location 29 relative to the marker 101 and imaging transducer 81. It may also be appreciated that the imaging transducer may be mounted such that the exit port is located directly at the point at which the transducer is affixed to the catheter, illuminating any displacement.
It will be appreciated that various other types of imaging or position sensing apparatus may be used as alternatives to the above-described imaging transducer 81/marker 101 combination to guide and orient the vessel wall penetrating catheter 11. For example, the vessel wall penetrating catheter 11 may incorporate an emitter that is useable in conjunction with an electromagnetic, potentiometric, or other electro-anatomical mapping and/or catheter guidance/positioning systems, such as those commercially available from or under development by
Biosense Webster, Inc., Diamond Bar, California; Cardiac Pathways Corporation, 995 Benicia Avenue, Sunnyvale, CA and/or Stereotaxis, Inc., 4041 Forrest Park Avenue, St. Louis, MO. Examples of these types of catheter guidance or positioning systems are described in United States Pat. Nos. 5,820,568 (Willis),5,931,818(Werp et al.), 5,654,864(Ritter et al.), 5,928,248 (Acker), 5,752,513 (Acker et al.), 5,558,091 (Acker et al.) and 5,833,608(Acker), the entire disclosures of which are expressly incorporated herein by reference.
Delivery Catheter
After the vessel wall penetrator 85 has been advanced to the desired extended position, the delivery catheter 12 may be advanced through the lumen of the penetrator 85 and out of its distal end. For applications where it is desired for the delivery catheter 12 to penetrate into myocardial tissue, the delivery catheter 12 may comprise a small cannula, hypotube or microcatheter formed of a suitable material such as polyimid, polytetrafluoroethylene, polypropylene, polyethylene, PebaxTM, etc. For many applications, including application wherein the delivery catheter 12 is used to deliver substances into the myocardium, the delivery catheter 12 may have an outer diameter of approximately 0.25-0.5 mm. In embodiments where it is intended for the delivery catheter to penetrate through tissue as it advances the distal tip of the delivery catheter 12 may be beveled or sharpened. Optionally, the delivery catheter 12 may have an energy emitting distal tip for enhanced tissue penetrating capability. For example, a radiofrequency electrode may be located on or near the distal tip of the delivery catheter to provide for tissue penetration enhanced by RF energy emission. Or, the delivery catheter may be adapted to ultrasonically vibrate, thereby improving its ability to penetrate through tissue.
The body of the delivery catheter 12 may be radio-opaque or one or more radio-opaque markers may be formed on the delivery catheter (e.g., at its distal tip) to permit imaging of the catheter and determination of the position of the catheter within the patient's body.
In some applications, such as those where drugs, substances or apparatus are to be chronically delivered to the target site over a period of days, weeks or months, the delivery catheter will be allowed to remain indwelling after the vessel wall penetrating catheter 11 has been removed. To facilitate this, a detachable or removable Luer connector 47 may mountable proximal end of the delivery catheter 12 as shown in Figures. 2 and 3b. This detachable or removable Luer connector may be removed when during proximal withdrawal and removal of the vessel penetrating catheter 11 while the delivery catheter 12 remains in place. Thereafter, in embodiments wherein the proximal end of the delivery catheter 12 remains exteriorized, the removable or detachable Luer connector 47 may be attached to the exteriorized proximal end of the delivery catheter 12 and may thereafter be used for subsequent attachment of a stopcock and/or syringe 50 as shown in FIG. 3b. In other embodiments, the proximal end of the delivery catheter 12 may be devoid of any hub or connector and may be connected to a pump, delivery device, subcutaneously implanted reservoir or injection port 52, as shown in FIG. 3a.
An opening for infusion or aspiration of substances/apparatus may be formed in the distal end of the delivery catheter 12 and/or one or more fluid outlet openings may be formed in the sidewall of the delivery catheter 12, near its distal end, as shown in FIG. 2c or 2d. For many applications, one or more openings may be laser drilled into the delivery catheter 12, such openings being no more than 2 the diameter of the catheter lumen through which the substance is being injected, such that high pressure jets of the substance will be created as the substance exits the delivery catheter 12. The creation of such elevated pressure as the substance exits the delivery catheter 12 serves to propel or drive the substance through cell membranes and into intracellular spaces cells rather than allowing the substance to remain in intercellular spaces (i.e., spaces or fluids between cells or outside of the cells) from which the substance would more rapidly distribute away from the injection site.
The delivery catheter may be straight or curved, as needed to accomplish the desired procedure. In some but not necessarily all cases, the delivery catheter may constitute a very small diameter catheter of a type known in the art as a microcatheter.
Interactive Apparatus on Delivery Catheter
As shown in FIG. 2C, one or more interactive members such as sensors, emitters, etc. may be positioned on or near the distal end of the delivery catheter 12 for emitting energy as described above or for sensing, sampling or receiving information from the tissues adjacent the distal portion of the delivery catheter 12. Interactive members that comprise sensor(s) may provide information on the position of the delivery catheter 12 or measurements of variables such as ECG, contractility, force of contraction, pressure, local ECG amplitude, local protein levels, local antibody levels, pO2, pCO2, oxygen saturation, blood flow rate, pH, local lactate levels, etc. By use of such information received from the target site, the clinician may assess or characterize the target site to ascertain its suitability before introducing a substance or apparatus into the target site.
