Abstract:
Medical devices and methods for making and using medical devices are disclosed. An example method may include a method for heating a body tissue region adjacent to a body lumen. The method may include positioning an energy delivery portion of a catheter within the lumen and engaging the body lumen with the energy delivery portion. Engaging the body lumen may complete a plurality of circuits. The method may also include determining a pulse characteristic in response to a thermal property of a first tissue type and applying controlled pulsed electrical energy with the pulse characteristic from the energy delivery portion through the plurality of circuits.

Description:
CROSS-REFERENCES TO RELATED APPLICATIONS 
     The present application is a continuation of U.S. Non-provisional application Ser. No. 12/617,519 filed Nov. 12, 2009, now U.S. Pat. No. 8,401,667, which claims the benefit under 35 U.S.C. 119(e) of U.S. Provisional Application No. 61/115,344 filed Nov. 17, 2008, each of which the full disclosure is incorporated herein by reference. 
     This application is related to U.S. application Ser. No. 11/975,474, filed on Oct. 18, 2007, entitled “Inducing Desirable Temperature Effects on Body Tissue”; U.S. application Ser. No. 11/975,383, filed on Oct. 18, 2007, and entitled “System for Inducing Desirable Temperature Effects on Body Tissues”, U.S. patent application Ser. No. 11/122,263, filed on May 3, 2005, entitled “Imaging and Eccentric Atherosclerotic Material Laser remodeling and/or Ablation Catheter”, and U.S. Provisional Application No. 61/099,155, filed on Sep. 22, 2008, entitled “Inducing Desirable Temperature Effects On Body Tissue Using Alternate Energy Sources”, the full disclosures of which are incorporated herein by reference. 
    
    
     BACKGROUND OF THE INVENTION 
     The present invention is generally related to medical devices, systems, and methods for heating body tissue. In exemplary embodiments, the invention provides catheter-based treatment for heating body tissue with energy that selectively accumulates in a desired type of tissue, particularly diseased tissue, with or without knowing the tissue topography a-priori. 
     Balloon angioplasty and other catheters often are used to open arteries that have been narrowed due to atherosclerotic disease. The trauma associated with balloon dilation can impose significant injury, so that the benefits of balloon dilation may be limited in time. Stents are commonly used to extend the beneficial opening of the blood vessel. Restenosis or a subsequent narrowing of the body lumen after stenting has occurred in a significant number of cases. 
     More recently, drug coated stents (such as Johnson and Johnson&#39;s Cypher™ stent, the associated drug comprising Sirolimus™) have demonstrated a markedly reduced restenosis rate, and others are developing and commercializing alternative drug eluting stents. In addition, work has also been initiated with systemic drug delivery (intravenous or oral) which may also improve the procedural angioplasty success rates. 
     While drug eluting stents appear to offer significant promise for treatment of atherosclerosis in many patients, there remain many cases where stents either cannot be used or present significant disadvantages. Generally, stenting leaves an implant in the body. Such implants can present risks, including mechanical fatigue, corrosion, and the like, particularly when removal of the implant is difficult and involves invasive surgery. Stenting may have additional disadvantages for treating diffuse artery disease, for treating bifurcations, for treating areas of the body susceptible to crush, and for treating arteries subject to torsion, elongation, and shortening. 
     A variety of modified restenosis treatments or restenosis-inhibiting treatment modalities have also been proposed, including intravascular radiation, cryogenic treatments, ultrasound energy, and the like, often in combination with balloon angioplasty and/or stenting. While these and different approaches show varying degrees of promise for decreasing the subsequent degradation in blood flow following angioplasty and stenting, the trauma initially imposed on the tissues by angioplasty remains problematic. 
     A number of alternatives to stenting and balloon angioplasty so as to open stenosed arteries have also been proposed. For example, a wide variety of atherectomy devices and techniques have been disclosed and attempted. Despite the disadvantages and limitations of angioplasty and stenting, atherectomy has not gained the widespread use and success rates of dilation-based approaches. More recently, still further disadvantages of dilation have come to light. These include the existence of vulnerable plaque, which can rupture and release materials that may cause myocardial infarction or heart attack. 
     In light of the above, it would be advantageous to provide methods and systems for inducing vasodilation in artery tissue and remodeling of the lumens of the body. It would further be desirable to avoid significant cost or complexity while providing structures which could remodel body lumens without having to resort to the trauma of extreme dilation, and to allow the opening of blood vessels and other body lumens which are not suitable for stenting. 
