text:
The Rolling Stones have returned to touring with a high-energy, sold-out show in Oslo, following a break of several months after the death of fashion designer and frontman Mick Jagger's partner, L'Wren Scott.
The classic rock quartet — comprising Jagger, Keith Richards, Charlie Watts and Ron Wood — played to approximately 23,000 fans at a late-night concert at Oslo's Telenor Arena Monday evening.
The Stones played hits such as Satisfaction, Brown Sugar, Sympathy for the Devil and You Can't Always Get What You Want (with Bergen's Edvard Grieg Youth Choir joining in on the latter), ultimately ending the gig with a fireworks display.
"It was a great rock 'n roll show," said 55-year-old fan Jan Martin Schultz, who attended the concert with two friends.
Having seen the Rolling Stones several times before, he also remarked on the band's energy onstage.
"I saw them in Gothenburg in 1982 and I thought then they seemed old. They didn't seem old tonight."
Several Norwegian music critics also gave the show a positive review in today's newspapers, noting in particular Jagger's physicality as he danced, strutted, sang for and joked with the audience.
The Stones suspended their current world tour in March after the death of Scott, who committed suicide in her Manhattan apartment.
At the time, the band was on the Australia and New Zealand leg of the tour. The shows were later rescheduled for this coming fall.
Jagger did not refer to Scott during Monday night's Oslo concert, which kicked off the band's upcoming European jaunt.


text:
- Report: #999887
Report - Rebuttal - Arbitrate
Complaint Review: Maggie Monteith
Maggie Monteith22647 Ventura Blvd. #1004 Woodland Hills, CA 9136 22647 Ventura Blvd. #1004 Woodland Hills, CA 226, California United States of America
Maggie Monteith MLM Magnet Media Dignity Distribution I can confirm that Maggie took at least 2m from investors in the UK promising to make films and pay them back 140% of what they received. They have received very little in return..typical example is 22647 Ventura Blvd. #1004 Woodland Hills, California
*General Comment: My experience of Maggie Monteith
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Over three years she probably took 8/9 m of UK investors money. And alongside other investors(she said) these investments financed the purchase of several fils that have never seen the light of day. Three other films have been made The Experiment,Thirteen, and Dark tide.
Maggie promised the investors their money back plus 40% profit. She guaranteed this in emails. investors have received less than 10% of their money back.... So there is at least 8m missing.
The amazing news is that Maggie is still in the UK raising money from unsuspecting investors and their advisers.
As all the reports say " she is very believable, very credible".
She also has the ability to cry at will ..... Cheap shot I know... But when pressed see what she does... Starts at Mea Culpa which morphs into "if only I had known".
The give away is... Try to find someone... An investor.. A business partner... An adviser... That has worked with her for more than enough time to find out about her.
If nothing else, I hope this report gets you to ask better questions.my clients and I will never give her any more money... This is purely based on what we experienced.
One client gave her 500,000.... He has had $69,000 back.
Is that the return you are expecting?
This report was posted on Ripoff Report on 01/19/2013 05:14 PM and is a permanent record located here: http://www.ripoffreport.com/r/Maggie-Monteith/22647-Ventura-Blvd-1004-Woodland-Hills-CA-226-California-/Maggie-Monteith-MLM-Magnet-Media-Dignity-Distribution-I-can-confirm-that-Maggie-took-at-l-999887. The posting time indicated is Arizona local time. Arizona does not observe daylight savings so the post time may be Mountain or Pacific depending on the time of year.
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#1 General Comment
My experience of Maggie Monteith
AUTHOR: Anne Elizabeth - ()
SUBMITTED: Friday, September 12, 2014POSTED: Friday, September 12, 2014
I and our company have been working with Maggie for some time now- and have nothing but positive things to say. She has been a comsummate professional- has an stellar background, has been absolutely transparent, including letting us know of the negative situations that have come up that have been reported. In the entertainment business, it is all too frequent that lawsuits are filed with one side of the story being laid out. As I look into things regarding those I am going to be working with, in this case, certainly- I have no qualms whatever about working with Maggie and we (our company) looks forward to a long term relationship.
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subset: commoncrawl


text:
Find. Book. Pitchup.
- We make it a doddle to book campsites, glamping sites and caravan parks throughout the UK, Europe and the Americas.
- Trusted by over 1m holidaymakers from 99 countries
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1 bookable site in Angus
Edzell, Angus, Scotland Show on map
|Backpacker non-electric grass tent pitch
|1 x
|From £8/€9.39/A$13.89/US$10.51/CA$13.66/CHF10.28/kr89.29/kr70.18/kr87.05/kr1,231/$158.10/$7,273/PEN35.18 per night
|Two-man non-electric grass tent pitch
|2 x
|From £12/€14.08/A$20.84/US$15.76/CA$20.50/CHF15.42/kr133.93/kr105.26/kr130.58/kr1,846/$237.15/$10,909/PEN52.77 per night
|Four-man non-electric grass tent pitch
|4 x
|From £16/€18.77/A$27.78/US$21.02/CA$27.33/CHF20.57/kr178.57/kr140.35/kr174.10/kr2,462/$316.21/$14,545/PEN70.36 per night
|Six-man non-electric grass tent pitch
|6 x
|From £18/€21.12/A$31.26/US$23.65/CA$30.74/CHF23.14/kr200.89/kr157.89/kr195.87/kr2,769/$355.73/$16,364/PEN79.16 per night
|Eight-man non-electric grass tent pitch
|8 x
|From £20/€23.46/A$34.73/US$26.27/CA$34.16/CHF25.71/kr223.21/kr175.44/kr217.63/kr3,077/$395.26/$18,182/PEN87.95 per night
|Electric hardstanding pitch
|6 x
|From £20/€23.46/A$34.73/US$26.27/CA$34.16/CHF25.71/kr223.21/kr175.44/kr217.63/kr3,077/$395.26/$18,182/PEN87.95 per night
Montrose, Angus, Scotland Show on map
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Story Lines Story Lines is the old fashion game of 'telephone' that has been appified with a pictionary twist to it. Someone selects the word or phrase and then passes the iPad to the next player who in turn has to draw the phrase, they then pass it on to the next player who hasRead More
Month: February 2012
Show Me the Money: SLP Salary Expectations
Upon entering the field of speech-language pathology, I certainly didn't expect to become the next millionaire, but I did expect to be able to live very comfortably. In a recent post on an SLP Facebook page, a young lady inquired about the average annual salary for speech therapists. She was inquiring because her parents wereRead More
Move Your Body! There are Crows Coming
Crows Coming by VisionHacker Do you have clients or students that simply can't access the iPad due to limited limb mobility but have good head control? Crows Coming created by Vision Hackers is using some cool camera technology that offers a fun experience without having to use the touch interface. VisionHacker is a team of computerRead More


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Chocolate Chip S'mores
Short grey days seem to linger with little purpose. Chilly mornings feel gelid and uninviting. They seem to say, "go back inside and sip on cocoa." Everybody searches for warmth.
Blankets are stacked high on beds and couches, always within reach. Fluffy coats hang by drafty doors. Fires roar to life inside and outside.
S'mores, the quintessential summertime treat, warm my soul during cold, dark winter days and nights.
Sub in some chocolate chip cookies for graham crackers and you have the best comfort treat around. The best part about these guys? They taste almost exactly like a s'more and you don't even have to go outside and build a campfire to enjoy them.
