Electrical ablation devices

Abstract
An electrical ablation apparatus comprises first and second electrodes. Each electrode comprises a first end configured to couple an energy source and a second end configured to couple to a tissue treatment region. An energy source is coupled to the first and second electrodes. The energy source is configured to deliver a first series of electrical pulses sufficient to induce cell necrosis by irreversible electroporation and a second series of electrical pulses sufficient to induce cell necrosis by thermal heating, through at least one of the first and second electrodes. The first series of electrical pulses is characterized by a first amplitude, a first pulse length, and a first frequency. The second series of electrical pulses is characterized by a second amplitude, a second pulse length, and a second frequency.
Description
BACKGROUND

Electrical ablation therapy has been employed in medicine for the treatment of undesirable tissue such as diseased tissue, cancer, malignant and benign tumors, masses, lesions, and other abnormal tissue growths. While conventional apparatuses, systems, and methods for the electrical ablation of undesirable tissue are effective, one drawback with conventional electrical ablation treatment is the resulting permanent damage that may occur to the healthy tissue surrounding the abnormal tissue due primarily to the detrimental thermal effects resulting from exposing the tissue to thermal energy generated by the electrical ablation device. This may be particularly true when exposing the tissue to electric potentials sufficient to cause cell necrosis using high temperature thermal therapies including focused ultrasound ablation, radiofrequency (RF) ablation, or interstitial laser coagulation. Other techniques for tissue ablation include chemical ablation, in which chemical agents are injected into the undesirable tissue to cause ablation as well as surgical excision, cryotherapy, radiation, photodynamic therapy, Moh's micrographic surgery, topical treatments with 5-fluorouracil, laser ablation. Other drawbacks of conventional thermal, chemical, and other ablation therapy are cost, length of recovery, and the extraordinary pain inflicted on the patient.


Conventional thermal, chemical, and other ablation techniques have been employed for the treatment of a variety of undesirable tissue. Thermal and chemical ablation techniques have been used for the treatment of varicose veins resulting from reflux disease of the greater saphenous vein (GSV), in which the varicose vein is stripped and then is exposed to either chemical or thermal ablation. Other techniques for the treatment of undesirable tissue are more radical. Prostate cancer, for example, may be removed using a prostatectomy, in which the entire or part of prostate gland and surrounding lymph nodes are surgically removed. Like most other forms of cancer, radiation therapy may be used in conjunction with or as an alternate method for the treatment of prostate cancer. Another thermal ablation technique for the treatment of prostate cancer is RF interstitial tumor ablation (RITA) via trans-rectal ultrasound guidance. While these conventional methods for the treatment of prostate cancer are effective, they are not preferred by many surgeons and may result in detrimental thermal effects to healthy tissue surrounding the prostate. Similar thermal ablation techniques may be used for the treatment of basal cell carcinoma (BCC) tissue, a slowly growing cutaneous malignancy derived from the rapidly proliferating basal layer of the epidermis. BCC tissue in tumors ranging in size from about 5 mm to about 40 mm may be thermally ablated with a pulsed carbon dioxide laser. Nevertheless, carbon dioxide laser ablation is a thermal treatment method and may cause permanent damage to healthy tissue surrounding the BCC tissue. Furthermore, this technique requires costly capital investment in carbon dioxide laser equipment. Undesirable tissue growing inside a body lumen such as the esophagus, large bowel, or in cavities formed in solid tissue such as the breast, for example, can be difficult to destroy using conventional ablation techniques. Surgical removal of undesirable tissue, such as a malignant or benign tumor, from the breast is likely to leave a cavity. Surgical resection of residual intralumenal tissue may remove only a portion of the undesirable tissue cells within a certain margin of healthy tissue. Accordingly, some undesirable tissue is likely to remain within the wall of the cavity due to the limitation of conventional ablation instrument configurations, which may be effective for treating line-of-sight regions of tissue, but may be less effective for treating the residual undesirable tissue.


Accordingly, there remains a need for improved electrical ablation apparatuses, systems, and methods for the treatment of undesirable tissue found in diseased tissue, cancer, malignant and benign tumors, masses, lesions, and other abnormal tissue growths. There remains a need for minimally invasive treatment of undesirable tissue through the use of irreversible electroporation (IRE) ablation techniques without causing the detrimental thermal effects of conventional thermal ablation techniques.





FIGURES

The novel features of the various described embodiments are set forth with particularity in the appended claims. The various embodiments, however, both as to organization and methods of operation, together with advantages thereof, may be understood in accordance with the following description taken in conjunction with the accompanying drawings as follows.



FIG. 1 illustrates one embodiment of an electrical ablation system.



FIGS. 2A-D illustrate one embodiment of the electrical ablation device in various phases of deployment.



FIG. 2E illustrates one embodiment of the electrical ablation device comprising multiple needle electrodes.



FIG. 3 illustrates one embodiment of the electrical ablation system shown in FIGS. 1 and 2A-D in use to treat undesirable tissue located on the surface of the liver.



FIG. 4 illustrates a detailed view of one embodiment of the electrical ablation system shown in FIG. 3 in use to treat undesirable tissue located on the surface of the liver.



FIG. 5 is a graphical representation of a series of electrical pulses that may be applied to undesirable tissue to create a first necrotic zone by inducing irreversible electroporation in the tissue and to create a second necrotic zone by inducing thermal effects near the electrode-tissue-interface using the electrical ablation system shown in FIG. 4.



FIGS. 6, 7, and 8 illustrate one embodiment of an electrical ablation device to treat undesirable tissue within body lumen using electrical energy, where FIG. 6 illustrates a sectioned view of one embodiment of an electrical ablation device, FIG. 7 illustrates an end view of one embodiment of the electrical ablation device shown in FIG. 6, and FIG. 8 illustrates a cross-sectional view of one embodiment of the electrical ablation device shown in FIG. 6.



FIG. 9 illustrates one embodiment of an electrical ablation system in use to treat non-metastatic prostate cancer in a patient.



FIG. 10 is a graphical representation of a series of electrical pulses that may be applied to undesirable tissue to induce irreversible electroporation suitable to ablate non-metastatic cancer of the prostrate as described in FIG. 9.



FIG. 11 illustrates one embodiment of the electrical ablation system described FIG. 1 in use to treat basal cell carcinoma (BCC) tissue.



FIG. 12 is a graphical representation of a series of electrical pulses for treating basal cell carcinoma (BCC) tissue as shown in FIG. 11 with irreversible electroporation energy.



FIG. 13A illustrates one embodiment of an electrical ablation device, in a collapsed state, the device having a configuration suitable for the treatment of abnormal tissue located in a lumen, abscess, void, or cavity.



FIG. 13B illustrates one embodiment of the electrical ablation device shown in FIG. 13A, in an inflated state, the device having a configuration suitable for the treatment of abnormal tissue located in a lumen, abscess, void, or cavity.



FIG. 14 is a cross-sectional view of the electrical ablation device showing a cross-sectional view of the conductive elastomer electrode and the non-conductive catheter shown in FIGS. 13A and 13B.



FIG. 15 illustrates one embodiment of the electrical ablation device shown in FIG. 13A inserted through the mouth and esophagus to ablate cancerous tissue in the esophagus using electrical pulses.



FIG. 16 illustrates a distal portion of an endoscope used in conjunction with the electrical ablation device shown in FIG. 13A.



FIG. 17 illustrates a cross-sectional view of a breast showing a cavity that may be left after a lumpectomy to remove a tumor from the breast.



FIG. 18 illustrates one embodiment of a catheter inserted into the cavity left in the breast following a lumpectomy procedure as shown in FIG. 17.



FIG. 19 illustrates an expanded sponge filling the cavity left in the breast following a lumpectomy as shown in FIG. 17.



FIG. 20 illustrates the expanded sponge intact to fill the cavity left in the breast as shown in FIG. 17 following irreversible electroporation ablation therapy.



FIG. 21 illustrates a mesh of a finite element model of a sponge inserted in the cavity left in the breast as shown in FIG. 17.



FIG. 22 is a graphical representation of electric potential and electrical field strength sufficient to induce irreversible electroporation when applied to the sponge located within the breast cavity as shown in FIG. 17.



FIG. 23 is a graphical representation of electric field strength contours in volts per meter (V/m) developed when electrodes are energized by an energy source.





DESCRIPTION

Various embodiments are directed to apparatuses, systems, and methods for the electrical ablation treatment of undesirable tissue such as diseased tissue, cancer, malignant and benign tumors, masses, lesions, and other abnormal tissue growths without causing any detrimental thermal effects to surrounding healthy tissue. Numerous specific details are set forth to provide a thorough understanding of the overall structure, function, manufacture, and use of the embodiments as described in the specification and illustrated in the accompanying drawings. It will be understood by those skilled in the art, however, that the embodiments may be practiced without the specific details. In other instances, well-known operations, components, and elements have not been described in detail so as not to obscure the embodiments described in the specification. Those of ordinary skill in the art will understand that the embodiments described and illustrated herein are non-limiting examples, and thus it can be appreciated that the specific structural and functional details disclosed herein may be representative and do not necessarily limit the scope of the embodiments, the scope of which is defined solely by the appended claims.


Reference throughout the specification to “various embodiments,” “some embodiments,” “one embodiment,” or “an embodiment” means that a particular feature, structure, or characteristic described in connection with the embodiment is included in at least one embodiment. Thus, appearances of the phrases “in various embodiments,” “in some embodiments,” “in one embodiment,” or “in an embodiment” in places throughout the specification are not necessarily all referring to the same embodiment. Furthermore, the particular features, structures, or characteristics may be combined in any suitable manner in one or more embodiments. Thus, the particular features, structures, or characteristics illustrated or described in connection with one embodiment may be combined, in whole or in part, with the features structures, or characteristics of one or more other embodiments without limitation.


It will be appreciated that the terms “proximal” and “distal” may be used throughout the specification with reference to a clinician manipulating one end of an instrument used to treat a patient. The term “proximal” refers to the portion of the instrument closest to the clinician and the term “distal” refers to the portion located furthest from the clinician. It will be further appreciated that for conciseness and clarity, spatial terms such as “vertical,” “horizontal,” “up,” and “down” may be used herein with respect to the illustrated embodiments. However, surgical instruments may be used in many orientations and positions, and these terms are not intended to be limiting and absolute.


Various embodiments of apparatuses, systems, and methods for the electrical ablation treatment of undesirable tissue such as diseased tissue, cancer, malignant and benign tumors, masses, lesions, and other abnormal tissue growths, are described throughout the specification and illustrated in the accompanying drawings. The electrical ablation devices in accordance with the described embodiments may comprise one or more electrodes configured to be positioned into or proximal to undesirable tissue in a tissue treatment region (e.g., target site, worksite) where there is evidence of abnormal tissue growth, for example. In general, the electrodes comprise an electrically conductive portion (e.g., medical grade stainless steel) and are configured to electrically couple to an energy source. Once the electrodes are positioned into or proximal to the undesirable tissue, an energizing potential is applied to the electrodes to create an electric field to which the undesirable tissue is exposed. The energizing potential (and the resulting electric field) may be characterized by multiple parameters such as frequency, amplitude, pulse width (duration of a pulse or pulse length), and/or polarity. Depending on the diagnostic or therapeutic treatment to be rendered, a particular electrode may be configured either as an anode (+) or a cathode (−) or may comprise a plurality of electrodes with at least one configured as an anode and at least one other configured as a cathode. Regardless of the initial polar configuration, the polarity of the electrodes may be reversed by reversing the polarity of the output of the energy source.