In applications where it is desired to facilitate the passage or distribution of an injected substance into the surrounding tissue, the interactive member may emit some facilitating energy, such as an electromagnetic field for iontophoretic transmission of the substance through the adjacent tissue.
In other applications, the interactive member may emit energy, such as radiofrequency energy, that will create a pocket in the surrounding tissue such that a substance or apparatus may be introduced into that pocket. The walls of the pocket may be seared by the energy so as to slow the distribution of the substance out of the pocket.
In other applications, the interactive member may emit energy, such as ultrasound, that facilitates distribution of a substance by permeating cell membranes or by vibrating the catheter tip.
Apertures for High Pressure Injection from Delivery Catheter
As shown in FIGS. 2c and 2d, the distal end of the delivery catheter may be closed and a plurality of small side apertures 24 may be formed in the sidewall of the delivery catheter 12 to provide for high pressure outflow of fluid from the delivery catheter and into the surrounding tissues.
Backflow Deterrent Apparatus on Delivery Catheter and/or Penetrator
In some applications, the injection of fluids through the delivery catheter 12 into a closely confined space or interstitial site may result in some regurgitation or backflow of the injected fluid through the tract through which the vessel wall penetrator 85 and/or delivery catheter 12 were advanced. In acute dosing situations where the delivery catheter is removed immediately after the dose, this backflow of the injected fluid may be prevented by sealing the penetration tract or by introducing a material (e.g., an adhesive or embolizing material) into the tract during immediately after removal of the catheter 12. This may be accomplished by injecting a suitable adhesive or embolizing material such as a cyanoacrylate, polyethylene glycol, hydrogel, fibrin glue through the delivery catheter lumen as the delivery catheter 12 is being pulled back through the tissue tract through which it was initially inserted. In other applications where the delivery catheter 12 remains indwelling, the backflow of fluid may be accomplished by a backflow barrier 22 (see FIG. 4) such as an annular rib or inflatable balloon formed on the shaft of the delivery catheter 12 near its distal end so as to block backflow of fluid around the catheter shaft or alternatively by causing the fluid to solidify or become gelatinous such that it can not backflow through the penetration tract. Such gelling or solidification of the injected fluid may be accomplished by subsequent injection or pre-mixing of the fluid with an oil, a gelatinous polymer carrier or reactant that will cause the desired thickening or solidification of the injected fluid.
Anti-Obstruction Apparatus for Maintaining Patency of Delivery Catheter
In some embodiments, especially those in which the delivery catheter 12 is allowed to remain indwelling for chronic delivery of substances or apparatus to the target site, the delivery catheter may incorporate anti-obstruction apparatus that will prevent cellular ingrowth or other matter from obstructing the lumen or outflow port(s) of the delivery catheter 12. Examples of such anti-blocking apparatus are shown in FIGS. 5-7.
In the embodiment of FIG. 5, the delivery catheter has a closed distal end 28 and a plurality of side outlet apertures 24. A solid stylet 26 is insertable through the lumen of the delivery catheter and the outer diameter of the stylet 26 is approximately the same as the inner diameter of the delivery catheter such that, when inserted, the stylet 26 will substantially close-off or block the side apertures 24 thereby preventing cellular ingrowth or other matter from entering the side apertures 24 or lumen of the delivery catheter. Thus, the stylet 26 may be inserted into the delivery catheter at times when no fluids or other substances are being infused, but may be removed at appropriate times to allow the desired infusions of fluids or other substances through the delivery catheter.
In an alternative variation of the embodiment shown in FIG. 5, the stylet 26 could have a lumen which extends longitudinally through the stylet to a closed distal end and side aperture(s) or slot(s) or other opening(s) could be formed in the stylet so as to be alignable with the side apertures 24 of the delivery catheter. In such embodiment, the stylet would be maintained in one position when it is desired to block the side apertures 24 to prevent cellular ingrowth or other matter from entering the side aperture's or lumen of the delivery catheter but may be rotated or otherwise moved to a second position wherein the aperture(s), slot(s) or other opening(s) of the style at 26 would become aligned with the side aperture's 24 of the delivery catheter is such that fluid may be injected through the lumen of the style that and outwardly through the side apertures of the delivery catheter 24. Thereafter, when the fluid injection has been completed, the stylet could be once again rotated or otherwise moved to the first position to once again close-off or block the side apertures 24 of the delivery catheter.
FIGS. 6A and 6B show another embodiment wherein the delivery catheter has a closed distal end 28 and a plurality of side outlet apertures 24. In this embodiment, an inflatable obturator 30 is disposed within the lumen of the delivery catheter. When the obturator 30 is inflated, as shown in FIG. 6A, it will close-off or block the side apertures 24 thereby preventing cellular ingrowth or other matter from entering the side apertures 24 or lumen of the delivery catheter. However, when the obturator 30 is deflated, as shown in FIG. 6B, fluids may be infused in the distal direction through the lumen of the delivery catheter and out of the side apertures 24.