- 24 Chocolate Chip Graham Crackers (recipe below)
- 2 cups Italian Meringue (recipe below)
- Prepare the cookies and the italian meringue according to the instructions.
- Arrange 12 of the cookies upside down.
- Spread italian meringue on the upside down cookies.
- Top each of the cookies with meringue with another cookie.
- Using a kitchen torch carefully torch the visible disk of meringue on each cookie sandwich.
These cookies are my standard chocolate chip cookies with extra chocolate (milk chocolate to mimic S'mores). It also uses graham flour to mimic the graham cracker flavor.
- 4 ounces unsalted butter
- , at room temp.
- 3 ounces brown sugar
- 3 ounces sugar
- 1 egg
- ½ teaspoon vanilla
- 3 ounces graham flour
- 3 ounces all-purpose flour
- 1 teaspoon baking soda
- ½ teaspoon salt
- 8 ounces milk chocolate,
- chopped
- Preheat the oven to 350°F. Line a cookie with parchment paper and set aside.
- Put the butter and sugar in a bowl. Beat until light and fluffy, about five minutes.
- Add the egg and vanilla. Beat until completely incorporated.
- Add the flours, baking soda and salt. Mix until a batter forms. Take care not to over mix.
- Add the chocolate chips. Mix in until evenly distributed.
- Spoon the dough onto the baking sheet, so that there are 24 cookies.
- Place in the refrigerator for at least an hour to rest.
- Remove from the fridge and place the cookies straight in the preheated oven. Bake for 13 to 16 minutes until the edges are golden brown and the center is just golden.
- Bake less for chewier cookies or bake longer for crispier cookies.
- Remove from the oven once baked and let cool on the cookie sheet a few minutes before removing to a cooling rack. Let cool completely.
While Italian meringue is the most difficult of the meringues to execute, it is the only meringue that doesn't require additional cooking and thus is perfect for this application. Italian meringue will also have a long shelf life when refrigerated so making a larger batch at once for multiple applications is always an option. In fact, italian meringue is pretty much an all natural version of marshmallow cream!
- 8 ounces sugar
- ¼ cup water
- ½ cup egg whites
- Place the sugar and water in a heavy bottomed pot and bring to a boil over high heat. Bring the sugar to 240°F.
- While the sugar is heating, begin whipping the egg whites until the are fluffy and have expanded 2 to 3 times in volume.
- Once the sugar is at 240°F and the egg whites are foamy, immediately begin slowly adding the hot sugar into the egg whites while whipping at medium-high speed. Be sure to add the sugar very in a needle thin stream in between the whisk attachment and the side of the mixer bowl.
- Once the sugar is added, whip the mixture at high speed until it is completely cooled and the egg whites form stiff peaks, about 1o to 20 minutes.


text:
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Sorry to bother so many people but I do not know the email of the list manager. I wish to be taken off the mailing list. Thank you. always; Beng Kiam ---------Received on Tuesday, 10 December 1996 21:00:23 UTC
This archive was generated by hypermail 2.3.1 : Tuesday, 6 January 2015 22:04:14 UTC


text:
Everything about this New York backyard wedding, from the Bride's pretty flower crown to the mouthwatering tower of donuts, is such a delight! It's a laidback affair with lawn games, DIY centerpieces and string lights, yet stays chic with accents inspired by the Italian coast. Daniel Cruz captures all the wonderful details in the full gallery right here.
All posts with Vendor
"Daniel Cruz"
You know what's better than spending the day basking in the gorgeousness that is this beautiful Lake Arrowhead engagement session? Nothing. Absolutely, positively nothing is better than hours upon hours of sweet, sweet time soaking in every last breathtaking moment captured by Daniel Cruz Photography. From the darling DIY details to the cool blue waters to one of the cutest couples you will ever virtually meet, it's a non-stop day...


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So far so good right? The game looks interesting and since I have too much time on my hands I 've been following it closely. Now Square has actually released a trailer with gameplay (if you missed it heres a link www.joystiq.com/2009/01/28/final-fantasy-xiii-countdown-ends-new-trailer-released/ ) . I hope this game has an overworld like the original final fantasy's but played from a third person perspective like FF-12. Also bring back the Airship!!! I loved piloting that thing around, the ones we got in FFX, FFX-2 and FF 12 where almost non-existent. Remeber in the past when you could enter the ship converse with crew and party members, I loved that. FFX and the sequel allowed this but it felt tacked on and kind of cheap.
Aside from the overworld the gameplay looks quite traditional plus they've brought back the ATB meter which I think is great. I've always liked the ATB battle system, I find it fluid and fast paced. I personally want to be able to control all characters at all times I hate A.I controlled characters in my RPG's, so I hope FF-13 ditches that feature introduced in FF-12. Also bring back guest characters like in FF-9, they had them in 12 but the computer controlled them, booorinnnng!!! Maybe Square will include multiplayer in the battles like they did in the PSone remakes of the old FF's, here's hoping. Ultimately all, or atleast some of the battle system will be revealed when Advent children comes out with a demo. On a final note I've read a couple of websites that have dissected the battles seen in the trailer, so far they've come to the conclusion that the battle system is essentially a cross between FF 8 and FF X-2. Now this is based on limited information so they could be horribly wrong but if they're right then the game could suffer from a coulpe of hiccup's if you know what I mean- I'm looking at you FF-8, the game was fun but it almost felt like a Final Fantasy Simulation.


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- Report: #1089585
Report - Rebuttal - Arbitrate
Complaint Review: Ross Auto & Tire Shop
Ross Auto & Tire Shop5034 Ross Avenue Dallas, Texas USA
Ross Auto & Tire Shop Are Crooks. Intentionally Destroyed my ECU in my Car To Triple the Charge. Burned The ECM! Can't Be Trusted. Greedy Pigs! Dallas Texas
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My experience of this shop couldn't have been worse. These guys tried to cheat me. They were very unethical and dishonest and even intentionally damaged my ECM on my Honda to get me to allow them to fix it. I truly believe the reason my Honda was stalling was a minor issue. But to be sure I had my car towed to their shop. I had four free tows through my phone company AT&T so I didn't have to pay anything.
These guys took my car in and the head guy kept trying to sell me a junk car that someone had allowed to stay at his shop incurring storage fees and had evidently lost it because of the storage fees. I refused. He was very persistent.
When these guys finally called me to tell me they had discovered the problem with my car the guy was holding my car's computer. The ECM. He said it had caught fire and was damaged. This is what gets me. He pulls out the ECM and shows it to me and the part he says was damaged was like someone had put a blow torch to it. [continued below]....
I was a single woman and they knew I wasn't from Dallas. I knew no one in Dallas. During my conversation with them I had confided that to them. I honestly think they were trying to take advantage of me. Honestly.
After being told it was my ECM I stepped into the other room and called around to a friend of mine and he gave me the number to a few shops who carried the part. I had already priced the part when the guys came to me and said they could get the part and the price they told me was several hundred dollars more than what I had priced at several different places.
I told them to pack my car up and I was leaving. I called the tow truck. The head Guy up front who I never had a good feeling about, he had a really unsavory aspect to him, then seemed shocked I was prepared to tow my car away from there. He asked me to "leave my car there". He almost begged me to let my car sit there. I asked if he charged storage and he said yes at $20 per day.
He knew I had three other free tows. Why would I leave my car there? Didn't make sense. So I towed the car and sold it.