In various embodiments, a suitable energy source may comprise an electrical waveform generator, which may be configured to create an electric field that is suitable to create irreversible electroporation in undesirable tissue at various electric filed amplitudes and durations. The energy source may be configured to deliver irreversible electroporation pulses in the form of direct-current (DC) and/or alternating-current (AC) voltage potentials (e.g., time-varying voltage potentials) to the electrodes. The irreversible electroporation pulses may be characterized by various parameters such as frequency, amplitude, pulse length, and/or polarity. The undesirable tissue may be ablated by exposure to the electric potential difference across the electrodes.


In one embodiment, the energy source may comprise a wireless transmitter to deliver energy to the electrodes using wireless energy transfer techniques via one or more remotely positioned antennas. Those skilled in the art will appreciate that wireless energy transfer or wireless power transmission is the process of transmitting electrical energy from an energy source to an electrical load without interconnecting wires. An electrical transformer is the simplest instance of wireless energy transfer. The primary and secondary circuits of a transformer are not directly connected and the transfer of energy takes place by electromagnetic coupling through a process known as mutual induction. Power also may be transferred wirelessly using RF energy. Wireless power transfer technology using RF energy is produced by Powercast, Inc. and can achieve an output of 6 volts for a little over one meter. Other low-power wireless power technology has been proposed such as described in U.S. Pat. No. 6,967,462.


The apparatuses, systems, and methods in accordance with the described embodiments may be configured for minimally invasive ablation treatment of undesirable tissue through the use of irreversible electroporation to be able to ablate undesirable tissue in a controlled and focused manner without inducing thermally damaging effects to the surrounding healthy tissue. The apparatuses, systems, and methods in accordance with the described embodiments may be configured to ablate undesirable tissue through the use of electroporation or electropermeabilization. More specifically, the apparatuses, systems, and methods in accordance with the described embodiments may be configured to ablate undesirable tissue through the use of irreversible electroporation. Electroporation increases the permeabilization of a cell membrane by exposing the cell to electric pulses. The external electric field (electric potential/per unit length) to which the cell membrane is exposed to significantly increases the electrical conductivity and permeability of the plasma in the cell membrane. The primary parameter affecting the transmembrane potential is the potential difference across the cell membrane. Irreversible electroporation is the application of an electric field of a specific magnitude and duration to a cell membrane such that the permeabilization of the cell membrane cannot be reversed, leading to cell death without inducing a significant amount of heat in the cell membrane. The destabilizing potential forms pores in the cell membrane when the potential across the cell membrane exceeds its dielectric strength causing the cell to die under a process known as apoptosis and/or necrosis. The application of irreversible electroporation pulses to cells is an effective way for ablating large volumes of undesirable tissue without deleterious thermal effects to the surrounding healthy tissue associated with thermal-inducing ablation treatments. This is because irreversible electroporation destroys cells without heat and thus does not destroy the cellular support structure or regional vasculature. A destabilizing irreversible electroporation pulse, suitable to cause cell death without inducing a significant amount of thermal damage to the surrounding healthy tissue, may have amplitude in the range of about several hundred to about several thousand volts and is generally applied across biological membranes over a distance of about several millimeters, for example, for a relatively long duration. Thus, the undesirable tissue may be ablated in-vivo through the delivery of destabilizing electric fields by quickly creating cell necrosis.


The apparatuses, systems, and methods for electrical ablation therapy in accordance with the described embodiments may be adapted for use in minimally invasive surgical procedures to access the tissue treatment region in various anatomic locations such as the brain, lungs, breast, liver, gall bladder, pancreas, prostate gland, and various internal body lumen defined by the esophagus, stomach, intestine, colon, arteries, veins, anus, vagina, cervix, fallopian tubes, and the peritoneal cavity, for example, without limitation. Minimally invasive electrical ablation devices may be introduced to the tissue treatment region using a trocar inserted though a small opening formed in the patient's body or through a natural body orifice such as the mouth, anus, or vagina using translumenal access techniques known as Natural Orifice Translumenal Endoscopic Surgery (NOTES)™. Once the electrical ablation devices (e.g., electrodes) are located into or proximal to the undesirable tissue in the treatment region, electric field potentials can be applied to the undesirable tissue by the energy source. The electrical ablation devices comprise portions that may be inserted into the tissue treatment region percutaneously (e.g., where access to inner organs or other tissue is done via needle-puncture of the skin). Other portions of the electrical ablation devices may be introduced into the tissue treatment region endoscopically (e.g., laparoscopically and/or thoracoscopically) through trocars or working channels of the endoscope, through small incisions, or transcutaneously (e.g., where electric pulses are delivered to the tissue treatment region through the skin).



FIG. 1 illustrates one embodiment of an electrical ablation system 10. The electrical ablation system 10 may be employed to ablate undesirable tissue such as diseased tissues, cancers, tumors, masses, lesions, abnormal tissue growths inside a patient using electrical energy. The electrical ablation system 10 may be used in conjunction with endoscopic, laparoscopic, thoracoscopic, open surgical procedures via small incisions or keyholes, percutaneous techniques, transcutaneous techniques, and/or external non-invasive techniques, or any combinations thereof without limitation. The electrical ablation system 10 may be configured to be positioned within a natural body orifice of the patient such as the mouth, anus, or vagina and advanced through internal body lumen or cavities such as the esophagus, colon, cervix, urethra, for example, to reach the tissue treatment region. The electrical ablation system 10 also may be configured to be positioned and passed through a small incision or keyhole formed through the skin or abdominal wall of the patient to reach the tissue treatment region using a trocar. The tissue treatment region may be located in the brain, lungs, breast, liver, gall bladder, pancreas, prostate gland, various internal body lumen defined by the esophagus, stomach, intestine, colon, arteries, veins, anus, vagina, cervix, fallopian tubes, and the peritoneal cavity, for example, without limitation. The electrical ablation system 10 can be configured to treat a number of lesions and ostepathologies comprising metastatic lesions, tumors, fractures, infected sites, inflamed sites. Once positioned into or proximate the tissue treatment region, the electrical ablation system 10 can be actuated (e.g., energized) to ablate the undesirable tissue. In one embodiment, the electrical ablation system 10 may be configured to treat diseased tissue in the gastrointestinal (GI) tract, esophagus, lung, or stomach that may be accessed orally. In another embodiment, the electrical ablation system 10 may be adapted to treat undesirable tissue in the liver or other organs that may be accessible using translumenal access techniques such as, without limitation, NOTES™ techniques, where the electrical ablation devices may be initially introduced through a natural orifice such as the mouth, anus, or vagina and then advanced to the tissue treatment site by puncturing the walls of internal body lumen such as the stomach, intestines, colon, cervix. In various embodiments, the electrical ablation system 10 may be adapted to treat undesirable tissue in the brain, liver, breast, gall bladder, pancreas, or prostate gland, using one or more electrodes positioned percutaneously, transcutaneously, translumenally, minimally invasively, and/or through open surgical techniques, or any combination thereof.


In one embodiment, the electrical ablation system 10 may be employed in conjunction with a flexible endoscope 12, as well as a rigid endoscope, laparoscope, or thoracoscope, such as the GIF-100 model available from Olympus Corporation. In one embodiment, the endoscope 12 may be introduced to the tissue treatment region trans-anally through the colon, trans-orally through the esophagus and stomach, trans-vaginally through the cervix, transcutaneously, or via an external incision or keyhole formed in the abdomen in conjunction with a trocar. The electrical ablation system 10 may be inserted and guided into or proximate the tissue treatment region using the endoscope 12.


In the embodiment illustrated in FIG. 1, the endoscope 12 comprises an endoscope handle 34 and an elongate relatively flexible shaft 32. The distal end of the flexible shaft 32 may comprise a light source and a viewing port. Optionally, the flexible shaft 32 may define one or more working channels for receiving various instruments, such as electrical ablation devices, for example, therethrough. Images within the field of view of the viewing port are received by an optical device, such as a camera comprising a charge coupled device (CCD) usually located within the endoscope 12, and are transmitted to a display monitor (not shown) outside the patient.


In one embodiment, the electrical ablation system 10 may comprise an electrical ablation device 20, a plurality of electrical conductors 18, a handpiece 16 comprising an activation switch 62, and an energy source 14, such as an electrical waveform generator, electrically coupled to the activation switch 62 and the electrical ablation device 20. The electrical ablation device 20 comprises a relatively flexible member or shaft 22 that may be introduced to the tissue treatment region using a variety of known techniques such as an open incision and a trocar, through one of more of the working channels of the endoscope 12, percutaneously, or transcutaneously.


In one embodiment, one or more electrodes (e.g., needle electrodes, balloon electrodes), such as first and second electrodes 24a,b, extend out from the distal end of the electrical ablation device 20. In one embodiment, the first electrode 24a may be configured as the positive electrode and the second electrode 24b may be configured as the negative electrode. The first electrode 24a is electrically connected to a first electrical conductor 18a, or similar electrically conductive lead or wire, which is coupled to the positive terminal of the energy source 14 through the activation switch 62. The second electrode 24b is electrically connected to a second electrical conductor 18b, or similar electrically conductive lead or wire, which is coupled to the negative terminal of the energy source 14 through the activation switch 62. The electrical conductors 18a,b are electrically insulated from each other and surrounding structures, except for the electrical connections to the respective electrodes 24a,b. In various embodiments, the electrical ablation device 20 may be configured to be introduced into or proximate the tissue treatment region using the endoscope 12 (laparoscope or thoracoscope), open surgical procedures, or external and non-invasive medical procedures. The electrodes 24a,b may be referred to herein as endoscopic or laparoscopic electrodes, although variations thereof may be inserted transcutaneously or percutaneously. As previously discussed, either one or both electrodes 24a,b may be adapted and configured to slideably move in and out of a cannula, lumen, or channel defined within the flexible shaft 22.


Once the electrodes 24a,b are positioned at the desired location into or proximate the tissue treatment region, the electrodes 24a,b may be connected to or disconnected from the energy source 14 by actuating or de-actuating the switch 62 on the handpiece 16. The switch 62 may be operated manually or may be mounted on a foot switch (not shown), for example. The electrodes 24a,b deliver electric field pulses to the undesirable tissue. The electric field pulses may be characterized based on various parameters such as pulse shape, amplitude, frequency, and duration. The electric field pulses may be sufficient to induce irreversible electroporation in the undesirable tissue. The induced potential depends on a variety of conditions such as tissue type, cell size, and electrical pulse parameters. The primary electrical pulse parameter affecting the transmembrane potential for a specific tissue type is the amplitude of the electric field and pulse length that the tissue is exposed to.