In the embodiment of FIG. 7, a semi-permeable diffusion barrier 58 is mounted about the outer surface of the delivery catheter so as to cover the catheter's side apertures 24. This diffusion barrier 58 is in the nature of a balloon and is formed of material that permits the substances or fluids injected through the catheter to diffuse outwardly through the barrier 58, but also prevents cellular ingrowth or other matter from invading the interior of the barrier 58 and entering the side apertures 24 or lumen of the delivery catheter. The desired semi-permeability of the diffusion barrier 58 may be a function of the size of pores or openings in the barrier or balloon 24. Thus, polymer films having appropriately sized pores may be used to form the diffusion barrier 58. One polymer material that may be used in film form to create the diffusion barrier 58 is commercially available as NutraporeTM from Anamed, Inc., 1 Technology Drive, Bldg. D-409, Irvine, Calif. 92618.
FIGS. 8A and 8B show another embodiment of a delivery catheter 12 having it opened distal end and a spring-mounted tip member 42 disposed within the distal end of the catheter 12. The tip member 42 has a fluid flow channel 44 that extends through the tip member 42 and opens through the side of the tip member 42, as shown. The tip member 42 is attached to the catheter 12 by way of a spring 40. The spring 40 is biased to a contracted position as shown in FIG. 8a, wherein the tip member 42 is drawn into the lumen of the catheter 12 such that the side opening of the fluid flow channel 44 is covered by the wall of the catheter 12 and cellular ingrowth or other matter is thereby prevented from entering the fluid flow channel 44 or lumen 32 of the delivery catheter 12. However, as shown in FIG. 8B, when fluid or some substances injected in the distal direction through the lumen 32 of the catheter 12, the pressure of the fluid or other substance will overcome the bias of the spring 40, causing the tip member 42 to advance to a second position whereby the side opening of the fluid flow channel 44 becomes unobstructed and the injected substance or fluid is permitted to flow outwardly through the fluid flow channel 44 and out of its side opening, into the surrounding tissue. Thereafter, when the substance or fluid is no longer being injected, the bias of the spring 40 will cause the tip member 42 to retract to its first position as shown in FIG. 8A.
In the embodiment shown in FIGS. 9A and 9B, there is provided a delivery catheter 12 that has an open distal end, a generally conical tip member 408 and a coil spring member 46 which attaches the tip member 48 to the distal end of the catheter 12. The coil spring member 46 is biased to a retracted position, as shown in FIG. 9A, wherein the convolutions of the coil spring member 46 are drawn into abutment with one another and with the respective ends of the catheter body 12 and tip member 48. In this manner the distal end of the catheter 12 is substantially closed, and cellular ingrowth or other matter is prevented from invading the lumen of the catheter 12. However, as shown in FIG. 9B, when a fluid or substance is injected through the lumen of the catheter 12 the pressure of the injected fluid or substance will overcome the bias of the coil spring member 46, thereby causing the tip member 46 to advance in the distal direction and the convolutions of the coil spring member 46 to separate such that spaces 46a will exist between the individual convolutions of the coil spring member 46. The injected substance or fluid will thus flow outwardly through the spaces 46a and into the surrounding tissue. After the injection of the substance or fluid has stopped, the bias of the coil spring member 46 will cause the tip member 48 to become retracted and the device will assume its closed configuration as shown in FIG. 9A.
Another way in which the patency of the lumen of the delivery catheter 12 may be maintained is by constant infusion and withdrawal of fluid therethrough. In this regard, fluid may be continually or periodically infused into a tissue pocket or reservoir at the distal end of the delivery catheter 12 and subsequently re-aspirated through the delivery catheter lumen. Alternatively, the delivery catheter 12 may have multiple lumens, one for infusion of fluid and one for withdrawal of fluid, and a periodic or continual infusion and withdrawal of fluid may be performed to keep these lumens of the delivery catheter 12 open and unobstructed with cellular ingrowth, clots, debris or other matter.
Apparatus/Substances for Anchoring of Delivery Catheter
The delivery catheter 12 may incorporate mechanical hooks, screws, barbs or other anchoring members (not shown) that engage surrounding tissue and deter inadvertent migration or movement of the delivery catheter 12 after it has been implanted. Such anchoring members may be formed of bioabsorbable material and may be designed to break away, detach upon delivery of a pulse of energy or to be otherwise jettisoned when the delivery catheter 12 is purposefully removed from the body. In instances where the optional interactive member comprises an energy emitter or electrode, such as a radio frequency electrode, such interactive member may be actuated after the delivery catheter 12 is in place for the purpose of fusing the catheter 12 to the surrounding tissue. Also, chemical glues, adhesives, or an ingrowth matrix such as a fabric (e.g., a woven material such as Dacron) into which surrounding tissue will grow, may be disposed on the delivery catheter 12 or introduced through the delivery catheter 12 after it is positioned, to deter inadvertent movement of the delivery catheter 12.
