text:
|Publication number
|Publication type
|Application number
|Publication date
|Feb 27, 2007
|Filing date
|Dec 20, 2002
|Priority date
|Dec 20, 2001
|Fee status
|Also published as
|Publication number
|Russell A. Houser, William D. Hare
|Original Assignee
|Russell A. Houser
|Export Citation
|BiBTeX, EndNote, RefMan
|Patent Citations (42), Referenced by (98), Classifications (15), Legal Events (4)
|External Links: USPTO, USPTO Assignment, Espacenet
This application claims priority from U.S. Provisional Patent Application 60/341,160 filed on Dec. 20, 2001 and titled Vascular Connectors, Techniques, Methods, and Accessories; 60/369,835 filed on Apr. 5, 2002 and titled Vascular Couplers, Techniques, Methods, and Accessories; 60/381,805 filed on May 21, 2002 and titled Vascular Couplers, Techniques, Methods, and Accessories; 60/385,216 filed on May 31, 2002 and titled Anastomic Coupler with Valve; 60/394,793 filed on Jul. 9, 2002 and titled Sutured Anastomotic Coupler Device and Method of Use; 60/399,710 filed on Aug. 1, 2002 and titled Vascular Couplers, Techniques, Methods, and Accessories; 60/408,032 filed on Sep. 3, 2002 and titled Vascular Couplers, Techniques, Methods, and Accessories; and 60/428,509 filed on Nov. 22, 2002 and titled Vascular Couplers, Techniques, Methods, and Accessories.
The field of the inventions generally relates to cardiovascular and vascular devices, and, more particularly, to vascular couplers.
Cardiovascular diseases are typically treated pharmacologically, using interventional cardiology, and surgically. For example, interventional, catheter-based treatments include percutaneous transluminal coronary angioplasty ("PTCA") with an angioplasty balloon to compress plaque to the wall of a coronary vessel, placement of a stent in a vessel to maintain the patency of the vessel, and atherectomy to use a cutting instrument to shave off and remove plaque from the lumen of the vessel. Surgical treatments include coronary artery bypass grafting procedures using cardiopulmonary support, beating heart techniques, minimally invasive approach, and robotically assisted instruments. In these procedures, the surgeon may use traditional, endoscopic, and/or laparoscopic instruments. In traditional coronary artery bypass grafting, the surgeon uses sutures to anastomose a synthetic or natural bypass vessel to, for example, the aorta at one end and a coronary artery at the other end, or from the internal mammary artery ("IMA") to a coronary artery. To form an anastomosis between an internal mammary artery and a coronary artery, blood flow through the internal mammary artery must be temporarily stopped, typically by applying a removable clamp to the mammary artery. The mammary artery is then severed downstream from the clamp to create a free end. An incision is created in the target coronary artery downstream of the blockage. The free end of the mammary artery can then be connected to the incision in the coronary artery, typically by suturing, such that blood can flow from the mammary artery through the incision into the coronary artery. Typical traditional coronary artery bypass grafting procedures involve aortic clamping and a procedure time of approximately ten to twenty minutes per anastomosis.
Some of the other devices used in beating heart and/or minimally invasive surgical treatments are produced by companies that include Converge Medical, Inc. (formerly Advanced Bypass Technologies, Inc.), By-Pass, Cardica (formerly Vascular Innovations), Coalescent Surgical, Corvascular, Ethicon, HeartPort, Heart-Tech, Intellicardia, Onux Medical, Origin MedSystems, Inc. (Guidant), St. Jude Cardiovascular Group (including Vascular Science), Sulzer Carbomedics, Vasconnect, and Ventrica.
In one general aspect, a coupler configured to connect a first tubular vessel to an aperture in a second tubular vessel. The coupler includes one or more radially extending members and a substantially nonmetallic tubular member. The substantially nonmetallic tubular member comprising an outer wall, an inner wall defining a lumen having an open distal end and an open proximal end, and a circumferential ridge encircling the outer wall, the radially extending members extending from the distal end of the tubular member.
Embodiments of the coupler may include one or more of the following features. For example, the extending member may include a first segment and a second segment, the first segment being at an angle of 90� or less with respect to the second segment, the first segment extending from the tubular member. The second segment defines a region that is wider than a region defined by the first segment. The extending member may include a nickel titanium alloy and/or 17-7PH stainless steel. The proximal end of the tubular member may include a strain relief.
The coupler may further include at least one securing member mounted to the distal end of the tubular member, the securing member including a first segment positioned adjacent to the inner wall, a second segment positioned against the outer wall, and a third segment connecting the first segment and the second segment.
The coupler may further include at least one securing member mounted to the distal end of the tubular member, the securing member including a first segment positioned adjacent to the inner wall, a second segment positioned within the wall between the inner wall and the outer wall, and a third segment connecting the first segment and the second segment. The coupler may further include a gasket extending from the distal end of the tubular member, the radially extending members extending from the gasket. The tubular member may include one or more of silicone, ePTFE, polyurethane, and polyisoprene.
The coupler may further include a gasket extending from the distal end of the tubular member and a strain relief extending from the proximal end of the tubular member. The tubular member, the ridge, the gasket, and the strain relief are an integral unit.
In another general aspect, a method of fabricating a coupler the method including fabricating radially extending members; placing the radially extending members within a mold; injecting a material into the mold; allowing the material to cure to form the coupler; and removing the coupler from the mold. The coupler includes a tubular member having an outer wall, an inner wall defining a lumen having an open distal end and an open proximal end, and a circumferential ridge encircling the outer wall. The radially extending members extend from the distal end of the tubular member.
Embodiment of the method may include one or more of the following. For example, the method may further comprise inserting one or more securing members at least partially within the mold. Fabricating the radially extending members comprises chemically etching a sheet of a metal alloy. Fabricating the radially extending members further comprises one or more of forming, annealing, chemical polishing, and electropolishing.
Allowing the material to cure to form the tubular member further comprises forming a ridge member around at least a portion of a circumference of the tubular member, forming a strain relief at the proximal end of the tubular member, and forming a gasket at the distal end of the tubular member. The material comprises one or more of silicone, ePTFE, polyurethane, and polyisoprene.
In another general aspect, a method of deploying a coupler includes forming an opening in a wall of a tubular vessel; deflecting the radially extending members into a longitudinally extending configuration; inserting the extending members at least partially into the opening; and releasing the extending members. The coupler includes one or more radially extending members, a substantially nonmetallic tubular member, the tubular member comprising an outer wall, an inner wall defining a lumen having an open distal end and an open proximal end, and a circumferential ridge encircling at least a portion of the outer wall, the radially extending members extending from the distal end of the tubular member.
Embodiments of the method may include one or more of the following features. For example, deflecting the radially extending members into a longitudinally extending configuration further includes deflecting the radially extending members and at least partially inserting the extending members into an opening in a deployment tool, the deployment tool including a handle and a distal plate, the distal plate including the opening. Releasing the extending members further includes placing the plate on the vessel and removing the plate from around the coupler, the removal of the plate allowing the extending members to return to the radially extending configuration.
The couplers described herein enable clampless-bypass surgery. By not utilizing a clamp on the aorta, this method has the potential to significantly reduce the incidence of postoperative cognitive dysfunction (POCD), which occurs in up to approximately 50% of patients undergoing coronary artery bypass grafting (CABG) surgery.
Benefits that can be provided by the vascular couplers described herein include: (1) a coupler system that enables clampless bypass surgery—minimizing aortic manipulation by not requiring cross-clamping or aortic side-biting during coronary artery bypass grafting (CABG); (2) allowing or augmenting radial vessel expansion and contraction similar to a sutured anastomosis; (3) single piece coupler design in which no separate external vessel component (e.g., collar) is required; (4) reinforced anastomosis area (top vessel ridge) for mechanical securing and acute hemostasis; (5) limited foreign material contact with blood or vessel (even with non-everted versions); (6) includes sutureless, sutured or combination versions; (7) includes aortic (proximal), coronary (distal), peripheral and valved versions for completeness; (8) does not enlarge or expand punch hole or arteriotomy during deployment; (9) once deployed, the coupler can ensure that all petals are in contact with the inside vessel wall; (10) no introducer or plunger is required for coupler deployment (although alternative versions may utilize these or similar accessories); (11) ability to employ multiple coupler deployment methods (push in, partially pull out; twist and advance; forward deflected (superelastic) or forward positioned (shape memory) petals during deployment, and allowed to recover to their annealed configuration, etc.); (12) couplers coated and/or embedded with therapeutic materials to positively affect healing; (13) much less costly to use with respect to other current systems because there are fewer components and accessories required; and (14) the coupler system is easy to learn and easy to use.
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In general, the overmolded vascular coupler can be fabricated using multiple, independent petals around which an overmolded component is fabricated. In general, a multi element or multi petal vascular coupler is overmolded with a compliant material, allows for radial expansion and contraction, and functions similarly to a traditional sutured anastomosis because this design allows for pulsatile, compliant, radial motion. To vary or tailor compliance, multiple slots, groves, hinges, reduced wall thickness areas may be formed in between the petal elements, and may increase the radial flexibility/compliance. Moreover, this general design provides for radial compression without a slit through the stem wall, and without the use of a hinge. This design also advantageously provides overlapping vessel-contacting petals because that feature is generally only possible when fabricating the vascular coupler from multiple, independent petals/elements—this is not possible for couplers that are fabricated from a single tube. This design also advantageously allows for the end of the petals extending outwardly from the stem to be larger (i.e., widen) as it extends away from the stem. Using multiple independent petals also allows for complete vessel contact by having overlapping petals at the site of the aortic punch or core site, and the arteriotomy for the coronary anastomosis. These features and advantages are discussed in more detail below.
In general, the overmolded multiple element versions of the vascular coupler is applicable as an aorta vascular coupler, coronary vascular coupler and peripheral vascular coupler. The range of diameters for the vascular couplers can be, for example, between approximately 1.0 mm and 4 mm (or larger for peripheral versions), and can be angled at between approximately 20 and 90 degree angles, or other, and be round, oval or other desired geometry.
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The securing members 145 are generally U-shaped and include an outer arm 170, an inner arm 175, and a connecting portion 180 that connects the outer arm to the inner arm. The outer arm 170 extends along the outer surface of the coupler 125, the connecting portion 180 extends across the distal end 155 of the coupler, and the inner arm 175 extends along and against the vessel 100 in the inner lumen 165 of the coupler. The outer arm 170 and the inner arm 175 include one or more protrusions 185 that, when the arms are compressed against the vessel 100 and the stem 130, provide resistance to pulling the vessel out of the coupler 125. The protrusions 185 can be of any configuration that provides resistance to pulling the vessel out of the coupler. For example, the protrusions can be in the form of a roughened surface or tissue penetrating pins. The securing members 145 can be made of, for example, a biocompatible superelastic, shape memory, or deformable metal or plastic that can be moved from an open position to a closed position. In the open position, the stem 130 and the vessel 100 can be inserted into a gap formed between the outer arm 170 and the inner arm 175. In the closed position, the gap is reduced to compress or hold the position of the vessel 100 relative to the stem 130. Thus, if the securing members 145 are made of a superelastic material, such as Nitinol, the securing members are formed to be in the closed position and the gap formed by exerting a opening force to the arms 170, 175. When that force is removed, the gap is reduced as the arms move towards each other. Similarly, if the securing members are made of a deformable material, a force is applied to close the gap by moving the arms towards each other.
The stem 130 and hemostatic gasket 143 are made of a biocompatible elastic/compliant/flexible material, including ePTFE, silicone, or polyurethane. The stem 130 includes the ridges 135, which extend outwardly from the circumference of the stem circumferentially adjacent to the petals 140. Each petal 140 includes a first arm 190 that is connected to a second arm 195 through a transition region 200. In this embodiment, the second arm has a generally T-shape, although many other shapes also are suitable if they adequately compress the receiving vessel (i.e., the vessel being bypassed) between the ridges 135 and the petals 140. The petals 140 extend from the distal end 155 of the stem 130, the first arm 190 being embedded within the stem 130, the transition region 200 extending from the stem 130 and the second arm generally parallel to the ridges 135. The petals 140 are made from a superelastic/shape memory material, such as Nitinol, a nickel-titanium alloy. In this manner, the petals 140 can be moved from a deflected position to a released position.
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The coupler 125 can be fabricated using many methods known to those of skill in the art. One representative method is described below. In these methods, the petals and securing members may be produced at the same time, either as individual separate components or connected together. Initially, the desired pattern of the petals and securing members is chemically etched onto a flat sheet of superelastic/shape memory material, such as Nitinol. The etching produces the coupler components. The resulting cross section geometry of the parts may be round, oval, square, square with rounded corners, or any other suitable shape. The etched pattern then is bent and/or annealed into a specific shape using a suitable fixture. The ends of the etched pattern then are joined together by using one or more of several methods including, for example, (1) inserting an end that includes a tab into a slot, groove, or hole; and (2) soldering, welding, adhesively bonding, or applying any other suitable joining process to the ends. Alternatively, the section or sections may not be joined, or otherwise attached together. The desired shape is imparted by the bending and/or annealing described above. The design that does not incorporate joining may allow additional flexibility at one or more regions of the coupler.
In the method described above, there are additional optional steps. For example, the etched pattern can be chemically polished or electropolished. In particular, the elements that will come in contact with blood and/or tissue may be polished. If desired or necessary, the etched pattern may be bent and/or annealed using the fixture one or more additional times to better form the elements' shapes and/or to impart a sharp curve or bend that would not be possible to impart with single annealing. Similarly, an etching or grinding process may be used to reduce the thickness of the sheet or other starting material, which additionally removes any unwanted material.