     BRIEF SUMMARY OF THE INVENTION 
     In a first aspect, embodiments of the present invention provide a method for heating a body tissue region adjacent a body lumen, the region having both a first tissue type and a second tissue type. The method includes positioning an energy delivery portion of a catheter body within the lumen adjacent the body tissue region to be heated, determining a pulse characteristic in response to a thermal property of the first tissue type and applying pulsed energy with the pulse characteristic from the energy delivery portion so as to therapeutically treat the second tissue type within the body tissue region by drawing heat from the first tissue type at a rate that avoids significant thermal damage to the first tissue type while building-up heat in the second tissue type. 
     In another aspect, embodiments of the present invention provide a catheter system for heating a body tissue region adjacent a body lumen, the region having both a first tissue type and a second tissue type. The system includes an elongate flexible catheter body having a proximal end and a distal end with an axis therebetween, an energy delivery portion proximate the distal end, an energy source coupled to the energy delivery portion and a processor coupled to the energy source, the processor configured to control a pulse characteristic of pulsed energy transmitted from the energy source to the energy delivery portion so as to therapeutically treat the second tissue type within the body tissue region by drawing heat from the first tissue type at a rate that avoids significant thermal damage to the first tissue type while building-up heat in the second tissue type. 
     In many embodiments, the pulsed energy preferentially heats the second tissue type more than the first tissue type, the preferential heating induced at least in part by one or more of the following group of characteristics of the second tissue type: lower thermal conduction than a thermal conduction of the first tissue type, lower specific heat capacity than a specific heat capacity of the first tissue type, less innate blood perfusion than an innate blood perfusion of the first tissue type, and/or larger distance away from well-perfused areas than a distance between well-perfused areas and the first tissue type. 
     In many embodiments, most of the group of characteristics cause heat to be drawn from the first tissue type at a rate that avoids significant thermal damage to the first tissue type, while allowing heat to build up in the second tissue type. 
     In many embodiments, the pulsed energy is delivered at an average rate of 0.25 to 5 watts to the body tissue region. 
     In many embodiments, each pulse of the pulsed energy provides between 4 to 45 Joules to the body tissue region. 
     In many embodiments, wherein an average rate of pulsed energy delivered to the body tissue region is between about 0.1 and 10.0 times the rate of energy dissipation by the first tissue type. 
     In many embodiments, a time period between pulses allows the first tissue type to dissipate its heat adequately to avoid thermal damage to the first tissue type by the pulsed energy. 
     In many embodiments, the time period between pulses of energy is between 0.1 to 180 seconds. 
     In many embodiments, a thermal time constant for the first tissue type is approximately how long it will take a discrete volume of that given tissue to lose 63% of its heat while undergoing an exponential decay. 
     In many embodiments, the pulsed energy is delivered to the body tissue region over a duration of at least several first tissue type time constants, wherein the thermal time constant of the first tissue is proportional to a thermal conductivity of the first tissue type. 
     In many embodiments, the thermal conductivity of the second tissue type is twice that of the first tissue type. 
     In many embodiments, the energy source comprises a radio frequency (RF) energy source. 
     In many embodiments, the energy delivery portion comprises a radially expandable structure engaging a plurality of electrode surfaces against the body lumen, wherein the plurality of electrode surfaces against the body lumen complete a plurality of circuits comprising the first tissue type and the second tissue type and pulsed energy is delivered to the plurality of circuits. 
     In many embodiments, the energy source comprises a laser energy source. 
     In many embodiments, the energy delivery portion comprises at least one radially oriented window coupled to at least one optical conduit extending between the proximal end of the catheter body and the at least one window for transmission of pulsed laser energy to the body tissue region. 
     In many embodiments, the energy source comprises an ultrasound transmitter configured to deliver pulsed ultrasound energy to the body tissue region. 
     In many embodiments, the energy source comprises a microwave energy source including at least one microwave antenna configured to deliver pulsed microwave energy to the body tissue region. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         FIG. 1  schematically illustrates one embodiment of a catheter system for heating artery tissue. 
         FIG. 2  illustrates one embodiment of a balloon for use in the catheter system of  FIG. 1 . 
         FIG. 3  shows what a temperature vs. time profile for heating both healthy tissue and diseased tissue at a constant pulsed rate of heat or energy. 