Other Surface Treatments of the Delivery Catheter
Apart from the above-described disposition of glues, adhesives or an ingrowth matrix on the surface of the delivery catheter 12 to facilitate its anchoring, there may additionally be other types of surface materials or surface treatments applied to the delivery catheter 12 for various other reasons. For example, the outer surface of at least the portion of the delivery catheter that becomes inserted into the patient's body may be coated or impregnated with and antibiotic or antimicrobial substance (e.g. provodine iodine, silver compounds, etc.) or other drugs or substances that affect the surrounding tissue in a desired way (e.g., a heparin coating that will reduce clot formation in areas adjacent to the catheter or within the blood vessels through which the catheter extends). One example of an anti-microbial coating that may be applied to the delivery catheter 12 is a proprietary material containing silver, carbon and platinum and used commercially under the name OligonTM (Edwards Lifesciences Corporation, Irvine, Calif.). Examples of commercially available heparin coatings that may be used include heparin-benzalkonium chloride complex, heparin-TDMAC complex and other medical coatings available from STS Biopolymers, Inc. 336 Summit Point Dr., Henrietta, N.Y.
Apparatus for Creating Pocket into which Substance or Apparatus is Introduced:
The delivery catheter 12 may optionally incorporate, or may be used in conjunction with, apparatus for creating a pocket (e.g., a void) within tissue located adjacent to the outflow aperture(s) 24 of the delivery catheter 12 such that substances infused through or apparatus introduced through the delivery catheter 12 will be received within that pocket. For example, an expandable cage may be deployable through or from the delivery catheter 12 to spread or separate the adjacent tissue, thereby creating the desired pocket. Or, the above-described interactive member may comprise an energy emitting apparatus capable of creating a pocket adjacent thereto. In this regard, the interactive member may comprise a radio frequency electrode that, when actuated, will ablate the adjacent tissue thereby creating the desired pocket. Alternatively, the pocket creating apparatus may comprise a laser port through which ablative laser energy may pass into the adjacent tissue, or a nozzle through which a high pressure jet of fluid may be injected so as to sever or separate the adjacent tissue, thereby creating the pocket.
Variable Delivery Catheter Trajectory from Single Penetrator
FIG. 13 shows that the vessel wall penetrator 85 may be of a pre-bent, curved configuration such that incremental advancement of the penetrator may cause its distal tip to be incrementally positioned at a series of different locates, such as point A (PA), point B (PB), point C (PC) and point D (PD) shown in FIG. 13. The delivery catheter 12 may then be advanced out of the penetrator at each of the points and drug or substances may be injected at periodic depot locations DL along the path of each advancement or retraction of the delivery catheter 12. In this manner, the drug or other substance may be deposited relatively uniformly over a generally wedge shaped region of tissue with only one penetration through the vessel wall.
B. Procedure for Transluminal Placement of a Delivery Catheter within and Interstitial Target Site and Acute or Chronic Delivery of Substances or Apparatus to the Target Site:
FIG. 1 generally depicts a catheter system 10 of the above-described type being used to perform a procedure for transvenous placement of a delivery catheter 12 in an ischemic region of the patient's myocardium (i.e., the target site) so that a substance or apparatus may be acutely or chronically delivered directly into the target site.
This procedure begins with the percutaneous insertion of the vessel wall penetrating catheter 11 into the patient's femoral vein and advancement of the vessel wall penetrating catheter 11 trough the inferior vena cava, through the right atrium, through the coronary venous sinus and into a coronary vein as shown in detail in FIG. 11. A vessel wall penetrator 85 is then advanced from the vessel wall penetrating catheter 11 and through the wall of the coronary vein in which the vessel wall penetrating catheter 11 is positioned. Thereafter, a delivery catheter 12 is advanced through the vessel wall penetrator 85 to the target location within the patient's myocardium.
In many applications, the vessel wall penetrating catheter 11 will be provided with or associated with guidance elements as described hereabove to guide the positioning, rotational orientation of the catheter 11 within the patient's body and/or the path, trajectory and extent of advancement of the penetrator 85. Typically, these guidance elements will be used to guide the longitudinal position and rotational orientation of the vessel wall penetrating catheter 11 before the penetrator 85 is advanced from the catheter 11. Thereafter, after the delivery catheter 12 has been advanced through the penetrator 85 to the target site, the penetrator 85 may be retracted into the vessel wall penetrating catheter 11 and the vessel wall penetrating catheter 11 may be withdrawn and removed, leaving only the delivery catheter 12 in place.
Optionally, as shown in FIG. 2c, an interactive member such as an emitter, sensor, marker, electrode, etc. may be mounted on the delivery catheter 12. This interactive member may be a sensor (e.g., an electrode, optical sensor, chemical sensor, strain gage, flow meter, etc.) that is connected to a receiver or instrumentation located outside the patient's body so as to provide information or analytical data regarding from the target site TS. Examples of the types of information or data that may be sensed and provided from the target site include ECG, contractility, force of contraction, pressure, local ECG amplitude, local protein levels, local antibody levels, pO2, pCO2, oxygen saturation, blood flow rate, pH, local lactate levels, etc.