In one embodiment, a protective sleeve or sheath 26 may be slidably disposed over the flexible shaft 22 and within a handle 28. In another embodiment, the sheath 26 may be slidably disposed within the flexible shaft 22 and the handle 28, without limitation. The sheath 26 is slideable and may be located over the electrodes 24a,b to protect the trocar and prevent accidental piercing when the electrical ablation device 20 is advanced therethrough. Either one or both of the electrodes 24a,b of the electrical ablation device 20 may be adapted and configured to slideably move in and out of a cannula, lumen, or channel formed within the flexible shaft 22. The second electrode 24b may be fixed in place. The second electrode 24b may provide a pivot about which the first electrode 24a can be moved in an arc to other points in the tissue treatment region to treat larger portions of the diseased tissue that cannot be treated by fixing the electrodes 24a,b in one location. In one embodiment, either one or both of the electrodes 24a,b may be adapted and configured to slideably move in and out of a working channel formed within a flexible shaft 32 of the flexible endoscope 12 or may be located independently of the flexible endoscope 12. Various features of the first and second electrodes 24a,b are described in more detail in FIGS. 2A-D.


In one embodiment, the first and second electrical conductors 18a,b may be provided through the handle 28. In the illustrated embodiment, the first electrode 24a can be slideably moved in and out of the distal end of the flexible shaft 22 using a slide member 30 to retract and/or advance the first electrode 24a. In various embodiments either or both electrodes 24a,b may be coupled to the slide member 30, or additional slide members, to advance and retract the electrodes 24a,b, e.g., position the electrodes 24a,b. In the illustrated embodiment, the first electrical conductor 18a coupled to the first electrode 24a is coupled to the slide member 30. In this manner, the first electrode 24a, which is slidably movable within the cannula, lumen, or channel defined by the flexible shaft 22, can advanced and retracted with the slide member 30.


In various other embodiments, transducers or sensors 29 may be located in the handle 28 of the electrical ablation device 20 to sense the force with which the electrodes 24a,b penetrate the tissue in the tissue treatment zone. This feedback information may be useful to determine whether either one or both of the electrodes 24a,b have been properly inserted in the tissue treatment region. As is particularly well known, cancerous tumor tissue tends to be denser than healthy tissue and thus greater force is required to insert the electrodes 24a,b therein. The transducers or sensors 29 can provide feedback to the operator, surgeon, or clinician to physically sense when the electrodes 24a,b are placed within the cancerous tumor. The feedback information provided by the transducers or sensors 29 may be processed and displayed by circuits located either internally or externally to the energy source 14. The sensor 29 readings may be employed to determine whether the electrodes 24a,b have been properly located within the cancerous tumor thereby assuring that a suitable margin of error has been achieved in locating the electrodes 24a,b.


In one embodiment, the input to the energy source 14 may be connected to a commercial power supply by way of a plug (not shown). The output of the energy source 14 is coupled to the electrodes 24a,b, which may be energized using the activation switch 62 on the handpiece 16, or in one embodiment, an activation switch mounted on a foot activated pedal (not shown). The energy source 14 may be configured to produce electrical energy suitable for electrical ablation, as described in more detail below.


In one embodiment, the electrodes 24a,b are adapted and configured to electrically couple to the energy source 14 (e.g., generator, waveform generator). Once electrical energy is coupled to the electrodes 24a,b, an electric field is formed at a distal end of the electrodes 24a,b. The energy source 14 may be configured to generate electric pulses at a predetermined frequency, amplitude, pulse length, and/or polarity that are suitable to induce irreversible electroporation to ablate substantial volumes of undesirable tissue in the treatment region. For example, the energy source 14 may be configured to deliver DC electric pulses having a predetermined frequency, amplitude, pulse length, and/or polarity suitable to induce irreversible electroporation to ablate substantial volumes of undesirable tissue in the treatment region. The DC pulses may be positive or negative relative to a particular reference polarity. The polarity of the DC pulses may be reversed or inverted from positive-to-negative or negative-to-positive a predetermined number of times to induce irreversible electroporation to ablate substantial volumes of undesirable tissue in the treatment region.


In one embodiment, a timing circuit may be coupled to the output of the energy source 14 to generate electric pulses. The timing circuit may comprise one or more suitable switching elements to produce the electric pulses. For example, the energy source 14 may produce a series of n electric pulses (where n is any positive integer) of sufficient amplitude and duration to induce irreversible electroporation suitable for tissue ablation when the n electric pulses are applied to the electrodes 24a,b. In one embodiment, the electric pulses may have a fixed or variable pulse length, amplitude, and/or frequency.


The electrical ablation device 20 may be operated either in bipolar or monopolar mode. In bipolar mode, the first electrode 24a is electrically connected to a first polarity and the second electrode 24b is electrically connected to the opposite polarity. For example, in monopolar mode, the first electrode 24a is coupled to a prescribed voltage and the second electrode 24b is set to ground. In the illustrated embodiment, the energy source 14 may be configured to operate in either the bipolar or monopolar modes with the electrical ablation system 10. In bipolar mode, the first electrode 24a is electrically connected to a prescribed voltage of one polarity and the second electrode 24b is electrically connected to a prescribed voltage of the opposite polarity. When more than two electrodes are used, the polarity of the electrodes may be alternated so that any two adjacent electrodes may have either the same or opposite polarities, for example.


In monopolar mode, it is not necessary that the patient be grounded with a grounding pad. Since a monopolar energy source 14 is typically constructed to operate upon sensing a ground pad connection to the patient, the negative electrode of the energy source 14 may be coupled to an impedance simulation circuit. In this manner, the impedance circuit simulates a connection to the ground pad and thus is able to activate the energy source 14. It will be appreciated that in monopolar mode, the impedance circuit can be electrically connected in series with either one of the electrodes 24a,b that would otherwise be attached to a grounding pad.


In one embodiment, the energy source 14 may be configured to produce RF waveforms at predetermined frequencies, amplitudes, pulse widths or durations, and/or polarities suitable for electrical ablation of cells in the tissue treatment region. One example of a suitable RF energy source is a commercially available conventional, bipolar/monopolar electrosurgical RF generator such as Model Number ICC 350, available from Erbe, GmbH.


In one embodiment, the energy source 14 may be configured to produce destabilizing electrical potentials (e.g., fields) suitable to induce irreversible electroporation. The destabilizing electrical potentials may be in the form of bipolar/monopolar DC electric pulses suitable for inducing irreversible electroporation to ablate tissue undesirable tissue with the electrical ablation device 20. A commercially available energy source suitable for generating irreversible electroporation electric filed pulses in bipolar or monopolar mode is a pulsed DC generator such as Model Number ECM 830, available from BTX Molecular Delivery Systems Boston, Mass. In bipolar mode, the first electrode 24a may be electrically coupled to a first polarity and the second electrode 24b may be electrically coupled to a second (e.g., opposite) polarity of the energy source 14. Bipolar/monopolar DC electric pulses may be produced at a variety of frequencies, amplitudes, pulse lengths, and/or polarities. Unlike RF ablation systems, however, which require high power and energy levels delivered into the tissue to heat and thermally destroy the tissue, irreversible electroporation requires very little energy input into the tissue to kill the undesirable tissue without the detrimental thermal effects because with irreversible electroporation the cells are destroyed by electric field potentials rather than heat.


In one embodiment, the energy source 14 may be coupled to the first and second electrodes 24a,b by either a wired or a wireless connection. In a wired connection, the energy source 14 is coupled to the electrodes 24a,b by way of the electrical conductors 18a,b, as shown. In a wireless connection, the electrical conductors 18a,b may be replaced with a first antenna (not shown) coupled the energy source 14 and a second antenna (not shown) coupled to the electrodes 24a,b, wherein the second antenna is remotely located from the first antenna. In one embodiment, the energy source may comprise a wireless transmitter to deliver energy to the electrodes using wireless energy transfer techniques via one or more remotely positioned antennas. As previously discussed, wireless energy transfer or wireless power transmission is the process of transmitting electrical energy from the energy source 14 to an electrical load, e.g., the abnormal cells in the tissue treatment region, without using the interconnecting electrical conductors 18a,b. An electrical transformer is the simplest instance of wireless energy transfer. The primary and secondary circuits of a transformer are not directly connected. The transfer of energy takes place by electromagnetic coupling through a process known as mutual induction. Wireless power transfer technology using RF energy is produced by Powercast, Inc. The Powercast system can achieve a maximum output of 6 volts for a little over one meter. Other low-power wireless power technology has been proposed such as described in U.S. Pat. No. 6,967,462.


In one embodiment, the energy source 14 may be configured to produce DC electric pulses at frequencies in the range of about 1 Hz to about 10000 Hz, amplitudes in the range of about ±100 to about ±3000 VDC, and pulse lengths (e.g., pulse width, pulse duration) in the range of about 1 μs to about 100 ms. The polarity of the electric potentials coupled to the electrodes 24a,b may be reversed during the electrical ablation therapy. For example, initially, the DC electric pulses may have a positive polarity and an amplitude in the range of about +100 to about +3000 VDC. Subsequently, the polarity of the DC electric pulses may be reversed such that the amplitude is in the range of about −100 to about −3000 VDC. In one embodiment, the undesirable cells in the tissue treatment region may be electrically ablated with DC pulses suitable to induce irreversible electroporation at frequencies of about 10 Hz to about 100 Hz, amplitudes in the range of about +700 to about +1500 VDC, and pulse lengths of about 10 μs to about 50 μs. In another embodiment, the abnormal cells in the tissue treatment region may be electrically ablated with an electrical waveform having an amplitude of about +500 VDC and pulse duration of about 20 ms delivered at a pulse period T or repetition rate, frequency f=1/T, of about 10 Hz. It has been determined that an electric field strength of 1,000V/cm is suitable for destroying living tissue by inducing irreversible electroporation.