Once the parts are etched, shaped (annealed), electropolished (if desired), and joined, as each of these steps are necessary, the etched and formed pattern then is placed into a mold and overmolded to produce the ridges 135, stem 130, strain relief 150, and hemostatic gasket 205. The coupler 125 next may be coated (e.g., dipped, sprayed, vacuum-assisted impregnation, or other suitable process or method) with a therapeutic or pharmacologic compound or material. The hemostatic gasket may be fabricated in a second, subsequent overmolding step using the same or a different material.
Of course, other methods and steps for fabricating the coupler can be substituted for the above process. For example, alternative machining methods to the chemical etching steps include but are not limited to photo-etching, electron discharge machining (EDM), laser cutting, grinding, traditional cutting. Similarly, alternative substrates or starting materials that can be used instead of the flat sheet include but are not limited to wire, rod, hoop, tube (e.g., having a round, square, or other geometry), coil, strip, or band. Instead of the overmold fabrication method of the stem, strain relief, and ridge, other methods may be used, including but are not limited to extrusion, casting, molding (injection or other), sintering, dip coating, spraying, weaving, laminating, stereo lithography (i.e., 3-D layering).
The vascular couplers described above (i.e., vascular coupler 125) and herein may be made from a variety of materials. For example, the petals may be made of a superelastic or shape memory metal or plastic that can be deformed during deployment to have the cross-sectional profile of the vascular coupler reduced. One example of a suitable superelastic/shape memory metal is Nitinol, a nickel and titanium alloy. Other suitable similar materials include other superelastic metal alloys, including spring stainless steel 17-7 PH, other spring metal alloys such as Elgiloy™, Inconel™, platinum-tungsten alloy, and superelastic polymers. The securing members may be made from the same or different materials as the petals.
The overmolded stem, ridges, and hemostatic gasket may be partially or completely fabricated from many different types of synthetic biocompatible materials, including silicone, polyurethane, polytetrafluoroethylene (PTFE), expanded polytetrafluoroethylene (ePTFE), polyester, Dacron™, Mylar™, polyethylene, PET (Polyethylene terephthalate), polyamide, polyamide, PVC, Kevlar™ (polyaramid), polyetheretherketone (PEEK), polypropylene, polyisoprene, polyolefin, or a composite of these or other suitable materials. Some polymer materials could be irradiated in a desired geometry, for the shape to be "set" into that position. A similar process using heat instead of radiation could be used where the thermoplastic polymer is annealed (and cooled) into a particular shape and geometry.
The stem, ridges, and hemostatic gasket also can be partially or completely made from many different types of biodegradable/bioabsorbable materials, including modified starches, gelatins, cellulose, collagen, fibrin, fibrinogen, elastin or other connective proteins or natural materials, polymers or copolymers such as polylactide [poly-L-lactide (PLLA), poly-D-lactide (PDLA)], polyglycolide, polydioxanone, polycaprolactone, polygluconate, polylactic acid (PLA), polylactic acid-polyethylene oxide copolymers, poly(hydroxybutyrate), polyanhydride, polyphosphoester, poly(amino acids), poly(alpha-hydroxy acid) or related copolymers of these materials, as well as composites and combinations thereof and combinations of other biodegradable/bioabsorbable materials.
Additionally, the stem, ridges, and hemostatic gasket can be partially or completely fabricated from materials that swell or expand when they are exposed to a fluid (such as blood, another body fluid, or an infused fluid). These materials include hydrophilic gels (hydrogels), foams, gelatins, regenerated cellulose, polyethylene vinyl acetate (PEVA), as well as composites and combinations thereof and combinations of other biocompatible swellable or expandable materials.
The stem, securing members, hemostatic gasket, and petals can be configured to have increased biocompatibility and/or blood compatibility, such as by having a textured surface that promotes endothelial cell growth and adhesion.
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Of course, numerous variations of the vascular coupler 125 are within the scope of this patent. For example, referring to
Because the securing members 145 are integrally mounted to the coupler, there is no need to have multiple ridges 135 that are spaced apart around the circumference of the coupler as are necessary to place the securing members 145 to the coupler. Instead, a single ridge 305 can be overmolded and the single ridge configured to encircle the entire circumference of the coupler. However, the single ridge 305 can be configured to encircle less than the entire circumference of the coupler such that the coupler can be curled within itself, as described in greater detail below.
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The coupler 350 is inserted into an opening in a blood vessel using one of a number of methods. For example, the coupler can be inserted using in a push-pull method. In this method, the petal is pressed against the opening in the vessel, which causes the petal to be bent in the direction of the ridge and thereby reduce the petal's diameter. The petal then slips through the opening and the physician pulls back on the coupler, if necessary, to seat it within vessel opening, between the ridge and petals. Alternatively, the petal can be pushed in at an angle such that part of the petal is within the opening and then the rest of the petal pushed in. In another alternative, the petal can be screwed in by putting part of the petal in the opening and then rotating it to place the rest of it within the opening.
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Although using wire or rod petals to minimize the amount of foreign material in the blood provides advantages, the petals may be fabricated from sheets or plates, as described above. For example, referring to
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The above vascular couplers are illustrated showing a 90� angle formed between the stem and the overmolded ridge. However, other angles can be formed, based in part on the location in the body in which the coupler is to be placed. For example, referring to
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The reinforcing ring can be a Nitinol hoop or band and may form a complete circumference or a partially circumference (e.g., complete or incomplete cross sectional circle, to maintain the same, or smaller diameter than a complete circle, depending on the annealed geometry and diameter). While Nitinol has many unique features and benefits, other materials may also be used for the reinforcing ring. The ring may have a square, rectangular, round, oval, combination or other shape or geometry. The surface of the metal or metal alloy, may be electropolished, or have a coating to enable or assist the healing process. Bonding and securing to tissue can be accomplished by sutures (traditional, Nitinol, or other), adhesive, combination or other. The ring may be expanded from its resting, annealed configuration, and attached to a deployment tool. The ring may then be attached to tissue (such as a valve annulus) and secured, using sutures, adhesive or a combination. The deployment tool may then be removed, allowing the ring to recover back to its resting, or as annealed configuration, cinching, placating, bunching, or otherwise bringing the tissue(s) together to resist increase in the valve annulus diameter, e.g., caused by chronic cardiac conditions.
A second configuration is similar to that above but further includes an overmolded jacket with a proximal strain relief in the stem region. Holes, slots, reduced thickness areas in the wall, combination or other may be used to guide and or enable the use of sutures.
A third configuration that is similar to those above does not include a stem region. This configuration resembles a circle and may have a reinforcing band, ring or other.
A fourth configuration includes holes, slots, reduced thickness areas, combination or other to guide, assist or enable the use of sutures with the anastomotic coupler.
The valved coupler can provide a safe, effective, quick and intuitive-to-use vascular coupler that incorporates a valve and quick connect, quick disconnect features. The purpose of the valve, when in its closed position, is to prevent, obstruct and or limit fluid or air flow. Another purpose is to prevent or obstruct flow, until a tube or other is inserted into the inner diameter of the coupler, opening the valve and allowing flow. Once the tube or other is removed, the valve would close. Alternatively, the coupler may not contain a valve—a replaceable plug, cap or occluding piece may be used when flow is not desired (in between treatments for example). The cap (or plug) may also be used with the valved coupler. When inserted, it may be shorter, and not be in contact with the valve (and thus the opening), but close enough to provide a reinforcement to the valve or valve assembly components.
Additional uses for the valved coupler include being used as a permanent or temporary access port for cardiovascular, gastrointestinal, neurological, reproductive, lymphatic, respiratory or other applications. The valved coupler may be used during therapeutic infusion, diagnostic monitoring or sampling, blood flow rerouting to provide ventricular assist for congestive heart failure (from femoral artery to another vessel, with or without the assistance of a pump). The valved coupler can be permanently closed by using a cap or other component or method. Sealing may be accomplished by mechanical interference fit, adhesive, combination or other. The coupler, with or without modifications, may be used as a device and method to deploy, and or secure (temporarily or permanently) medical devices, including, but not limited to, such devices as a ventricular conduit (between ventricle and coronary artery, or other) from companies including Ventrica (Fremont, Calif.) and HeartStent (Minneapolis, Minn.), and AV shunts from companies such as Vasca (Tewksbury, Mass.). The valved coupler also can be used for therapeutic infusion, diagnostic monitoring or sampling, and reinforcement/replacement of cardiac valves. The valved coupler also can be removed, and replaced with another device. The replacement device may be another valved coupler, non-valved coupler, or other device.
The valved coupler can be of any diameter (e.g., from 1 mm to 20 mm or larger), any angle (e.g., from 15 to 120 degrees), any geometry (e.g., round, oval, square, combination, etc.), and have any suitable stem length (e.g., from 2 mm to 20 mm or longer). In addition, the ridge section may be a different geometry than the stem (e.g., the stem may be round, while the ridge may be oval).
The design of the valve can include a separate piece bonded inside the inner diameter of coupler (i.e., using an adhesive, solvent, heat, combination or other suitable process), a removable valve assembly, an overmold and valve fabricated as one piece with the coupler petals, on the connection tube end the coupler piece may utilize a removable/replaceable plug or cap rather than a valve, or the valve may be designed to not completely close to allow a restricted flow to pass through the coupler. The valve type can be a duck bill, a flapper, a check valve, a dilating membrane, or other suitable type and design. The valve can be located at any location inside and or on the outside of the coupler. The preferred location is inside the inner diameter of the stem. Moreover, one or more valves may be used.
The engagement of the valved coupler with the connecting tube (e.g., bypass graft or vessel) can be by using mating threads, a push in/twist to lock, a tapered tube/friction fit, or an expandable, complete or partial circumferential balloon (or other expanding/engaging structure) on or near the end of the connecting tube. The expandable structure may provide both a mechanical connection, as well as a fluid tight seal between the OD of the connecting tube end, and the ID of the valve structure.
The connecting tube may have reference markings, and or a larger diameter section to abut up against the edge of the stem, or other method to confirm that the tubing end has been fully inserted, and that the valve is in the open position.
The valve material may be made of the same or different material from coupler or coupler overmold component. The valve may contain a reinforcing material, such as Nitinol, to act as a hinge, and or a reinforcing support. The hinge or support may be on the inside, outside, in-between or combination of the valve structure. The reinforcing hinge or support material may be flat, round, combination or other.
Of course, the vascular couplers described above can be implemented with numerous variations in the components. For example, referring to
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In another variation of the vascular couplers described above, the securing members also can be varied in numerous manners. For example, referring to
The securing members also can be configured to have a J-shape. In this configuration, the shorted segment is positioned below the ridge and then the longer segment extends unto the lumen of the coupler to secure the vessel to the coupler. In this manner, the ridge does not need channels to receive the securing member.
The securing members can be further modified to increase the retention strength for retaining the vessel 100 within a coupler by including tissue penetrating members. For example, a securing member 1060 includes a U-shaped member 1065 and a tissue penetrating member 1066. The tissue penetrating member 1066 is directed inwardly from a first arm 1067 in the direction of a second arm 1068. Referring to
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Another variation in the vascular couplers described above is the use of a circumferential spring member. For example, referring to
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Although the above vascular couplers have generally been formed to include an overmolded portion, vascular couplers of a non-overmolded design also can be fabricated. For example, referring to
The stem 2130 includes an upper opening 2145, a channel 2150 passing between the upper opening 2145 and the base 2140, and a lengthwise slot 2155 along the entire length of the stem and passing from an outer surface of the stem to the channel 2150. As described in more detail below, the lengthwise slot 2155 allows the cross-sectional profile of the stem 2130 to be advantageously reduced during loading of the bypass vessel on or in the coupler and during implantation of the vascular coupler 2125. The stem 2130 also includes lengthwise slots 2160 that pass from the outer surface of the stem to the channel 2150. However, the slots 2160 do not extend the entire length of the stem 2130 but instead extend only a portion of the length of the stem. The slots 2160 remove material from the stem and thereby, when the coupler is implanted in a vessel, reduce the amount of foreign material in contact with tissue and blood.
The petals 2135 include an inner clip 2165 and an outer clip 2170, both of which extend from the base 2140. The petals 2135 are used to attach the vascular coupler 2125 to a vessel, such as the aorta. In particular, either of the inner clips 2165 or the outer clips 2170 are inserted through an opening in the vessel and allowed to expand to contact the inner lumen of the vessel. The other of the inner clips 2165 and the outer clips 2170 are positioned on the outside of the vessel. In this manner, the vessel is positioned between the inner clips 2165 and the outer clips 2170.
The inner clip 2165 is in the form of a pair of lengthwise edges 2175 that extend from the base 2140 at a first end of the edges and a widthwise edge 2180 at a second, opposite end of the edges. The lengthwise edges 2175 and the widthwise edge 2180 are surrounded by a pair of lengthwise edges 2185 and a widthwise edge 2190 of the outer clip 2170. The various edges of the outer clip 2170 are separated from the various edges of the inner clip by a channel 2193 that extends from the base 2140 to the widthwise edge 2185. Like the edges of the inner clip 2165, the lengthwise edges 2185 extend from the base 2140 at a first end of the edges and the widthwise edge 2190 is at a second, opposite end of the edges and connects the lengthwise edges 2185.
The various lengthwise and widthwise edges have upper surfaces 2195 and lower surfaces 2200 that are connected by side surfaces 2205. The joints between the side surfaces 2205 and the upper surfaces 2195 and the lower surfaces 2200 may be smoothed, angled, gradual, or sharp. In general, the joints will be configured to limit the likelihood of damage to tissue or blood when, as described below, the coupler 2125 is implanted in a vessel.