Substances or apparatus may be introduced through the lumen of the delivery catheter 12 at desired time points or intervals. Also, separate sensor(s) or other separate apparatus may be delivered through the delivery catheter 12 so as to provide diagnostic information or other information regarding the physiological status of the myocardium in which the delivery catheter 12 is indwelling and/or the specific positioning of the distal end of the second catheter 12. After all of the desired sampling, diagnosis, delivery of substances and/or delivery of apparatus has been completed, the dosing catheter 12 may then be removed from the body of the patient. Some examples of tissue penetrating catheters 10 useable in this invention include those described in PCT International Patent Publications No. PCT/US99/07115 and PCT/US99/07112.
The delivery catheter 12 may comprise any suitable type of flexible catheter sized to pass through the lumen of the vessel wall penetrator 85 in the manner described here above. A commercially available extrusion may be used to form the delivery catheter 12.
When the invention is used to deliver substances (e.g., drugs, therapeutic agents, biologicals, etc.) to ischemic site(s) within the myocardium, the types of substances that may be delivered include angiogenic factors (e.g. VEGF, FGF, EGF, PDGF or Hepatocyte Growth Factor (AHGFα), gene therapy compositions (e.g. a replication-deficient adenovirus vector containing a transgene which codes for an angiogenic protein or peptide), pro-angiogenic agents or combinations (e.g. an adenosine receptor agonist in combination with heparin), myocardial cells, myocytes, myoblasts, or other cardiac or systemic drugs such as antiarithmic agents, beta blockers, calcium channel antagonists, platelet glycoprotein (GP) IIb/IIIa inhibitors, etc.
In some applications, the invention may be used to treat neurdegenerative diseases such as Parkinson's Disease, Amilotrophic Lateral Sclerosis (Lou Gehrig's Disease), Alzheimer's Disease, etc.) By delivering to a target site within the brain or central nervous system a substance that delays the nerve cell degeneration or causes new nerve cells or new nerve cell connections to form, such substances including but not limited to glial cell line-derived neurotropic factor (GDNF), nerve growth factor, neuro-immunophilin ligand, poly ADP-Ribose polymerase, and combinations thereof.
In some applications of the invention, the delivery catheter 12 will be provided with small side apertures 24 and a closed distal end, or some other aperture or nozzle arrangement, that causes the substance to be expelled from the delivery catheter 12 in fine, high velocity jets or streams such that dissemination of the substance into the surrounding tissue will be enhanced. In some instances an interactive member on the delivery catheter may be used emit energy or otherwise interact with the delivered substance to affect the substance in a desired way (e.g., to emit an iontophoretic field to drive the substance into adjacent tissue or to cause the distal tip of the delivery catheter 11 to become warm or to vibrate ultrasonically in a way that enhances the distribution or cell membrane permeation of the substance). Also, in some applications, a substance injected through the delivery catheter 12 may be mixed with or followed by a second substance which causes the first substance to solidify, gel, adhere or to become otherwise altered in a desired manner (e.g., in a way that affects the distribution, bioavailability, potency, duration of action or pharmacologic activity of the first substance. In this regard, a mixture of angiogenic factors (e.g., VegF and FGF) may be prepared in a liquid polymer matrix and injected in a bolus through the delivery catheter 12 into a myocardial target site. Thereafter, a second solution containing a catalyst that causes the polymer matrix to solidify to form a biodegradable solid may be injected as a second bolus through the delivery catheter. The mixture of the first solution with the second solution within the target site will cause the first solution to solidify in the form of a biodegradable solid or foam. This in situ solidification of the matrix will cause the injected angiogenic factors to remain within the target site for a longer period of time than if they had been injected and allowed to remain as an aqueous solution. Examples of materials that may be formed in situ in this application include those described in U.S. Pat. No. 6,139,574 (Vacanti).
The present invention allows for mapping or assessment of the site at which the delivery catheter 12 is positioned to confirm that the site is, or continues to be, suitable for the intended purpose. For example, a radio-labeled compound, radio-isotope or other traceable substance may be introduced through the delivery catheter and the rate at which the radio-labeled substance or isotope distributes away from the injection site may be measured by well known techniques. If the distribution away from the site is determined to be too rapid or too slow, the delivery catheter 12 may be repositioned before the desired therapeutic or diagnostic substance is injected. In chronic dosing applications wherein the delivery catheter 12 remains indwelling for days or months, this technique may be used to ensure that the delivery catheter 12 has not migrated or moved from the intended injection site, or that the site has not become excessively vascularized since delivery of the last dose. In some applications, it may be desirable for the delivery catheter 12 to have multiple lumens, such that the desired therapeutic or diagnostic substance or apparatus may be delivered through one lumen and a traceable substance useable for mapping or assessment of the target site may be delivered through another lumen.