FIGS. 2A-D illustrate one embodiment of the electrical ablation device 20 in various phases of deployment. In the embodiment illustrated in FIGS. 2A-D, the sheath 26 is disposed over the flexible shaft 22, however, those skilled in the art will appreciate that the sheath 26 may be disposed within the flexible shaft 22. The electrical ablation device 20 may be used in conjunction with the electrical ablation system 10 shown in FIG. 1. It will be appreciated that other devices and electrode configurations may be employed without limitation. FIG. 2A illustrates an initial phase of deployment wherein the sheath 26 is extended in the direction indicated by arrow 40 to cover the electrodes 24a,b. The electrodes 24a,b may have dimensions of about 0.5 mm, about 1 mm, or about 1.5 mm in diameter. It will be appreciated that the dimensions of the electrodes 24a,b may be anywhere from about 0.5 mm to about 1.5 mm in diameter. The electrical ablation device 20 may be introduced into the tissue treatment region through a trocar, as illustrated in FIG. 3, for example. FIG. 2B illustrates another phase of deployment wherein the sheath 26 is retracted within the handle 28 in the direction indicated by arrow 42. In this phase of deployment, the first and second electrodes 24a,b extend through the distal end of the flexible shaft 22 and are ready to be inserted into or proximate the tissue treatment region. The first electrode 24a may be retracted in direction 42 through a lumen 44 formed in the flexible shaft 22 by holding the handle 28 and pulling on the slide member 30. FIG. 2C illustrates a transition phase wherein the first electrode 24a is the process of being retracted in direction 42 by pulling on the slide member 30 handle, for example, in the same direction. FIG. 2D illustrates another phase of deployment wherein the first electrode 24a is in a fully retracted position. In this phase of deployment the electrical ablation device 20 can be pivotally rotated about an axis 46 defined by the second electrode 24b. The electrodes 24a,b are spaced apart by a distance “r.” The distance “r” between the electrodes 24a,b may be 5.0 mm, about 7.5 mm, or about 10 mm. It will be appreciated that the distance “r” between the electrodes 24a,b may be anywhere from about 5.0 mm to about 10.0 mm. Thus, the electrical ablation device 20 may be rotated in an arc about the pivot formed by the second electrode 24b, the first electrode 24a may be placed in a new location in the tissue treatment region within the radius “r.” Retracting the first electrode 24a and pivoting about the second electrode 24b enables the surgeon or clinician to target and treat a larger tissue treatment region essentially comprising a circular region having a radius “r,” which is the distance between the electrodes 24a,b. Thus, the electrodes 24a,b may be located in a plurality of positions in and around the tissue treatment region in order to treat much larger regions of tissue. Increasing the electrode 24a,b diameter and spacing the electrodes 24a,b further apart enables the generation of an electric field over a much larger tissue regions and thus the ablation of larger volumes of undesirable tissue. In this manner, the operator can treat a larger tissue treatment region comprising cancerous lesions, polyps, or tumors, for example.


Although the electrical ablation electrodes according to the described embodiments have been described in terms of the particular needle type electrodes 24a,b as shown and described in FIGS. 1 and 2A-D, those skilled in the art will appreciate that other configurations of electrical ablation electrodes may be employed for the ablation of undesirable tissue, without limitation. In one embodiment, the electrical ablation device 20 may comprise two or more fixed electrodes that are non-retractable. In another embodiment, the electrical ablation device 20 may comprise two or more retractable electrodes, one embodiment of which is described below with reference to FIG. 2E. In another embodiment, the electrical ablation device 20 may comprise at least one slidable electrode disposed within at least one working channel of the flexible shaft 32 of the endoscope 12. In another embodiment, the electrical ablation device 20 may comprise at least one electrode may be configured to be inserted into the tissue treatment region transcutaneously or percutaneously. Still in various other embodiments, the electrical ablation device 20 may comprise at least one electrode configured to be introduced to the tissue treatment region transcutaneously or percutaneously and at least one other electrode may be configured to be introduced to the tissue treatment region through at least one working channel of the flexible shaft 32 of the endoscope 12. The embodiments, however, are not limited in this context.



FIG. 2E illustrates one embodiment of an electrical ablation device 800 comprising multiple needle electrodes 824m, where m is any positive integer. In the illustrated embodiment, the electrical ablation device 800 comprises four electrodes 824a, 824b, 824c, 824d. It will be appreciated that in one embodiment, the electrical ablation device 800 also may comprise three needle electrodes 824a, 824b, 824c, without limitation. The electrical ablation device 800 may be used in conjunction with the electrical ablation system 10 shown in FIG. 1. It will be appreciated that other devices and electrode configurations may be employed without limitation. The electrodes 824a-m each may have dimensions of about 0.5 mm, about 1 mm, or about 1.5 mm in diameter. It will be appreciated that the dimensions of each of the electrodes 824a-m may be anywhere from about 0.5 mm to about 1.5 mm in diameter. The electrical ablation device 800 may be introduced into the tissue treatment region through a trocar, as subsequently described and illustrated with reference to FIG. 3, for example.


The electrical ablation device 800 comprises essentially the same components as the electrical ablation device 20 described with reference to FIGS. 2A-D. The electrical ablation device 800 comprises the relatively flexible member or shaft 22, the protective sheath 26, and one or more handles 28 to operate either the sheath 26, the electrodes 824a,b,c,d, or both. The electrodes 824a,b,c,d may be individually or simultaneously deployable and/or retractable in the direction indicated by arrow 842. The electrodes 824a,b,c,d extend out from the distal end of the electrical ablation device 800. In one embodiment, the first and second electrodes 824a, 824b may be configured as the positive electrode coupled to the anode of the energy source 14 via corresponding first and second electrical conductors 818a, 818b, and the third and fourth 824c, 824d may be configured as the negative electrode coupled to the cathode of the energy source 14 via corresponding third and fourth electrical conductors 818c, 818d, or similar electrically conductive leads or wires, through the activation switch 62. Once the electrodes 824a,b,c,d are positioned at the desired location into or proximate the tissue treatment region, the electrodes 824a,b,c,d may be connected/disconnected from the energy source 14 by actuating/de-actuating the switch 62.


As previously discussed with reference to FIGS. 2A-D, as shown in FIG. 2E in one embodiment, the protective sleeve or sheath 26 may be slidably disposed over the flexible shaft 22 and within the handle 28. In an initial phase of deployment, the sheath 26 is extended in direction 40 to cover the electrodes 824a,b,c,d to protect the trocar and prevent accidental piercing when the electrical ablation device 800 is advanced therethrough. Once the electrodes 824a,b,c,d are located into or proximate the tissue treatment region, the sheath 26 is retracted in direction 42 to expose the electrodes 824a,b,c,d. One or more of the electrodes 824a,b,c,d of the electrical ablation device 800 may be adapted and configured to slideably move in and out of a cannula, lumen, or channel formed within the flexible shaft 22. In one embodiment all of the electrodes 824a,b,c,d are configured to slideably move in and out channels formed within lumens formed within the flexible shaft 22, referred to for example as the lumen 44 in FIGS. 2A-D, to advance and retract the electrodes 824a,b,c,d as may be desired by the operator. Nevertheless, in other embodiments, it may be desired to fix all or certain ones of the one or more electrodes 824a,b,c,d in place.


The various embodiments of electrodes described in the present specification, e.g., the electrodes 24a,b, or 824a-m, may be configured for use with an electrical ablation device (not shown) comprising an elongated flexible shaft to house the needle electrodes 24a,b, or 824a-m, for example. The needle electrodes 24a,b, or 824a-m, are free to extend past a distal end of the electrical ablation device. The flexible shaft comprises multiple lumen formed therein to slidably receive the needle electrodes 24a,b, or 824a-m. A flexible sheath extends longitudinally from a handle portion to the distal end. The handle portion comprises multiple slide members received in respective slots defining respective walls. The slide members are coupled to the respective needle electrodes 24a,b, or 824a-m. The slide members are movable to advance and retract the electrode 24a,b, or 824a-m. The needle electrodes 24a,b, or 824a-m, may be independently movable by way of the respective slide members. The needle electrodes 24a,b, or 824a-m, may be deployed independently or simultaneously. An electrical ablation device (not shown) comprising an elongated flexible shaft to house multiple needle electrodes and a suitable handle is described with reference to FIGS. 4-10 in commonly owned U.S. patent application Ser. No. 11/897,676 titled “ELECTRICAL ABLATION SURGICAL INSTRUMENTS,” filed Aug. 31, 2007, the entire disclosure of which is incorporated herein by reference in its entirety.


It will be appreciated that the electrical ablation devices 20, 800 described with referenced to FIGS. 2A-E, may be introduced inside a patient endoscopically (as shown in FIG. 15, transcutaneously, percutaneously, through an open incision, through a trocar (as shown in FIG. 3), through a natural orifice (as shown in FIG. 15), or any combination thereof. In one embodiment, the outside diameter of the electrical ablation devices 20, 800 may be sized to fit within a working channel of an endoscope and in other embodiments the outside diameter of the electrical ablation devices 20, 800 may be sized to fit within a hollow outer sleeve 620, or trocar, as shown in FIG. 15, for example. The hollow outer sleeve 620 or trocar is inserted into the upper gastrointestinal tract of a patient and may be sized to also receive a flexible endoscopic portion of an endoscope 622 (e.g., gastroscope), similar to the endoscope 12 described in FIG. 1.



FIG. 3 illustrates one embodiment of the electrical ablation system 10 shown in FIGS. 1 and 2A-D in use to treat undesirable tissue 48 located on the surface of the liver 50. The undesirable tissue 48 may be representative of a variety of diseased tissues, cancers, tumors, masses, lesions, abnormal tissue growths, for example. In use, the electrical ablation device 20 may be introduced into or proximate the tissue treatment region through a port 52 of a trocar 54. The trocar 54 is introduced into the patient via a small incision 59 formed in the skin 56. The endoscope 12 may be introduced into the patient trans-anally through the colon, trans-orally down the esophagus and through the stomach using translumenal techniques, or through a small incision or keyhole formed through the patient's abdominal wall (e.g., the peritoneal wall). The endoscope 12 may be employed to guide and locate the distal end of the electrical ablation device 20 into or proximate the undesirable tissue 48. Prior to introducing the flexible shaft 22 through the trocar 54, the sheath 26 is slid over the flexible shaft 22 in a direction toward the distal end thereof to cover the electrodes 24a,b (as shown in FIG. 2A) until the distal end of the electrical ablation device 20 reaches the undesirable tissue 48.


Once the electrical ablation device 20 has been suitably introduced into or proximate the undesirable tissue 48, the sheath 26 is retracted to expose the electrodes 24a,b (as shown in FIG. 2B) to treat the undesirable tissue 48. To ablate the undesirable tissue 48, the operator initially may locate the first electrode 24a at a first position 58a and the second electrode 24b at a second position 60 using endoscopic visualization and maintaining the undesirable tissue 48 within the field of view of the flexible endoscope 12. The first position 58a may be near a perimeter edge of the undesirable tissue 48. Once the electrodes 24a,b are located into or proximate the undesirable tissue 48, the electrodes 24a,b are energized with irreversible electroporation pulses to create a first necrotic zone 65a. For example, once the first and second electrodes 24a,b are located in the desired positions 60 and 58a, the undesirable tissue 48 may be exposed to an electric field generated by energizing the first and second electrodes 24a,b with the energy source 14. The electric field may have a magnitude, frequency, and pulse length suitable to induce irreversible electroporation in the undesirable tissue 48 within the first necrotic zone 65a. The size of the necrotic zone is substantially dependent on the size and separation of the electrodes 24a,b, as previously discussed. The treatment time is defined as the time that the electrodes 24a,b are activated or energized to generate the electric pulses suitable for inducing irreversible electroporation in the undesirable tissue 48.


