Abstract:
At the present time, physicians often treat patients with atrial fibrillation (AF) using radiofrequency (RF) catheter systems to ablate conducting tissue in the wall of the Left Atrium of the heart around the ostium of the pulmonary veins. These systems are expensive and take time consuming to use. The present invention circular ablation system CAS includes a multiplicity of expandable needles that can be expanded around a central axis and positioned to inject a fluid like ethanol to ablate conductive tissue in a ring around the ostium of a pulmonary vein quickly and without the need for expensive capital equipment. The expansion of the needles is accomplished by self-expanding or balloon expandable structures. The invention includes centering means so that the needles will be situated in a pattern surrounding the outside of the ostium of a vein. Also included are members that limit the distance of penetration of the needles into the wall of the left atrium. The present invention also has application to ablating tissue around the ostium of a renal artery for the treatment of hypertension.

Description:
CROSS-REFERENCE TO RELATED APPLICATIONS 
       [0001]    This application is a continuation of U.S. patent application Ser. No. 14/057,972, filed on Oct. 18, 2013, which is a divisional of U.S. patent application Ser. No. 13/092,363, filed on Apr. 22, 2011, now issued as U.S. Pat. No. 8,663,190. The entirety of each of the foregoing applications is hereby incorporated by reference herein. 
     
    
     FIELD OF USE 
       [0002]    This invention is in the field of devices to ablate muscle cells and nerve fibers for the treatment of cardiac arrhythmias and/or hypertension. 
       BACKGROUND OF THE INVENTION 
       [0003]    At the present time, physicians often treat patients with atrial fibrillation (AF) using radio frequency (RF) catheter systems to ablate conducting tissue in the wall of the Left Atrium of the heart around the ostium of the pulmonary veins. Similar technology, using radiofrequency energy, has been used inside the renal arteries to ablate sympathetic and other nerve fibers that run in the wall of the aorta on the outside of the renal arteries, in order to treat high blood pressure. In both cases these are elaborate and expensive catheter systems that can cause thermal, cryoablative, or other injury to surrounding tissue. Many of these systems also require significant capital outlays for the reusable equipment that lies outside of the body, including RF generation systems and the fluid handling systems for cryoablative catheters. 
         [0004]    Because of the similarities of anatomy, for the purposes of this disclosure, the term target vessel will refer here to either the pulmonary vein for AF ablation applications or the renal artery for hypertension therapy applications. The term ostial wall will refer to the wall of the Left Atrium surrounding a pulmonary vein for AF application and to the wall of the aorta for the hypertension application. 
         [0005]    In the case of atrial fibrillation ablation, the ablation of tissue surrounding multiple pulmonary veins can be technically challenging and very time consuming. This is particularly so if one uses RF catheters that can only ablate one focus at a time. There is also a failure rate using these types of catheters for atrial fibrillation ablation. The failures of the current approaches are related to the challenges in creating reproducible circumferential ablation of tissue around the ostium (peri-ostial) of a pulmonary vein. 
         [0006]    There are also potential risks using the current technologies for RF ablation to create sympathetic nerve denervation inside the renal artery for the treatment of hypertension. The long-term sequelae of applying RF energy inside the renal artery itself are unknown, but this could lead to late restenosis, embolization of debris into the renal parenchyma, or other problems inside the renal artery. There may also be uneven or incomplete sympathetic nerve ablation, particularly if there are anatomic abnormalities, or atherosclerotic or fibrotic disease inside the renal artery, such that there is nonhomogeneous delivery of RF energy. This could lead to treatment failures, or the need for additional and dangerous levels of RF energy to ablate the nerves that run along the adventitial plane of the renal artery. There are also significant safety issues with current technologies related to very long fluoroscopy and procedure times that lead to high levels of radiation exposure to both the patient and the operator, and may increase stroke risk in atrial fibrillation ablation. 
         [0007]    Finally, while injection of ethanol as an ablative substance is used within the heart and other parts of the body, there has been no development of an ethanol injection system specifically designed for circular ablation of the ostial wall of a target vessel. 
       SUMMARY OF THE INVENTION 
       [0008]    The present invention Circular Ablation System (CAS) is capable of producing damage in the tissue that surrounds the ostium of a blood vessel in a relatively short period of time using a disposable catheter requiring no additional capital equipment. The primary focus of use of CAS is in the treatment of cardiac arrhythmias and hypertension. 
         [0009]    Specifically, there is a definite need for such a catheter system that is capable of highly efficient, and reproducible circumferential ablation of the muscle fibers and conductive tissue in the wall of the Left Atrium of the heart surrounding the ostium of the pulmonary veins which could interrupt atrial fibrillation (AF) and other cardiac arrhythmias. 
         [0010]    This type of system may also have major advantages over other current technologies by allowing time efficient and safe circumferential ablation of the nerves in the wall of the aorta surrounding the renal artery (peri-ostial renal tissue) in order to damage the sympathetic nerve fibers that track from the peri-ostial aortic wall into the renal arteries, and thus improve the control and treatment of hypertension. Other potential applications of this approach may evolve over time. 
         [0011]    The present invention is a catheter which includes multiple expandable injector tubes arranged circumferentially around the body of the CAS near its distal end. Each tube includes an injector needle at its distal end. There is a penetration limiting member proximal to the distal end of each needle so that the needles will only penetrate into the tissue of the ostial wall to a preset distance. This will reduce the likelihood of perforation of the ostial wall and will optimize the depth of injection for each application. The injector needles are in fluid communication with an injection lumen in the catheter body which is in fluid communication with an injection port at the proximal end of the CAS. Such an injection port would typically include a standard connector such as a Luer connector used to connect to a source of ablative fluid. 