         FIG. 4  shows another a temperature vs. time profile for tissue having both healthy tissue and diseased tissue in which the heat or energy is applied at different rates. 
         FIG. 5  shows heat dissipation&#39;s effect on temperature. 
         FIG. 6  schematically illustrates one embodiment of balloon catheter system for use for bipolar treatment of tissue in a leg 
         FIG. 7  schematically illustrates one embodiment of balloon catheter system for use for monopolar treatment of tissue in a leg. 
         FIGS. 8A-8C  illustrate a method of using a balloon catheter system treating artery tissue. 
     
    
    
     DETAILED DESCRIPTION OF THE INVENTION 
     Many therapies have been developed to replace or improve upon traditional balloon angioplasty and stents. Many of the devices described in the BACKGROUND OF THE INVENTION either cut, ablate, or vaporize diseased tissue in an artery. For example, laser devices vaporize plaque and flush it downstream. Atherectomy devices excise plaque and suck it out of the body. Cutting balloons incise the artery wall, damaging the tissue. 
     It would be advantageous to provide systems and devices that do not cut, ablate, or vaporize. Three modalities of treatment avoid these drawbacks, they include: cooling the tissue; non-ablative forms of direct molecular denaturing; and non-ablative heating. Cooling has been implemented using devices such as Boston Scientific&#39;s Cryo-cath. Direct molecular denaturing can be achieved with radiation—gamma rays, for instance. The present invention is directed to the remaining modality, non-ablative heating. 
     Some embodiments of the present invention generally provide devices, systems, and methods for heating artery tissue with diseased portions using selective accumulation of energy in the artery tissue with or without knowledge of tissue topography, discussed in more detail below. The invention will be particularly useful for remodeling materials along a partially occluded artery in order to open the artery lumen and increase blood flow. The devices, systems, and methods disclosed herein may be used in any artery, for example, the femoral, popliteal, coronary and/or carotid arteries. Devices for heating artery tissue have been disclosed in co-pending U.S. patent application Ser. Nos. 11/975,474, 11/975,383, 11/122,263 and U.S. Provisional Application No. 61/099,155, the full disclosures of which are incorporated herein by reference. 
     While the disclosure focuses on the use of the technology in the vasculature, the technology would also be useful for any luminal obstruction. Other anatomical structures in which the present invention may be used are the esophagus, the oral cavity, the nasopharyngeal cavity, the auditory tube and tympanic cavity, the sinus of the brain, the arterial system, the venous system, the heart, the larynx, the trachea, the bronchus, the stomach, the duodenum, the ileum, the colon, the rectum, the bladder, the ureter, the ejaculatory duct, the vas deferens, the urethra, the uterine cavity, the vaginal canal, and the cervical canal. 
     Some embodiments of the system will be able to treat tissue by gentle heating in combination with dilation of the artery. The heating of the vessel wall may be done before, during, and/or after dilation with the balloon, with dilation pressures which are at or significantly lower than standard, unheated angioplasty dilation pressures. For example, where balloon inflation pressures of 10-16 atmospheres may be appropriate for standard angioplasty dilation of a particular lesion, modified dilation treatments combined with gentle heating described herein may employ from 10-16 atmospheres or may be effected with pressures of 6 atmospheres or less, and possibly as low as 1 to 2 atmospheres. In case of calcification in the artery plaque, it may be more difficult to remodel and open the diseased artery, so the catheter may use a standard angioplasty balloon in combination with ultrasonic energy to break down the calcium and remodel and open the lumen. 
     The gentle heating energy added before, during, and/or after dilation of a blood vessel may increase dilation effectiveness while lowering complications. In some embodiments, such controlled heating with balloon dilatation may exhibit a reduction in recoil, providing at least some of the benefits of a stent-like expansion without the disadvantages of an implant. Benefits of gentle heating may be enhanced (and/or complications inhibited) by limiting heating of the adventitial layer below a deleterious response threshold. In many cases, such heating of the intima and/or media may be provided using heating times of less than about 10 seconds, often being less than 3 (or even 2) seconds. In other cases, very low power may be used for longer durations. 
     Heating of the body tissue involves the application of energy, typically in the form of RF, microwave and/or ultrasound energy, and the like. This energy will be controlled so as to limit a temperature of the body tissue. In some embodiments, the body tissue temperature range is from about 50° C. to about 90° C., depending on the energy applied and tissue type. 