This procedure may be repeated to destroy relatively larger portions of the undesirable tissue 48. The position 60 may be taken as a pivot point about which the first electrode 24a may be rotated in an arc of radius “r,” the distance between the first and second electrodes 24a,b. Prior to rotating about the second electrode 24b, the first electrode 24a is retracted by pulling on the slide member 30 (FIGS. 1 and 2A-D) in a direction toward the proximal end and rotating the electrical ablation device 20 about the pivot point formed at position 60 by the second electrode 24b. Once the first electrode 24a is rotated to a second position 58b, it is advanced to engage the undesirable tissue 48 at point 58b by pushing on the slide member 30 in a direction towards the distal end. A second necrotic zone 65b is formed upon energizing the first and second electrodes 24a,b. A third necrotic zone 65c is formed by retracting the first electrode 24a, pivoting about pivot point 60 and rotating the first electrode 24a to a new location, advancing the first electrode 24a into the undesirable tissue 48 and energizing the first and second electrodes 24a,b. This process may be repeated as often as necessary to create any number of necrotic zones 65p, where p is any positive integer, within multiple circular areas of radius “r,” for example, that is suitable to ablate the entire undesirable tissue 48 region. At anytime, the surgeon or clinician can reposition the first and second electrodes 24a,b and begin the process anew. In other embodiments, the electrical ablation device 800 comprising multiple needle electrodes 824a-m described with reference to FIG. 2E may be employed to treat the undesirable tissue 48. Those skilled in the art will appreciate that similar techniques may be employed to ablate any other undesirable tissues that may be accessible trans-anally through the colon, and/or orally through the esophagus and the stomach using translumenal access techniques. Therefore, the embodiments are not limited in this context.



FIG. 4 illustrates a detailed view of one embodiment of the electrical ablation system 10 shown in FIG. 3 in use to treat undesirable tissue 48 located on the surface of the liver 50. The first and second electrodes 24a,b are embedded into or proximate the undesirable tissue 48 on the liver 50. The first and second electrodes 24a,b are energized to deliver one or more electrical pulses of amplitude and length sufficient to induce irreversible electroporation in the undesirable tissue 48 and create the first necrotic zone 65a. Additional electric pulses may be applied to the tissue immediately surrounding the respective electrodes 24a,b to form second, thermal, necrotic zones 63a,b near the electrode-tissue-interface. The duration of an irreversible electroporation energy pulse determines whether the temperature of the tissue 63a,b immediately surrounding the respective electrodes 24a,b raises to a level sufficient to create thermal necrosis. As previously discussed, varying the electrode 24a,b size and spacing can control the size and shape of irreversible electroporation induced necrotic zone 65a. Electric pulse amplitude and length can be varied to control the size and shape of the thermally induced necrotic zones near the tissue-electrode-interface. In other embodiments, the electrical ablation device 800 comprising multiple needle electrodes 824a-m may be used to treat the undesirable tissue 48 located on the surface of the liver 50, for example.



FIG. 5 is a graphical representation of a series of electrical pulses that may be applied to undesirable tissue to create a first necrotic zone by inducing irreversible electroporation in the tissue and to create a second necrotic zone by inducing thermal effects near the electrode-tissue-interface using the electrical ablation system 10 shown in FIG. 4. Time (t) is shown along the horizontal axis and voltage (VDC) is shown along the vertical axis. Initially the undesirable tissue 48 is exposed to a first series of electrical pulses 70 of a first predetermined amplitude, length, and frequency sufficient to induce the irreversible electroporation necrotic zone 65a. Subsequently, the undesirable tissue near the electrode-tissue-interface is exposed to a second series of electrical pulses 72 of a second predetermined amplitude, length, and frequency sufficient to induce thermal necrotic effects on the tissue and create thermal necrotic zones 63a,b. As shown in FIG. 5, the first series of pulses 70 comprises about 20 to 40 electric pulses having an amplitude of about 1000 VDC, pulse length t1 of about 10 μs to about 15 μs, and a period T1 (e.g., pulse repetition rate f1=1/T1) of about 10 μs (f1=10000 Hz). The first series of pulses is sufficient to induce irreversible electroporation in the necrotic zone 65a. The period T1 is defined as the pulse length t1 plus the pulse spacing 74, e.g., the time between a falling edge of a pulse and a rising edge of a subsequent pulse. The second series of pulses 72 may comprises a single pulse or multiple pulses having an amplitude of about 500 VDC, pulse length t2 of about 10 ms to about 15 ms, and a period T2 of about 100 ms (f2=10 Hz). The second series of pulses is sufficient to create thermal necrotic zones 63a,b in the tissue near the electrode-tissue-interface immediately surrounding the respective electrodes 24a,b. In one embodiment, f1=f2=10 Hz (i.e., T1=T2=100 ms).


In one embodiment, the thermal necrotic zones 63a,b formed in the tissue immediately surrounding the electrodes 24a,b at the tissue-electrode-interface are beneficial to stop bleeding in the undesirable tissue 48 as a result of the mechanical trauma resulting from inserting or embedding the electrodes 24a,b into the undesirable tissue 48 of the liver 50. Although in general irreversible electroporation induced by electric pulses do not cause thermal necrosis or other detrimental thermal effects, the longer electrical pulses 72 may be applied to the undesirable tissue 48 in succession to thermally seal the tissue immediately surrounding the electrodes 24a,b at the tissue-electrode-interface. Thus, the technique of applying a combination of a first series of substantially shorter electrical pulses 70 (in the microseconds range) and a second series of substantially longer energy pulses 72 (in the milliseconds range) may be employed for sealing vessels prior to transecting a vessel. Accordingly, the first series of pulses 70 may be applied to a vessel to induce cell necrosis by irreversible electroporation. Then, the second series of pulses 72 may be applied to vessel to create thermal necrotic zones to seal the vessel prior to dissecting the vessel.


In various embodiments, a series of electrical pulses may be characterized according to the following parameters as may be provided by the energy source 14, for example. In one embodiment, the energy source 14 may be configured to produce DC electric pulses at frequencies in the range of about 1 Hz to about 10000 Hz, amplitudes in the range of about ±100 to about ±3000 VDC, and pulse lengths (e.g., pulse width, pulse duration) in the range of about 1 μs to about 100 ms. The polarity of the electric potentials coupled to the electrodes 24a,b may be reversed during the electrical ablation therapy. For example, initially, the DC electric pulses may have a positive polarity and an amplitude in the range of about +100 to about +3000 VDC. Subsequently, the polarity of the DC electric pulses may be reversed such that the amplitude is in the range of about −100 to about −3000 VDC. In one embodiment, the undesirable cells in the tissue treatment region may be electrically ablated with DC pulses suitable to induce irreversible electroporation at frequencies of about 10 Hz to about 100 Hz, amplitudes in the range of about +700 to about +1500 VDC, and pulse lengths of about 10 μs to about 50 μs. In another embodiment, the abnormal cells in the tissue treatment region may be electrically ablated with an electrical waveform having an amplitude of about +500 VDC and pulse duration of about 20 ms delivered at a pulse period T or repetition rate, frequency f=1/T, of about 10 Hz.



FIGS. 6, 7, and 8 illustrate one embodiment of an electrical ablation device 290 to treat undesirable tissue located within body lumen using electrical energy. FIG. 6 illustrates a sectioned view of one embodiment of the electrical ablation device 290. FIG. 7 illustrates an end view of the embodiment of the electrical ablation device 290 shown in FIG. 6. FIG. 8 illustrates a cross-sectional view of the embodiment of the electrical ablation device 290 shown in FIG. 6. As previously discussed, reflux disease of the greater saphenous vein (GSV) can result in a varicose vessel 292, which is illustrated in FIG. 8. Conventionally, varicose veins have been treated by stripping and then applying either chemical or thermal ablation to internal portions of a lumen defined by the varicose vessel 292. In the embodiment illustrated in FIGS. 6-8, the electrical ablation device 290 is configured to couple to the energy source 14 and to be inserted within a lumen defined by the varicose vessel 292. Once inserted into the varicose vessel 292, the electrical ablation device 290 may be energized by the energy source 14 to apply high-voltage DC electrical pulses to an inner wall 294 portion of the varicose vessel 292. High-voltage DC pulses may be used to ablate the undesirable tissue and to subsequently seal the varicose vessel 292. The embodiment illustrated in FIGS. 6-8, however, is not limited in this context, and the electrical ablation device 290 may be employed to treat and seal tissue within any inner body lumen using energy in the form of electrical pulses supplied by the energy source 14.


Referring to FIGS. 6-8, the electrical ablation device 290 comprises a probe 296 comprising a cannula, channel, or lumen 300 extending longitudinally therethrough. The distal end 298 of the probe 296 comprises first and second ring electrodes 302a,b to which a potential difference may be applied by the energy source 14. The first and second ring electrodes 302a,b may be coupled to respective positive and negative terminals of the energy source 14 through corresponding first and second electrical conductors 304a,b. The first and second electrical conductors 304a,b extend through respective conduits 306a,b formed within the probe 296 and extend longitudinally therethrough. The first and second electrical conductors 304a,b may be electrically coupled to the first and second ring electrodes 302a,b in any suitable manner. The first and second ring electrodes 302a,b are adapted to receive energy in the form of electrical pulses from the energy source 14. The electrical pulses generate an electric field suitable for treating, e.g., ablating, the undesirable tissue within a lumen such as the lumen defined by the varicose vessel 292 as shown in FIG. 8. In one embodiment, once energized by the energy source 14, the first and second ring electrodes 302a,b generate an electric field suitable to induce irreversible electroporation in the undesirable tissue. It will be appreciated that a potential difference may be created across the first and second ring electrodes 302a,b to generate an electric field strength suitable to induce irreversible electroporation in the undesirable tissue. In other embodiments, the probe 296 may comprise one or more electrodes in addition to the first and second ring electrodes 302a,b.


The electrical ablation probe 296 has a form factor that is suitable to be inserted within a lumen defined by the varicose vessel 292 and to ablate tissue in the tapered lumen 298 portion of the varicose vessel 292. The probe 296 engages the inner wall 294 of the varicose vessel 292 in the tapered lumen 298 portion of the varicose vessel 292. Suction 306 applied at a proximal end of the probe 296 draws a vacuum within the lumen 300 of the probe 296 to collapse the varicose vessel 292 at the distal end 298 of the probe 296. Once the vessel 292 is collapsed or pulled down by the suction 306, a first pulse train 302 of high-voltage DC electrical pulses at a first amplitude A1 (e.g., ˜1000V amplitude) and a first pulse length T1 (e.g., ˜50 microseconds) is applied to the first and second ring electrodes 302a,b by the energy source 14. The high-voltage DC pulse train 302 eventually kills the cells within the tapered lumen 298 portion of the varicose vessel 292 by irreversible electroporation. A second pulse train 304 having a lower voltage amplitude A2 (e.g., ˜500 VDC) and a second longer pulse length T2 (e.g., ˜15 milliseconds) is applied to the first and second ring electrodes 302a,b of the probe 296 to thermally seal the varicose vessel 292. As previously discussed, in one embodiment, the polarity of the electrical pulses may be inverted or reversed by the energy source 14 during the ablation or sealing treatment process. In various embodiments, the electrical pulses may be characterized by the parameters in accordance with the output of the energy source 14 as discussed with respect to FIGS. 1 and 5, for example.



FIG. 9 illustrates one embodiment of an electrical ablation system 400 in use to treat non-metastatic prostate cancer in a patient. As previously discussed, a radical prostatectomy in which the entire prostate 404 and surrounding lymph nodes are removed is one of the conventional treatments for prostate cancer. Like most other forms of cancer, radiation therapy may be used in conjunction with or as an alternate method for the treatment of prostate cancer. Another thermal ablation technique for the treatment of prostate cancer is RF interstitial tumor ablation (RITA) via trans-rectal ultrasound guidance. While these conventional methods for the treatment of prostate cancer are effective, they are not preferred by many surgeons and may result in detrimental thermal effects to healthy tissue surrounding the prostate. The electrical ablation system 400 in accordance with the described embodiments provides improved electrical ablation of prostate cancer using irreversible electroporation pulses through supplied by an energy source to electrodes positioned into and/or proximate the prostrate cancer tissue.