         [0012]    The expandable injector tubes may be self-expanding made of a springy material or a memory metal such as NITINOL or they may be expandable by mechanical means. For example, the expandable legs with distal injection needles could be mounted to the outside of an expandable balloon whose diameter is controllable by the pressure used to inflate the balloon. 
         [0013]    The entire CAS is designed to be advanced over a guide wire in either an over the wire configuration where the guide wire lumen runs the entire length of the CAS or a rapid exchange configuration where the guide wire exits the catheter body at least 10 cm distal to the proximal end of the CAS and runs outside of the catheter shaft for its proximal section. 
         [0014]    The distal end of the CAS also includes a centering means at or near its distal end. The centering means could be a mechanical structure or an expandable balloon. The centering means will help to ensure that the injector tubes will be engaged circumferentially around and outside of the ostium of the target vessel. If the injector tubes are expanded by a balloon, then it is envisioned that the distal portion of the balloon would have conical or cylindrical distal portions that would facilitate centering the CAS in the target vessel. 
         [0015]    The CAS would also be typically packaged inside an insertion tube that constrains the self-expanding legs prior to insertion into a guiding catheter, and allows the distal end of the CAS to be inserted into the proximal end of a guiding catheter or introducer sheath. 
         [0016]    The CAS might also be packaged to include an outer sheath that runs the entire length of the CAS so as to cover and protect the needles and also protect them from getting caught as the CAS is advanced distally to the desired location. 
         [0017]    It is also envisioned that the injection needles could be formed from a radiopaque material such as tantalum or tungsten or coated with a radiopaque material such as gold or platinum so as to make them clearly visible using fluoroscopy. 
         [0018]    It is also envisioned that one or more of the injector needles could be electrically connected to the proximal end of the CAS so as to also act as a diagnostic electrode(s) for evaluation of the electrical activity in the area of the ostial wall. 
         [0019]    It is also envisioned that one could attach 2 or more of the expandable legs to an electrical or RF source to deliver electric current or RF energy around the circumference of a target vessel to the ostial wall to perform tissue ablation. 
         [0020]    For use in the treatment of AF the present invention CAS would be used with the following steps:
       Access to the left atrium via a large peripheral vein, such as the femoral vein, typically with the insertion of a sheath.   Use a trans septal approach to get into the left atrium, via the vein, to the right atrium, to enter the left atrium. This approach is a well known procedure.   Advance a guide wire and guiding catheter across the inter-atrial septum into the left atrium.   Using a guiding catheter with a shaped distal end or guiding sheath, engage the first targeted pulmonary vein. This can be confirmed with contrast injections as needed.   Advance a guide wire through the guiding catheter into the pulmonary vein.   Place the distal end of an insertion tube which constrains the distal end of the CAS into the proximal end of the guiding catheter.   Advance the distal end of the CAS into and advance the CAS through the guiding catheter, and tracking over the guidewire, until it is just proximal to the distal end of the guiding catheter.   Advance the CAS over the guidewire until the distal portion of its centering means is within the target vessel.   Expand the centering means. If the centering means is cylindrical, expand it until it is just slightly less (1-4 mm less) than the diameter of the target vessel. This will ensure that the catheter will be roughly “centered” within the target vessel to enable the circumferential deployment of the legs of the CAS around the target vessel ostium so that injection will be centered around the ostium of the target vessel.   Pull back the guiding catheter to leave space for the expanding injector tubes to open.   Expand the injector tubes or let them expand if they are self-expanding. If balloon expandable, adjust the balloon pressure to get the desired diameter. If selfexpanding, the circumference of the self-expansion can be adjusted in vivo by varying the distance of the pullback of the guiding catheter. That is, if one wants a smaller diameter (circumference) expansion to fit the ostial dimension of that specific target vessel, one can partially constrain the injector tube expansion by not fully retracting the guiding catheter all the way to the base of the tubes. However, the preferred method is to have the final opening distance be preset for the CAS, with the injector tubes fully expanded to their memory shape. Typically the CAS size would be pre-selected based on the anticipated or measured diameter of the ablation ring to be created, such that the fully expanded injector tubes create the correctly sized ablation “ring.”   Advance the CAS until the injector needles at the distal end of the self-expanding injector tubes penetrate the ostial wall, with the penetration depth being a fixed distance limited by the penetration limiting member attached to each needle at a preset distance proximal to the distal end of the needle. If the centering means is conical, as the CAS is advanced distally, the cone will engage the ostium of the vein which will center the CAS.   Attach a syringe or injection system to the injection connector at the CAS proximal end.   Engagement of the ostial wall can be confirmed by injection of a small volume of iodinated contrast via a syringe, through the needles, prior to injection of the “ablative” fluid such as alcohol. If there is contrast “staining” of the tissue this will confirm that the needles are engaged into the tissue and not free floating in the left atrium or aorta.   Inject an appropriate volume of ethanol (ethyl alcohol) or other appropriate cytotoxic fluid from the syringe or injection system through the catheter and out of the needles into the ostial wall. A typical injection would be 1-10 ml. This should produce a multiplicity of circles of ablation (one for each needle) that will intersect to form an ablative ring around the ostium of the target vessel. Contrast could be added to the injection to allow x-ray visualization of the ablation area.   Once the injection is complete, retract the CAS back into the guiding catheter, which will collapse the self-expanding injector tubes. If the device is balloon expandable deflate the balloon and retract back into the guiding catheter.   In some cases, one may rotate the CAS 20-90 degrees and then repeat the injection if needed to make an even more definitive ring of ablation.   The same methods as per prior steps can be repeated to ablate tissue around the one or more of the other pulmonary veins during the same procedure, as indicated to ensure AF inhibition.   Remove the CAS from the guiding catheter completely.   When indicated, advance appropriate diagnostic electrophysiology catheters to confirm that the ablation has been successful.   Remove all remaining apparatus from the body.   A similar approach can be used with the CAS, via access from a peripheral artery such as the femoral artery, to treat hypertension, via ablation of tissue in the periostial aortic wall tissue surrounding one or both of the renal arteries, with the goal of ablating afferent and/or efferent sympathetic nerve fibers entering or exiting the kidney.       