It will be appreciated that the above-described examples of the application of the catheter system 10 may further be combined with some or all of the other optional elements of the catheter system 10 described here above, such as the high-pressure distribution nozzles, tissue-pocket-creating apparatus, sponges or other apparatus/substances afford to wait or affect the dissemination or distribution of the injected substance, anti-obstruction apparatus, apparatus/substances for a three of the delivery catheter, sensors or other apparatus for characterization of the targets i.e. or regions adjacent the delivery catheter, etc.
C. Method for Intravenous Retroperfusion
The present invention further includes a method wherein a retrovenous delivery catheter 112, a shown in FIGS. 11 and 12, is used to deliver a substance into a vein while temporarily obstructing the vein, thereby allowing the substance to enter a target step by undergoing retrograde flow through the venous vasculature to a capillary bed at the target site. The retrovenous delivery catheter 112 generally comprises a flexible tubular catheter described hereabove of the above-described type may be inserted into a selected vein (e.g., a coronary vein) and used acutely or chronically to deliver substances to a particular target site by retroperfusion of the substance through the vein, to a capillary bed located within the target site. An example of this embodiment of the invention is shown in FIGS. 11 and 12. As shown, the retrovenous catheter 112 has a distal end opening and an inflatable occlusion balloon 50 formed a spaced distance proximal to the distal end opening. The catheter 112 is inserted into the venous vasculature and advanced into a specific vein such as a coronary vein located near an area of ischemic myocardium, as shown in FIGS. 11 and 12. Before a desired substance is delivered through the catheter 112, the occlusion balloon 50 is inflated so as to occlude the vein and prevent venous blood from flowing through the vein in the normal direction of venous blood flow. The desired substance (e.g., a drug or biological) is then injected through the catheter 112 and out of its distal end opening into the vein. Because the vein is occluded by the balloon, the injected substance will flow in retrograde fashion through the vein and to the capillary bed within the ischemic region of the myocardium. The balloon may remain inflated for a desired period of time to allow the drug or substance to be effectively absorbed by the tissues adjacent to that capillary bed. Thereafter, the balloon is deflated, allowing normal venous flow through the vein. The catheter 112 may be removed after a single dose is delivered or it may remain indwelling for a period of time (e.g., hours, days, weeks or months) to permit repeated doses to be delivered by repeating the foregoing injection procedure. Any or all of the attributes and options described above with respect to the extravascular delivery catheter 12 may also be incorporated into this retrovenous delivery catheter 112, to the extent feasible and not adverse to the intended function of this retrovenous delivery catheter as described herein.
D. Catheter Devices for Intramyocardial Delivery of Substances or Articles Via an Endocardial Approach
Although the following examples relate to applications wherein the penetrating catheter is positioned within a chamber of the heart, it is to be understood that the methods, devices and systems described and claimed in this regard are useable, not only in chambers of the heart, but in any anatomical cavity, lumen or structure that is substantially larger in diameter than the outer diameter of the penetrating catheter used.
FIGS. 14-19 show embodiments of the invention that may be used for delivery of substances or articles into the myocardial wall via an endocardial approach. In these embodiments, the tissue penetrating catheter 10, 200 or 200a is advanced through the vasculature to a position within a chamber of the heart. Thereafter the penetrator 85, 204 or 206 is advanced from the catheter body 13, 202 or 202a and into the adjacent wall of the heart. A delivery catheter 12 is then advanced through the lumen of the penetrator 85, 204 or 206 and into the myocardium. A desired substance may then be injected through the delivery catheter 12 and onto the myocardium at desired location(s). As explained herebelow, the configuration of the penetrator 85, 204, 206 may control the direction in which the delivery catheter 12 advances. In particular, the penetrator 85, 204 or 206 may be configured such that it directs the delivery catheter 12 in a direction that is substantially or roughly parallel to the adjacent endocardial wall of the myocardium.
Referring specifically to FIGS. 14 and 15, there is shown a catheter system 200 comprising an elongate flexible catheter body 202 having a distal end opening 203 out of which a resilient tissue penetrator 204 is advanceable. The tissue penetrator 204 in the particular embodiment shown comprises a hollow needle. The penetrator 204 that is pre-bent such that a single, gradual 90 bend is formed therein, as shown. In operation, the catheter body 202 is advanced through the vasculature and into a chamber of the heart (e.g., the left ventricle). With the penetrator 204 retracted within the catheter body 202, the distal end DE of the catheter body 202 is placed in abutting contact with, or close to, the endocardial surface of the myocardium. Thereafter, the penetrator 204 is advanced out of the distal end opening 203 and into the myocardium M. The approximate 90 bend formed in the penetrator 204 causes the distal tip of the fully advanced penetrator 204 to be aimed in a direction that us generally perpendicular to the longitudinal axis of the catheter body 202 and generally parallel to the endocardial surface of the myocardium. The delivery catheter 12 is then advanced through the lumen or bore of the hollow penetrator 204, out of the distal end of the penetrator 204 and though a quantity of myocardial tissue in a direction that is generally parallel to the endocardial surface of the myocardium. The desired drug or substance is then injected through the delivery catheter 12. As described above in relation to another embodiment, it is possible to create a continuous trail of substance or a plurality of spaced-apart substance deposition sites by slowly withdrawing or advancing the delivery catheter 12 while continuously or periodically injecting the desired substance through the delivery catheter. If subsequent dosing or later delivery of substance or apparatus is desired, the penetrator 204 may be retracted into the catheter body 202 and the penetrating catheter 200 may be removed, leaving the delivery catheter 12 in place for subsequent use.