Stay away from this shop. These guys are so greedy it is my belief they intentionally damaged my car, hiked the part up several hundred dollars and were trying to get almost a grand out of me.
Last, they left my car in pieces. They didn't even bother putting anything back together
This report was posted on Ripoff Report on 10/04/2013 04:54 PM and is a permanent record located here: http://www.ripoffreport.com/r/Ross-Auto-Tire-Shop/Dallas-Texas-75206/Ross-Auto-Tire-Shop-Are-Crooks-Intentionally-Destroyed-my-ECU-in-my-Car-To-Triple-the-1089585. The posting time indicated is Arizona local time. Arizona does not observe daylight savings so the post time may be Mountain or Pacific depending on the time of year.
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Worldwide Free Shipping
Product Warranty: 90-day warranty to replace, 180-day hassle-free warranty. See details.Payment & Returns
Add to wish list Error Report Price Match
this 3.5 touch screen android smartphone supports Wi_fi,Fm,gps and bluetooth. you can download the application with the android 4.03 os freely and surf the internet corveniently with the wi-fi function
|Supports full high-definition resolutions up to 1920x1080
Supports video and audio playbakc in many formats
High speed USB 2.0 supports USB storage devices
Remote control operation
|General Specs
|Brand & Model
|Egreat R6S Pro
|RTD1186DD, 750MHz
|512MB DDR3 SDRAM, 512MB nano flash
|External 3.5" or 2.5" E-SATA HDD, DVD ROM, BD ROM, U-disk
|Additional Functions
|Video Format
|Video Containers: RM/RMVB; MPEG1/2/4 Elementary (M1V, M2V, M4V)
MPEG1/2 PS (M2P, MPG); MPEG2 Transport Stream (TS, TP, TRP, M2T, M2TS, MTS); VOB; AVI, ASF, WMV; Matroska (MKV), MOV (H.264), MP4, RMP4; IFO, DVD-ISO,BD-ISO; MINI BD, BD-9, BD25, RBD, D5, D9, DVD, CD, FLV; swf/(.swf) *, 3GP/.3gp, AVS/(.avs), 3D Bluray(DISC/ISO)/Single-File(*.ts/*.m2ts)
Video Decoders: MPEG1,VCD1.0/2.0, SVCD(Up to 1920x1080@30P/60I or 1280*720@60P);
HD MPEG2 MP/HL, ISO, IFO, VOB, TS(Up to 1920x1080@30P/60I or 1280x720@60P); HD MPEG4 SP/ASP, Xvid (Up to 1920x1080@30P/60I or 1280x720@60P); H.264 BP@L3, email@example.com, firstname.lastname@example.com (Up to 1920x1080@30P/60I or 1280x720@60P); WMV9, VC-1 AP@L31920x1080@30P/60I or 1280x720@60P); DivX3/4/5(Up to 1920x1080@30P/60I or 1280x720@60P); XVID SD/HD(Up to 1920x1080@30P/60I or 1280x720@60P); RM/RMVB 8/9/10(Up to 1280x720@30P); AVS: Jizhum profile @ level 2.0/ 4.0/ 4.2/ 6.0/ 6.2
|Audio Format
|Audio Containers: AAC, M4A, MPEG audio (MP1, MP2, MP3, MPA),
Audio Decoders: MPEG I Layer 1/2/3(2-CH), MPEG II 1/2(Multi-Channel), LPCM, ADPCM, FLAC, AAC, WAV, OGG, DTS digital+stereo; Dolby Digital, RA1/RA-cook/RA-Lossless
|Audio Pass-through
|DTS, DTS-HD HR, DTS-HD MA, Dolby Digital, Dolby Digital Plus
|Photo Formats
|JPEG, BMP, PNG, GIF, TIFF, jps(3D), mpo(3D)
|Subtitle Formats
|MicroDVD [.sub], SubRip [.srt], Sub Station Alpha [.ssa], Sami [.smi], idx+sub, PGS
|Menu Languages
|English, Czech, Greek, French, German, Hebrew, Italian, Russian, Simplified/Traditional Chinese, Spanish, Turkish
|File System
|FAT32, NTFS, EXT3, HFS format
|Video Output
|HDMI 1.4 1080Poutput (Resolution: 480P, 576P, 720P@50Hz, 720P@60Hz, 1080I@50Hz, 1080I@60Hz, 1080P@50Hz, 1080P@60Hz)
Composite Output (Resolution: 576I@PAL, 480I@NTSC)
|Audio Output
|Stereo analog audio, SPDIF Optical
|10/100M Ethernet
|1 x USB 2.0 host, 1 x USB 3.0 host
|1 x E-SATA interface, HDD, DVD ROM and BD ROM attachable
|Power Source
|134 x 102 x 28 mm
|1.0 kg
|Weight of Remote Controller
|0.1 kg
Credit Card
1, Please key in the correct shipping address in English while checking out with
PayPal. Or the order will be shipped to your PayPal address.
2, If your home address (habitually receiving address) has been changed, please edit your PayPal address in time to avoid editing receiving address repeatedly while checking out with PayPal.
3, Normally, dropshipping order will be shipped out in 1 business day and non-dropshipping order 2 business days.
Shipping Method
|Delivery time
|Delivery time
|In Peak Season
|United States, Canada
|15-20 calendar day
|25-30 calendar days
|Australia, New Zealand, Singapore, Vietnam, Malaysia, Israel,Indonesia, Turkey
|20-25 calendar days
|30-35 calendar days
|Russia, United Kingdom, France, Spain, Germany, Netherlands, Spain, Ukraine, Japan, Belgium, Denmark, Finland, Ireland, Norway, Portugal, Sweden, Switzerland
|25-30 calendar days
|35-40 calendar days
|Italy, Brazil, Argentina, Chile, Mexico
|30-40 calendar days
|40-50 calendar days
|United States, United Kingdom,Russia,Australia
|7-15 calendar days
|15-25 calendar days
|3-7 calendar days worldwide
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The Campus Climate for Gay Students Who Leave 'the Closet'
Coming out is ultimately liberating for gays, but the process is exhausting and fraught with many fears and doubts -- even at a college or university. Diversity is often celebrated rhetorically on college campuses, but they can be uncomprehending...
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USAO Social Media
At USAO, we're more than just a university, we are a community. To this end, we work diligently to provide valuable resources for future and current students, as well as alumni, faculty, staff and friends of the university on a variety of popular social media platforms. Check out our offerings and see what best suits your needs.
USAO's Facebook page has more than 8,000 family members and grows every day. It's a great place to see photos that offer a glimpse into the everyday awesomeness that goes down on campus, get the latest news about the university and interact with other Drovers, past, present and future.
Updates: 1-2 per day.
Look for us @usaodrovers to access our stream of news, quotes, event liveblogging and meet other Tweeters that are part of our community. Also an important account to follow for weather and crisis updates should the need arise.
Updates: 4-6 per day or as needed.
If you have a Gmail or YouTube account, chances are you already have a Google+ profile. Why not use it to circle up with our most content rich social media channel? With longer posts and a wider variety of media supported, Google+ is poised to become THE go to platform for community-based content sharing.
Updates: 1-3 times per week or as available resources demand.
Speaking of YouTube, our channel features new episodes of In the Saddle every week and monthly episodes of Around the Oval during the school year to keep you up to date on all the sports happenings and the players and coaches that make it happen. We also use the channel to document yearly events like our Symposia series as well as interviews with faculty and students to give you an inside look at the university.