The inner clip 2165 also includes an optional slit 2210 along its length. The slit 2210 can be wide or narrow and its shape is not particularly limited. Moreover, the slit 2210 can have widthwise slits (not shown) extending into the lengthwise edges 2175 and the widthwise edge 2180. Similarly, the lengthwise edges 2185 and the widthwise edge 2190 of the outer clip 2170 optionally may have slits (not shown) extending from the slit 2210 into the edges 2185 and 2190. These optional slits are used to provide more flexibility to the clips 2165 and 2170 and, further, to reduce the amount of foreign material in contact with the recipient's blood and tissue. The inner clip 2165 and the outer clip 2170 are curved to generally have a radius of curvature that matches the inside of the vessel in which the coupler 2125 is to be implanted.
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To deploy the coupler 2125, the physician simply uses one hand to hold the coupler while removing the deployment tool from around the coupler, through the slot 2350, which removes the compressive force on the outer clips 2170 such that the clips are released within the lumen of the vessel. The outer clips 2170 expand in the direction of the inner vessel wall. Because the inner clips 2165 are in contact with the outer vessel wall, when the outer clips 2170 expand against the inner vessel wall, the vessel wall will be secured between the clips 2165 and 2170. In this manner, the coupler 2125 and attached bypass graft (not shown) will be securely attached to the vessel. Of course, whether necessary or not, the physician can use stay sutures to additionally ensure that the coupler 2125 will remain secured to the vessel.
Of course, the vascular couplers described herein also can be deployed using a hand held retractor, hemostat, tweezers, or other similar device, including those described above.
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Although the vascular coupler 2375 is illustrated as having the slots 2380 and 2385, a vascular coupler can be formed with either or both of the types of slots, and/or one or more of the slots 2385. For example, a vascular coupler can be formed with four slots 2385 such that the coupler can have its profile maximally reduced at the interface between the petals and the stem. Similarly, a vascular coupler can be formed with the slot 2380 and no slots 2385, or the slot 2380 and, for example, one slot 2385.
In general, the vascular couplers 2125, 2230, 2275, 2300, and 2325 are configured for deployment in a vessel, such as the aorta. The angles between the stem and petals described above, i.e., approximately 35 degrees to 55 degrees and approximately 80 degrees to 100 degrees, may be selected based on considerations, such as fluid dynamics and the flow path of the blood between the blood supplying vessel (e.g., the aorta) and the bypassed vessel (e.g., a coronary artery). A vascular coupler placed in the coronary artery has a generally smaller angle formed between the stem and the petals of the coupler, although there may be some overlap in the range of acceptable angles. For example, typically, that angle is between approximately 20 degrees and 45 degrees, and more particularly, approximately 30 degrees. Vascular couplers for the coronary arteries are described next.
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The lateral petals 2413 each include an inner clip 2440 and an outer clip 2445. The inner clip 2440 is configured to be placed around the outer coronary artery wall of the coronary artery in which the vascular coupler 2400 is implanted. In particular, the inner clip 2440 may be configured to have a radius of curvature that is similar to that of the outer diameter of the coronary artery wall. Similarly, the outer clip 2445 is configured to be placed inside the coronary artery and engage the wall of the lumen of the coronary artery. As such, the outer clip 2445 has a radius of curvature that approximates that of the inner diameter of the coronary artery. The outer clips 2445 are configured such that they include a first section 2450 and a second section 2455 that it is at an angle to the first section 2450. The length of the first section 2450 is selected to approximate the thickness of the vessel wall through which it passes and against the inner surface of which the second section 2455 is placed.
Differences between the lateral petals 2413 and the longitudinal petals 2410 include the relative length and the relative curvature of the outer clips. For example, the diameter or cross-sectional profile of the stem is close to that of the vessel (e.g., coronary artery) in which the coupler is inserted or mounted. As such, there is more length of the artery to use the petals 2410 to secure the coupler to the vessel than there is width of the artery to use the petals 2413 to secure the coupler to the vessel. Because of these constraints, there is no need to have a radius of curvature of the outer clip 2425 along its length, although there is a need to specify a radius of curvature of the outer clip along its width. In contrast, because there is little width of artery to use to secure the coupler to the vessel, there is an increased need to fabricate the radius of curvature of the outer clip 2445 such that it will engage a substantial amount of the circumference of the inner luminal wall of the artery. The vascular couplers 2125, 2230, 2275, 2300, and 2325 are designed for insertion into the aorta, which has an inner diameter that is significantly greater than that of the stem of the coupler, and, as such, the petals that are aligned with the circumference will have less of a need to be short or have a sharp radius of curvature because the radius of curvature of the inner diameter of the vessel is not as tight as in a coronary artery.
The stem 2405 of the vascular coupler 2400 is formed from flattened or parallel walls 2460 and curved front and rear walls. In contrast, the vascular couplers described above had curved front, rear, and side walls, although they could easily be formed with flattened side walls and curved front and rear walls. The flat sides maximize cross-section area through the lumen of the vascular coupler, with the limitation on the diameter of the coupler being that of the opening into the artery in which the vascular coupler is to be placed. To increase the cross-sectional area of the tube through which blood flows, the inventors have increased the length of the cross-section while leaving the width the same as approximately the width of the opening in the artery. As described below, when the vascular coupler 2400 is implanted in a coronary artery, the vascular coupler advantageously forms a fit that maximizes the cross-sectional area of the entry of the blood into the coronary artery from the vascular coupler. This is believed to advantageously promote hemodynamics and reduce damage to the blood cells as well as the posterior vessel wall (opposite from the site of the anastomosis). By having flattened, extended sides and longer side clips, there is potentially better engagement and securement because there is a greater amount of vessel in contact with the coupler.
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The vascular couplers described above, and in particular the vascular couplers illustrated in
Similarly, although deployment tools have been disclosed, alternative versions of these deployment tools can be used. For example, referring to
To deploy a coupler that has been installed in the channel 2625, the physician merely applies pressure on the pusher tube 2617 to urge the coupler through the slot 2630, which removes the compressive force on the outer clips such that the clips are released within the lumen of the vessel. The outer clips expand in the direction of the inner vessel wall. Because the inner clips are in contact with the outer vessel wall, when the outer clips expand against the inner vessel wall, the vessel wall will be secured between the inner and outer clips.
The gasket (e.g., vascular coupler 2500) may be configured to have circumferential grooves that improve acute hemostasis by using the elasticity of the blood vessel to tightly mate within one of the grooves. The grooves and the gasket may be coated with an adhesive, therapeutic agent, and/or other beneficial material.
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The coupler 2900 optionally may contain a slot 2950 passing completely through the wall thickness of the tubular conduit and passing between the proximal end 2910 and the distal end 2915. The configuration of the slot 2950 is not limited and may be, for example, straight and along the entire length of the tubular conduit 2905 (
Although the vascular couplers described above have been generally described as including petals or other members to assist in the securing the coupler to a vessel arteriotomy, such petals are not strictly necessary. For example, referring to
The primarily metallic vascular couplers described above may be made of a superelastic or shape memory metal or plastic that can be deformed during deployment to have its cross-sectional profile reduced as described above. For example, the stem can be made of Nitinol. The inner and outer surfaces of the stem also or optionally can be electropolished. The inner and outer surfaces of the stem can be configured to have increased biocompatibility and blood compatibility, such as by having a textured surface that promotes endothelial cell growth and adhesion, as described in more detail below.
Materials other than superelastic shape memory alloys may be used as the stem, the inner clips, and/or the outer clips provided they can be elastically deformed within the temperature, stress, and strain parameters required to maximize the elastic restoring force thereby enabling the device recover to a specific diameter and/or geometry once deployed over or on top of the vessel or other location. Such materials include other superelastic metal alloys, spring stainless steel 17-7, other spring metal alloys such as Elgiloy™, Inconel™, superelastic polymers, etc.
The vascular coupler could contain a single or multiple superelastic/shape memory metallic alloy component such as a wire, rod, hoop, tube, coil, sheet, strip, band, or other geometry in the middle, outer, in between, side, horizontal and or vertical plane, or combination on the device. The superelastic/shape memory elements could be located in a single, or multiple plane configuration(s). The thickness could be between 0.005″ to 0.040″ or other. The superelastic/shape memory alloy material could be annealed in one configuration during manufacture and processed (and packaged) in another configuration. When the material is exposed to normal body temperature (37� C.), will expand to engage the vessel wall, recovering to the optimum size, diameter and geometry to provide acute hemostasis and mechanical securement. Alternatively, a superelastic material could be used, being deformed/deflected during deployment, and designed to recover and provide acute hemostasis and mechanical securement to the vessel.
It is important to understand basic terminology when describing metals with elastic, superelastic, or shape memory behavior. Elasticity is the ability of the metal, under a bending load, for example, to deflect (strain) and not take a permanent "set" when the load (stress) is removed. Common elastic metals can strain to about two percent before they set. Superelastic metals are unique in that they can withstand up to about ten percent strain before taking a set. This is attributed to a "stress-induced" phase change within the metal to allow it to withstand such dramatic levels of strain. This is a desirable feature in anastomosis connection devices. Depending on the composition of the metal, this temperature that allows such a phase change can vary. And if the metal is "set" at one temperature, and then the temperature is changed, the metal can return to an "unset" shape. Then, upon returning to the previous "set" temperature, the shape changes back. This is a "shape memory" effect due to the change in temperature changing the phase within the metal. This summary describes these different metal behaviors, along with the compositions of various shape memory alloys.
When a metal is loaded (stressed) and undergoes, for example, bending, it may deflect (strain) in a "springy" fashion and tend to return to its original shape when the load is removed, or it may tend to "set" and stay in a bent condition. This ability to return to the original shape is a measure of the elasticity or "resilience" of the metal. This ability for a metal to be resilient is desirable for such things as springs, shock absorbing devices, and even wire for orthodontic braces, where the ability to deflect, but not deform (set) is important to maintain an applied force. Thus, elasticity is a highly desirable feature for a flexible, anastomosis device for connecting arterial grafts.
If, under a bending load, the metal takes a set, it is said to have plastically (versus elastically) deformed. This is because the imposed stress, produced by the bending load, has exceeded the "yield strength" (stress) of the metal. Technically, this level of stress that produces a set, is referred to as the "elastic limit", but is about the same as the yield strength. If the applied load increases past the yield strength of the metal, it will produce more plasticity and can eventually break. The higher the yield strength of the metal, the more elastic it is. "good" elastic metals can accommodate up to about two percent strain prior to taking a set. But this is not the only factor governing "elasticity".
Another factor that determines the ability of a metal to deflect to a given, desired amount, but not take a set, is the "elastic modulus", or often called the modulus of elasticity. The "modulus" of the metal is an inherent property. Steels, for example, have a relatively high modulus (30 msi) while the more flexible aluminum has a lower modulus of about 10 msi. The modulus for titanium alloys is generally between 12 and 15 msi.
Resilience is the overall measure of elasticity or "spring-back ability" of a metal. The ratio of the yield strength divided by the modulus of the metal is the resilience. Although it is one thing for a metal to be resilient, it must also have sufficient strength for the intended service conditions.
As discussed above, when a metal is loaded, each increment of load (stress) produces a given increment of deflection (strain) within the metal. And the metal remains elastic if the applied is below the yield stress. However, there is a unique class of metal alloys that behave in an even more elastic manner. These are the "superelastic" metals, where, for a given applied stress (load) increment, the strain in the metal can reach 5 or 6 percent or more without taking a set. In these type metals, the overall strain required to produce a set can reach an impressive 10 percent. This phenomenon is related to a phase change within the metal, and which is induced by the applied stress. This "stress-induced" phase change can also allow the metal to be set at one temperature and return to another shape at another temperature. This is a "shape memory" effect which is discussed later.
The most common superelastic metal, used in many commercial applications, is an alloy comprised of about equal parts of nickel (Ni) and titanium (Ti), and has a trade name of "Nitinol". It is also referred to as "NiTi". By slightly varying the ratios of the nickel and titanium in Nitinol, the stability of the internal phases in the metal can be changed. Basically, there are two phases. An "austenite" phase and a lower-temperature, "martensite" phase. When the metal is in an austenitic phase condition and is stressed, then a stress-induced martensite forms, resulting in the superelasticity. This is reversible, and the original shape returns upon release of the applied stress.
It is preferred that the Ni-to-Ti ratio in the Nitinol be selected so that the stress-induced martensite forms at ambient temperatures for the case of superelastic brace and support devices, which are used in ambient conditions. The specific composition can be selected to result in the desired temperature for the formation of the martensite phase (Ms) and the lower temperature (Mf) at which this transformation finishes. Both the Ms and Mf temperatures are below the temperature at which the austenite phase is stable (As and Af). The performance of an anastomosis connecting device can be further enhanced with the use of superelastic materials such as Nitinol. The superelasticity allows for greatly improved collapsibility, during deployment, such as by finger manipulation, with a surgical tool, or utilizing a delivery device or catheter, and which will return to its intended original shape when released within the vessel. The high degree of flexibility is also more compatible with the stiffness of the engaged vessel.
By manipulating the composition of Nitinol, a variety of stress-induced superelastic properties can result, and over a desired, predetermined service temperature range. This allows the metal to behave in a "shape memory" or "shape recovery" fashion. In this regard, the metal is "set" to a predetermined, desired shape at one temperature when in a martensitic condition, and which returns to the original shape when the temperature is returned to the austenitic temperature.
The shape memory phenomena occurs from a reversible crystalline phase change between austenite and the lower-temperature martensite. In addition to this transformation occurring from an induced stress as described previously, it can, of course, also change with temperature variations. This transformation is reversible, but the temperatures at which these phase changes start and finish differ depending on whether it is heated or cooled. This difference is referred to as a hysteresis cycle. This cycle is characterized by the four temperatures mentioned previously, As, Af, Ms, and Mf. Upon heating from a lower-temperature martensite, the transformation to austenite begins at the As, and will be fully austenite at Af. And upon cooling, austenite will begin to transform back to martensite at the Ms temperature, and become fully martensitic at the Mf. Again, the specific composition of the alloy can result in a desired combination of these four transformation temperatures.