 
         [0043]    It is also envisioned that two or more of the legs/injector tubes may be connected to an electrical or RF field source to allow for electrical discharge or RF ablation to enable tissue ablation of the tissue in the ostial wall. 
         [0044]    It is also envisioned that one could mount injector tubes with needles on the outer surface of an expandable balloon on the CAS in order to deliver 2 or more needles around the circumference of the ostium of a target vessel to inject ablative fluid to the ostial wall. 
         [0045]    In this case, the distal portion of the balloon could include the centering means of a cylindrical or conical shape. This embodiment could also include an elastic band covering the injector tubes where the elastic band could both help maintain a smooth outer surface of the CAS to facilitate delivery as well as act as the penetration limiting member to limit the penetration of the injection needles. 
         [0046]    Thus it is an object of the present invention CAS is to have a percutaneously delivered catheter that can be used to treat atrial fibrillation with a one, or more injections of an ablative fluid into the wall of the left atrium surrounding one or more pulmonary vems. 
         [0047]    Another object of the present invention CAS is to have a percutaneously delivered catheter that can be used to treat hypertension with one, or more injections of an ablative fluid into the wall of the aorta surrounding a renal artery. 
         [0048]    Still another object of the present invention CAS is to have a percutaneously delivered catheter that includes a multiplicity of circumferentially expandable injector tubes, each tube having a needle at its distal end for injection of an ablative fluid into the ostial wall of a target vessel. 
         [0049]    Still another object of the present invention CAS is to have a centering means located at or near the catheter&#39;s distal end. The centering means designed to allow the injector to be centered on the target vessel so that the injected ablative fluid will form an ablative ring outside of the ostium of the target vessel. The centering means can be fixed or expandable, and may include a cylindrical or conical portion. 
         [0050]    Another object of the invention is to have a penetration limiting member or means attached to the distal potion of the injector leg or as part of the distal portion of the CAS in order to limit the depth of needle penetration into the ostial wall. 
         [0051]    Yet another object of the present invention CAS is to have one or more of the injector needles act as diagnostic electrodes for measurement of electrical activity within the ostial wall of the target vessel. 
         [0052]    These and other objects and advantages of this invention will become obvious to a person of ordinary skill in this art upon reading of the detailed description of this invention including the associated drawings. 
     
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         [0053]      FIG. 1  is a three dimensional sketch of the distal end of the present invention Circular Ablation System (CAS). 
           [0054]      FIG. 2  is a longitudinal cross sectional drawing of the distal end of the CAS. 
           [0055]      FIG. 3  is a longitudinal cross sectional drawing showing area  3  of  FIG. 2  which is the distal end of the self-expanding injector leg, injector needle and penetration limiter. 
           [0056]      FIG. 4  is a longitudinal cross sectional drawing showing area  4  of  FIG. 2  which is the proximal end of the self-expanding injector legs and how they are in fluid communication with the injection lumen of the CAS. 
           [0057]      FIG. 5  is a three dimensional sketch showing the CAS with centering balloon expanded. 
           [0058]      FIG. 6A  is a three dimensional sketch showing the CAS with legs collapsed inside the distal end of a guiding catheter as the distal end of the CAS is inserted into the target vessel. 
           [0059]      FIG. 6B  is a three dimensional sketch showing the CAS after the CAS centering means has been expanded and the guiding catheter has been pulled back (retracted) allowing the self-expanding legs to expand. 
           [0060]      FIG. 6C  is a three dimensional sketch showing the CAS now advanced in the distal direction until the injector needles penetrate the ostial wall and the penetration limiters on each needle limit the penetration as they touch the ostial wall. In this configuration an ablative substance such as alcohol is injected into the ostial wall through the needles causing a complete circular ablation of tissue in the ostial wall in a ring surrounding the target vessel. 
           [0061]      FIG. 6D  shows target vessel and ostial wall after the CAS and guiding catheter have been removed from the body and the ablated tissue in the ostial wall remains. 
           [0062]      FIG. 6E  is a three dimensional sketch showing the overlapping area of ablation in the ostial wall that form a circle around the ostium of the target vessel. 
           [0063]      FIG. 7  is a longitudinal cross sectional drawing of the proximal end of the present invention CAS. 
           [0064]      FIG. 8  is a longitudinal cross sectional drawing of an alternative version of the injector needle and penetration limiting means. 
           [0065]      FIG. 9  is a longitudinal cross section of the CAS with the injector needle of  FIG. 8  with the injector tubes shown collapsed inside the introducer tube used to insert the CAS into the proximal end of a guiding catheter or sheath; and 
           [0066]      FIG. 10  is a three dimensional sketch of an other embodiment of the CAS that uses a balloon to expand the expandable injector tubes used to deliver the ablative substance to the ostial wall of the target vessel. 