Updates: Weekly or more often as content demands
Of course, no social media experience would be complete without Pinterest. Now on our second year with the site, USAO highlights the best images, stories and re-pins on eight carefully curated boards designed to give you the inside skinny on the sights you will enjoy everyday on our campus.
Updates: Twice a week or as needed.
USAO's Instagram shows creative pictures and short, fun videos on all things USAO. We capture everything from freshman orientation to graduation day. We also host Instagram contests and love it when our Drovers show us some love by using our hashtags. Follow DROVERPROUD to see what's going on in the #DroverNation.
Updates: Weekly or more often as content demands


text:
|Publication number
|Publication type
|Application number
|Publication date
|Jul 18, 1989
|Filing date
|Jul 29, 1988
|Priority date
|Dec 11, 1981
|Fee status
|Publication number
|Kenneth R. Fox, A. Arthur Coster
|Original Assignee
|Fox Kenneth R, Coster A Arthur
|Export Citation
|BiBTeX, EndNote, RefMan
|Patent Citations (38), Non-Patent Citations (36), Referenced by (96), Classifications (12), Legal Events (15)
|External Links: USPTO, USPTO Assignment, Espacenet
The present invention relates to a method of and apparatus for the laser treatment of occluded body lumens of mammals, especially humans, and more particularly to the intraluminal use of laser energy to perforate and/or remove luminal occlusions, such as thrombi and/or atherosclerotic placques in the cardiovascular system.
Cardiovascular disease is a major cause of death and morbidity and manifests a grave concern to both the scientific community and the lay public. Arteriosclerotic cardiovascular pathophysiology is a complex of diseases which affects many blood vessels in the body, the decreased lumen diameter causing tissue ischemia. Other very common diseases, such as diabetes mellitus, enhance the occlusion of important blood vessels and ischemia of the organs they supply. Those diseases, aggravated by such other common abnormalities as hypertension, and other vascular diseases and cardiovascular diseases, account for cerebrovascular accidents, myocardial infarctions, and other devastating illnesses, including loss of life and limb. Unfortunate individuals affected with arteriosclerotic cardiovascular disease and the related vasculopathies often manifest disease in coronary, carotid and cerebral arteries, in popliteal, tibial and dorsalis pedis arteries of the lower extremities and in other vessels. Those individuals, apart from having a shortened life expectancy, and suffering from sudden death, frequently also suffer from other debilitating problems including angina, shortness of breath and restricted activity, claudication or restricted use of the lower extremities, sometimes with loss of those extremities from disease, and loss of functions of movement, speech, cerebral interpretation and cognitive abilities.
Historically, there are few effective means for preventing some of the foregoing disastrous medical problems. Patients with certain types of coronary insufficiencies documented by certain coronary angiographic findings may be helped symptomatically by coronary artery bypass operations. Other patients sometimes may be benefited by other types of arterial surgery, for example, various bypass operations, or endarterectomies, which surgically attempt recanalization of certain occluded blood vessels or other operations. Those are generally patients with severe disease, but yet who meet certain diagnostic criteria and who are healthy enough to undergo what amounts to major surgery with relatively high morbidity and mortality rates. The cost is immense for many of these operations and incumbent hospitalization, including expensive special equipment which is required, and special training which is necessary for a team to operate the special surgical equipment. For example, it is estimated that a single coronary bypass operation may cost a patient over $50,000 including the hospitalization fees, and surgical fees. Availability of this special type of surgery for vascular problems is limited. Long term efficacy of coronary bypass surgery is as yet unknown, and the appropriate diagnostic and surgical criteria remain controversial. Because of the severity of the morphology and nature of the disease, for many patients treatment has been unavailable and has been beyond the current scope of surgical intervention. For example, many patients lose extremities or their lives by virtue of having these inoperable conditions.
In a different context, problems of lumens of the body, particularly small lumens, are complicated by occlusive diseases of other types. As an example in the nervous system, the Aqueduct of Sylvius, in the ventricular system of the brain, may be blocked in a child born with congenital hydrocephalus. This condition necessitates a complicated and often unsuccessful corrective neurosurgical procedure known as shunting. Considering the genito-urinary system, for example, fallopian tubes may become occluded by inflammatory or other disease processes. This may cause infertility and is a common problem. There is no effective treatment for this problem at this point in time, and this has stimulated interest in the "test tube baby" controversy.
One suggested solution to the problem of atherosclerotic obstructions is a non-operative technique to improve coronary blood flow known as percutaneous transluminal coronary angioplasty (PTCA). Generally, PTCA involves introducing a balloon catheter into the femoral artery or by brachial cutdown and fluorscopic positioning at the appropriate coronary ostium. Pressure monitoring is also used to aid in positioning the balloon tip of the catheter at the stenosis. The balloon is inflated for 3-5 seconds to mechanically enlarge the stenosis and is then deflated for measurement of distal coronary pressure. The cycle may be repeated several times until a satisfactory decrease in pressure gradient is achieved.
Although the PTCA technique is sometimes effective to improve coronary blood flow, there are complications which must be weighed before undertaking the procedure. Such complications which may occur include arterial spasms, myocardial infarction, thrombotic occlusion, embolization and dissection, or frank perforation of the vessel wall.
It has also been suggested that cardiovascular occlusions, as well as occlusions in other body lumens, might be vaporized by means of continuous wave (CW) laser energy. U.S. Pat. No. 4,207,874 to Choy, for example, discloses a flexible conduit which accommodates a fiberoptic bundle divided into light source, viewing and laser bundle portions. The flexible conduit is introduced into a vein or other body lumen and advanced until it contacts an obstruction such as a thrombus. A laser apparatus optically associated with the laser fiber bundle is then activated so that the laser energy vaporizes the obstruction, the remaining particles of which are then removed by suction.
Other flexible laser endoscopes for use in the therapeutic laser treatment of body lumens are disclosed in U.S. Pat. Nos. 4,072,147; 4,146,019; 4,170,997; and German Offenlegungsschrift No. 2,640,406. Such intraluminal laser devices typically are said to function by thermal vaporization and/or coagulation of the luminal obstruction mass.
One of the most serious risks inherent in the intraluminal use of laser radiation, especially in coronary or cerebral blood vessels, is the possibility of perforation of or thermal damage to the vessel walls and surrounding tissue. Accordingly, intravascular recanalization of occluded blood vessels is still an experimental procedure.
Recently, investigators have reported the use of continuous wave (CW) argon, neodymium-YAG and carbon dioxide laser sources to successfully vaporize, coagulate and penetrate atherosclerotic placque in animals and in sections of coronary arteries taken from human cadavers. However, the investigators also report perforation of the vessel walls in many cases, particularly at laser energy levels which have been increased to a level sufficient to effect vaporization of the placque.
Such laser energy levels are appropriately characterized as the "thermal" mode of laser operation which involves causing damage to tissue by virtue of heat accumulation in the tissue impinged by the laser radiation. Excessive heat accumulation causes thermal degradation or thermal necrosis. In other words, the temperature of the tissue rises, tissue proteins are denatured and ultimately the tissue is coagulated and "evaporated" or "vaporized." While the laser thermal energy mode is effective in coagulating and vaporizing many tissues, including the tissues forming atherosclerotic placques and stenoses, its use heretofore in occluded coronary and cerebral blood vessels, for example, is not sufficiently safe and controllable. Consequently, the problem of inadvertent damage to or destruction of surrounding vessel tissue has been a major obstacle in the development of an acceptable microsurgical technique for laser angioplasty in the human vascular system.