In the malleable martensitic state, the alloy can be easily deformed (set). Then upon heating back to the austenitic temperature, the alloy will freely recover back to it's original shape. Then if cooled back to the martensitic state, the deformed shape re reform. The typical sequence of utilizing this shape memory property is to set the shape of, for example, a stent or anastomosis coupler, while in the higher-temperature austenitic state. Then, when cooled, deform the martensite material, and then heat to recover the original shape.
With the background given above, it can be seen that, if the Nitinol material requires and exceptionally tight bend, and one that would normally exceed the elastic limit of the material, and thus permanently deform it, a bend can be placed in the device and the device annealed to relieve the bending stresses within the device. Following this first bend, the device can be bent further to produce an even sharper bend, and then re-annealed to alleviate the stress from this additional bending. This process can be repeated to attain the desired, sharp bend or radii that would otherwise permanently deform the device if the bend were attempted in a single bending event. The process for recovery from the position of the most recent bend is then performed as described above.
This shape memory ability is very useful for the delivery and deployment of several types of medical devices, including self-expanding coronary stent devices and anastomotic couplers. These devices are deformed and maintained in their martensitic state (can require a cooling agent if Mf is below room temperature) until they are introduced and released in the body. A warm, sterile solution, short electrical activation, or other suitable means (free recovery if Af is less than 37C) and trigger the recovery to the predetermined shape. Ideally, the material remains austenitic after cooling to body temperature. This is achieved by choosing an alloy composition with a hysteresis such that Ms is never reached upon cooling to normal operating conditions (Ms below body temperature). High-temperature martensite shape memory alloys are also an alternative solution.
Although the example of Nitinol, discussed above, is, by far, the most popular of the superelastic metals, there are other alloys that can also exhibit superelastic or shape memory behavior. These include Copper-40 at % Zinc; Copper-14 wt % Aluminum-4 wt % Nickel; Iron-32 wt % Manganese-6 wt % Silicone; Gold-5 to 50 at % Cadmium; Nickel-36 to 38 at % Aluminum; Iron-25 at % Platinum; Titanium-40 at % Nickel-10 at % Copper; Manganese-5 to 35 at % Copper; and Titanium-49 to 51 at % Nickel (Nitinol).
The unique ability of Nitinol to serve in a superelastic or shape memory capacity, along with the excellent corrosion resistance and biocompatibility afforded this material by the large amount of titanium in the composition, render this alloy ideal for anastomosis connecting devices. Such devices are designed to connect blood vessel segments, including vascular grafts to arteries. This alloy can be expected to allow for improved deflection while being deployed, such as by finger manipulation or by deployment tool, and memory required for the device to return to its intended service shape when released within the blood vessel. Further, this highly elastic alloy can allow for an inherently lower-stiffness design, and thus less mismatch with the elasticity of the engaged blood vessel.
In summary, there are various ways of describing elasticity, but the main criteria is the ability of the metal to return to its initial, pre-loaded shape. Some metals can only deflect a couple percent and remain elastic while others, such as superelastic Nitinol, can deflect up to about ten percent. Nitinol is also biocompatible and corrosion resistant. This unique combination of properties allows a device made of Nitinol, such as an anastomosis connecting device, to be deflected, constrained, and be subsequently released, at a particular site within the vessel, to form its intended service shape.
The vascular couplers formed from a sheet of Nitinol described herein can be formed to have single or multiple layers. To form the vascular coupler, the material is first processed into the desired shape. The device and/or elements (i.e., clips) could then the positioned over a forming fixture. The forming fixture would have one or more surfaces where the device and/or elements would be constrained into the final, as in vivo deployed configuration. The annealing fixture is then partially, or completely subjected to temperatures sufficient to cause the desired effect. The heat source can be an oven, or salt pot. To anneal superelastic/shape memory alloys, the temperature is approximately 300 to 600� C. After a predetermined time, the fixture containing the superelastic/shape memory (SE/SM) alloy elements is then removed from the heat source (such as a salt pot) and quickly quenched in cold water. This process may be repeated as many times as needed to make small incremental changes in the radius, angle or other, during each annealing cycle, to prevent over stressing the material when securing to the fixture. Once the desired final shape has been achieved, and the fixture is cool to the touch, the device and/or elements are removed from the fixture for further processing.
To anneal a thermoplastic polymer, the heat must be above the glass transition (Tg) temperature of the particular polymer. After a predetermined time, the fixture is then removed from the heat source (for this application, an oven) the fixture is removed and allowed to cool gradually. Once the fixture is cool to the touch, the device and/or elements are removed from the fixture for further processing.
The annealing fixture may be made from a metallic material able to withstand the annealing temperatures, and may have single or multiple components or sections. In the case of multiple components or sections, the various components or sections could be held together with clamps, screws, rods combination or other, and may have the ability to anneal devices and/or elements for a single, or multiple devices at one time.
When thermally forming superelastic/shape memory component layer, the superelastic material(s), previously cut into the desired pattern and/or length, are stressed and constrained into the desired resting configuration over a mandrel, or other forming fixture having the desired resting shape of the device depending on the vessel size or other location where the device is intended to be used, and secured. The material is heated to between 300 and 600 degrees (or other) Celsius for a period of time, typically between 30 seconds and 30 minutes, or other. Once the volume of superelastic/shape memory material reaches the desired temperature, the material is quenched by inserting into chilled water or other fluid, or otherwise allowed to return to ambient temperature. As such the superelastic/shape memory component layer(s) are fabricated into their resting configuration. This process may be repeated with the material being annealed in smaller increments of bending or shaping, so as to not stress the material past its elastic limit (approximately 8 to 10%). The superelastic/shape memory layer(s) may be located full or partial length or width of the device.
Any metal or metal alloy that comes in contact with blood and/or tissue can be electropolished. Electropolishing may reduce platelet adhesion causing thrombosis, and encourage endothelization of the exposed metallic areas. Electropolishing also beneficially removes or reduces flash and other artifacts from the fabrication of the device.
The superelastic/shape memory elements could be processed into the desired shape and configuration using several methods, such as electron discharge machining (EDM), laser, chemical etching, grinding, cutting, combination or other, prior to or after the annealing process.
Superelastic/shape memory materials are available in many configurations, from several suppliers, including, NDC (Fremont, Calif.), Memry Corporation (Bethel, Conn.) and Shape Memory Applications, Inc. (San Jose, Calif.).
The vascular coupler also can be partially or completely coated with a polymer coating or covering with a polymer covering, such as, for example, expanded polytetrafluoroethylene, polyurethane, polyethylene terephathalate, or other coating material, as described herein. In general, the coating or covering provides a blood and body compatible surface and also can be used to attach a graft or vessel to the coupler. The covering or coating also provides a surface through which fluid, such as blood, cannot pass, but yet permits the coupler to have its cross-sectional profile reduced. A coating or covering also can be used to reinforce the anasomotic site.
The stem, and or other areas of the substantially metallic version of the device may be annealed in a larger configuration than the vessel (either bypass or host) it will be inserted into, so that once deployed, the larger annealed size could have a greater potential contact force against the host or bypass vessel, than if the device was sized exactly to the vessel.
The stem region may have one or more "hinge" regions that are designed to flex when compressed. The hinge can be an area where the wall is reduced in thickness and or width. The hinged regions may be located so as to assist/enable reduced cross section deployment and or securing the device to either the bypass graft, host vessel, or other. The stem area may be compressed and inserted into the inner diameter (ID) of the bypass vessel. When the stem is no longer compressed, it will expand and engage the inside of the bypass vessel. The outside of the stem may have an adhesive, and or a suture tied around the outside of the bypass vessel. A simple loading tool may be used to compress the stem of the device, or alternatively, hemostats or other common surgical instrument may be used. Alternatively, or in addition, the stem may have a slit or slot to enable reducing the cross section for insertion into the ID of the bypass vessel or other purpose.
If a substantially tubular structure (tube) is used for the device, it may be initially round (concentric), and then processed such that the end shape is an oval, or has two flat sides (flattened), with the top and bottom being substantially round, combination or other.
The host vessel tissue contacting elements that are designed to remain on the outside of the vessel, may be annealed in a different plane than the elements that will be on the inside, to take into account the thickness of the vessel wall.
In loading the vascular coupler into a bypass vessel, the bottom of the coupler may be compressed using a hemostat or other device, to compress the stem region to enable insertion into the end of the bypass vessel. Once inserted into the vessel, the distal ends of the hemostat can be opened, removing the compressive force, allowing the stem to expand radially, making contact with the inside of the vessel. The contact/bond between the device and the bypass vessel may be aided using a biologically acceptable adhesive (contact or other), and or tissue engaging tabs or other that may be biased outward. A suture may also be positioned around the bypass vessel, at the device stem area, providing compression between the vessel and device. For the "paper clip" stem version of the device, the exterior vessel host vessel tissue contacting elements may be deflected outward (to load the vessel to the device) manually, or by using a tool.
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Several designs of automatic arteriotomy devices can be used. The designs include: (1) a modified version of the aortic punch that cuts only the vessel wall and does not remove tissue; (2) a specific/specified length Potts type scissors that, for example, has reference length markings on the blade; (3) other scissors or cutting devices having reference length markings; or (4) a scalpel edged device that is advanced through the vessel wall and has a stop to prevent the scalpel blade from advancing too far. These or other devices are used to make a specific length cut through the vessel wall while at the same time preventing posterior vessel perforation. In addition, the automatic arteriotomy device may have one or more electrodes on the cutting surface and uses RF energy to make the cut in a similar manner as the RF aortic punch described above.
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In one general aspect, the side-to-side vascular coupler is configured as a tubular structure with predominately linear slots (through the wall) on both ends of the tube. The slots do not continue along the full length of the tube, leaving a section (e.g., in the middle) of the tube intact. After further processing, the device has the ability to be constrained into a smaller cross sectional profile during insertion and positioning using a deployment device. Once the deployment device is at the desired location, the constraining force is removed and the side-to-side device reverts to its annealed geometry and profile, engaging and compressing the tissue together, between the end elements. The tissue contacting/engaging elements on one or both ends of the tubular device may be formed to be aligned with each other, or offset, depending on the application.
The purpose of the side-to-side includes providing a conduit, or reinforcement to a conduit for use in cardiovascular, neurological, reproductive, urology, lymphatic, respiratory, or other applications where a conduit or conduit reinforcement is desired. The device may be used completely or partially, outside, inside, in between or combination with any lumen, tubular, duct, organ, hollow body organ or cavity, or other structures within the body. The design and deployment method is especially useful as an endoscopically created gastrojejunal anastomosis.
The vascular coupler may be made of a superelastic/shape memory alloys such as Nitinol, as well as the other materials described herein. The side-to-side vascular coupler may be completely or partially coated with ePTFE and/or other suitable material. The vascular coupler may be coated with other materials to assist with the bonding of the tissue contacting regions, and may include therapeutic materials for acute or chronic elution treatment, as described herein.
In fabricating the vascular coupler, a Nitinol tube is cut to length, linear slots are made through the wall of the tube in the desired geometry using laser machining, wire EDM, etching, photo-etching, a combination of these methods, or other suitable method. The tube is then placed into or on the annealing fixture and annealed into the final, post deployed configuration. Once the heat cycle has been completed, the tube is then quenched in cold water and removed from the fixture. The tube/side-to-side vascular coupler can be further processed if desired. Further processing can include, but is not limited to, electropolishing (i.e., especially desirable if the device will be in contact with blood) and coating (therapeutic or other) or overmolding.
The side-to-side vascular coupler can be deployed with a deployment device such that the vascular coupler is advanced into position and deployed using a catheter or hand held device, specifically designed for the side-to-side device. Modifications of the catheter and hand held deployment devices may be used for endoscopic and laparoscopic procedures. The tip of the deployment device may have a "screw, or corkscrew" type configuration, so that advancement through tissue can occur without significant forward pressure or force being applied—instead, the device can be advanced by rotation of the deployment device.
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In particular, the side-to-side coupler 3520 can be used to provide a connection between adjacent vessel walls 3550 and 3555 (
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An initial incision using a scalpel blade is made through the aorta, at the site of the proximal anastomosis. The tip of the aortic punch then is inserted into the incision, and the punch is actuated, cutting and capturing a round disc of the wall of the aorta. The vascular coupler then is inserted, and deployed into and through the opening created in the aorta.
place the vascular couplers described herein, an aortotomy typically is formed. To prevent excessive blood loss through the arteriotomy, an occluding device can be used. For example, referring to
In use, occluder 3787 is slidably installed over the distal end of the punch 3700 and the cutting disc 3720 is positioned within a vessel through a small opening in the vessel. Then, the slidable tube 3710 is advanced to advance the cutting element 3715 towards the cutting disc 3720, which cuts tissue positioned between the cutting element and the cutting disc. After the cut is made, the punch is advanced to position the occluding ball 3790 against the opening to prevent excessive bleeding.
The size of the occluding ball 3790 can be of a similar size as the cutting disc to fit against the vessel. The occluding ball 3790 can be fully inserted into the vessel such that the interaction of the occluding stop 3791 rests against the vessel to reduce blood loss. If the ball is positioned within the vessel and the stop is positioned against the vessel wall, the punch can be slidably withdrawn from the occluder and minimal blood leakage results.
The punch 3700 also can be configured to have a power source that heats the cutting element such that the tubular vessel tissue is mechanically cut and thermally cut. The shaft or handle of the punch/coring/arteriotomy device may act as a guide for a localized tissue stabilizer, introducer (splitable or tearable, or with another removable means), occluder, combination of these, or any other device for any desired purpose, before, during, and/or after the cutting process.
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The vascular couplers described herein typically are or can be part of a system with various accessories. For example, a vascular coupler can be used with a graft, adhesive materials, therapeutic agents, and radiopaque materials.