       
    
    
     DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENT 
       [0067]      FIG. 1  is a three dimensional sketch of the distal end of the present invention Circular Ablation System (CAS)  10  in its state before it is loaded into a guiding catheter or sheath for delivery over the guide wire  20  into a human being. The proximal portion of the CAS  10  includes three tubes, an outer tube  12 , a middle tube  14  and an inner tube  18 . The guidewire  20  can be slidably advanced or removed through the guide wire lumen  13  inside of the inner tube  18 . An expandable cylindrical balloon  16  is attached at its proximal end to the middle tube  14  and at its distal end to the inner tube  18 . The balloon inflation lumen is located between the inner tube  18  and the middle tube  14 . The balloon  16  can be inflated by injection of a fluid through the balloon inflation lumen and deflated by applying suction to the balloon inflation lumen. 
         [0068]    A injector transition manifold  11  is sealed onto the outside of the middle tube  14 . The outer tube  12  is sealed at its distal end onto the outside of the injector transition manifold  11 . The expandable injector tubes  15  are attached at their proximal end to or through the injector transition manifold  11  so that the proximal lumen of the injector tubes  15  are in fluid communication with the fluid injection lumen  22  that lies between the middle tube  14  and the outer tube  12 . The injector tubes  15  could be made of a springy metal such as L605 or the preferred embodiment being made from a memory metal such as NITINOL. A plastic hub  17  is attached to the distal end of each injector tube  15 . An injector needle  19  extends distally from the distal end of each plastic hub  17 . The lumen of each injector needle  19  is in fluid communication with the lumen of the expandable injector tube (leg)  15 . Each hub  17  acts as a penetration limiting member to limit the penetration of the distally attached needle  19  into the ostial wall of the target vessel. In this embodiment it is envisioned that the penetration of the needles  19  would be limited to pre-set distance, for example the distance might be between 0.5 mm and 1 cm. 
         [0069]      FIG. 2  is a longitudinal cross sectional drawing of the distal end of the CAS  10  in its state before it is loaded into a guiding catheter or sheath for delivery over the guide wire  20  into a human being. The proximal portion of the CAS  10  includes three tubes, an outer tube  12 , a middle tube  14  and an inner tube  18 . The guidewire  20  can be advanced or removed through the guide wire lumen  13  inside of the inner tube  18 . An expandable cylindrical balloon  16  is attached at its proximal end to the middle tube  14  and at its distal end to the inner tube  18 . The balloon  16  may be either an elastic balloon or a folded inelastic balloon such as is used for angioplasty. The proximal end of the balloon  16  is attached to the middle tube  14  and the distal end of the balloon  16  is attached to the inner tube  18  such that the area under the balloon  16  is in fluid communication with the balloon inflation lumen  24  that lies between the middle tube  14  and the inner tube  18 . The balloon  16  can be inflated by injection of a fluid or gas through the balloon inflation lumen  24  and deflated by applying suction to the balloon inflation lumen  24 . Normal saline solution including a fluoroscopic contrast agent would be the typical fluid used to inflate the balloon  16 . 
         [0070]    The injector transition manifold  11  is sealed onto the outside of the middle tube  14 . The outer tube  12  is sealed at its distal end onto the outside of the injector transition manifold  11 . The expandable injector tubes  15  are attached at their proximal end through the injector transition manifold  11  so that the proximal lumen of the injector tubes  15  are in fluid communication with the fluid injection lumen  22  that lies between the middle tube  14  and the outer tube  12 .  FIG. 4  shows an expanded version of the area  4  of  FIG. 2 . The injector tubes  15  could be made of a springy metal such as L605 or the preferred embodiment being made from a memory metal such as NITINOL. A plastic hub penetration limiter  17  with flattened distal end to act as a means of limiting the penetration of the needle  19  is attached over the distal end of each of the 8 expandable injector tubes  15 . An injector needle  19  extends distally from the distal end of each plastic hub  17 . The lumen of each injector needle is in fluid communication with the lumen of the expandable injector tube  15 . 
         [0071]      FIG. 3  is an enlarged longitudinal cross sectional drawing showing area  3  of  FIG. 2  which is the distal end of the self-expanding injector tube  15  with injector tube lumen  21 , injector needle  19  and penetration limiter  17 . While  FIG. 3  shows the limiters  17  as being symmetric around the injector tube  15 , it is also envisioned that an asymmetric penetration limiter, for example a limiter with significant material only on the inside might be preferable as it would be less likely to catch on a guiding catheter when the CAS  10  is advanced through or retracted back into the guiding catheter at the end of the procedure. 
         [0072]      FIG. 4  is an enlarged longitudinal cross sectional drawing of the CAS  10  showing area  4  of  FIG. 2  which is the proximal end of the self-expanding injector tubes  15  with lumens  21 .  FIG. 4  shows detail on how the lumens  21  of the injector tubes  15  are in fluid communication with the injection lumen  22  of the CAS  10 . Specifically, the proximal section of each injector tube  15  is inserted through a hole in the injector transition manifold  11  and fixedly attached and sealed to the manifold  11  so that the proximal end of the each tube  15  has its proximal end and opening in fluid communication with the injector lumen  22  that lies between the outer tube  12  and the middle tube  14  of the CAS  10 . As another way of achieving this structure it is also conceived that the injector manifold  11  might be a single piece of plastic molded over the proximal ends of the injector tubes  15  in a molding operation prior to assembly. 