Apart from the risk of using continuous wave (CW) laser energy in the human vascular system, the prior art intraluminal laser devices lack effective mechanisms for "aiming" the laser beam to minimize the possibility of inadvertent damage to the vessel walls and to maximize the exposure of a large area of the occlusion, e.g., the atherosclerotic placque, to the laser energy.
In view of the foregoing limitations and shortcomings of the prior art intraluminal laser devices, as well as other disadvantages not specifically mentioned above, it should be apparent that there still exists a need in the art for a laser microsurgical apparatus for use in coronary angioplasty which is capable of effecting recanalization of occluded coronary and cerebral blood vessels at minimum risk of perforation or thermal necrosis of the vessel walls. It is, therefore, a primary objective of this invention to fulfill that need by providing a novel coronary arterial catheter and associated laser microsurgical system and a method of using the same whereby the laser energy radiated within the cardiovascular system is carefully controlled and aimed in such a way as to effectively destroy or penetrate atherosclerotic placque, yet minimize the risk of vascular perforation or thermal necrosis of the surrounding tissue.
More particularly, it is an object of the present invention to provide an effective method of delivering laser energy in a safe, substantially non-heat conducting or conduction-free mode by controlling the pulse width or duration, pulse repetition rate, and duty cycle of the laser energy within predetermined ranges and by using optical switching to sequentially direct the laser energy at selected target areas.
It is another object of the present invention to provide a flexible catheter adapted to be inserted into a body lumen, such as an obstructed coronary artery, said catheter having one or more quartz glass laser fibers which can be "aimed" at a particular target within a target area comprising substantially the entire cross-sectional area of the body lumen.
Yet another object of the invention is to provide a laser microsurgical system connected to the proximal end of a flexible angiographic catheter for controlling the positioning, illumination, visualization, firing and analysis functions of the system.
Still another object of the invention is to provide a flexible angiographic catheter for use in occluded blood vessels in combination with laser microsurgical apparatus, said catheter having one or more laser fibers, each of which is provided with a lens system which minimizes divergence of the laser beam and prismatically cants the laser beam toward the center of the blood vessel to intensify the cutting effect of the beam and to minimize the possibility of perforation of the vessel walls.
Another object of the invention is to provide a flexible catheter adapted to be inserted into a body lumen and having a plurality of laser fibers disposed within the catheter, such fibers being selectively scanned with laser energy by an optical scanner to "aim" the laser energy at a particular target area in the overall cross-sectional area of the body lumen.
Briefly described, the aforementioned objects of the invention are accomplished according to its apparatus aspects by providing a flexible catheter having an outside diameter from about 1.2 to about 5.0 millimeters, which is especially suitable for use in coronary, cerebral and somewhat larger carotid blood vessels, for example, to remove occlusions, such as atheromatous placque. Within the catheter sheath there are provided a plurality of optical fibers and fluid channels.
In one embodiment of the invention, the optical fibers include a bundle of laser transmitting fibers eccentrically arranged relative to the catheter axis and radially movable toward that axis by means of a balloon positioned within the catheter sheath. Each laser fiber has a distal lens system which converges and cants the radiation beam away from the circumference of the catheter and toward the axis thereof. Alternate embodiments of the catheter include distal lens systems for the laser fibers which may comprise one or more diverging lenses for special applications or techniques to be hereinafter described.
A flexible optical fiber viewing element with a distal lens system is provided within the catheter sheath which comprises a plurality of individual fibers having a glass cladding and extending over a substantial part of the cross-sectional area of the catheter, for instance, 50% or more. An illuminating system comprising several individual plastic clad quartz glass fibers cooperates with the optical viewing element and is arranged adjacent thereto for delivering white light from a conventional light source.
Fluid systems within the catheter include an outflow or suction channel for removal of fluids and debris and two or more inflow channels for injection of saline, pharmacologic agents, radiopaque positioning dyes, immuno-specific antibodies and the like. Carbon dioxide gas channels are also provided for inflation/deflation of both the laser aiming balloon and a balloon circumferentially disposed about the catheter adjacent the distal end thereof for occluding the vascular lumen and for establishing stabilization of the catheter distal end relative to said lumen.
A laser microsurgical system is operatively connected to the proximal end of the flexible angiographic catheter and comprises a proximal optical and fluid coupler for interconnecting the optical fibers and fluid channels of the catheter to the various system components, such as the laser apparatus and control, laser fiber optical scanner, illumination and visualization systems, positioning systems and fluid systems.
The objects of the invention are accomplished according to its method aspects by the use of visible light laser energy in the wavelength range of 351 to 515 nanometers, and, preferably, the blue-green emission lines at wavelengths of 488 and 514 nanometers from an argon-ion laser with a peak power output of about 20 watts, such as a Spectra-Physics 171 Laser. The argon laser apparatus is operated in the pulsed or non-conducting mode using a pulse width or duration in the range of from 5 to 200 milliseconds and a pulse repetition rate of 1 to 50 pulses per second with a duty cycle of between 5 and 50%. The preferred pulse energy is in the range of from 150 to 500 millijoules. Spot size for each fiber in the laser fiber bundle may be from 100 to 500 microns, preferably, the largest possible spot size in that range compatible with energy density requirements.
The above parameters of the pulsed laser energy are selected to effect damage to a luminal obstruction with substantially no thermal necrosis of the surrounding tissue. A hole is drilled in the obstruction by heating a given volume of the tissue thereof to its boiling point and then supplying the heat of vaporization to that volume to convert it to vapor. Ideally, the total laser energy needed to vaporize the given volume of the tissue of the obstruction is delivered in such a short period of time that heat conduction to the surrounding tissue is negligible. That time period is defined as the "thermal time constant" or "thermal relaxation time" for the given volume of tissue. According to the invention, the pulse characteristics, e.g., pulse width, pulse repetition rate and energy, are selected to operate in the conduction-free mode, that is, the laser energy is preferably delivered just at the threshold of the thermal relaxation time of the illuminated volume of the obstruction tissue.
Experimental results have indicated that over the range of laser focal diameters of 50 to 100 microns for an argon-ion laser, the diameter of the laser drilled hole in arterial placque is approximately 500 microns, i.e., 5 to 10 times greater than the laser focal diameter. That phenomenon is believed to be the result of a combination of strong, small angle scattering and weak absorption of the placque tissue. The larger area, and consequent larger volume, of illuminated tissue results in a greater energy threshold for drilling the placque, that is, a greater thermal input is necessary because of the scattering of the laser light and the absorption characteristics of the placque. For the argon-ion laser, the energy threshold is about 200 millijoules per pulse over a pulse width of 200 milliseconds or less.
An alternate embodiment of the invention takes advantage of the foregoing experimental results by locating a plurality of laser fibers in a flexible catheter in an array with the laser fibers appropriately spaced to provide substantially complete coverage of the cross-sectional area of a body lumen or vessel with little or no overlapping of the drilled laser hole. Thus, "aiming" may be accomplished by optically scanning the plurality of laser fibers to impinge laser energy on selected target areas, e.g., a plurality of target areas, each having a 500 micron diameter, over the entire cross-sectional area confronting the distal end of the catheter. Optical scanning of the laser fibers in a predetermined sequence also permits a greater number of pulses or "shots" to be made in a given time period without exceeding the energy threshold and causing thermal necrosis of the surrounding tissue. The laser fibers disposed adjacent the outermost periphery of the catheter may also be "skewed" toward the center of the catheter to minimize the possibility of perforation of the luminal wall.