The vascular couplers could be used with harvested biological grafts such as the internal mammary artery (IMA), radial artery, saphenous vein, or other. Additionally, grafts made from various other biological materials, or combination of biological and synthetic materials, may also be used. Synthetic vessels include Cardiopass™ from Cardiotech (Woburn, Mass.) and Aria™ from Thoratec (Pleasanton, Calif.), as well as others.
The device could have a biocompatible contact adhesive or other material to bond or secure the device to the vessel, sealing the anastomosis site. In addition, adhesives may be used to secure, or assist in securing the bypass graft to the coupler. The adhesive/bonding compounds/solutions could be added during the manufacturing process, just prior to deployment, or after the device has been deployed. The bonding materials could be in the form of a liquid, semi solid, or solid. Suitable bonding materials include gels, foams and microporous mesh. Suitable adhesives include acrylates, cyanoacrylates, epoxies, fibrin-based adhesives, other biological based adhesives, UV light and/or heat activated or other specialized adhesives. The adhesive could bond on initial contact, or longer, to allow repositioning if desired. The preferred adhesive may be a crystalline polymer that changes from a non-tacky crystalline state to an adhesive gel state when the temperature is raised from room temperature to body temperature. Such material is available under the trade name Intillemer™ adhesive, available from Landec Corp. as well as composites and combinations thereof and combinations of other materials. Suppliers of surgical adhesives include, but aren't limited to, Plasto (Dijon, France), Haemacure (Montreal, Canada), Cohesion (Palo Alto, Calif.), Cryolife (Kennesaw, Ga.), TissueLink (Dover, N.H.), and others. To increase the work time of the adhesive or allow repositioning of the vascular coupler after it has been deployed, the adhesive can be blended with a material, such as a starch or other material, that dissolves and retards or delays bonding to allow repositioning of the coupler after it has been deployed. A degradable coating can be placed over the adhesive coating so that it degrades and exposes the adhesive.
The vascular couplers described herein may be coated with materials such as Parylene or other hydrophilic materials that are biologically inert and reduce surface friction. Another method to reduce surface tension for metallic or metallic alloy couplers or overmolded couplers with metallic or metallic alloy elements or components is to chemically polish or electropolish those surfaces that will come in contact with blood or tissue. Sandblasting, beadblasting or other may be performed prior to polishing. It is believed that chemical polishing or electropolishing reduces platelet adhesion because of the smooth surface that results. Chemical polishing and or electropolishing process can also be used as an effective way to reduce the thickness of metal or metal alloy coupler components.
The coupler device may incorporate one or more coatings, materials, compounds, substances, drugs, therapeutic agents, etc. that positively affect healing at the site, at and or near where the device is deployed, either incorporated into the structure forming the device, incorporated into a coating, or both. Thromoboresistance materials, antiproliferative materials, or other coatings intended to prevent thrombosis (acute and or chronic), hyperplasia, platelet aggregation, or other negative response, at or near the attachment of the bypass graft, as well as at or near the implantation site of the coupler through the host vessel. The coatings, materials, compounds, substances, drugs, therapeutic agents, etc. may be used by themselves, and/or contained in a carrier such as a polymeric matrix, starch, or other suitable material or method. The coatings may be liquid, gel, film, uncured, partially cured, cured, combination or other suitable form.
Coatings on the coupler may be used to deliver therapeutic and pharmaceutic agents include (but are not limited to): antiproliferative/antimitotic agents including natural products such as vinca alkaloids (i.e. vinblastine, vincristine, and vinorelbine), paclitaxel, epidipodophyllotoxins (i.e. etoposide, teniposide), antibiotics (dactinomycin (actinomycin D) daunorubicin, doxorubicin and idarubicin), anthracyclines, mitoxantrone, bleomycins, plicamycin (mithramycin) and mitomycin, enzymes (L-asparaginase which systemically metabolizes L-asparagine and deprives cells which do not have the capacity to synthesize their own asparagine); antiplatelet agents such as G(GP) II.sub.b/III.sub.a inhibitors and vitronectin receptor antagonists; antiproliferative/antimitotic alkylating agents such as nitrogen mustards (mechlorethamine, cyclophosphamide and analogs, melphalan, chlorambucil), ethylenimines and methylmelamines (hexamethylmelamine and thiotepa), alkyl sulfonates-busulfan, nirtosoureas (carmustine (BCNU) and analogs, streptozocin), trazenes—dacarbazinine (DTIC); antiproliferative/antimitotic antimetabolites such as folic acid analogs (methotrexate), pyrimidine analogs (fluorouracil, floxuridine, and cytarabine), purine analogs and related inhibitors (mercaptopurine, thioguanine, pentostatin and 2-chlorodeoxyadenosine {cladribine}); platinum coordination complexes (cisplatin, carboplatin), procarbazine, hydroxyurea, mitotane, aminoglutethimide; hormones (i.e. estrogen); anticoagulants (heparin, synthetic heparin salts and other inhibitors of thrombin); fibrinolytic agents (such as tissue plasminogen activator, streptokinase and urokinase), aspirin, dipyridamole, ticlopidine, clopidogrel, abciximab; antimigratory; antisecretory (breveldin); anti-inflammatory: such as adrenocortical steroids (cortisol, cortisone, fludrocortisone, prednisone, prednisolone, 6.alpha.-methylprednisolone, triamcinolone, betamethasone, and dexamethasone), non-steroidal agents (salicylic acid derivatives i.e. aspirin; para-aminophenol derivatives i.e. acetominophen; indole and indene acetic acids (indomethacin, sulindac, and etodalac), heteroaryl acetic acids (tolmetin, diclofenac, and ketorolac), arylpropionic acids (ibuprofen and derivatives), anthranilic acids (mefenamic acid, and meclofenamic acid), enolic acids (piroxicam, tenoxicam, phenylbutazone, and oxyphenthatrazone), nabumetone, gold compounds (auranofin, aurothioglucose, gold sodium thiomalate); immunosuppressives: (cyclosporine, tacrolimus (FK-506), sirolimus (rapamycin), azathioprine, mycophenolate mofetil); angiogenic agents: vascular endothelial growth factor (VEGF), fibroblast growth factor (FGF); angiotensin receptor blockers; nitric oxide donors; anti-sense oligionucleotides and combinations thereof; cell cycle inhibitors, mTOR inhibitors, and growth factor signal transduction kinase inhibitors. Alternatively, a clot promoter may be used, such as protamine sulphate or calcium hydroxide. Endothelial cells may also be added to the coupler device.
The therapeutic compounds/solutions may be blended with the device base materials during fabrication, applied just prior to deployment, or after the device has been deployed.
The therapeutic materials may be located on, through, inside, or combination of the device in holes, grooves, slots (or other indentations) or designs. For example, the surface under the vessel reinforcement ridge, as well as the under ridge hemostatic gasket may have partial or complete holes grooves, or other indentations, filled with a therapeutic substance, in contact with the host vessel tissue. In addition, the area of the coupler that comes in contact with the bypass vessel may also incorporate this feature. The petals may also have partial or complete holes, slots, grooves, or other filled with a therapeutic substance, or simply coated on the outside surfaces. This design allows direct contact of the therapeutic substance, while maintaining the functional ability of the coupler or coupler component. Combinations of therapeutic substances or coatings may be used on the same coupler. For example, a more viscous (gel or other) therapeutic substance may be used to fill the partial or complete holes (or other) on the vessel reinforcing ridge and hemostatic gasket under the ridge, while the petals are coated with a less viscous (liquid) material. The therapeutic substance may be the same, or a combination of more than one type used on a single coupler. The coatings may be designed to provide benefits acutely, and/or over a period of time. The coatings, materials, compounds, substances, therapeutic agents, etc. may be desired to be static, and/or eluding. The coatings, materials, compounds, substances, therapeutic agents, etc. elutes from the coated (or embedded) device (or component) over time and enters the surrounding tissue. The coatings, materials, compounds, substances, drugs, therapeutic agents, etc. preferably remain on the coupler for at least three days, and up to approximately six months, and more preferably between seven and thirty days.
Post device fabrication coating methods include, but are not limited to, spin coating, RF-plasma polymerization, dipping, spraying, brushing, submerging the devices into a beaker containing a therapeutic solution while inside a vacuum chamber to permeate the device material, etc.
Alternatively, or in combination with the above therapeutic substances, a material such as platinum, gold, tantalum, tin, tin-indium, zirconium, zirconium alloy, zirconium oxide, zirconium nitrate, phosphatidyl-choline, pyrolytic carbon, combination or other material, may be deposited onto the coupler surface using electroplating, sputtering vacuum evaporation, ion assisted beam deposition, vapor deposition, silver doping, boronation techniques, or other coating process.
In addition to the above therapeutic methods and materials, similar and additional methods of coating and materials are described in detail in U.S. Patent Application No. 2002/0133183, the contents of which are incorporated in their entirety by reference.
Radiopaque material such as barium sulfate, bismuth trioxide, tantalum or other can be added to the vascular couplers, reinforcement structure (e.g. the overmold) or bonding material. Additionally, platinum, gold, or other material may be added to the coupler by sputter coating, ion deposition, vapor deposition, combination, or other process.
The vascular couplers described above can be used with various accessories, as necessary, to improve the outcome for the patient receiving the coupler. For example, the bypass graft can be reinforced with a vessel reinforcement device to prevent kinking, collapsing, or other types of restrictions to blood flow. Examples are provided in the figures. Also, the reinforcement device could prevent bypass graft vessel over expansion once blood flow has been reestablished. The reinforcement device can be used with any anastomosis type, such as a coupler, staple, suture, etc. Similarly, the vessel reinforcement device can be used with harvested biological grafts such as the internal mammary artery (IMA), radial artery, saphenous vein, or other. Additionally, the vessel reinforcement device can be used with grafts made from other biological materials, or combinations of biological and synthetic materials.
The vessel reinforcement device may be used on the outside or inside of the bypass graft, and may fabricated with a contact adhesive, as described herein, and or therapeutic material, as also described herein, on the tissue contacting surfaces. The adhesive may be applied after the bypass graft has been secured, before or after blood flow has been reestablished.
The vessel reinforcement device may be of a single piece configuration, or may be fabricated from multiple pieces that overlap. The reinforcement, or reinforcements may be as long as the entire length of the bypass graft, or only at the two ends of the anastomosis to function as a strain relief. The vessel reinforcement device can be placed around the bypass graft before the second end of the graft is secured, or after both ends of the bypass graft has been secured if using a version of the reinforcement device that allows side access. The vessel reinforcement device may have a consistent diameter and geometry, or the ends (i.e., the site of the anastomosis) may be flared to fit over the anastomosis to thereby function as an anastomosis reinforcement device. The vessel reinforcement device may be used as a side access version that has the ends directly oppose each other, although they may be offset.
The vessel reinforcement device may be partially or completely made of metal, metal alloy (such as Nitinol), polymer (such as ePTFE), combination of these or other suitable material. The device materials could be in the form of, for example, a wire, hoop, oval, rod, band, ribbon, tube, sheet, combination of these or other suitable shape. Additionally, the materials could be formed in a wound, coiled, undulated, sinusoidal, braided, combination of these or other suitable configuration.
The core material, which may be, for example, Nitinol or other suitable material, is annealed as described herein over a mandrel matching the outer diameter of the bypass graft vessel. The geometry of the mandrel may be round, oval, or of another suitable shape, and may have a consistent size and geometry, or a larger diameter and/or shape, at one or both ends.
The vessel reinforcement device may be partially or completely coated or overmolded using several methods and processes including sintering, molding (such as injection molding), casting, adhesive bonding, laminating, dip coating, spraying as well as composites and combinations thereof and combinations of other methods and processes.
Another accessory to the vascular coupler is a deployment device. Examples of deployment devices have been described above. In general, the vascular coupler is radially compressible in some configurations and can be deployed using fingers, standard surgical instruments (including Rongeur clamp), modified surgical instrument or specially designed tools. Specially designed tools include modified surgical instruments (length, contact area, compression force, compression diameter, etc.), as well as tools/devices specifically designed to compress the cross section of the anastomotic device while being advancing through a hollow, tapered tube. The anastomosis device could be advanced through the deployment tool by an elongated stylet that attaches to the outside of the anastomosis device, inside or outside of the deployment tool. Advancement from outside the deployment tool, using a stylet or plunger, could be accomplished by way of a slot through the wall of the funnel type deployment tool.
The deployment tool may be designed to deflect some or all of the interior vessel engagement elements (i.e., inner or outer clips) into a position that assists deployment (i.e., forward, backward, or other suitable position). Once deployed inside the vessel, the tool is removed from the vascular coupler.
The deployment tools and devices may have the ability for the distal end to be steered (e.g., controllable from the proximal end of the tool or device) while having the ability to compress the vascular coupler during deployment, and release the coupler once it is positioned in the desired location within the vessel. This version of a deployment tool is particularly useful during minimally invasive, endoscopic and robotically assisted surgery, or other where access space within the chest cavity is limited. Steering capability can be accomplished using one or more pull wires attached to a ring, collar, flat leaf spring, or other member that is designed to deflect when the pull wire is pulled. Alternatively, the distal section of the deployment tool/device can be formed in a curve, and a straight rod or stylet can be advanced from the proximal end, towards the distal end, straightening the distal end. Another option is to advance a preformed curve, or steerable device, into a lumen of the deployment tool/device. A clip that can be removed from the side after deployment also can be used.
The vascular coupler is versatile and can be deployed in a number of methods, some of which have been described above or are described below. To access the heart, the surgeon uses a thoracotomy, thoracostomy, or median sternotomy, or other suitable surgical approaches. The vascular coupler and accessories described herein can be used with cardiopulmonary support, beating heart, open field, minimally invasive, endoscopic, laparoscopic and robotically assisted surgery, or other cardiovascular technique.