         [0073]      FIG. 5  shows a three dimensional sketch showing the CAS  10 ′ with centering balloon  16 ′ expanded. Also shown are the outer tube  12 , middle tube  11  and inner tube  18  with guidewire  20 . The injector tubes  15  protrude in the distal direction from the distal end of the injector manifold  11  and have hubs  17  (penetration limiting members) with injector needles  19  at their distal end. The expanded balloon  16 ′ should be inflated to be just slightly less than the diameter of the target vessel. This will allow it to act as a centering means without causing undue injury to the target vessel wall. Ideally, the balloon  16 ′ would be a low pressure elastic balloon where the diameter can be adjusted by using the appropriate pressure to inflate the balloon  16 ′ through the balloon inflation lumen  24 . It is also conceived that the CAS  10 ′ would have a non-compliant or semicompliant molded folded balloon with a limited diameter range vs. pressure such as is used in an angioplasty balloons. 
         [0074]      FIG. 6A  is a three dimensional sketch showing the CAS  10  with injector tubes  15  collapsed inside the distal end of a guiding catheter  30  as the distal end of the CAS  10 ′ is inserted into the target vessel over the guide wire  20 . The distal end of the guiding catheter  30  would normally first be placed inside of the ostium of the target vessel (engaged) and is shown here slightly back from the ostium as it would be during the first part of its distal retraction. From the position shown in  FIG. 6A , the guiding catheter  30  is pulled back (retracted) in the proximal direction allowing the self expanding injector tubes  15  to spring open to their open position. The extent of leg expansion could be adjusted (limited and smaller) in vivo by not fully retracting the guiding catheter, thus modestly constraining the expanded dimension of the expandable tubes  15 . 
         [0075]      FIG. 6B  is a three dimensional sketch showing the CAS  10 ′ after the guiding catheter has been pulled back and the inflatable balloon  16 ′ has been expanded with the guide wire  20  still lying within the target vessel. From this state, the CAS  10 ′ with expanded balloon  16 ′ is advanced in the distal direction until the needles  19  penetrate the ostial wall surrounding the target vessel. Engagement of the ostial wall could be confirmed by injection of a small volume of iodinated contrast through the needles, prior to injection of the “ablative” fluid such as alcohol. 
         [0076]      FIG. 6C  is a three dimensional sketch showing the CAS  10 ″ now advanced in the distal direction with the injector needles  19  fully penetrating the ostial wall and the penetration limiting members (hubs)  17  on each needle limiting the penetration as they touch the ostial wall. In this configuration an ablative substance such as ethanol is injected into the ostial wall through the needles  19 . The ablative fluid will disperse from the needles and as more ablative fluid is injected, the area of fluid dispersion shown in  FIG. 6C  will increase so as to eventually cause a complete circular ablation of tissue in the ostial wall in a ring surrounding the target vessel. The balloon  16 ′ is then deflated and the CAS  10  is pulled back in the proximal direction until the needles  19  are no longer penetrating the ostial wall. The CAS  10  is then pulled back more in the proximal direction into the distal end of the guiding catheter  30  which will collapse the selfexpanding injector tubes  15 . At this point the guide wire  20  may be advanced into another target vessel and the ablation procedure repeated. After the last target vessel is treated, the CAS  10  can then be removed from the patient&#39;s body. At this point electrophysiology catheters may be introduced through the guiding catheter to verify the success of the procedure. 
         [0077]      FIG. 6D  shows target vessel and ostial wall after the CAS  10  and guiding catheter have been removed from the body and the ablated tissue in the ostial wall remains. 
         [0078]      FIG. 6E  is a three dimensional sketch showing a representation of the overlapping areas of ablation in the ostial wall from each needle  19  that form a ring around the ostium of the target vessel after the procedure using the CAS  10  has been completed. While  FIG. 6E  shows overlapping circles to highlight the ablation from each needle  19 , in reality because ethanol disperses readily in tissue, the circles would actually blend together. 
         [0079]      FIG. 7  is a longitudinal cross sectional drawing of the proximal end of the present invention CAS  10 . The proximal end of the inner tube  18  is attached to a Luer fitting  38  that can be used to inject fluid to flush the guide wire lumen  13  inside of the inner tube  18 . The guide wire  20  is inserted through the guide wire lumen  13 . The proximal end of the middle tube  14  is attached to the side tube  34  with lumen  36 . The proximal end of the side tube  34  is attached to the Luer fitting  36  which can be attached to a syringe or balloon inflation device to inflate and deflate the balloon  16  of  FIGS. 1 and 2 . The lumen  36  is in fluid communication with the balloon inflation lumen  24  that lies between the middle tube  14  and the inner tube  18 . The proximal end of the outer tube  12  is connected to the distal end of the side tube  32  with lumen  33 . The side tube  32  is connected at its proximal end to the Luer fitting  31  that can be connected to a syringe or fluid injector to inject an ablative substance such as ethanol through the lumen  33  into the injection lumen  22  through the injector tubes  15  and out the needles  19  into the ostial wall of the target vessel. Additional valves and stopcocks may also be attached to the Luer fittings  35  and  31  as needed. 