With the foregoing and other objects, advantages and features of the invention that will become hereinafter apparent, the nature of the invention may be more clearly understood by reference to the following detailed description of the invention, the appended claims, and to the several views illustrated in the attached drawings
FIG. 1 is a transverse cross-sectional view of a first embodiment of the flexible catheter of the present invention taken along line 1--1 of FIG. 2;
FIG. 2 is a longitudinal cross-sectional view, partly broken, of the first embodiment of the catheter of the invention taken along line 2--2 of FIG. 1;
FIGS. 3A-3D are transverse cross-sectional views similar to FIG. 1 showing the positioning of the laser fiber bundle;
FIG. 4 is a view illustrating the positioning of the distal end of the catheter in a body lumen adjacent a partial occlusion of the lumen;
FIG. 5 is a schematic block diagram showing the laser microsurgical system of the present invention;
FIG. 6 is a transverse cross-sectional view of the distal end of an alternate embodiment of the flexible catheter of the present invention, taken along line 7--7 of FIG. 6; and
FIG. 7 is a longitudinal cross-sectional view of the catheter of FIG. 6 taken along line 7--7 showing skewing of the outermost laser fibers.
Referring now in detail to the drawings wherein the same parts are designated by the same reference numerals throughout, there is illustrated in FIGS. 1 and 2 cross-sectional details of the distal end of the inventive flexible catheter which is designated generally by reference numeral 10. In those circumstances wherein a particular element or aspect of the invention has been described in greater detail in one or more of the aforementioned copending related applications, appropriate reference will be made herein to such application(s).
The catheter 10 comprises a plastic sheath 12 which may be a non-toxic polyvinylchloride (PVC) or other suitable non-toxic plastic material. The outside diameter of the catheter 10 for use in the laser coronary angioplasty techniques described herein is from about 1.2 to about 5.0 millimeters, but may be larger in diameter for use in other, larger body lumens.
Disposed within the catheter sheath about the central axis 14 thereof are a plurality of elements extending longitudinally of the catheter and, for convenience of illustration, are shown in FIGS. 1 and 3A-3D as being somewhat loosely disposed in spaced relation to one another. In the actual construction of the catheter, the elements are in closer proximity to one another than shown in the drawings to provide a somewhat greater packing density consistent with the requirement for shifting the laser fiber bundle relative to the catheter axis in the manner described hereinafter.
A laser fiber bundle 16 is arranged eccentrically of the catheter axis 14 and, in a preferred form, comprises four quartz glass laser fibers 18a-18d for transmitting the laser energy, each fiber having a core diameter of from 50 to 200 microns. Laser fibers 18a-18d are embedded in a laminated sheath or cladding 20 of non-toxic polyethylene or PVC. As shown in FIG. 1, the four laser fibers are preferably orthogonally arranged with the axes of two of the fibers 18a and 18c disposed on a radial plane through the catheter axis 14.
An elongate balloon 22 is bonded or otherwise affixed to the circumference of the laser fiber bundle 16 at the portion thereof proximate the catheter sheath 12 and extends parallel to the axis of the laser fiber bundle as shown in FIG. 2. Inflation of the balloon 22 exerts a radially inward force on the laser bundle 16 tending to urge the same toward the catheter axis 14 and thereby "aiming" the laser energy as more fully described hereinafter in connection with FIGS. 3A-3D.
Arranged at the lowermost portion of the catheter, as viewed in FIG. 1, is a visualization optical element 24 which is of generally conventional construction. Optical viewing element 24 is generally crescent-shaped in cross-section and comprises a plurality of 5,000 to 10,000 individual glass fibers 26, each having a hexagonal cross-section to improve the packing factor The fibers 26 each have a flat-to-flat dimension of about 4 microns and are packed tightly together and fused only at their proximal and distal ends to preserve flexibility. The bundle of fibers is ensheathed in a glass cladding 28 and a lens system 30 (FIG. 2) of known configuration, i.e., two plano-convex lenses, is fused to the distal end of the viewing element 24 for providing wide angle visualization within the body lumen. See also related U.S. patent application Ser. No. 329,978.
Illumination of the surgical area is provided by three fused quartz glass fibers 32, 34, 36 of about 50 microns diameter which are clad with a PVC sheath 38 As shown in FIG. 1, the illuminating fibers are preferably arranged substantially diametrically for most effective illumination of the central portion of the body lumen.
The fluid systems of the catheter, in addition to the laser fiber aiming balloon 22, include a suction channel 40 and two inflow channels 42, 44. The suction channel 40 is used for debris removal and for suctioning fluids from the intraluminal region at the distal end of the catheter Inflow channels 42, 44 are employed for injecting fluids such as saline, pharmacologic agents, radiopaque positioning dyes and immuno-specific antibodies, among others.
A conventional circumferential balloon 43 is arranged about the catheter 10 adjacent the distal end thereof as shown in FIG. 4. Inflation of balloon 43 occludes flow in the lumen L and establishes a fixed, stabilized position of the distal end of the catheter 10. Such balloons and the methods and apparatus for inflating and deflating the same are well-known in the art and, therefore, need not be described in greater detail herein.
As shown in FIG. 2, at the distal end of each laser fiber 18a-18d, there is epoxied a converging lens 46 for focusing the laser energy beam and preventing undesirable divergence toward the luminal wall and a prism 48 for bending or "canting" the eccentric laser beam from each fiber toward the center of the lumen. Total divergence angle of the preferred 100-500 micron diameter spot for each fiber is preferably no greater than 5�. Preferably, the optical axes of the prismatically canted laser beams are maintained in parallel relationship to prevent spot "overlap" and beam divergence.
In certain circumstances, it may be desirable to insert a catheter with a laser fiber bundle having a diverging lens system at the end of each laser fiber. For instance, if the distal end of the catheter directly abuts an occlusion of atheromatous placque, a greater laser impact area could be achieved with a diverging lens arrangement. After destruction of the first few millimeters of the placque is accomplished the catheter would normally be replaced by a catheter having the converging lens system shown in FIG. 2
With reference now to FIGS. 3A-3D, FIG. 3A corresponds substantially to FIG. 1 and shows the balloon 22 in its deflated condition with the laser fiber bundle in its most eccentric radial position in relation to the central axis 14 of the catheter. As the balloon 22 is gradually inflated, the laser fiber bundle is incrementally urged substantially radially toward the axis 14 until it reaches a position of minimum eccentricity as shown in FIG. 3B.
FIGS. 3C and 3D illustrate the same conditions of inflation/deflation of balloon 22 as shown in FIGS. 3A and 3B, respectively, except that the catheter 10 has been rotated exactly 180�. It will be understood by those skilled in the art that by the appropriate selection of angle of rotation of the catheter and incremental inflation/deflation of balloon 22, the four 200 micron spots from the laser fibers 18a-18d can be positioned to impinge at any target area over virtually the entire cross-sectional area of the body lumen being treated.