With specific reference to FIG. 16, there is shown an alternative or modified embodiment of the catheter system 200a wherein the tissue penetrator 206 comprises a resilient hollow needle that is preformed to a helical or corkscrew configuration. As in the embodiment shown in FIGS. 14-15, the catheter body 202a is advanced into a chamber of the heart and maneuvered to a position where its distal end is in abutment with or close-spaced to the endocardial surface of the myocardium. Thereafter, the penetrator 206 is advanced out of the catheter's distal opening 203a and the penetrator 206 is rotated as it is advanced into the myocardium. The rotation of the penetrator 206 as it is advanced causes the corkscrew penetrator 206 to essentially screw into the myocardium. The delivery catheter 12 is then advanced through the lumen of the penetrator and into the myocardium where it is used, in the manner described above, to deliver the desired substance in a desired deposition area 207 (e.g., a trail, elongate track, series of depots or deposits, in a line, etc.) It will be appreciated that, in this embodiment, after one deposition area 207 has been created, the delivery catheter 12 may be retracted into the lumen of the penetrator 206 and the penetrator 206 may be rotated to a new position, at which time the delivery catheter may once again be advanced into an area of myocardial tissue that is different from the area into which the delivery catheter had been previously advanced. In this manner, an array of substance deposition patterns 207 may be formed in a substantial 360 radius around the central axis of the corkscrew penetrator 206 as illustrated in FIG. 16a. If subsequent dosing or later delivery of substance or apparatus is desired, the penetrator 206 may be rotatably retracted into the catheter body 202a and the penetrating catheter 200a may be removed, leaving the delivery catheter 12 in place for subsequent use.
FIG. 17 shows an example of the use of a side exiting penetrating catheter system 10a that is a modification of that type shown in FIGS. 2 and 2A. This catheter system is also useable to accomplish the delivery of a substance into the myocardial wall, via an endocardial approach. In the example shown in FIG. 17, the tissue penetrating catheter 10a comprises a catheter body 13a which may be the same or similar to that shown in FIGS. 2 and 2A or may be constructed in any suitable manner known in the art of catheter design and construction. A penetrator exit port 37a is formed in the catheter body 13a and a curved penetrator 85a comprising a hollow needle is advanceable from the exit port 37a as shown in the example of FIG. 17. An optional guide catheter may be used to guide the penetrating catheter to a position adjacent the wall of the atrium or ventricle in the area where it is desired to deliver the substance (or article). In operation, the penetrating catheter body 13 is maneuvered into juxtaposition with the endocardial surface of the myocardium, with or without the use of the optional guide catheter 210. The penetrating catheter 10a is then placed in a rotational orientation whereby the side exit port 37a is aimed at or directly juxtaposed with the endocardial surface to be penetrated. Optional rotational-orientation-indicating markers on the catheter body 13a, imaging apparatus (on board the catheter body 13 a or located elsewhere), electro-anatomical catheter navigation systems or other apparatus for discerning the specific rotational orientation of the catheter relative to the trajectory or path upon which the penetrator 85a will advance, may be used as described above and in the prior patent applications incorporated herein by reference. After the exit port 37a has been positioned in juxtaposition to the endocardial surface, the penetrator 85a is advanced into the adjacent myocardial tissue. The curve(s) and shape of the penetrator 85a are such that as it advances it reaches a position where its distal tip is directed generally parallel to the endocardial surface, as shown in FIG. 17. Thereafter, the delivery catheter 12 is advanced through the penetrator 85a and into the myocardium. As in the other embodiments described above, the positioning and shape of the penetrator causes the delivery catheter to advance on a path that does not result in the delivery catheter a) repuncturing through the endocardium and into the chamber of the heart or b) passing outwardly through the epicardial surface of the heart and/or c) perforating a substantially sized coronary blood vessel in a manner that would cause untoward bleeding or other potential complications. The substance (or article) is then in injected through the delivery catheter and into the myocardium. As described above in relation to the other embodiments, it is possible to create multiple spaced-apart intramyocardial depots of a substance or a continuous, elongate depot of the substance by slowly advancing or retracting the delivery catheter 85a while continuously or periodically injecting the desired substance. If subsequent dosing or later delivery of substance or apparatus is desires, the penetrator 85a may be retracted into the catheter body 13a and the penetrating catheter 10 may be removed, leaving the delivery catheter 12 in place for subsequent use.