     While the methods and devices described herein are not selective in tissue treatment of the blood vessel, the devices can be used for treatment of both concentric and eccentric atherosclerosis. This non selective treatment is a particular advantage because atherosclerosis may be eccentric relative to an axis of the blood vessel over 50% of the time, possibly in as much as (or even more than) 75% of cases. 
     While the present invention may be used in combination with stenting, the present invention is particularly well suited for increasing the open diameter of blood vessels in which stenting is not a viable option. Potential applications include treatment of diffuse disease, in which atherosclerosis is spread along a significant length of an artery rather than being localized in one area. The present invention may also find advantageous use for treatment of tortuous, sharply-curved vessels, as no stent need be advanced into or expanded within the sharp bends of many blood vessel. Still further advantageous applications include treatment along bifurcations (where side branch blockage may be an issue) and in the peripheral extremities such as the legs, feet, and arms (where crushing and/or stent fracture failure may be problematic). 
     The disclosed system includes at least an energy source and a catheter with an energy delivery portion configured for heating a body tissue region adjacent a body lumen, the region having both a first tissue type, such as healthy tissue, and a second tissue type, such as diseased tissue. The catheter may be similar to a balloon catheter commonly used to treat artery disease today, except for the addition of electrodes used for heating. Other embodiments may use transducers disposed on the balloon to apply ultrasound heating to the vessel wall or microwave antennas disposed on the balloon to apply microwave heating to the vessel wall. The energy source may be coupled to a processor to control a pulse characteristic of pulsed energy transmitted from the energy source to the energy delivery portion so as to therapeutically treat the tissue within the body treatment region without causing sufficient thermal damage to the body treatment region so as to induce a long-term occlusive response. 
     In use, the energy delivery portion of a catheter body is positioned within the lumen adjacent the body tissue region to be heated. A pulse characteristic is determined in response to a thermal property of the first tissue type, and the pulsed energy is applied with the pulse characteristic from the energy delivery portion so as to therapeutically treat the body tissue region. 
       FIG. 1  shows one embodiment of a catheter system  10  for heating artery tissue. The catheter system  10  includes a balloon catheter  12  having a catheter body  14  with a proximal end  16  and a distal end  18 . Catheter body  14  is flexible and defines a catheter axis  15 , and may include one or more lumens, such as a guidewire lumen  22  and an inflation lumen  24  (see  FIG. 2 ). Still further lumens may be provided if desired for other treatments or applications, such as perfusion, fluid delivery, imaging, or the like. Catheter  12  includes an inflatable balloon  20  adjacent distal end  18  and a housing  29  adjacent proximal end  16 . Housing  29  includes a first connector  26  in communication with guidewire lumen  22  and a second connector  28  in fluid communication with inflation lumen  24 . Inflation lumen  24  extends between balloon  20  and second connector  28 . Both first and second connectors  26 ,  28  may optionally comprise a standard connector, such as a Luer-Loc™ connector. A distal tip may include an integral tip valve to allow passage of guidewires, and the like. 
     Housing  29  also accommodates an electrical connector  38 . Connector  38  includes a plurality of electrical connections, each electrically coupled to electrodes  34  via conductors  36 . This allows the electrodes  34  to be easily energized, the electrodes often being energized by a controller  40  and energy source  42 , such as bipolar or monopolar RF energy, microwave energy, ultrasound energy, or other suitable energy sources. In one embodiment, electrical connector  38  is coupled to an RF generator via a controller  40 , with controller  40  allowing energy to be selectively directed to electrodes  38 . When monopolar RF energy is employed, patient ground may (for example) be provided by an external electrode or an electrode on catheter body  14 . 
     In some embodiments, controller  40  may include a processor or be coupled to a processor to control or record treatment. The processor will typically comprise computer hardware and/or software, often including one or more programmable processor unit running machine readable program instructions or code for implementing some or all of one or more of the methods described herein. The code will often be embodied in a tangible media such as a memory (optionally a read only memory, a random access memory, a non-volatile memory, or the like) and/or a recording media (such as a floppy disk, a hard drive, a CD, a DVD, a non-volatile solid-state memory card, or the like). The code and/or associated data and signals may also be transmitted to or from the processor via a network connection (such as a wireless network, an Ethernet, an internet, an intranet, or the like), and some or all of the code may also be transmitted between components of catheter system  10  and within processor via one or more bus, and appropriate standard or proprietary communications cards, connectors, cables, and the like will often be included in the processor. Processor will often be configured to perform the calculations and signal transmission steps described herein at least in part by programming the processor with the software code, which may be written as a single program, a series of separate subroutines or related programs, or the like. The processor may comprise standard or proprietary digital and/or analog signal processing hardware, software, and/or firmware, and will typically have sufficient processing power to perform the calculations described herein during treatment of the patient, the processor optionally comprising a personal computer, a notebook computer, a tablet computer, a proprietary processing unit, or a combination thereof. Standard or proprietary input devices (such as a mouse, keyboard, touchscreen, joystick, etc.) and output devices (such as a printer, speakers, display, etc.) associated with modern computer systems may also be included, and processors having a plurality of processing units (or even separate computers) may be employed in a wide range of centralized or distributed data processing architectures. 