         [0080]      FIG. 8  is a longitudinal cross sectional drawing of an alternative version of the injector needle  49  of the CAS  40  with two differences from that shown in  FIG. 3 . First, here the injector needle  49  is the sharpened distal end of the self-expanding tube  45  with injector tube lumen  41  while in  FIG. 3  the self-expanding tube  15  was attached to a separate injector needle  19  with lumen  21 . The penetration limiting means of this embodiment is the limiter  50  with tubular section  52  that is attached to the outside of the tube  45  with self-expanding legs  57 A and  57 B that will open up as the CAS  40  is deployed. The limiter  50  would typically be made from a single piece of NITINOL preset into the shape shown with at least 2 self-expanding legs. The major advantage if this design is that the penetration limiting means takes up very little space within the guiding catheter used for device delivery making it easier to slide the CAS  40  through the guiding catheter. Although two legs  57 A and  57 B are shown it is conceived that 1, 3, 4 or more legs could be attached to the tube  45  to act as a penetration limiting member or means when the needle  49  is advanced to penetrate the ostial wall of the target vessel. 
         [0081]      FIG. 9  is a longitudinal cross section of the distal portion of the CAS  40  with the injector needle  49  and limiter  50  of  FIG. 8  with the injector tubes  45  shown collapsed inside an insertion tube  60  with handle  65  used to insert the CAS  40  into the proximal end of a guiding catheter or sheath. This is how the CAS  40  would be typically packaged although the insertion tube  60  might be packaged proximal to the injector tubes  15  where the insertion tube  60  would be slid in the distal direction to collapse the injector tubes  15  just before the CAS  40  is inserted in the guiding catheter or sheath. Such an insertion tube  60  could be used with all of the embodiments of the present invention disclosed herein. The steps to prepare it for use would be as follows:
       1. Remove the sterilized CAS  40  from its packaging in a sterile field.   2. Flush the guide wire lumen  13  with saline solution.   3. Access to the left atrium via a large peripheral vein, such as the femoral vein, typically with the insertion of a sheath.   4. Use a trans septal approach to get into the left atrium, via the vein, to the right atrium, to enter the left atrium. This approach is a well known procedure.   5. Advance a guide wire and guiding catheter across the inter-atrial septum into the left atrium.   6. Using a guiding catheter or guiding sheath with a shaped distal end, engage the first targeted pulmonary vein. This can be confirmed with contrast injections as needed.   7. Advance a guide wire through the guiding catheter into the pulmonary vein.   8. Insert the proximal end of the guide wire into the guide wire lumen  13  of the CAS  40  and bring the wire through the CAS  40  and out the proximal end Luer fitting  38  of  FIG. 7 .   9. Place the distal end of an insertion tube  60  which constrains the distal end of the CAS  40  into the proximal end of the guiding catheter. There is typically a TuohyBorst fitting attached to the distal end of a guiding catheter to constrain blood loss. The insertion tube  60  can be pushed through the opened Tuohy-Borst fitting and the Tuohy-Borst fitting closed on its outside to hold it in place.   10. Advance the distal end of the CAS  40  out of the insertion tube  60  and into the guiding catheter.   11. Advance the CAS  40  (or  10 ) through the guiding catheter  30  of  FIG. 6A , and tracking over the guide wire  20 , until the unexpanded tubes  45  (or  15 ) are located just proximal to the distal end of the guiding catheter  30 . This is shown in  FIG. 6A .   12. Advance the CAS  40  or  10  over the guide wire  20  until the balloon  16  used for centering is within the target vessel.   13. Expand the balloon  16  used for centering until it is just slightly less (1-4 mm less) than the diameter of the target vessel. This will ensure that the distal portion of the CAS  40  or  10  will be roughly “centered” within the target vessel to enable the circumferential deployment of the expandable tubes  45  or  15  centered around the target vessel ostium so that injection into the ostial wall will be centered around the ostium of the target vessel.   14. Pull back the guiding catheter  30  so that the self-expanding injector tubes  15  open. The circumference of the tube  15  expansion can be adjusted in vivo by varying the distance of the pullback of the guiding catheter  30 . That is, if one wants a smaller diameter (circumference) of expansion to fit the ostial dimension of that specific target vessel, one can partially constrain the injector tube  15  expansion by not fully retracting the guiding catheter  30  beyond the proximal end of the injector tubes  15 . However, the preferred method is to have the final opening distance be preset for the CAS  40  or  10 , with the injector tubes  45  (or  15 ) fully expanded to their maximum diameter governed by their memory shape. Typically the CAS  40  or  10  maximum diameter of the injector tubes  15  would be pre-selected based on the anticipated or measured diameter of the ablation ring to be created, such that the fully expanded injector tubes create the correctly sized ablation “ring.” This step is portrayed in  FIG. 6B .   15. Advance the CAS  40  or  10  until the injector needles in the self-expanding injector tubes  45  (or  15 ) penetrate the ostial wall, as seen in  FIG. 6C  with the penetration depth being a fixed distance limited by the penetration limiting members  17  of  FIG. 6C  or  50  of  FIGS. 8 and 9 .   16. Attach a syringe or injection system to the Luer fitting  35  of  FIG. 7 .   17. Prior to injection of the “ablative” fluid such as alcohol engagement of the ostial wall could be confirmed by injection of a small volume of iodinated contrast via a syringe through the Luer fitting  35  and out of the needles  49  or  19  of  FIG. 6C . If there is contrast “staining” of the tissue this will confirm that the needles  49  or  19  are engaged into the tissue and not free floating in the left atrium or aorta.   18. Inject an appropriate volume of ethanol (ethyl alcohol) or other appropriate cytotoxic fluid from the syringe or injection system through the catheter and out of the needles  49  or  19  into the ostial wall. A typical injection would be 1-10 ml. This should produce a multiplicity of interlocking circles of ablation (one for each needle) that will run together and intersect to form a ring or ablated tissue around the ostium of the target vessel as is seen in  FIG. 6E .   19. In some cases, one may rotate the CAS 20-90 degrees and then repeat the injection to make an even more definitive ring of ablation.   20. Retract the CAS  40  or  10  back into the guiding catheter  30  which will collapse the self-expanding injector tubes  45  or  15 .   21. The same methods as per steps 6-19 can be repeated to ablate tissue around the one or more of the other pulmonary veins during the same procedure, as indicated to ensure AF ablation or the 2nd Renal artery in the treatment of hypertension.   22. Remove the CAS  40  (or  10 ) from the guiding catheter  30  completely pulling it back into the insertion tube  60 . Thus if the CAS  40  (or  10 ) needs to be put back into the body it is collapsed and ready to go.   23. When indicated, advance appropriate diagnostic electrophysiology catheters through the guiding catheter to confirm that the ablation has been successful.   24. Remove all remaining apparatus from the body.       