With reference to FIG. 9, the electrical ablation system 400 comprises an electrical ablation device 402 comprising at least two electrodes 402a,b, and the energy source 14. The electrical ablation system 400 may be adapted for use in conjunction with the electrical ablation system 10 described in FIG. 1. The electrodes 402a,b are configured to be positioned within internal body lumens or cavities and, in one embodiment, may be configured for use in conjunction with the flexible endoscope 12 also described in FIG. 1. The electrodes 402a,b are configured to couple to the corresponding electrical conductors 18a,b, the handpiece 16, the activation switch 62, and the energy source 14, as previously discussed in FIG. 1. The first electrode 402a comprises a wire or flexible conductive tube that may be introduced through the urethra 406 into the prostate 404 proximally to the bladder 410. The first electrode 402a may be located into the prostate 404 using well known fluoroscopy or ultrasonic guidance, for example. The second electrode 402b comprises a pad and may be introduced into the anus 408 and advanced to a location proximate to the prostate 404. The first electrode 402a has a much smaller surface area relative to the trans-anally placed second electrode 402b pad. The first electrode 402a may be connected to the positive (+) terminal of the energy source 14 and the second electrode 402b may be connected to the negative (−) terminal of the energy source 14. In one embodiment, the energy source 14 may e configured as a high-voltage DC electric pulse generator. The activation switch 62 portion of the handpiece 16, as shown in FIG. 1, can be used to energize the electrical ablation system 400 to ablate the non-metastatic cancer in the prostrate 404 by irreversible electroporation pulses supplied by the energy source 14 and delivered through the electrodes 402a,b as described in FIG. 10 below. In other embodiments, the probe 296 may comprise one or more electrodes in addition to the first and second electrodes 402a,b.



FIG. 10 is a graphical representation of a series of electrical pulses 412 that may be applied to undesirable tissue to induce irreversible electroporation suitable to ablate non-metastatic cancer of the prostrate 404 as described in FIG. 9. Time (t) is shown along the horizontal axis and voltage (V) is shown along the vertical axis. A series of electrical pulses 412 having a predetermined amplitude Vo and pulse length to sufficient to induce irreversible electroporation may be applied to the prostate 404 through the electrodes 402a,b to ablate the undesirable cancerous tissue. Multiple electrical pulses 412, for example, 20 to 40 pulses, of amplitude of about 1500 to about 3000 volts DC (Vo) each having a pulse length to of about 10 μs to about 50 μs, and a period (T) of about 10 ms. The electrical pulses 412 having such parameters are sufficient to induce irreversible electroporation to ablate the cancerous tissue in the prostate 404. The period T (e.g., pulse repetition rate f=1/T) may be defined as the pulse length to plus the length of time between pulses, or the pulse spacing 414. A conductive fluid may be introduced into the urethra 406 to extend the range of the positive electrode 402a. In various embodiments, the electrical pulses may be characterized by the parameters in accordance with the output of the energy source 14 as discussed with respect to FIGS. 1 and 5, for example.



FIG. 11 illustrates one embodiment of the electrical ablation system 10 described FIG. 1 in use to treat basal cell carcinoma (BCC) tissue. In FIG. 11, the electrical ablation system 10, described in FIG. 1, is shown in use to treat BCC tissue 502. BCC tissue 502 is a slowly growing cutaneous malignancy derived from a rapidly proliferating basal layer of the epidermis 504. As previously discussed, conventional treatments for BCC include surgical excision, cryo-therapy, radiation, photodynamic therapy, Moh's micrographic surgery, and topical treatments with 5-fluorouracil. Minimally-invasive methods of treating BCC include laser ablation with a pulsed carbon dioxide laser. Although, the treatment of BCC with a carbon dioxide laser has been shown to be effective on tumors ranging in size from about 5 mm to about 40 mm, carbon dioxide treatment is a thermal method of treating tissue that may cause permanent thermal damage to healthy tissue surrounding the BCC tissue and requires costly capital investment in carbon dioxide laser equipment.


The electrical ablation device 20 of the electrical ablation system 10 may be used to induce irreversible electroporation suitable to treat undesirable BCC tissue using electrical pulses supplied by the energy source 14. The first and second electrodes 24a,b are transcutaneously inserted through the epidermis 504 and embedded into the BCC tissue 502. The first and second electrodes 24a,b are separated by a distance “D.” The first electrode 24a is electrically to the positive (+) output of the energy source 14 and the second electrode 24b is electrically connected to the negative (−) output of the energy source 14. In one embodiment, the energy source 14 may be a high-voltage DC generator. The energized the electrodes 24a,b generate an electric field inducing irreversible electroporation suitable for ablating the undesirable BCC tissue 502 located between the electrodes 24a,b. A larger portion of the BCC tissue 502 may be ablated by relocating and re-energizing the first and second electrodes 24a,b using the technique previously described with reference to FIG. 3, for example. As previously discussed, varying the electrode 24a,b size and spacing can control the size and shape of irreversible electroporation induced necrotic zone. Accordingly, as previously discussed, increasing the electrode 24a,b diameter and spacing between the electrodes 24a,b enables the generation of an electric field over a much larger tissue regions and thus the ablation of larger volumes of undesirable tissue. In other embodiments, the electrical ablation device 800 comprising multiple needle electrodes 824a-m may be used to treat the BCC tissue 502, for example.



FIG. 12 is a graphical representation of a series of electrical pulses 512 that may be applied to undesirable tissue to induce irreversible electroporation suitable to ablate BCC tissue as described in FIG. 11. Time (t) is shown along the horizontal axis and voltage (V) is shown along the vertical axis. As shown in FIG. 12, a series of electrical pulses 512 having a predetermined amplitude Vo and pulse length to sufficient to induce irreversible electroporation may be applied to the BCC tissue 502 to ablate the undesirable cancerous tissue. About 20 to about 40 pulses 512 of with an amplitude of about 1500 to about 3000 VDC (Vo), a pulse length to of about 10 μs to about 50 μs, a period T (the pulse length to plus the pulse spacing 54) of about 10 ms may be suitable for inducing irreversible electroporation to ablate the undesirable BCC tissue 502 in the region D between the electrodes 24a,b. Multiple placements of the electrode 24a,b in rapid succession and the application of additional pulses 512 can be used to ablate larger portions of the BCC tissue 502, as previously discussed in FIG. 3. As previously discussed, varying the electrode 24a,b size and spacing can control the size and shape of irreversible electroporation induced necrotic zone. Accordingly, increasing the electrode 24a,b diameter and spacing the electrodes 24a,b further apart (e.g., greater than “D”) enables the generation of an electric field over a much larger tissue regions and thus the ablation of larger volumes of undesirable tissue. Injecting a conductive fluid into the BCC tissue 502 is another technique to increase the size and shape of the irreversible electroporation induced necrotic zone and extend the range of the positive electrode 24a, for example. In various embodiments, the electrical pulses may be characterized by the parameters in accordance with the output of the energy source 14 as discussed with respect to FIGS. 1 and 5, for example.



FIG. 13A illustrates one embodiment of an electrical ablation device 600 in a collapsed state. The electrical ablation device 600 has a configuration suitable for the treatment of undesirable tissue located in a lumen, abscess, void, or cavity. Although other electrode configurations may be effective for treating line-of-sight regions of tissue, such electrodes may not be as effective at treating tissue within a cavity. To overcome these limitations, the electrical ablation device 600 comprises an electrode configured to inflate and expand into the cavity to make contact with tissue along the inner wall of the cavity. The electrical ablation device 600 comprises an elongate tubular body extending from a proximal end to a distal end. In one embodiment, the electrical ablation device 600 may comprise a conductive elastomer electrode 602 portion (e.g., balloon, tip) and a non-conductive catheter 604 portion, which may be formed of a non-electrically conductive (e.g., electrically insulative) elastomeric material. The electrical ablation device 600 may be referred to as a balloon catheter, balloon probe, or balloon-tipped catheter, for example, without limitation. In one embodiment, the inflatable portion of the conductive elastomer electrode 602 may be formed of an electrically conductive elastomer suitable for coupling to the energy source 14 via an electrically conductive terminal 610 and a first electrically conductive wire 608a. Once inflated, the elastomeric properties of the conductive elastomer electrode 602 conform to the internal walls of the cavity. Upon energizing, the conductive elastomer electrode 602 delivers electrical pulses to the tissue within the internal walls of the cavity to induce irreversible electroporation.


In one embodiment, the electrical ablation device 600 may be fabricated using a concurrent injection process such that the conductive elastomer electrode 602 portion and the non-conductive catheter 604 portion are formally integrally. In another embodiment, the electrical ablation device 600 may be fabricated by manufacturing the conductive elastomer electrode 602 and the non-conductive catheter 604 separately and then joining the two components using any suitable joining method such as, for example, bolting, screwing, welding, crimping, gluing, bonding, brazing, soldering, press fitting, riveting, heat shrinking, heat welding, ultrasonic welding, or any other suitable method.



FIG. 13B illustrates one embodiment of the electrical ablation device 600 shown in FIG. 13A in an inflated state. As previously discussed, in an inflated state the conductive elastomer electrode 602 may be employed for ablating cancerous tumors growing within internal body lumens such as the esophagus or the large bowel, or in cavities remaining when cancerous tumors are removed from solid tissue, such as the breast. Although surgical resection of tumors in solid tissue can include a margin of healthy tissue, cancer cells may remain in the tissue within the cavity. The conductive elastomer electrode 602 may be inserted in the cavity, inflated, and energized by the energy source 14 to expose the tissue within the cavity to electrical pulses suitable to induce irreversible electroporation to ablate any cancer cells remaining within the cavity.



FIG. 14 is a cross-sectional view of the electrical ablation device 600 showing a cross-sectional view of the conductive elastomer electrode 602 and the non-conductive catheter 604 shown in FIGS. 13A and 13B. The conductive elastomer electrode 602 may be coupled to a first end 606 of the electrically conductive wire 608a. The wire 608a may be located through the non-conductive catheter 604 and the first end 606 electrically connected (e.g., bonded, soldered, brazed) to the conductive elastomer electrode 602 through the electrically conductive terminal 610. In one embodiment, the non-conductive catheter 604 may be extruded with an embedded strip of conductive material serving as the electrically conductive terminal 610. The wire 608a may be electrically connected to one end of the electrically conductive terminal 610. In one embodiment, the electrical ablation device 600 may be configured to couple to one terminal of the energy source 14 via a second end of the electrically conductive wire 608a. A return electrode 612 (e.g., in the form of a pad or needle electrode) is coupled to a second electrically conductive wire 608b, which is coupled to another terminal of the energy source 14. The return electrode 612 may be orientated proximal to the conductive elastomer electrode 602 of the electrical ablation device 600 (e.g., the balloon catheter). When irreversible electroporation energy pulses are applied to the conductive elastomer electrode 602 of the electrical ablation device 600, the tissue between the conductive elastomer portion 602 and the return electrode 608b is ablated, e.g., destroyed by the pulsed irreversible electroporation energy. In other embodiments, the return electrode 612 may comprise multiple electrodes, for example.