     Balloon  20  is illustrated in more detail in  FIG. 2 . Balloon  20  generally includes a proximal portion  30  coupled to inflation lumen  24  and a distal portion  32  coupled to guidewire lumen  22 . Balloon  20  expands radially when inflated with a fluid or a gas. In some embodiments, the fluid or gas may be non-conductive and/ cooled. In some embodiments, balloon  20  may be a low pressure balloon pressurized to contact the artery tissue. In other embodiments, balloon  20  is an angioplasty balloon capable of higher pressure to both heat the artery tissue and expand the artery lumen. Balloon  20  may comprise a compliant or non-compliant balloon having helical folds to facilitate reconfiguring the balloon from a radially expanded, inflated configuration to a low profile configuration, particularly for removal after use. 
     Electrodes  34  are mounted on a surface of balloon  20 , with associated conductors  36  extending proximally from the electrodes. Electrodes  34  may be arranged in many different patterns or arrays on balloon  20 . The system may be used for monopolar or bipolar application of energy. For delivery of monopolar energy, a ground electrode is used, either on the catheter shaft, or on the patients skin, such as a ground electrode pad. For delivery of bipolar energy, adjacent electrodes are axially offset to allow bipolar energy to be directed between adjacent circumferential (axially offset) electrodes. In other embodiments, electrodes may be arranged in bands around the balloon to allow bipolar energy to be directed between adjacent distal and proximal electrodes. In some embodiments, the electrodes  34  may be positioned internal of balloon  20 . Electrodes  34  may be arranged in many different patterns or arrays on balloon  20 . As mentioned previously, other embodiments may include ultrasound transducers or microwave antennas mounted on a surface of balloon  20 . 
     The embodiments disclosed herein revolve around the concept of selective accumulation of energy in artery tissue with or without knowledge of tissue topography. This is accomplished by taking advantage of the differences in tissue properties between healthy tissue and diseased tissue. The preferential heating of the tissues with different properties can be accomplished without knowing the location or type the different tissues. If a first tissue type has a better thermal conductivity (k) than a second tissue type, it will conduct heat away more rapidly. If the second tissue type has a lower specific heat capacity (c p ) than the first tissue type, its temperature will increase more given the same amount of energy applied to the same mass (and volume, assuming relatively similar tissue density). If the first tissue type has denser vasculature, or is reliably in closer proximity to well-perfused areas, it will conduct heat away more rapidly than the second tissue type. 
     This present invention allows preferentially heating of a type of tissue that has one or more of the following characteristics:
         Relatively poor (lower) thermal conduction,   Lower specific heat capacity,   Less innate blood perfusion, and/or   Relatively larger distance away from well-perfused areas.       

     In the case of diseased tissue, all of the above characteristics apply. The disease is generally comprised of lipidic fat-like diseased tissue and/or fibrous collagen-like tissue. Both of these tissues have a lower specific heat capacity and lower thermal conductivity than healthy vascular tissue, particularly media. Healthy vascular tissue also has more microvasculature, and is in closer proximity to well-perfused tissue, therefore healthy tissue can sink heat away more effectively, without the heat flux “backing up” like a traffic jam. 
     The key to taking advantage of this discrepancy in tissue properties is the following: Heat is applied or generated within the tissue at a rate commensurate with the thermal time constants of the tissues involved, possibly using a pulse width modulation (PWM) approach. During each “pulse”, the same quantity of energy is delivered or generated regardless of the tissue type. Tissue topography may be unknown, therefore the same “treatment” is applied everywhere. However, in the diseased tissue, the temperature profile will be higher everywhere because it has a lower heat capacity. The diseased tissue will also retain its heat longer because it has lower thermal conductivity and therefore a longer thermal time constant. Thus, the healthy tissue will heat up slower and cool off faster, which is exactly what is desired for this particular application. The goal is to heat diseased tissue while not heating healthy tissue. The amount of time between pulses can then be tailored to allow the healthy tissue to cool and dissipate its heat adequately so as not to exceed a particular amount of thermal damage the healthy tissue. 