 
         [0106]    A similar approach can be used with the CAS, via access from a peripheral artery such as the femoral artery, to treat hypertension, via ablation of tissue in the periostial aortic wall tissue surrounding one or both of the renal arteries, with the goal of ablating afferent and/or efferent sympathetic nerve fibers entering or exiting the kidney. 
         [0107]    While the proximal end of the metallic injector tubes  15  and  45  shown here terminate in the injector manifold  11 , it is also envisioned that these tubes could connect to wires that run to the proximal end of the CAS to allow the injector needles  19  and  49  to act as electrodes for sensing signals from the ostial wall of the target vessel as well as potentially delivering electrical stimulation or higher voltages and currents to ablate the tissue in the ostial wall by electrical or RF ablation. 
         [0108]      FIG. 10  is a three dimensional sketch of an other embodiment of the CAS  70  that uses a balloon  76  to expand the expandable injector tubes  75  used to deliver the ablative substance to the ostial wall of the target vessel through the injection needles  79 . The  8  injector tubes  75  connect to the manifold  71  that is free to slide distally and proximally along the catheter outer tube  74  as the balloon  76  is inflated and deflated. The manifold  71  connects the lumens of the injector tubes  75  to the tube  72  with fluid injection lumen  81 . The tube  72  connects to a fitting at the proximal end of the CAS  70  such as the Luer fitting  33  of  FIG. 7 . A source of ablative fluid would attached to the fitting and be used to inject the ablative fluid through the fluid injection lumen  81  of the tube  72  into the expandable tubes  75  and out the injection needles  79  into the ostial wall of the target vessel. The balloon  76  is inflated and deflated by delivery of a fluid through the lumen formed between the outer tube  74  and the inner tube  78 . The proximal shaft  84  of the balloon  76  is attached to the outside of the outer tube  74  and the distal shaft  82  of the balloon  76  is attached to the outside of the inner tube  78 . The inside of the inner tube  78  provides a guide wire lumen  85  for the guide wire  20 . The distal end of the inner tube  78  includes a radiopaque marker  73  to assist in visualizing the distal end of the CAS  70  as it is inserted into the target vessel. The balloon  76  includes a distal shaft  82 , a proximal shaft  84 , a proximal conical section  87 , a central cylindrical section  88 , and a distal conical section  89 . The injector tubes  74  are attached to the outside of the central cylindrical section  88  of the balloon  76  and are also held by the expandable band  77  that covers the outside of the injector tubes  75  and the central cylindrical section  88  of the balloon  76 . While the expandable band  77  is shown in  FIG. 10  as covering only the central cylindrical portion  88  of the balloon  76 , it is envisioned that it might also extend in the proximal direction to cover the injector tubes  75  over their entire length proximal to the needles  79  which would make a smoother outer surface of the CAS  70  over this portion. The needles  79  extend in the distal direction from the distal end of the injector tubes  75  and may be made of a standard needle material such as stainless steel or a more radiopaque material such as tantalum or tungsten or plated with a radiopaque material such as gold or platinum. The expandable band  77  also serves the purpose for the CAS  70  of being the penetration limiting member located proximal to the distal end of each needle  70  that only allows each needle  70  to penetrate a preset distance into the ostial wall of the target vessel. In this embodiment the penetration limiting member  77  should limit needle penetration to a depth between 0.5 mm and 1 em. It is also envisioned that the entire CAS  70  could be covered by a sheath (not shown) that would protect the needles  79  from coming into contact with the inside of the guiding catheter used to delivery the CAS  70  to the target vessel. The sheath would be slid back in the proximal direction once the CAS  70  is positioned with the guide wire  20  within the target vessel. The CAS  70  can also be used with an insertion tube  60  as shown in  FIG. 9 . 
         [0109]    The balloon  76  can be either an elastic balloon or a semi-compliant or non-compliant balloon such as used in angioplasty catheters. Such a balloon is typically inflated with normal saline solution including a contrast agent. 
         [0110]    It is also envisioned that the best way to protect the needles  79  of the CAS  70  would be to have an elastic band (not shown in  FIG. 10 ) attached to the distal shaft of the balloon  82  or the inner tube  78  (or both) cover the distal ends of the needles  79  in the pre-deployment condition. Inflation of the Balloon  76  would pull the needles  79  in the proximal direction out from under such an elastic band. Such an elastic band would prevent the needles  79  from catching on the inside of the guiding catheter as the CAS  70  is advanced into the body. 
         [0111]    For this embodiment of the CAS  70 , the method of use would be the following steps:
       1. Remove the sterilized CAS  70  from its packaging in a sterile field.   2. Flush the guide wire lumen  85  with saline solution.       