In one embodiment, the conductive elastomer electrode 602 may be fabricated from or may comprise an electrically conductive material suitable for conducting electrical energy from the energy source 14 to the internal cavity sufficient tot induce irreversible electroporation to the tissue within the cavity. The electrically conductive elastomer material is similar to conductive elastomers used as gasket material for electronic enclosures used for shielding electronic devices from electromagnetic interference (EMI). Conductive elastomers may be formed by infiltrating an elastomeric matrix with electrically conductive filler materials such as silver, gold, copper, or aluminum, to produce a hybrid material having the elastic properties of the elastomeric matrix and the electrically conductive properties of the metallic filler materials (some materials may have volume resistivity values as low as 0.004 Ω-cm, for example). The conductive elastomer may be formed as thin sheets, catheters, and balloons suitable for medical applications. In one embodiment, the conductive elastomer electrode 602 may be fabricated from medical grade polyurethane material comprising at least one electrically conductive coating on an outer surface thereof. In another embodiment, the conductive elastomer electrode 602 may be made from an electrically conductive material. In yet another embodiment, the conductive elastomer electrode 602 may be made from an electrically insulative material, such as the medical grade polyurethane, and inflated with a conductive fluid (e.g., saline) to form the electrically conductive portion of the conductive elastomer electrode 602.


In one embodiment the conductive elastomer electrode 602 may be coupled to the anode (+) electrode of the energy source 14 and in another embodiment the conductive elastomer electrode 602 may be coupled to the cathode (−) electrode of the energy source 14. It will be appreciated that the polarity of the conductive elastomer electrode 602 may be reversed by reversing the output polarity of the energy source 14. In one embodiment, the conductive elastomer electrode 602 may be coupled to either the anode (+) or the cathode (−) of the energy source 14. For example, the conductive elastomer electrode 602 may be coupled to the cathode (+) of the energy source 14 relative to a ground plane cathode (−) in contact with the patient and coupled to the negative terminal of the energy source 14.



FIG. 15 illustrates one embodiment of the electrical ablation device shown in FIG. 13A inserted through the mouth and esophagus to ablate cancerous tissue in the esophagus using electrical pulses. As shown in FIG. 15, a hollow outer sleeve 620 or trocar is inserted into the upper gastrointestinal tract of a patient and receives a flexible endoscopic portion of an endoscope 622 (e.g., gastroscope), similar to the endoscope 12 described in FIG. 1. A variety of different types of endoscopes are known and, therefore, their specific construction and operation will not be discussed in great detail herein. In various embodiments, the flexible endoscopic portion 620 may be fabricated from nylon or high-density polyethylene plastic, for example. FIG. 15 illustrates, in general form, one embodiment of the electrical ablation device 600 that can be inserted through a natural orifice such as the mouth 626 and advanced through a cavity or lumen such as the esophagus 628, e.g., esophageal cavity, to apply electrical pulses sufficient to induce irreversible electroporation to ablate the undesirable cancerous tissue 630 located in the esophagus 628.



FIG. 16 illustrates the distal portion 624 of the endoscope 622 shown in FIG. 15. As shown in FIG. 16, the electrical ablation device 600 is advanced through the distal end 624 of the endoscope 622. In various embodiments, the endoscope 622 can serve to define various tool-receiving passages 628, or “working channels,” that extend from the natural orifice 626 to the surgical site. In addition, the endoscope 622 comprises a viewing port 630. The endoscope 622 may be used for viewing the surgical site within the patient's body. Various cameras and/or lighting apparatuses may be inserted into the viewing port 630 of the endoscope 622 to provide the surgeon with a view of the surgical site.


With reference now to FIGS. 15 and 16, the electrical ablation device 600 is one of the tools or surgical instruments that can be accommodated in the tool-receiving passage 628 of the endoscope 622. The conductive elastomer electrode 602 (e.g., balloon, tip) and the non-conductive catheter 604 are configured to communicate with at least one pressurized air source 634 and a vacuum source 632 to respectively inflate and deflate the conductive elastomer electrode 602. In one embodiment, a vacuum/air tube 636 can be sized to receive other surgical instruments therein. In various embodiments, the endoscope 622 may comprise a video camera that communicates with a video display unit 638 that can be viewed by the surgeon during the operation. In addition, the endoscope 622 may further comprise a fluid-supply lumen therethrough that is coupled to an inflation fluid such as a water source 640, saline solution, and/or any other suitable inflation fluid and/or an air supply lumen that is coupled to the air source 642. In various embodiments, the fluid-supply lumen, e.g., the inflation fluid line, may be coupled to conventional inline valves (not shown) to control the flow of inflation fluid. For example, a proximal end of the inline valve may be removably coupled to a conventional inflation syringe. The fluid-supply lumen defines an inflation lumen that fluidically communicates with the interior of the conductive elastomer electrode 602 (e.g., the balloon electrode) via an aperture (not shown). The fluid-supply lumen provides a fluid communication path for inflating the conductive elastomer electrode 602 with a conductive fluid. The fluid may be either saline or air or other suitable electrically conductive inflation fluid. As previously discussed, the conductive elastomer electrode 602 is coupled to the energy source 14 to delivers electrical pulses to the esophageal cavity. The transcutaneous electrode 612 is also coupled to the energy source 14 through electrically conductive wire 608b.


In use, the electrical ablation device 600 may be introduced into a natural orifice such as the mouth 626 and advanced into a lumen, abscess, void, or cavity such as the esophagus 628, as shown in FIG. 15. In the illustrated embodiment, the conductive elastomer electrode 602 is inserted through the working channel 628 of the endoscope 622 and into the lumen or cavity defined by the esophagus 628 and the return electrode 612 is inserted transcutaneously and is located proximate to the cancerous tissue 630. Once located within the esophagus 628, the conductive elastomer electrode 602 may be inflated using either the water source 640 or the air source 642. The water source 640 may supply a conductive solution (e.g., saline solution) to enhance the conductivity of the conductive elastomer electrode 602 and to enhance the contact area between the conductive elastomer electrode 602 and the inner wall of the esophageal cavity 628 including the cancerous tissue 630. Once inflated, the conductive elastomer electrode 602 is energized by the energy source 14 with a number of high-voltage DC electrical pulses to cause necrosis of the undesirable the cancerous tissue 630 between the conductive elastomer electrode 602 and the return electrode 612. In this example, the high-voltage DC electrical pulses generate an electric field in a concentric zone around the esophageal cavity 628. The electric field has a sufficient magnitude and pulse length to induce irreversible electroporation in the undesirable cancerous tissue 630. The depth of the necrotic zone depends on the amplitude of the applied electric field, the pulse length, the number of pulses, and the repetition rate or frequency of the pulses. In various embodiments, the electrical pulses may be characterized by the parameters in accordance with the output of the energy source 14 as discussed with respect to FIGS. 1 and 5, for example.



FIGS. 17-20 illustrate a method of treating residual undesirable tissue within cavities formed in the solid tissue after removal of a mass of undesirable tissue. FIG. 17 illustrates a cross-sectional view of a breast 702 showing a cavity 700 that may be left after a lumpectomy to remove a tumor from the breast 702. In tumors that grow in solid tissue, the rate of recurrence of undesirable tissue depends on the margin of healthy tissue relative to the undesirable tissue that is removed. Accordingly, to minimize the recurrence of the tumor once the undesirable tissue is removed from the breast 702, the residual tissue in the cavity 700 should be ablated. The residual tissue may be ablated using the techniques previously described in FIGS. 13-16 above or the techniques described in FIGS. 18-20 below.



FIG. 18 illustrates one embodiment of a catheter 704 inserted into the cavity 700 left in the breast 702 after a lumpectomy procedure. A distal end 706 of the catheter 704 comprises a compressed sponge 708 or any suitable type of expandable foam material. A sleeve 710 slidably disposed over the catheter 704 and the sponge 708 contains the sponge 708 until it is ready to expand into the cavity 700. When the sleeve 710 is retracted in the direction indicated by arrow 712, the sponge 708 may be expanded into the cavity 700 by pumping saline into the sponge 708 through the catheter 704. An electrode 714 is inserted through the catheter 704 and into the sponge 708 such that the electrode 714 is in electrical communication with the sponge 708. The electrode 714 may be coupled to the positive terminal of the energy source 14, for example.



FIG. 19 illustrates an expanded sponge filling the cavity 700 left in the breast 702 following a lumpectomy as shown in FIG. 17. As shown in FIG. 19, the sponge 708 has been soaked with saline solution and has expanded to fill the cavity 700 upon removal of the sleeve 710. Multiple wire electrodes 714 may be embedded in the saline soaked sponge 708. Each of these wire electrodes 714 may be coupled to the positive terminal of the energy source 14. The body or outer portion of the breast 702 may be electrically grounded through one or more large surface area electrodes 716a,b. It will be appreciated that in other embodiments that either a single surface area electrode or more than two surface area electrodes may be employed, without limitation. The negative electrodes 716a,b are connected to the negative terminal of the energy source 14. The sponge 708 and the residual tissue within the cavity 700 are exposed to a series of electric pulses (e.g., high-voltage DC electric pulses) suitable for inducing irreversible electroporation. The high-voltage DC electric pulses in the form graphically illustrated in FIG. 5, 10, or 12 generate an electric field sufficient to cause apoptosis/necrosis in a zone extending beyond the edge of the cavity 700, for example. In various embodiments, the electrical pulses may be characterized by the parameters in accordance with the output of the energy source 14 as discussed with respect to FIGS. 1 and 5, for example.



FIG. 20 illustrates the expanded sponge 708 intact to fill the cavity 700 left in the breast 702 as shown in FIG. 17 following irreversible electroporation ablation therapy. After the irreversible electroporation ablation treatment is completed, the positive electrode 714 is removed from the cavity 700 and the negative electrodes 716a,b are removed from the breast 702. The sponge 708, however, may be left inside to fill the cavity 700.



FIG. 21 illustrates a mesh of a finite element model 709 of a sponge inserted in the cavity 700 left in the breast 702 as shown in FIG. 17. The horizontal and the vertical axes represent distance in meters (m) with the center defined at (0,0). As shown in FIG. 21, the mesh of the finite element model 709 is a two-dimensional representation of the sponge similar to the sponge 708 inserted in the cavity 700 of the breast 702 previously described in FIGS. 17-20, for example.



FIG. 22 is a graphical representation of electric potential and electrical field strength sufficient to induce irreversible electroporation when applied to the sponge 708 located within the breast cavity 700 as shown in FIG. 17. The horizontal and the vertical axes represent distance in meters (m) with the center defined at (0,0). As shown in FIG. 22, electric field strength in Volts/meter (V/m) is represented by electric field lines 718 shown as concentric contours or circles extending from an outer perimeter of the sponge 708 to a point in space 726 where the electric field strength is at a minimum. A scale 722 to the right of the graph represents electric field strength in V/m. Electric potential 720 in Volts (V) applied to the sponge 708 within the cavity 700 is represented by the shaded zones 720. A vertical scale 724 shown to the right of the electric field strength scale 722 represents electric potential in V with the minimum potential at the bottom and the maximum potential at the top. The electrical field lines 718a,b just outside the outer perimeter of the sponge 708 are representative of an electric field potential 720a of about 1400 to about 2000 V sufficient to cause cell necrosis by irreversible electroporation.