       FIG. 3  shows what a temperature vs. time profile for heating both healthy tissue  110  and diseased tissue  120  at a constant pulsed rate of heat or energy. The diseased tissue temperature will rise faster and cool slower than the healthy tissue, therefore accumulating heat and receiving treatment significantly more than healthy tissue. 
       FIG. 4  shows another a temperature vs. time profile for tissue having both healthy tissue and diseased tissue in which the heat or energy is applied at different rates. The figure shows it is possible to initially apply or generate heat faster (at the beginning of the treatment) in order to ramp up the tissue temperature more quickly. This could be done with power modulation or PWM with a variable pulse width. The purpose of this would be to heat the tissue quickly and then allow the healthy tissue to dissipate heat between pulses, which would decrease the total treatment time required to achieve (and possibly soak at) a certain temperature. 
     Time Constant: 
               t   =     RC   =       (       l   n     ⁢   k     )     ⁢     (     m   ⁢           ⁢     c   p       )           ,         
where healthy t≈7 s and diseased t≈14 s.
 
     Heat Capacity: 
     Media c p ≈3.9 
     Adventitia c p ≈3.1 
     Fat c p ≈2.4 
     Thermal Conductivity: 
     Media k≈0.59 
     Adventitia k≈0.49 
     Fat k≈0.20 
     The “TIME CONSTANT” above is the thermal time constant. This is approximately how long it will take a discrete volume of that given tissue to lose 63% of its heat (and therefore temperature) while undergoing an exponential decay. The thermal time constant is directly proportional to the thermal conductivity. Therefore, because there is approximately a 2:1 ratio between the thermal conductivity of fatty diseased tissue and healthy media tissue, there is also a 2:1 ratio between their time constants. 
     The thermal time constant for healthy media tissue was estimated to be 7 seconds based upon a treatment volume of 32 mm 3 , a thermal conductivity of 0.5 W/m/K, a thermal front cross-sectional area of 32 mm 2 , and a specific heat capacity of 3.6 J/g/K. In this case, one would want to deliver an appropriate therapeutic dose of energy over a duration of at least several time constants, e.g. 35 seconds, 70 seconds, etc. 
       FIG. 5  shows heat dissipation&#39;s effect on temperature versus time. Because thermal dissipation will happen according to an exponential decay, the rate of cooling will vary nonlinearly with time. So, the period has to be selected appropriately in conjunction with the power and duty cycle. The power and the heat capacity, neglecting heat dissipation, will determine the rate of temperature increase during heating. The combination of power, duty cycle, heat capacity, and the rate of continuous heat dissipation, will determine the average rate of temperature change. Diseased tissue  210  and healthy tissue  220  both have higher average temperatures without heat dissipation than diseased tissue  215  and healthy tissue  225  with heat dissipation. 
     The important thing to note about  FIG. 5  is that the average power (average energy per time) has to be low enough that the rate of heat dissipation is significant in comparison. In other words, if we were to assume that healthy vessel tissue in a certain geometry can effectively dissipate energy at a rate of 2 Joules per second (2 Watts), then the average rate of energy application needs to be on this order of magnitude as well, in order for the effect to be significant. 
     This is the main crux of the invention—applying energy at an average rate commensurate with the thermal time constants involved such that significant differences in the tissues&#39; thermal properties can be leveraged to our advantage. 