Referring now to FIG. 4, the distal end of the catheter 10 is shown fixed in position in a lumen L adjacent a partial occlusion X. The uppermost pair of diverging dotted lines represents a laser energy beam B from laser fiber 18a when said fiber is positioned on a vertical plane at a location of greatest eccentricity from the catheter axis. Beam B has a total divergence angle 50 of 5�; however, because the beam has been prismatically canted by the lens system 46, 48 shown in FIG. 2, the diverging beam does not impinge on the wall of the lumen L, but rather is directed toward the central portion of the lumen L. Likewise, the lowermost pair of diverging dotted lines in FIG. 4 represents a laser energy beam B' from laser fiber 18a when said fiber is positioned exactly 180� from the position at which beam B was generated. Beam B' also has a total divergence angle 52 of 5� as shown in FIG. 4.
It should be apparent from the foregoing description of FIGS. 3A-3D and FIG. 4 that the laser energy beams transmitted by the laser fiber bundle 16 of the catheter are not only capable of being "aimed" at virtually any target area within the lumen, but are converged and canted so as to minimize the possibility of laser beam impingement on the lumen walls.
Positioning of the distal end of the catheter 10 is aided by known radiographic visualization procedures. For this purpose, it is advantageous to mark the periphery of the distal end of the catheter with a plurality of radiopaque strips 54, 56, 58 of predetermined size and positioned for determining both the rotational and axial positions of the catheter within a coronary artery, for example
The laser microsurgical system 60 of the invention is shown schematically in FIG. 5 The system 60 includes a laser source 62 which is preferably an argon-ion laser, such as a Spectra-Physics 171 Laser for generating a pulsed laser beam. The output of laser source 62 is a pulsed laser beam 64 which is inputted to a multi-fiber optical scanner 66 of a known type, for example, of the type described by Fujii et al in Applied Optics, Vol. 21, No. 19, pp. 3437-3442, Oct. 1, 1982. Scanner 66 is used to scan the four laser fibers 18a-18d of the laser fiber bundle 16 with pulsed laser beam 64.
Control of pulse width or duration, pulse repetition rate, wavelength, length of exposure, intensity and firing is provided by a laser control 68 associated with the laser source 62. Firing of the laser 62 is accomplished by closing a firing switch 69 which may be, for example, a foot pedal switch
The proximal end of the optical visualization element 24 supplies an optical image to a viewing microscope 70 which has a built-in eyepiece shutter mechanism 72. The shutter 72 is responsive to activation of the laser source 62 to prevent back-scatter of laser energy which could damage the surgeon's eyes.
The optical image from optical element 24 is also supplied to an image analyzer 74 controlled by microprocessor 76 both of which are used to analyze the visual images transmitted from the intraluminal region at the distal end of the catheter and to aid in longitudinal positioning of the catheter distal end, "aiming" of the laser fiber or fibers at the appropriate target in the intraluminal region and timing of the laser firing signal in relation to the cardiac cycle. A suitable microprocessor and image analyzer is a Videoplan Computerized Image Analyzer available from Carl Zeiss, Inc., 444 Fifth Avenue, New York, New York 10018.
A conventional cathode ray tube video display 78 and video recorder 80 are connected to the image analyzer for real time observation and recording, if desired, of the microsurgical procedure.
An illumination source 82 is connected to the proximal ends of optical fibers 32, 34, 36 for delivery of white light thereto. The light is provided by mercury or xenon high pressure arc lamps within quartz enclosures; however, other types of light sources may be used. A vacuum unit 84 and fluids input unit 86 are connected to the suction channel 40 and fluid inflow lines 42, 44, respectively
For inflation and deflation of the aiming balloon 22 and circumferential balloon 43, a fluid pressure source 88, such as pressurized carbon dioxide, is connected through respective electrically-operable solenoid valves 90, 92 to the pneumatic tubes 94, 96 supplying the aiming balloon 22 and the circumferential balloon 43, respectively
The proximal end of the catheter 10 is mounted in an axial and rotational drive mechanism 98 which rotates the catheter about its axis and moves the same axially in response to mechanical or electrical signals from a micromanipulator 100 which, in turn, receives command signals from the microprocessor 76. Suitable micropositioners are well-known in the art and are available from numerous sources, such as Klinger Scientific Corporation, 110-120 Jamaica Avenue, Richmond Hill, New York 11148. See also related application, Ser. No. 329,978.
It is also advantageous to synchronize the occlusion of the coronary artery with the balloon 43 and the firing of the laser 62 with the cardiac cycle. Generally, it is desirable to inflate the catheter balloon 43 during the filling phase of the cardiac cycle and deflate the balloon during the pumping phase of the cardiac cycle. In that way, blood flow is occluded under minimal pressure conditions in the coronary artery. For this purpose, a conventional counterpulsator 102 may be used which senses ventricular output with an aortic catheter independently of the catheter 10 of the invention. One suitable counterpulsator is known as System 82 and is manufactured by Datascope Corporation, 580 Winters Avenue, Paramus, New Jersey 07652. See also related application, Ser. No. 329,978.
An alternative or second embodiment of the catheter of the invention is shown in FIG. 6 and identified with reference numeral 110. The catheter 110 comprises a plastic sheath 112 similar to the sheath 12 of the FIG. 1 or first embodiment of the invention, the outside diameter of which is preferably from about 1.2 to about 5.0 millimeters for use in the described laser coronary angioplasty techniques. The FIG. 6 embodiment illustrates a catheter having an outside diameter of about 1.5 millileters which diameter is essentially defined by the arrangement of the laser fiber array disposed within the sheath 112 as explained in greater detail hereinafter.
A plurality of elements similar to those illustrated in FIGS. 1 and 2 are arranged to extend longitudinally within the sheath 112 about the longitudinal axis 114 thereof and, like the showing of FIG. 1, are somewhat loosely disposed in relation to one another, although in actual practice the elements are packed in closer proximity, preferably in a fixed relationship to one another and to the sheath 112.
The catheter 110 has a similar arrangement of optical viewing element 124, illumination fibers 132, 134, 136, suction channel 140 and inflow channels 142, 144 as the first embodiment of the invention. However, in contrast to the laser fiber bundle 16 of the first embodiment of the invention, individually clad laser fibers 118 of the second embodiment are disposed about the catheter axis 114 in a predetermined, parallel array designed to provide impingement of laser energy on substantially the entire cross-sectional area of an obstruction confronted by the catheter 110 with little or no overlapping of laser impingement.
Inasmuch as experiments have indicated that drilled holes with an argon-ion laser have a diameter of about 500 microns regardless of laser focal diameter, an array of seven (7) 50 to 200 micron diameter fibers 118 in the arrangement shown in FIG. 6 will provide laser energy coverage of virtually the entire cross-sectional area of a luminal obstruction confronting the catheter 110, particularly in the central region thereof as shown by the dashed line areas 116 of laser impingement. Advantageously, the largest areas 120 not included in the total laser impingement area are located at the outermost periphery of the catheter adjacent the vessel walls where laser energy impingement is least desirable, and, in fact, may be detrimental.
In view of the above teachings, various arrangements of laser fibers for different diameter catheters will be apparent to those skilled in the art. For example, the same seven (7) fiber array may be used for a 1.2 millimeter diameter catheter by arranging the centers of the laser fibers at a 400 micron spacing rather than the 500 micron spacing shown in FIG. 6. While a certain amount of laser impingement overlap will result from that arrangement, by appropriate scanning of the laser fibers with laser energy any overheating of the tissue can be avoided.