FIGS. 18 and 19 show an example of a procedure wherein a therapeutic substance (e.g., myoblasts, angiogenic factors, muscle grafts, etc.) may be deposited directly into an infarct zone IZ wherein myocardial tissue has become necrotic. In this example, the penetrating catheter 10 has been advanced into a coronary vein CV adjacent to the infarct zone IZ. A penetrator 85 having an approximate 90 degree curvature is advanced from the penetrating catheter 10, though the wall of the coronary vein CV and into or near the infarct zone IZ. The delivery catheter 12 is then advanced though the lumen of the penetrator 85 and though all or a portion of the infarct zone, as specifically shown in FIG. 19. Thereafter, as the therapeutic substance is being injected through the delivery catheter 12, the delivery catheter 12 is slowly retracted in the proximal direction (see arrows on FIG. 19), thereby providing an elongate deposition pattern DP wherein the therapeutic substance is deposited. In addition to the area where the delivery catheter 12 is being used to deposit the therapeutic substance, FIG. 19 also illustrates a previously created deposition patter DP (see cross-hatched area on FIG. 19). This previously created deposition pattern DP is an elongate region, as shown. A deposition pattern axis DPA projected through the elongate deposition pattern DP is non-perpendicular and preferable tangential or nearly tangential to the adjacent endocardial surfaces of the right and left ventricles RV, LV. As explained hereabove, this generally tangential or non-perpendicular approach allows a greater length of delivery catheter 12 to be advanced into the myocardium than would have been possible if the penetrator 85 had been aimed or directed such that the delivery catheter 12 advanced perpendicular to and toward the left or right ventricle LV, RV.
The procedure illustrated in FIGS. 18-19 may be used to revitalize or restore function to regions of the myocardium that are necrotic or severely damaged. Thus, this technique may be useable to treat congestive heart failure. In addition to the deposition of myoblasts, stem cells, other cellular preparations, angiogenic factors, drugs or other therapeutic substances intended to improve the contractility or function of the impaired myocardium, this technique may also be used to implant grafts of muscle tissue into the myocardium. In this regard, a coring needle may be used to harvest an elongate segment of healthy cardiac or other muscle tissue. That harvested tissue graft may then be loaded into the delivery catheter 12 and deposited into the infarct zone IZ as the delivery catheter 12 is retracted, thereby creating an elongate tissue graft that extends fully or partially through the infarct zone IZ.
Although exemplary embodiments of the invention have been shown and described, many changes, modifications and substitutions may be made by those having ordinary skill in the art without necessarily departing from the spirit and scope of this invention. Specifically, elements or attributes described in connection with one embodiment may also be used in connection with another embodiment provided that the inclusion or use of such element or attribute would not render the embodiment in which it is incorporated unusable or otherwise undesirable for an intended application. Accordingly, all such additions, deletions, modifications and variations to the above-described embodiments are to be included within the scope of the following claims.

## Claims

1. A catheter device for delivering a therapeutic substance to a perivascular treatment site, the catheter device comprising:
an elongate member comprising a distal portion that is advanceable into a lumen of a blood vessel located within a body of a human or animal subject;
a needle within the distal portion of the elongate member and comprising telescoping hollow members, the needle being moveable in a lateral direction after the distal portion of the elongate member has been advanced into the lumen of the blood vessel to cause the needle to penetrate a wall of the blood vessel, wherein the needle is configured such that incremental advancement or retraction of the needle relative to the elongate member positions a distal section of the needle at a plurality of angular locations, wherein at each angular location of the plurality of angular locations, the distal section is at a different angle relative to a longitudinal axis of the distal portion of the elongate member, the needle having a needle lumen and an outlet opening, wherein the needle is configured to deliver the therapeutic substance through the needle lumen and out the outlet opening;
an injection port fluidically connected to the needle lumen; and
an imageable marking on the elongate member, useable to determine, by an imaging procedure, the lateral direction in which the needle will move from the distal portion of the elongate member while the distal portion of the elongate member is within the lumen of the blood vessel.

2. A catheter device according to claim 1 wherein the imageable marking marks a location adjacent to a needle exit port defined by the distal portion of the elongate member, from which the needle will move laterally from the elongate member.

3. A catheter device according to claim 1 wherein a depth to which the needle will penetrate into the wall of the blood vessel is adjustable.

4. A catheter device according to claim 1 wherein the imageable marking is radiographically imageable.

5. A system comprising a catheter device according to claim 1 in combination with an injection device that contains a mixture comprising the therapeutic substance and a radiographic agent, the injection device being connected to the injection port and useable to inject the mixture through the needle lumen and out of the outlet opening, after the needle has penetrated the wall of the blood vessel.

6. A system according to claim 5 further in combination with an imaging device useable to image the mixture after the mixture has been injected.

7. A catheter device according to claim 1 wherein at least two hollow members of the telescoping hollow members have different curvatures.

8. A catheter device according to claim 1 wherein at least two hollow members of the telescoping hollow members have different shapes.

9. A catheter device according to claim 1 wherein the telescoping hollow members are configured to allow the needle to follow a multicurvate path of advancement.