The bypass graft is prepared by cutting a graft to the desired length, and the ends are cut to the desired angle (e.g., 30 degrees or other suitable angle). Further, additional cuts, such as a longitudinal cut, may also be made to the ends of the graft to produce the desired final geometry, or for other surgical or therapeutic purposes. The vascular coupler is sized according to the type, size and anastomosis location. The vascular coupler then is loaded and secured to the bypass graft by way of securing members, an adhesive in and/or on the tissue contacting surfaces, and/or by using one or more sutures (e.g., tissue penetrating or non-penetrating sutures). Alternatively, adhesive can be applied to the vascular coupler after the coupler has been loaded and secured to the bypass graft. The tip of a vascular dilator or other suitable instrument may be inserted into the bypass graft lumen, gently expanding the end diameter of the graft into contact with the inner diameter of the vascular coupler, securing the coupler to the bypass graft. Alternatively, the bypass graft may be positioned and secured over the vascular coupler, and secured with adhesive already on or in the coupler, and/or may be applied after positioning. The adhesive used typically will be selected for its ability to withstand submersion in papaverine or other solution just prior to implantation.
The tissue may need to be stabilized. For example, a localized tissue-stabilizing device may be used during the coronary bypass procedure. One or more stabilizing devices could be positioned on the surface of the heart, in parallel with the coronary artery, at the site of the anastomosis. The stabilizing devices can access the internal cavity through one or more locations, and can be attached on the proximal end to a retractor, or other arm, rail or other stabile platform, inside or outside of the patient's body. The localized tissue stabilizer may be positioned, adjusted, and locked into any direction and position. The adjustment includes, but is not limited to, the width in between the tissue contacting sections, and the amount of compression and stabilization on the heart surface.
Typically, a proximal aortotomy is made in the aorta. This generally is termed the proximal anastomosis site. The initial puncture is typically made in the aorta using a scalpel blade, followed by rapid insertion of an aortic punch at the site of the incision. The punch is used to create a hole of the appropriate size and geometry. Once the hole has been made, the punch is removed and the proximal vascular coupler with an attached bypass graft is deflected and inserted into the opening. The compressing or restraining (deflecting) force on the vascular coupler then is removed so that the vascular coupler is allowed to expand and engage the horizontal and vertical planes of the anastomosis site. This engagement creates a hemostatic seal between the wall of the aorta and the anastomotic device.
Alternatively, an aortic punch with a forward leading edge scalpel blade, or other sharp point can be used to form the aortotomy and punch using the same device.
The surgeon forms a distal anastomosis, typically in a coronary artery. This site is generally termed the distal anastomosis site. The arteriotomy is typically created using the tip of a scalpel blade for the initial puncture, and then using surgical scissors (e.g., Potts type or other suitable scissors) to increase the longitudinal length of the incision. The scissors may include reference measurement numbers that the surgeon can use when creating the arteriotomy. Once the arteriotomy has been made, the anastomosis site maybe held open with a spreader, making it easier for the device to be inserted.
Alternatively, an automatic arteriotomy device may be used. The device would have the ability to make a predetermined length cut, preventing the arteriotomy from being made too long. As noted above, if the arteriotomy is too long, it may be difficult to achieve hemostasis after the device has been deployed.
For most coronary artery bypass grafting (CABG) procedures, the distal (coronary) anastomosis is performed first, followed by the proximal (aorta) connection. Once the bypass graft has been prepped, the end of the anastomosis device (containing the end of the graft) is compressed or deflected forward to produce a smaller cross section and inserted into the coronary artery through the arteriotomy. The device can be compressed by the surgeon using fingers, a common surgical tool, a modified surgical tool, or special deployment tool. The anastomosis device has geometric design features and other that prevents positioning the device too far into the artery, and is designed to expand and engage the artery wall (vertical, and or horizontal engagement), once the compressive force has been removed. Once positioned, the device can be held in place as the adhesive, on or in the tissue contacting surfaces, cures, providing acute hemostasis and mechanical securement to the arterial wall. A similar process is used to make the proximal (aorta) anastomosis. Acute hemostasis can also be realized by mechanical expansion, and or geometric interference fit alone.
Additional securement/reinforcement can be used (if desired). For example, a biocompatible adhesive can be applied around the site of the anastomosis, a suture (such as a purse string or other type of configuration) can be applied, combination of these or other suitable methods.
An external strain relief can be positioned around the bypass graft before, during or after the CABG procedure has been completed. Adhesive could be used to bond the securement device/strain relief to the bypass vessel.
There are additional techniques that are typically considered when deploying the vascular coupler. These techniques are the push in/pull out technique and the deflection technique.
The push in/pull out technique has been briefly described above, but is presented here in greater detail. When inserting vascular coupler into the hole or slot of the vessel, the hinged elements will tend to deflect backwards until the device is inside the target site. The vascular coupler can then be gently pulled back to "seat," or position in the final location between the tissue (vessel) wall. The longer hinged elements, petals, or clips (i.e., inner members having, for example a U-shape or paper clip configuration) prevent the device from coming out of the target area when pulling back. Then, when further gently retracting the vascular coupler away from the vessel, the shorter, outer elements (i.e., paper clip-shaped element, U-shaped element) will be released to spring back against the outer wall of the vessel as soon as it is out of the vessel and the larger, inner members will be released outwardly to compress the vessel between them upon release. If a ridge configuration is used instead of the hinged outer elements, the hinged inner elements will compress the vessel wall between the ridge and the inner elements.
The deflection method requires the use of a disposable, single use only, circular clip or partial ring ("C" geometry, or other) tool, designed to deflect a portion, or the complete hinged element, forward, backward, or combination during insertion. The width of the deployment clip is shorter than the length of the hinged elements, and is removed, preferably from the side, once the distal ends of the hinged elements are inside the target area (i.e., vessel). This deployment tool is described in greater detail above.
The distance between the overmolded ridge/tissue contacting/reinforcing ridge, and the top of the petals is anticipated to be available in different distances, to produce different compressive forces—depending on the vessel thickness, the shorter the distance between the ridge and petals, the higher the compression between the outside and inside of the vessel. This distance may also be adjustable just prior to implantation. Availability to optimally compress several different vessel thicknesses, custom and or adjustable vessel compression feature. Tissue compression modified by different ridge to petal distances.
The securing members and petals can be individual elements, or connected, partially or completely continuous. The securing members and petals may be made from the same or different materials (for example, the petals can be made from Nitinol, and the securing members can be made from stainless steel).
There are additional utilities and uses for the vascular coupler. For example, there can be a sutured anastomosis site reinforcement. In this configuration, a version of the vascular coupler (and or strain relief) with or without side access slit or other, to be placed (from the side or over the top) and secured to site after the bypass graft to host vessel anastomosis has been sutured, to prevent kinking, bypass graft closure, vessel "ballooning," due to a compliance mismatch, etc. Another use is to create an anastomosis through a graft that has been deployed in the abdominal aorta, reattaching vessels that would have otherwise been occluded by the graft. The opposite end could be attached using an end-to-end anastomosis device.
The vascular coupler can be used as an arterial to venous shunt for hemodialysis, AV fistula, and pulmonary uses. The vascular coupler and techniques can be used for cardiovascular, gastrointestinal, neurological, reproductive, lymphatic, respiratory or other applications where partial or complete, temporary or permanent closure, compression, sealing or reinforcement is desired. Additionally, any lumen, duct, organ, hollow body organs or cavity, or other structures or tissues, where partial or complete, temporary or permanent sealing, crimping, compression, plugging, reinforcement or other purpose is desired. The coupler, with or without modifications, may be used as a stent in an ostium anywhere in the body, but especially in the aortic ostium. The expanding members could act as a stop, so as not to insert the stent too far into the coronary artery. The coupler can be deployed either percutaneously (with a catheter), or during a surgical procedure with a hand held tool, or by hand.
Alternatively, the device could be used as a conduit, conduit support and or reinforcement by itself, or used with a synthetic and or autogenous/autologous conduit or lumen. For conduit or conduit reinforcement applications, the material and design used would be sufficiently flexible, but resistant to kinking and or compressive closure. The device may be used completely or partially, outside, inside, in between, or combination with any lumen, vessel, duct, organ, hollow body organs, cavity, and or other structures or tissues within the body.
The coupler may be closed off if the bypass graft becomes occluded, or for any other reason, by the use of a cap, clamp, adhesive, combination or other method. A new bypass graft may be attached to the original coupler, or attached to a new coupler and inserted inside or near the original coupler. If the new coupler is intended to be inserted into the original coupler, the new coupler may be adapted to be secured inside by a gasket type material around the outside (to produce a mechanical and fluid tight seal), engaging elements, interlocking elements, adhesive, combination or other suitable design and method. The coupler also can be used as a temporary holding device for indwelling catheters, cannula, introducers or other devices. The coupler may be used to hold a catheter or other, at a fixed or movable length from the outside of a patient. The catheter or other may be inserted through the center of the coupler, with the tissue contacting ridge attached to the skin using an adhesive, suture(s), combination or other. The inside of the coupler may have a valve, ring, gasket or other, that provides fluid sealing as well as mechanical interference fit between the inside of the coupler and the outside of the catheter or other device.
Alternatively, the coupler may be configured to compress onto itself, providing closure, compression, sealing or reinforcement for any lumen, duct, organ, hollow body organs or cavity, or other structures or tissues, where partial or complete, temporary or permanent sealing, crimping, compression, plugging, reinforcement or other purpose is desired.
The vascular coupler also can have the following features, concepts, and configurations, as necessary and desirable. For example, the vascular coupler can be partially or completely made using several methods and processes including extrusion, sintering, molding (injection and other), casting, adhesive bonding, laminating, dip coating, spraying as well as composites and combinations thereof and combinations of other methods and processes.
The vascular coupler can be fabricated using injection-molding or overmolding techniques. The molds would be designed to mold the device material, inside, outside, in-between, around, etc. the superelastic/shape memory (or other material) elements, making the elements an integral part of the device. In general, the steps are as follows: an injection mold is prepared, having the general characteristics that will result in a device shown in the drawing sections. The superelastic/shape memory elements are placed at desired locations in the mold. The desired polymeric material is then injected into the mold with the elements in place, prevented from moving, so that they are integrated into the mold. The injected material is allowed to cure, and the device (with the elements) is removed.
Any area or region of the device may be biased in a direction (or directions) to increase the contact or holding/compression force, or for other purposes, than without the biased configuration (increase compression force) once the device has been deployed (or when the bypass graft is loaded onto the device, in the case of the stem).
A compliant material may be added to any or all areas of the device (stem and or petals), to aid sealing between the vessel and the device (similar to a gasket). For example, the compliant material may be applied to the region in between the inner and outer petals, and or one or both of the inner and outer vessel petals. The compliant material may also have one or more grooves, slots or other, to assist with hemostasis, prevent slippage, and or any other purpose. The compliant material may be, or contain, an adhesive or therapeutic substance. The compliant material may be added to the device by dip coating, spraying, brushing, molding, combination or any other method.
The stem may be overmolded or have a second piece jacket that would have a lip or other feature that would contact the top of the vessel, to prevent, or stop the vessel from splitting, as well as to reinforce the anastomotic site. Adhesive may be located on the bottom, vessel-contacting surface, or may be applied after deployment. If the piece is separate from the device, it may be placed around the bypass vessel before the two ends are secured, or placed from the side (slot or slit through the side of the piece). The tissue contacting area may be biased in such a way (downward) that may increase the tissue contacting force. Jacket may be reinforced with superelastic/shape memory materials, or other, and may be overmolded with silicone, ePTFE, combination or other biologically acceptable material.
Each tissue-contacting element (petal) may have one or more elements. One element may be deflected forward during deployment, with another element, or section of an element, acting as a depth stop to limit insertion. The deflected element may engage the interior of the host vessel.
The host vessel tissue contacting elements(s) may be part of the coupler, separate piece, or combination.
The host vessel tissue contacting elements may be flat, concave, convex, combination or other, at any location.
The host vessel tissue contacting elements may have a radiused (full or other), square, "V," combination, or other tip geometry.
Each host vessel tissue contacting elements may have an inside and outside vessel section, compressing the vessel wall in between. There may be a radiused (or other shape) cut out in the device to better "seat" the end of the vessel in between the host vessel tissue contacting elements. This may also allow the host vessel tissue contacting elements to lay flatter against the vessel wall.
The petals (or horizontal host vessel tissue contacting elements) may have one or more curves ("S," or other shape or configuration), to increase the contact area with the vessel, or other purpose.
A suture (commonly used, NiTi, coil, combination or other) may be used to secure the device to the bypass vessel, device to the host vessel, or both. The host vessel tissue contacting elements may have features such as holes, slots, cut outs reduced width, combination or other, specifically designed to accommodate any type of suture or clip. Alternatively, a standard design device could be used with sutures, at any location, bonding, or assisting with the bonding, of the vessels and the device.
An odd or even number of host vessel tissue contacting elements may be used—matched pairs or other configuration.
Longer and shorter host vessel tissue contacting elements may be used on the same device—they don't have to all be the same length.
The "Bite and Lock" design for one of the tissue penetrating versions of the device—the ends and or sided of the host vessel tissue contacting elements may be designed to fit and lock together during or after deployment.
The external side host vessel tissue contacting elements for the coronary version may extend onto the epicardium. Side host vessel tissue contacting elements may be partially, or completely (substantially) flat. The side host vessel tissue contacting elements may have adhesive on the tissue contacting surfaces, a suture, combination or other may also be used to enhance the contact between the device and vessel wall.
The desired host vessel tissue contacting elements are deflected forward, and the "C" section of the deployment tool is snapped, or positioned (from the side or top) around the desired host vessel tissue contacting elements of the device.