Generally speaking, a laser fiber disposed on the axis 114 of the catheter is preferred, but is not essential. Thus, although a 1.2 millimeter diameter catheter is preferably provided with an array of 5 to 7 laser fibers, an array of four (4) laser fibers equiangularly spaced may be provided with their impingement areas in targential relationship. While such an arrangement would not provide laser impingement in the central region of an obstruction confronting the catheter, destruction of the obstruction surrounding the central region will eliminate support of such central region and ultimately cause it to gravitate to a laser impingement area where it will be destroyed.
In larger diameter catheters, a larger number of laser fibers are preferably employed. For instance, a 5.0 millimeter diameter catheter encompasses an area 100 times greater than the 500 micron diameter area impinged by a single laser fiber. Therefore, an array of 80 to 100 laser fibers would be required to cover the entire area confronted by a 5.0 millimeter diameter catheter.
The laser microsurgical system 60 shown schematically in FIG. 5 may also be used with the second embodiment of the catheter 110 of the invention shown in FIG. 6. Advantageously, the multi-fiber optical scanner 66 may be programmed to scan each of the laser fibers 118 with pulsed laser energy in a preselected sequence. The scanning sequence is preferably selected to operate in the conduction-free or non-heat conducting mode. In that way, the possibility of overheating and the consequent thermal necrosis of a given impingement area is avoided, while at the same time the number of pulses of laser energy that can be delivered to the impingement area in a given time period is maximized.
Although the laser fibers 118 of the second embodiment of the invention are described above as extending parallel to the catheter axis 114, as shown in FIG. 7, the distal ends of the outermost laser fibers may also be inclined or skewed inwardly toward the catheter axis by an angular amount identified by reference numeral 122. The amount of skewing may amount to between 5� and 45�. Preferably, the distal ends of the laser fibers 118 are inserted or molded into an end plate 126 fixed to the sheath 112. The end plate 126 may also receive the other longitudinally extending elements of the catheter, such as the viewing element 124, illumination fibers 132, 134, 136 and fluid channels 140, 142, 144.
The above-described skewing of the peripheral laser fibers advantageously causes the outermost laser energy beams to converge toward the axis of the body lumen or vessel and thereby provide further protection against the possibility of perforation of the luminal wall. Such skewing, however, reduces the total area of laser illumination of a given diameter of catheter and arrangement of laser fibers and results in varying degrees of laser beam overlap depending on the distance between the obstruction and the distal end of the catheter.
It would be possible to skew the distal ends of some of the interiorly disposed laser fibers of an array having fiber groups disposed at varying radial distances from the axis of the catheter. Such skewing may cause the axes of the fibers to diverge or converge with the catheter axis so as to achieve overlapping of laser impingement if desired or to "aim" at areas not impinged by the laser beam or blind spots caused by the positioning of other elements in the catheter, such as the elements 124, 132, 134, 136, 142, 144, etc.
According to the method of the present invention, laser energy is not supplied as continuous wave (CW) laser energy in the thermal mode to vaporize atheromatous occlusions as in the prior art, but rather as pulses of 5-200 millisecond duration at a pulse repetition rate of 1-50 pulses per second and a duty cycle of between 5 and 50%. The pulse energy is from 150 to 500 millijoules. The laser source 62 is an argonion laser delivering 20 watts peak power at wavelengths of about 488 and 514 nanometers and a preferred spot size of about 100-500 microns diameter. Pulsing of the laser source in the ranges described above has been advantageously found to be both safe and effective; safe from the standpoint that the vessel walls will neither be perforated nor subjected to thermal necrosis, and effective from the standpoint that the laser energy is sufficiently great to effect vaporization of the occlusion.
The selection of specific values for the pulse duration, pulse repetition rate, pulse energy parameters within the aforesaid ranges to effect destruction of an occlusion without thermal necrosis is dependent to a large extent on the thermal time constant and absorption characteristics of particular type or material of the occlusion, e.g., fibrin, cholesterol, calcium, collagen, low-density lipoproteins and the like. Based on the teachings herein, however, one skilled in the art can readily select a suitable value for each pulse parameter to effect conduction-free operation, i.e., destruction of the tissue of the occlusion with substantially no thermal necrosis of the surrounding tissue.
Although only preferred embodiments are specifically illustrated and described herein, it will be appreciated that many modifications and variations of the present invention are possible in light of the above teachings and within the purview of the appended claims without departing from the spirit and intended scope of the invention.
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|U.S. Classification
|International Classification
|Cooperative Classification
|European Classification
|Nov 27, 1990
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text:
Finn Harps 0-3 Limerick
Pat Scully's Limerick turned on the style as they chalked up a convincing win over a surprisingly uninventive Finn Harps in Ballybofey on Friday night.
Pat Scully's Limerick turned on the style as they chalked up a convincing win over a surprisingly uninventive Finn Harps in Ballybofey on Friday night.
Finn Harps slumped to their fourth successive defeat as they went down to Pat Scully's Limerick at Finn Park.
Limerick FC have appointed former Shamrock Rovers supremo Pat Scully as their new manager.
Shamrock Rovers and Pat Scully have mutually agreed to part company with immediate effect.
Shamrock Rovers engineered yet another smash and grab raid at the Brandywell on Friday night; Pat Scully's side securing all three points thanks to an 82nd minute goal from substitute striker Tadhg Purcell.
Post-match interviews with Pat Scully, Padraig Amond, and Paul Cook.
Watch Ed Leahy's interview with Shamrock Rovers manager Pat Scully ahead of the new season.
Ed Leahy reveals why he is relishing the new season in the first of this year's columns. Also watch his interview with Pat Scully.
Shamrock Rovers' boss Pat Scully has added Longford Town's Dessie Baker to his squad to bring the number of his new signings to five.
Shamrock Rovers boss Pat Scully is wasting little time in bringing in new players to strengthen the Hoops' squad for the 2008 season.
Shamrock Rovers manager Pat Scully has wasted no time in wielding the axe at the Dublin club, releasing no less than 11 players.
Gerard Rowe and Tadhg Purcell proved that they're the most productive front two in the Premier Division as they both scored again to make it 16 goals between them this season.
Shamrock Rovers manager Pat Scully has completed the signing of three players in his bid to the Hoops' Premier Division title charge.
Pat Scully has pledged his future to Shamrock Rovers, while also announcing several new arrivals for the 2007 eircom League season.
An under-strength Finn Harps were beaten 4-0 by title chasing Shamrock Rovers at Tolka Park as Pat Scully's side went three points clear at the top of the First Division.
Shamrock Rovers have midfielder Paul Shiels back from injury as they hope to put what boss Pat Scully described as their worst performance of the season in Kilkenny behind them.
Pat Scully's Shamrock Rovers kept the pressure on eircom League First Division leaders Dundalk as they chalked up a vital win over Finn Harps at Finn Park.
'We let our standards slip in Monaghan last week when we played extremely poorly,' said Rovers boss Pat Scully of their 2-2 draw at Century Homes Park.
Shamrock Rovers manager Pat Scully has a pleasant selection headache for the visit to Century Homes Park to take on Monaghan United this evening, kick-off at 8.00pm.
Pat Scully's return to Buckley Park as Shamrock Rovers manager was a unspectacular one as his promotion chasing side were held to a 0-0 draw by Kilkenny City.


text:
Lobbyists representing Alliance for Employee Benefit Co-Ops, 2008:
|Lobbying Firm Hired
|Subsidiary (Lobbied For)
|Venable LLP
|Alliance for Employee Benefit Co-Ops
Donovan, William
O'Neill, John J
Quinn, Thomas H
Smith, Robert L Jr
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