 
         [0114]    Access to the left atrium via a large peripheral vein, such as the femoral vein, typically with the insertion of a sheath. 
         [0115]    Use a trans septal approach to get into the left atrium, via the vein, to the right atrium, to enter the left atrium. This approach is a well known procedure. 
         [0116]    Advance a guide wire and guiding catheter across the inter-atrial septum into the left atrium. 
         [0117]    Using a guiding catheter or guiding sheath with a shaped distal end, engage the first targeted pulmonary vein. This can be confirmed with contrast injections as needed. 
         [0118]    Advance a guide wire through the guiding catheter into the pulmonary vein. 
         [0119]    Insert the proximal end of the guide wire  20  into the guide wire lumen  85  of the CAS and bring the wire  20  through the CAS  70  and out the proximal end Luer fitting  38  of  FIG. 7 . 
         [0120]    Place the distal end of an insertion tube  60  of  FIG. 9  which constrains the distal end of the CAS  70  into the proximal end of the guiding catheter. There is typically a Tuohy-Borst fitting attached to the distal end of a guiding catheter to constrain blood loss. The insertion tube  60  can be pushed through the opened Tuohy-Borst fitting and the Tuohy-Borst fitting closed on its outside to hole it in place. 
         [0121]    Advance the distal end of the CAS  70  out of the insertion tube  60  and into the guiding catheter. 
         [0122]    Advance the CAS  70  through the guiding catheter, and tracking over the guide wire  20 , until the distal marker band  73  is located just proximal to the distal end of the guiding catheter. 
         [0123]    Advance the CAS  70  over the guide wire  20  until the marker band  73  is within the target vessel and the distal shaft  82  of the balloon  76  is just proximal to the target vessel. 
         [0124]    Pull the guiding catheter back so that the balloon  76  is now distal to the distal end of the guiding catheter. 
         [0125]    Inflate the balloon  76  until it is the appropriate diameter which is between 1 and 10 mm larger in diameter than the target vessel. 
         [0126]    Advance the CAS until the injector needles in the injector tubes  75  penetrate the ostial wall, with the penetration depth being a fixed distance limited by the expandable band  77 . The distal conical section of the balloon  76  will act to center the CAS  70  as it is advanced into the target vessel. 
         [0127]    Attach a syringe or injection system to the Luer fitting  35  of  FIG. 7  that provides ablative fluid that will be injected into the ostial wall. 
         [0128]    Engagement of the ostial wall could be confirmed by injection of a small volume of iodinated contrast via a syringe through the Luer fitting  35  and out of the needles  79  prior to injection of an “ablative” fluid such as alcohol. If there is contrast “staining” of the tissue this will confirm that the needles  79  are engaged into the tissue and not free floating in the left atrium or aorta. 
         [0129]    Inject an appropriate volume of ethanol (ethyl alcohol) or other appropriate cytotoxic fluid from the syringe or injection system through the lumen  81  of the tube  82  and out of the needles  79  into the ostial wall. A typical injection would be 1-10 ml. This should produce a multiplicity of interlocking circles of ablation (one for each needle) that should intersect to form a ring around the ostium of the target vessel as is seen in  FIG. 6E . 
         [0130]    Deflate the balloon  76  and retract the CAS  70  back into the guiding catheter. 
         [0131]    In some cases, one may rotate the CAS  70  between 20-90 degrees and then repeat the injection to make an even more definitive ring of ablation. 
         [0132]    The same methods as per steps 6-20 can be repeated to ablate tissue around the one or more of the other pulmonary veins during the same procedure, as indicated to ensure AF ablation or the 2nd Renal artery in the treatment of hypertension. 
         [0133]    Remove the CAS  70  from the guiding catheter completely pulling it back into the insertion tube  60 . Thus if the CAS  70  needs to be put back into the body it is collapsed and ready to go. 
         [0134]    When indicated, advance appropriate diagnostic electrophysiology catheters through the guiding catheter to confirm that the ablation has been successful. 
         [0135]    Remove all remaining apparatus from the body. 
         [0136]    A similar approach can be used with the CAS  70 , via access from a peripheral artery such as the femoral artery, to treat hypertension, via ablation of tissue in the periostial aortic wall tissue surrounding one or both of the renal arteries, with the goal of ablating afferent and/or efferent sympathetic nerve fibers entering or exiting the kidney. 
         [0137]    While the CAS  70  shows a separate tube  72  it is envisioned the fluid injection lumen of the CAS  70  catheter body could be constructed similar to that of the CAS  10  of  FIGS. 1-5  where an additional outer tube would be placed with the fluid injection lumen being between the outer and middle tubes. It is also envisioned that instead of concentric tubes with lumens between the tubes, a multi-lumen catheter could be used with separate lumens formed during extrusion of the catheter body. Similarly, while the shape of the tubes and lumens shown here are cylindrical, other shapes are also envisioned. 
         [0138]    While the present invention described here has an expandable balloon as a centering means, it is envisioned that a fixed diameter centering section could be used or a mechanical expandable structure could also facilitate centering of the CAS. While the version of the CAS shown here is an over the wire design, it is also envisioned that a rapid exchange guide wire system where the wire exits the catheter body at a location between the proximal end and the fluid injection ring would be feasible here. In addition, a fixed wire design such as that shown by Fischell et al in U.S. Pat. No. 6,375,660 for a stent delivery catheter would also work here. 
         [0139]    Various other modifications, adaptations, and alternative designs are of course possible in light of the above teachings. Therefore, it should be understood at this time that within the scope of the appended claims the invention may be practiced otherwise than as specifically described herein.