Simple, disposable, hand-held tool, designed to deflect one or more host vessel tissue contacting elements (and/or host vessel tissue contacting elements component) forward during insertion into the host vessel (deployment) and be removed from around the host vessel tissue contacting elements. The "C" section (constraining) of the tool may have weakened areas (reduced wall and or width) that assist in removing the simple deployment tool from the device (acting as a hinge). The tool may also have a means to separate the anastomotic device from the deployment tool, such as a pin that could pass through the deployment tool, contacting and pushing the device from the tool, as the pin or other is depressed.
The deployment tool may be plastic, and or have plastic, rubber, or other non-metallic surface at the device contact areas so as not to scrape, or otherwise remove the oxide from the surface of the NiTi device.
The deployment tool may incorporate a tissue-stabilizing feature, to assist deployment on a beating heart (features and designs may be similar to those produced by Medtronic, Guidant or other, and may include vacuum and or mechanical, or other, stabilization).
The vascular couplers described herein can provide numerous advantages. For example, the couplers can be a single piece coupler. No collar may be required to secure a bypass vessel to the coupler. The primarily metallic coupler has interior and exterior vessel engagement/supports on the same host vessel tissue contacting elements. Some versions of the couplers do not require a deployment tool and can be inserted and secured by hand. The deployment devices and methods do not expand, dilate, enlarge or otherwise exert radial force on the arteriotomy or aortotomy. No sheath is required for deployment of the couplers. The deployment system engages and releases the couplers from the side, not through a circumferential sheath. For the primarily metallic coupler, some of the host vessel tissue contacting elements are deflected forward for deployment, and some are left in the as annealed position, which acts as a depth stop to prevent over insertion of the coupler into the vessel. The overmolded ridge covers, and can be bonded to the tissue surrounding the arteriotomy or aortotomy, reinforcing the area and preventing any enlargement of the vessel access punch or incision. The coupler host vessel tissue contacting elements design compensates for any irregularities in the arteriotomy and or aortotomy, as well as the vessel wall.
In general, the stem of the vascular couplers may be overmolded straight, sinusoidal, a combination of these configurations, or any other suitable geometry. For example, to increase the compliance of the vascular couplers, the stem may be formed with longitudinal slots that run the length of the stem but do not cut entirely through the stem. The stem also can be configured as a surface for suturing the coupler to the bypass vessel wall. As with other areas on the coupler, holes, slots, grooves, reduced wall sections, or other openings or slots may be included on the stem to locate a running or interrupted suture or assist the physician's use of a running or interrupted suture.
In some of the above configurations, the overmolded stem may have a groove, slot, and or slit in-between the inner and outer wall of the stem. This space may be used to insert and secure a bypass vessel or a bypass graft to the coupler, using an interference fit, compression, adhesively bonded, suture, or combination of these or other suitable connecting means.
The circumferential ridge (i.e., outer vessel ridge) may be an integral part of the stem or may be a separate piece that is separately molded or adhered to the stem. The circumferential ridge functions as a top vessel contacting ridge to reinforce the anastomotic site, as well as to act as a depth stop to limit coupler insertion into the artery. The ridge can be completely or partially circumferential and may be reinforced (as described below). The ridge also can have a threaded region, such as a diagonal slot through the ridge, which allows a twisting movement to back out the ridge from inside the vessel during a push in—partially pull out deployment method. The ridge also can function as a surface for suturing the vascular coupler to the host vessel wall. As with other areas of the coupler, the ridge can include holes, slots, grooves, reduced wall sections, or other openings to locate and assist in the use of a running or interrupted suture. The vascular couplers above can be modified such that the ridge can be used with a suture, or to better enable suturing, to attach the bypass to the host vessel. In place of or along with the suture, an adhesive may be used as previously described. For example, a woven Dacron fabric can be adhered to the ridge such that vessel can be sutured or adhered to the Dacron fabric to attach the vessel to the ridge. Moreover, to assist with acute hemostasis, a compliant "gasket" can be molded or adhered under the overmolded ridge—the gasket may also be part of the overmolded component. The gasket can be, for example, the same material as previously described, including silicone, polyurethane, combination or other suitable material. Moreover, as described above, the bypass vessel or bypass graft may be attached to the inside, outside or in-between the stem of the vascular coupler. The attachment between the bypass graft and coupler may be completely based on or augmented by a mechanical interference fit, one or more sutures, an adhesive, a combination of these methods, and/or any other suitable method.
One or more sections of the ridge, as well as the entirety of the overmolded section of the coupler, may include a reinforcing layer or layers of material, such as woven Dacron, ePTFE, a combination of these, or other suitable material. The materials strengthen the ridge, thereby reinforcing or preventing the suture from pulling out and away, which may split the compliant ridge. The reinforcement material may be positioned on the top, bottom, in between, or combination of sections of the ridge and/or overmolded section or sections of the coupler. The suture reinforcement also may be formed in the shape of a partial or complete hoop or other structure.
In general, the multiple element version of the coupler may be fabricated with individual petals or petals that are formed as a group of more than one petal. The vascular coupler may be fabricated by overmolding of, e.g., a polymer to secure the petal or petal groups together to form the stem of the coupler. The petals or petal groups may also be joined together with a hoop configuration that may be split (i.e., open), completely closed circumferentially, or other configuration between these two configurations before being overmolded. The coupler petals may be fabricated as part of the stem, attached to the stem, and/or as separate pieces which are then joined to the stem. The end of the petals that are oriented away or outwardly from the stem can be further away (i.e., wider) as they extend from the stem.
By using multiple independent petals, the vascular coupler advantageously is configured for complete or greater than circumferential vessel contact at the site of the aortic punch or core site, and the arteriotomy for the coronary anastomosis.
As described above, the stem and petals may be fabricated from a material that has a round, flat, concave, or convex geometry. Of course, materials of other geometries can be used. Similarly, although the overmolded vascular coupler has been illustrated using individual petals, the petals described previously (e.g., paper clip, two elements on one petal) also may be used with the overmolded versions of the coupler.
The petals for the overmolded version can be formed as coils and advantageously have very minimal foreign material on the inside of the vessel. The coil wire used to fabricate the petals can be round, oval, or a combination of these or other geometries. Similarly, the coil wires may be made from single or multiple wires or a combination of these configurations or other continuous or interrupted wire configurations.
The coil wind angle may be consistent, and or varied. In this manner, the wider the separation between the coil winds, the more flexible the section (or region) in which the coil winds are positioned.
One, nearly complete circumferential loop (or other) of wire from the coupler provides the interior vessel contact. More than one wire may be used to create multiple, independent, partial circumferential vessel contacting elements that together may be nearly, or more than 360 degrees or other.
The coil wire used to fabricate the petals can be made of a material as described herein. For example, in version, the material may be a NiTi wire that has been electropolished and heat formed (as disclosed in detail above) around a suitable fixture or tool.
If a coiled strain relief is located above the overmolded stem, the coil strain relief may be on the inside or outside of the vessel and be secured with an adhesive, suture, or other attachment means, as described above.
In general, the vascular coupler can be deployed using a number of methods. For example, the vascular couplers may be deployed using any of the tools and techniques describe above. Examples of suitable method include the push in-pull out deployment technique, deflecting forwardly the interior vessel components, rotating the coupler during insertion, deploying by hand, and/or compressing the stem,
Radiopaque material such as barium sulfate, bismuth trioxide, tantalum or other can be added to the vascular couplers described herein, reinforcement structure or bonding material. Additionally, platinum, gold, or other material may be added to the device by sputter coating, ion deposition, vapor deposition, combination, or other process.
In general, the bypass vessel can be attached to the vascular couplers and the vascular couplers can be attached to the host vessel using sutures, staples (e.g., tissue penetrating and or non tissue penetrating), clips (e.g., tissue penetrating and or non tissue penetrating), adhesives, mechanical compression, combination or other. The bypass graft can be attached to the vascular couplers on the outside, inside, or in between.
In general, the securing members for the couplers described herein can be tissue penetrating or non penetrating. The securing members can be any shape, such as flat, round, concave, convex, oval, combination or other. The securing member(s) may have a single end, or a "U," "V," or other shape, including a "paperclip" type configuration. The securing members may be separate individual pieces, or attached to the petals, and overmolded. Alternatively, the securing members (individual or attached to the petals or other) may be separate from the coupler and crimped, allowed to self recover (for the superelastic/shape memory version) or otherwise bonded to the coupler. The securing member(s) may be connected to the petals (single piece), and or stem, or may be a separate element, or combination. The securing member(s) may be in the shape of a "J", "U" or other suitable shape or design. For "U" or other type securing member(s) that are separate from the coupler prior to attachment, the overmolded ridge may have a section (or sections) removed, to allow the outside of the securing member(s) to be of longer length, and lay against the coupler surface. The securing members may have horizontal and or diagonal (or other) slots, grooves or other, on one or more surfaces, to prevent slippage. Adhesive may also be used to assist the securing members' attachment to the tissue, or to the coupler. Deformable securing member(s) may be separate, independent piece(s) that are used to attach the bypass vessel to the coupler, and are applied using a hand tool (crimper, or other). Superelastic/shape memory securing member(s) may be separate, independent piece(s) that are used to attach the bypass vessel to the coupler, and are applied using a hand tool (crimper, or other). The securing member(s) may be designed and used to penetrate the tissue, compress the tissue against the coupler, or combination. The securing member(s) may be the same material as the petal and or stem, or different. The securing member(s) may be a metal, metal alloy, combination or other. The securing member(s) may be Nitinol, and automatically compress the vessel to the coupler when a deflecting force (during the loading process) is removed (through the fixturing/annealing/quenching and repeating the process if desired), or stainless steel (or other) that is bent, compressing the vessel to the coupler. The securing member(s) may be metal, metal alloy, or other as previously described for the coupler, or coupler element. The securing member(s) may also be covered or coated with an adhesive, biocompatible material, therapeutic material, combination or other, as previously described. Any bare metal on the securing member(s) may be electropolished.
The securing members may be overmolded with the coupler instead of separate members. As previously disclosed, the bypass vessel can be placed on the inside or outside of the stem (may be the same or different version of the coupler, and or securing member(s), depending on if the vessel is on the inside or outside of the stem). If the vessel is placed on the inside of the coupler, the securing member(s) may be held open (deflected) with a tool, fingers, and or fixture. The distal vessel edge is positioned, against or near the securing member(s). The deflection force is removed, allowing the securing member(s) to return to the annealed configuration, compressing the vessel wall against the coupler body. The same configuration can be used or modified for use when the bypass graft is on the outside of the coupler stem.
One or more bendable securing members can be used to attach the graft to the coupler. In this case, the bypass vessel can be placed on the inside or outside of the stem (may be the same or different version of the coupler, and or securing member(s), depending on if the vessel is on the inside or outside of the stem). If the vessel is placed on the inside of the coupler, the vessel is positioned against or near the securing member(s). The securing member(s) may be in an open position, to assist with the insertion and positioning of the vessel edge. Once positioned, the securing member(s) may be bent against the vessel, compressing the vessel against the coupler, by using a tapered dilator (or similar instrument) inserted into the inner diameter of the coupler, until the outer surface of the dilator contacts and forces the securing member(s) against the vessel. If the vessel is placed on the outside of the coupler, the vessel is positioned against or near the securing member(s). The securing member(s) may be in an open position, to assist with the insertion and positioning of the vessel edge. Once positioned, the securing member(s) may be bent against the vessel, compressing the vessel against the coupler, by using fingers or a tool.
The inside diameter of the coupler may be straight, flared, combination or other.
No dilating member needed or required before or during the deployment of the coupler.
The petal element(s) of the overmolded coupler may be movable through, or alongside, the wall of the overmolded body during deployment. While the coupler is positioned over the incised (or punched) vessel, the proximal ends of the petal elements may be advanced (one at a time, more than one, or all at once) through the stem, with the distal petal end protruding through the bottom of the coupler, advancing into the vessel and coming into contact with the vessel wall. The proximal ends of the petal elements may be secured in place by mechanical interference fit, adhesive, combination or other suitable designs or methods. This embodiment would work well with petals made from superelastic or shape memory materials (specifically, but not limited to, Nitinol).
When using petals (or other coupler component(s)) made from shape memory Nitinol, the petals (and or other component(s) may be activated to bend/expand outward and engage the host vessel, from a straight or other configuration, by temperature when the petals come in contact with blood. The petal elements may be flat, angled, concave, convex, combination or other geometry. Individual petal elements may be grouped together with more than one petal, for example within the overmolded section or sections of the coupler.
The tissue securing members may be assisted by the use of an adhesive, interior coupler geometry, combination or other, to provide a fluid tight seal between the bypass graft and coupler. The securing members further may be activated to contact/secure the bypass graft to the coupler by temperature (shape memory), when using securing members made from Nitinol. The securing members may be initially bent using a dilator-like tool, and followed up with a hemostat or other similar instrument, to further bend the securing members against the vessel wall. The securing members may be incorporated in the metallic tube version of the coupler. The securing members may be formed at the same time as the petals are formed (laser, wire EDM, chemical etching, combination or other) from the tubing. Alternatively, the securing members may be separate pieces.
The overmolded coupler may be formed over the petals, securing members, etc., or molded as a separate piece and the various components (such as petals, securing members, etc.) added as a second process. The overmolded coupler and or tissue contacting/reinforcing ridge sections may contain pores or holes through the wall, sufficient to feed new intima growth from outside of the vessel, so that endothelial cells may attach, or for any other purpose. The pore size may be in the range of 5 to 80 microns, with 30 microns being optimum. The pores or holes in the structure may be inherent in the material, present as the result of weaving, braiding, expanding material processing (such as ePTFE) or other process or method, or produced as a secondary process, such as laser, or by any other suitable process. The overmolded body may be produced by using a sintering process around any coupler component. The overmolded section or sections may contain holes, grooves, slots reduced thickness areas, combination or other, to modify the rigidity/flexibility/compliance of the section or sections, or for any other reason.