       FIG. 6  schematically illustrates bipolar treatment of tissue with the system  10 . Balloon  20  having electrode pairs  34 A and  34 B is positioned within an artery lumen having fatty disease/necrotic core  48 , fibrous disease/fibrous cap  44 , healthy tissue  45 . Treatment is done to healthy tissue  45  and the fatty disease/necrotic core  48 , fibrous disease/fibrous cap  44  by pulsed energy between electrode pairs  34 A and  34 B. The electrode pairs may be any electrode pairs on the balloon, for example, in some embodiments, the electrode pairs may be  34 A and  34 C, or  34 A and  34 D, or any combination of  34 A- 34 D. This arrangement creates an energy path  50  through the tissue that delivers energy or heat (“tissue remodeling energy”) to the artery tissue between the electrode pairs (“remodeling zones”). Using different combinations of electrode pairs may reduce or eliminate gaps between the remodeling zones by using overlapping pairs. Using electrode pairs with bipolar energy may avoid some potential issues of the monopolar approach. Diseased artery tissue  48  has a higher electrical resistivity than healthy artery tissue  45 . By using pairs of electrodes  34 A,  34 B in a bipolar system, the energy path  50  will go through the healthy tissue, diseased tissue, or a combination of both healthy and diseased tissues between the electrode pairs. Any number of electrode pairs may be used in different patterns or arrays. 
       FIG. 7  schematically illustrates bipolar treatment of tissue with the system  10 . Balloon  20  having electrode pairs  34 A and  34 B is positioned within an artery lumen having fatty disease/necrotic core  48 , fibrous disease/fibrous cap  44 , healthy tissue  45  and one or more electrical grounds (not shown) are used, such as positioned on the patients skin. When power is applied to the multiple monopolar electrodes  34  arranged around the circumference of the artery lumen, energy  54  is directed radially outward through the artery wall and treats both diseased and healthy artery tissue. 
     The use of catheter system  10  for treating tissue by pulsed energy can be understood with reference to  FIGS. 8A-8C . As seen in  FIG. 8A , accessing of a treatment site will often involve advancing a guidewire  56  within a blood vessel  58  at a target region of diseased tissue  48 . Location of balloon  20  may be facilitated by radiopaque markers or by radiopaque structure (or corresponding radiopaque markers placed on or near) balloon  20 , and/or by the use of radiopaque electrodes  34 . Guidewire  56  may be positioned under fluoroscopic (or other) imaging. 
     Catheter  12  is advanced distally over guidewire  56  and positioned adjacent to atherosclerotic material  48 . Balloon  20  expands radially within the lumen of the blood vessel so that electrodes  34 , or electrodes  34 A and  34 B, radially engage artery tissue. As diseased tissue  48  may be distributed eccentrically about catheter  12 , electrodes  34  may engage diseased tissue  48 , healthy tissue  60 , or a combination of both tissues. 
     As discussed above, electrodes  34  are positioned circumferentially around the balloon  20 . Pulsed energy is directed to electrodes  34 , or adjacent pairs of electrodes  34 A and  34 B, treating both diseased tissue  48  and the healthy tissue  60 . The controller  40  may provide pulsed energy to energize the electrodes with about 0.25 to 5 Watts average power for 0.1 to 180 seconds, or with about 4 to 45 Joules. The power and duration are calibrated to be less than enough to cause severe damage, and particularly less than enough to ablate tissue within a blood vessel. 
     Referring now to  FIG. 8C , as described above, balloon  20  may be an angioplasty balloon that combines heating with opening the artery lumen, such that the heat is preferentially delivered to the diseased tissue  48 , for example to mildly heat a cap structure (to induce thickening of the cap and make the plaque less vulnerable to rupture) and/or heat a lipid-rich pool of the vulnerable plaque (so as to remodel, denature, melt, shrink, and/or redistribute the lipid-rich pool), while the healthy tissue  60  dissipates the heat without damage. 
     In some embodiments, balloon  20  may be repeatedly contracted, axial movement of the catheter  12  employed to reposition balloon  20 , with subsequent expansion of balloon  20  at each of a plurality of treatment locations along diseased tissue. 
     While generally described herein with reference to the vasculature, embodiments of the catheter devices, systems, and methods described herein may also find applications in the lumens of other vessels of the human anatomy having tissue types with different tissue properties, as discussed above. The anatomical structure into which the catheter is placed may be for example, the esophagus, the oral cavity, the nasopharyngeal cavity, the auditory tube and tympanic cavity, the sinus of the brain, the larynx, the trachea, the bronchus, the stomach, the duodenum, the ileum, the colon, the rectum, the bladder, the ureter, the ejaculatory duct, the vas deferens, the urethra, the uterine cavity, the vaginal canal, and the cervical canal, as well as the arterial system, the venous system, and/or the heart. 
     While the exemplary embodiments have been described in some detail, by way of example and for clarity of understanding, those of skill in the art will recognize that a variety of modifications, adaptations, and changes may be employed. Hence, the scope of the present invention should be limited solely by the claims.