If a hemostatic gasket is used, it may be part of the overmolded body, tissue contacting/reinforcing ridge or any other component. Alternatively, it may be a separate piece. The gasket may be made from any of the previously disclosed materials, and or any suitable material. Any portion of the gasket may be flat, concave, convex, combination, or any other suitable geometry.
The top vessel reinforcing ridge may be part of the overmolded body, or a separate piece. The top vessel reinforcing ridge may be biased toward the vessel, to increase the compression between the vessel wall. Top vessel reinforcing ridge may prevent the coupler from rotation once deployed/implanted. The top vessel reinforcing ridge may be a different geometry and or material than the coupler stem. The top vessel reinforcing ridge may be oval or elongated, to be parallel with the vessel (coronary for example). The top vessel reinforcing ridge may be flat, angled, concave, convex, combination or other geometry. When viewed from above, the top vessel reinforcing ridge may be completely circumferential, an incomplete circle, sinusoidal, and or have one or more cut out areas (for crimped securing members, flexibility, or for any other purpose). The top vessel reinforcing ridge may have protrusions, on the tissue contacting surface that may be of sufficient length, and may be employed to prevent/limit coupler rotation once deployed onto (into) the host vessel.
Holes, slots, grooves, concave areas or regions, or other shapes may contain a therapeutic agent, bonding agent, combination or other, on or inside any section, region or component of the coupler. Materials, coating or coatings may be contained or applied to any area, region or component of the coupler to reduce or prevent post implant adhesions. Any coupler surface may be textured for any purpose (such as to encourage neo intimal, and or endothelial growth). When using deformable securing members to secure the bypass graft to the coupler, the crimping tool (modified hemostats or other) may have a stop, or other, to limit the amount the securing member can be compressed, to prevent over crimping and damage or weakening to the securing member that may result.
The coupler regions/components may be produced from different materials with different physical properties. For example, the external vessel ridge may be completely or partially made from a softer or harder material than the stem.
The petals produced from a sheet (for example using chemical etching or other as previously described), may include a secondary process to join at least one section to another section (one edge to a second edge or end). The secondary process may include inserting one end (including a tab) into a slot, groove, hole or other, soldering, welding, adhesively bonding, combination or other suitable process. Alternatively, the section or sections may not be bonded, or other wise attached together. This design may allow additional flexibility at one or more regions of the coupler (overmolded or non-overmolded).
The top vessel reinforcing ridge may have the same, smaller or larger diameter as the deployed petals. The ridge may have at least one section or surface that is flat, concave, convex, combination or any other suitable geometry, to provide/assist with the vertical compression for coupler securement and or acute hemostasis.
The stem/strain relief may be produced in one configuration, and designed to bend or deflect, but not kink, once a bypass graft has been attached to the coupler and implanted into a host vessel. For example, the coupler stem and or strain relief may be produced at a 90� angle, but deflect (again without kinking) to approximately 45�. This may be accomplished by reducing or eliminating at least one section or region in the wall of the stem, or alternatively, reinforcing at least one section or region of the stem/strain relief wall. The stem/strain relief may include an elbow or other suitable geometry—straight or combination. The stem/strain relief may be any angle (measured from the reinforcing ridge to the end of the stem/strain relief), and may be the same or different than the angle between the petal and the reinforcing ridge. For example, the vessel petal and the exterior reinforcing ridge may be aligned so that the outside edges of each are parallel, while the angle of the stem/strain relief may be at a 45� (or other suitable) angle.
The stem, strain relief, overmolded ridge, combination or other section, region or area of the coupler may contain at least one component or element, designed for any desirable purpose including the ability to expand and contract, producing a kinetic, dynamic, radial spring action, and or response to deflection, similar to a natural or sutured anastomosis.
The coupler may be packaged already attached to the deployment tool. Alternatively, the coupler could be inserted/attached/loaded in the deployment tool just prior to deployment.
Another coupler fabrication method includes stereo lithography (3-D layering) to partially or completely produce any or all coupler component(s) (stem and ridge section for example). The stereo lithography process may envelop/secure at least one or more tissue contacting elements, or other components that may be covered, partially or completely by the SL process. The process may also produce cavities for the later insertion/securing of coupler components (securing members/petals, etc.) as a secondary process.
The types of couplers described herein can be coronary, aortic, peripheral, valved, and other. The versions can be end to side, end to end, side to side. The coupler groups include sutureless or sutured. The coupler design options may have a diameter: 1.0 mm to >8 mm; geometry: Concentric, oval, combination or other, angle: 20� to 90� or other, and stem length: 0 mm to 8 mm or larger. The deployment methods include: (1) Compression of stem (using fingers or tool); (2) Forward deflection of inner vessel elements; (3) Remove simple tool from around coupler side, allowing superelastic petals to return to non-constrained configuration, engaging vessel wall; (4) shape memory petals recover to annealed position once inside vessel (using the bodies own heat, or by using a secondary heat source); (5) Push in, partially pull out; (6) Twist during insertion; and (7) Remote deployment devices and methods of use (to enable use of coupler during minimally invasive, endoscopic, laparoscopic, robotically assisted, catheter-based, as well as other types of procedures).
While several particular forms of the invention have been illustrated and described, it will be apparent that various modifications and combinations of the invention detailed in the text and drawings can be made without departing from the spirit and scope of the invention. For example, references to materials of construction, specific dimensions, and utilities or applications are also not intended to be limiting in any manner and other materials and dimensions could be substituted and remain within the spirit and scope of the invention. For example, the everted versions of the couplers without petals but having reinforcing ridges, described herein, can be joined together. The ridges are adhered together, as described herein, and the everted edges of the vessels are thereby placed in contact to provide an end-to-end anastomosis. Finally, it is contemplated that any single feature or any combination of optional features of the inventive variations described herein may be specifically excluded from the claimed invention and be so described as a negative limitation. Accordingly, it is not intended that the invention be limited, except as by the appended claims.
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|Dec 19, 2003
|Jul 15, 2004
|Robert Stobie
|Heart valve holders and handling clips therefor
|Dec 22, 2004
|Jul 7, 2005
|I. & S. -Idee & Sviluppo S.R.L.
|Device for end-to-side anastomosis
|Apr 16, 2003
|Jul 28, 2005
|Scott Manzo
|Method and apparatus for anastomosis including annular joining member
|Apr 12, 2004
|Oct 13, 2005
|Binmoeller Kenneth F
|Automated transluminal tissue targeting and anchoring devices and methods
|Feb 17, 2006
|Sep 14, 2006
|Rox Medical, Inc.
|Device and method for establishing an artificial arterio-venous fistula
|Feb 10, 2005
|Oct 26, 2006
|Loubser Paul G
|Apparatus and method for holding a transesophageal echocardiography probe
|Jun 8, 2006
|Dec 14, 2006
|Binmoeller Kenneth F
|Methods and devices for endosonography-guided fundopexy
|Dec 14, 2006
|Jun 14, 2007
|Binmoeller Kenneth F
|Methods and devices for anchoring to tissue
|Nov 22, 2006
|Jul 26, 2007
|Brenneman Rodney A
|Device and method for establishing an artificial arterio-venous fistula
|Mar 9, 2007
|Aug 9, 2007
|Martin Brian B
|Devices for restoring blood flow within blocked vasculature
|Mar 9, 2007
|Aug 9, 2007
|Martin Brian B
|Devices for restoring blood flow within blocked vasculature
|Mar 9, 2007
|Aug 23, 2007
|Martin Brian B
|Devices for restoring blood flow within blocked vasculature
|Mar 9, 2007
|Aug 23, 2007
|Martin Brian B
|Methods for restoring blood flow within blocked vasculature
|Mar 12, 2007
|Aug 23, 2007
|Martin Brian B
|Methods for restoring blood flow within blocked vasculature
|Feb 27, 2007
|Sep 27, 2007
|Houser Russell A
|Catheter Securement Device
|Feb 5, 2007
|Sep 27, 2007
|Martin Brian B
|Methods and devices for restoring blood flow within blocked vasculature
|Apr 4, 2007
|Oct 25, 2007
|Rox Medical, Inc.
|Device and method for establishing an artificial arterio-venous fistula
|Oct 4, 2007
|Oct 2, 2008
|Binmoeller Kenneth F
|Luminal Structure Anchoring Devices and Methods
|Apr 17, 2007
|Oct 23, 2008
|Lazarus Effect, Inc.
|Complex wire formed devices
|Apr 17, 2007
|Oct 23, 2008
|Lazarus Effect, Inc.
|Complex wire formed devices
|Jul 2, 2008
|Jan 1, 2009
|Vascular Closure Systems, Inc.
|Arteriotomy closure devices and techniques
|Dec 7, 2005
|Jan 29, 2009
|Xlumena, Inc.
|Method and Apparatus for Performing Needle Guided Interventions
|Jul 10, 2008
|Feb 26, 2009
|Cardiovascular Technologies, Inc.
|Methods and Devices for Coupling a Device Insertable within a Mammalian Body
|Sep 10, 2007
|Mar 12, 2009
|Lazarus Effect, Inc.
|Articulating retrieval devices
|Oct 31, 2008
|Jun 4, 2009
|Houser Russell A
|Vascular closure devices, systems, and methods of use
|Dec 3, 2008
|Jun 4, 2009
|Houser Russell A
|Guided Tissue Cutting Device, Method of Use and Kits Therefor
|Dec 9, 2008
|Jun 11, 2009
|Med Institute, Inc.
|Lubrication Apparatus for a Delivery and Deployment Device
|Jun 17, 2009
|Oct 22, 2009
|Jan Otto Solem
|Device, A Kit And A Method For Treatment Of Disorders In The Heart Rhythm Regulation System
|Apr 21, 2009
|Nov 12, 2009
|Xlumena, Inc.
|System and method for transluminal access
|Nov 12, 2009
|Xlumena, Inc.
|Tissue anchor for securing tissue layers
|Dec 3, 2009
|Lazarus Effect, Inc.
|Retrieval systems and methods for use thereof
|Sep 30, 2009
|May 27, 2010
|Rox Medical, Inc.
|Methods for screening and treating patients with compromised cardiopulmonary function
|Dec 19, 2008
|Jun 24, 2010
|St. Jude Medical, Inc.
|Systems, apparatuses, and methods for cardiovascular conduits and connectors
|Feb 3, 2010
|Aug 19, 2010
|William Swanson
|Electrical Conduction Block Implant Device
|Apr 9, 2010
|Oct 21, 2010
|Xlumena, Inc.
|Methods and apparatus for advancing a device from one body lumen to another
|Apr 9, 2010
|Oct 21, 2010
|Xlumena, Inc.
|System and method for delivering expanding trocar through a sheath
|Oct 21, 2010
|Rox Medical, Inc.
|Device and method for establishing an artificial arterio-venous fistula
|Nov 11, 2010
|Tyco Healthcare Group Lp
|Method and Apparatus for Anastomosis Including an Expandable Anchor
|Oct 17, 2007
|Dec 2, 2010
|Stevan Nielsen
|Shape-Changing Medical Device, Kit, Method Of Production, And Method Of Use
|May 12, 2011
|Xlumena, Inc.
|Apparatus and method for deploying stent across adjacent tissue layers
|Aug 21, 2009
|May 3, 2012
|S & C Systems Gmbh
|Blood vessel attachment for a vascular prosthesis
|Nov 15, 2010
|May 17, 2012
|Dr. Wilson T. Asfora
|Sutureless vascular anastomosis connection
|May 23, 2013
|Rox Medical, Inc.
|Device and method for establishing an artificial arterio-venous fistula
|Jul 12, 2012
|Jan 16, 2014
|Makor Issues And Rights Ltd.
|Tailor-made stent graft and procedure for minimally invasive aneurysm repair with novel tailor-made balloon, novel guidewire, and novel capsulated bioglue
|Mar 28, 2012
|Aug 14, 2014
|Northwood Medical Innovation Limited
|Ear scaffold
|Apr 17, 2009
|May 4, 2011
|Blood vessel anastomat
|Jul 29, 2012
|Nov 14, 2012
|Attaching clamp for cardiovascular operation cannula
|Oct 1, 2008
|Jun 16, 2010
|Xlumena, Inc.
|Luminal structure anchoring devices and methods
|Apr 24, 2008
|Feb 19, 2014
|Emory University
|Conduit device and system for implanting a conduit device in a tissue wall
|Sep 12, 2008
|Mar 19, 2009
|Lazarus Effect, Inc.
|Articulating retrieval devices
|Oct 17, 2007
|Apr 23, 2009
|Syntach Ag
|Shape-changing medical device, kit, method of production and method of use
|Dec 16, 2009
|Aug 19, 2010
|St. Jude Medical, Inc.
|Systems, apparatuses, and methods for cardiovascular conduits and connectors
|Jul 16, 2010
|Jan 19, 2012
|Ethicon Endo-Surgery, Inc.
|A device and method for directing bile from the gallbladder in the intestine
|U.S. Classification
|606/155, 606/154, 623/1.36
|International Classification
|Cooperative Classification
|European Classification
|Aug 9, 2008
Owner name: CARDIOVASCULAR TECHNOLOGIES, INC., CALIFORNIA
Free format text: ASSIGNMENT OF ASSIGNORS INTEREST;ASSIGNORS:HOUSER, RUSSELL A;HARE, WILLIAM D;REEL/FRAME:021365/0511;SIGNING DATES FROM 20060731 TO 20061003
|Jan 8, 2009
Owner name: CARDIOVASCULAR TECHNOLOGIES, INC., CALIFORNIA
Free format text: ASSIGNMENT OF ASSIGNORS INTEREST;ASSIGNORS:HOUSER, RUSSELL A.;HARE, WILLIAM D.;REEL/FRAME:022074/0397;SIGNING DATES FROM 20060731 TO 20061003
|Jul 28, 2010
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|Jul 30, 2014
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