FIG. 23 is a graphical representation of electric field strength contours in volts per meter (V/m) developed when electrodes are energized by an energy source. The horizontal and the vertical axes represent distance in meters (m) with the center defined at (0,0). FIG. 23 illustrates a graph 730 of electric field strength contours developed when the electrodes 24a,b are inserted into the sponge 708 and energized by the energy source 14, as described in FIGS. 17-22. A vertical scale 732 shown to the right of the graph 730 represents the electric field strength in a range from a minimum of about 50,000V/m (bottom) to a maximum of about 100,000V/m (top). Irreversible electroporation energy in this range of electric field strength (e.g., about 50,000V/m to about 100,000V/m) are suitable for efficient and effective treatment of medical conditions that require the ablation of undesirable tissue from a localized region (i.e., in the case of the treatment of cancer). With reference to the embodiment described in FIGS. 17-22, needle-probes or electrodes 24a,b are inserted into the sponge 708. As shown in the graph 730, electric field strength contours 734, 736 represent the maximum electric field strength (e.g., about 80,000 to about 100,000V/m) in a region proximate to the location where the needle electrodes 24a,b are inserted into the sponge 708. Electric field strength contour 738 represents electric field strength of about 50,000V/m. In regions outside the sponge 708, the electric field strength peaks at contour 742 to about 100,000V/m and then tapers off with distance to about 80,000V/m at contour 744 to about 50,000V/m at contour 746. It will be appreciated that other electric field strength contours may be developed to render effective irreversible electroporation ablation therapy. Accordingly, the embodiments described herein should not be limited in this context.


The embodiments of the electrical ablation devices described herein may be introduced inside a patient using minimally invasive or open surgical techniques. In some instances it may be advantageous to introduce the electrical ablation devices inside the patient using a combination of minimally invasive and open surgical techniques. Minimally invasive techniques provide more accurate and effective access to the treatment region for diagnostic and treatment procedures. To reach internal treatment regions within the patient, the electrical ablation devices described herein may be inserted through natural openings of the body such as the mouth, anus, and/or vagina, for example. Minimally invasive procedures performed by the introduction of various medical devices into the patient through a natural opening of the patient are known in the art as NOTES™ procedures. Surgical devices, such as an electrical ablation devices, may be introduced to the treatment region through the working channels of the endoscope to perform key surgical activities (KSA), including, for example, electrical ablation of tissues using irreversible electroporation energy. Some portions of the electrical ablation devices may be introduced to the tissue treatment region percutaneously or through small—keyhole—incisions.


Endoscopic minimally invasive surgical and diagnostic medical procedures are used to evaluate and treat internal organs by inserting a small tube into the body. The endoscope may have a rigid or a flexible tube. A flexible endoscope may be introduced either through a natural body opening (e.g., mouth, anus, and/or vagina). A rigid endoscope may be introduced via trocar through a relatively small—keyhole—incision incisions (usually 0.5-1.5 cm). The endoscope can be used to observe surface conditions of internal organs, including abnormal or diseased tissue such as lesions and other surface conditions and capture images for visual inspection and photography. The endoscope may be adapted and configured with working channels for introducing medical instruments to the treatment region for taking biopsies, retrieving foreign objects, and/or performing surgical procedures.


Once an electrical ablation device is inserted in the human body internal organs may be reached using trans-organ or translumenal surgical procedures. The electrical ablation device may be advanced to the treatment site using endoscopic translumenal access techniques to perforate a lumen, and then, advance the electrical ablation device and the endoscope into the peritoneal cavity. Translumenal access procedures for perforating a lumen wall, inserting, and advancing an endoscope therethrough, and pneumoperitoneum devices for insufflating the peritoneal cavity and closing or suturing the perforated lumen wall are well known. During a translumenal access procedure, a puncture must be formed in the stomach wall or in the gastrointestinal tract to access the peritoneal cavity. One device often used to form such a puncture is a needle knife which is inserted through the working channel of the endoscope, and which utilizes energy to penetrate through the tissue. A guidewire is then feed through the endoscope and is passed through the puncture in the stomach wall and into the peritoneal cavity. The needle knife is removed, leaving the guidewire as a placeholder. A balloon catheter is then passed over the guidewire and through the working channel of the endoscope to position the balloon within the opening in the stomach wall. The balloon can then be inflated to increase the size of the opening, thereby enabling the endoscope to push against the rear of the balloon and to be feed through the opening and into the peritoneal cavity. Once the endoscope is positioned within the peritoneal cavity, numerous procedures can be performed through the working channel of the endoscope.


The endoscope may be connected to a video camera (single chip or multiple chips) and may be attached to a fiber-optic cable system connected to a “cold” light source (halogen or xenon), to illuminate the operative field. The video camera provides a direct line-of-sight view of the treatment region. The abdomen is usually insufflated with carbon dioxide (CO2) gas to create a working and viewing space. The abdomen is essentially blown up like a balloon (insufflated), elevating the abdominal wall above the internal organs like a dome. CO2 gas is used because it is common to the human body and can be removed by the respiratory system if it is absorbed through tissue.


Once the electrical ablation devices are located at the target site, the diseased tissue may be electrically ablated or destroyed using the various embodiments of electrodes discussed herein. The placement and location of the electrodes can be important for effective and efficient electrical ablation therapy. For example, the electrodes may be positioned proximal to a treatment region (e.g., target site or worksite) either endoscopically or transcutaneously (percutaneously). In some implementations, it may be necessary to introduce the electrodes inside the patient using a combination of endoscopic, transcutaneous, and/or open techniques. The electrodes may be introduced to the tissue treatment region through a working channel of the endoscope, an overtube, or a trocar and, in some implementations, may be introduced through percutaneously or through small—keyhole—incisions.


Preferably, the various embodiments of the devices described herein will be processed before surgery. First, a new or used instrument is obtained and if necessary cleaned. The instrument can then be sterilized. In one sterilization technique, the instrument is placed in a closed and sealed container, such as a plastic or TYVEK® bag. The container and instrument are then placed in a field of radiation that can penetrate the container, such as gamma radiation, x-rays, or high-energy electrons. The radiation kills bacteria on the instrument and in the container. The sterilized instrument can then be stored in the sterile container. The sealed container keeps the instrument sterile until it is opened in the medical facility.


It is preferred that the device is sterilized. This can be done by any number of ways known to those skilled in the art including beta or gamma radiation, ethylene oxide, steam.


Although the various embodiments of the devices have been described herein in connection with certain disclosed embodiments, many modifications and variations to those embodiments may be implemented. For example, different types of end effectors may be employed. Also, where materials are disclosed for certain components, other materials may be used. The foregoing description and following claims are intended to cover all such modification and variations.


Any patent, publication, or other disclosure material, in whole or in part, that is said to be incorporated by reference herein is incorporated herein only to the extent that the incorporated materials does not conflict with existing definitions, statements, or other disclosure material set forth in this disclosure. As such, and to the extent necessary, the disclosure as explicitly set forth herein supersedes any conflicting material incorporated herein by reference. Any material, or portion thereof, that is said to be incorporated by reference herein, but which conflicts with existing definitions, statements, or other disclosure material set forth herein will only be incorporated to the extent that no conflict arises between that incorporated material and the existing disclosure material.

Claims
  • 1. An electrical ablation apparatus, comprising: a shaft;first and second selectably deployable electrodes slideably receivable within the shaft, each electrode comprising a first end configured to couple to an energy source and a second end configured to couple to a tissue treatment region, wherein the first selectably deployable electrode is deployable independent of the second selectably deployable electrode and the second selectably deployable electrode is deployable independent of the first selectably deployable electrode;a sheath slideably coupled to the first and second electrodes, the sheath slideable with respect to the first and second electrodes and the shaft, the sheath is disposable in a first position and a second position, the first position covers the first and second electrodes in a deployed state and the second position exposes the first and second electrodes in a deployed state; andan energy source coupled to the first and second selectably deployable electrodes, the energy source configured to deliver a first series of electrical pulses sufficient to induce cell necrosis by irreversible electroporation and a second series of electrical pulses sufficient to induce cell necrosis by thermal heating, through at least one of the first and second selectably deployable electrodes;wherein the first series of electrical pulses is characterized by a first amplitude, a first pulse length, and a first frequency; andwherein the second series of electrical pulses is characterized by a second amplitude, a second pulse length, and a second frequency.
  • 2. The electrical ablation apparatus of claim 1, wherein the first amplitude is about 1000 VDC, the first pulse length is about 10 μs to about 15 μs, and the first frequency is about 10 Hz; and wherein the second amplitude is about 500 VDC, the second pulse length is about 10 ms to about 15 ms, and the second frequency is about 10 Hz.
  • 3. The electrical ablation apparatus of claim 1, wherein the first amplitude is selected in the range of about +100 to about +3000 VDC, the first pulse length is selected in the range of about 1 μs to about 100 ms, and the first period is selected in the range of about 1 Hz to about 10000 Hz.
  • 4. The electrical ablation apparatus of claim 1, wherein the first series of electrical pulses comprises about 20 to about 40 pulses and the second series of electrical pulses comprises at least one pulse.
  • 5. The electrical ablation apparatus of claim 1, wherein the first and second electrodes are needle electrodes each having a diameter in the range of about 0.5 mm to about 1.5 mm and are separated by a distance of about 5.0 mm to about 10.0 mm.
  • 6. The electrical ablation apparatus of claim 5, wherein the first series of electrical pulses is sufficient to create a first necrotic zone in a first portion of tissue induced by irreversible electroporation in an area surrounding both the first and second electrodes and wherein the second series of electrical pulses is sufficient to create a second necrotic zones in a second portion of tissue induced by thermal heating in an area near the electrode-tissue-interface.
  • 7. The electrical ablation apparatus of claim 6, wherein the first series of electrical pulses is sufficient to ablate basal cell carcinoma tissue.
  • 8. The electrical ablation apparatus of claim 6, wherein the first series of electrical pulses is sufficient to ablate prostrate cancer tissue.
  • 9. The electrical ablation apparatus of claim 1, wherein the first and second electrodes are ring electrodes.
  • 10. The electrical ablation apparatus of claim 9, wherein the first series of electrical pulses is sufficient to create a first necrotic zone in a first portion of tissue induced by irreversible electroporation in a body lumen and wherein the second series of electrical pulses is sufficient to create a second necrotic zones in the body lumen by thermal heating to seal the body lumen.
  • 11. The electrical ablation apparatus of claim 10, wherein the first series of pulses is sufficient to ablate varicose vein tissue resulting from reflux disease of the greater saphenous vein.
  • 12. The electrical ablation apparatus of claim 1, wherein the first electrode comprises a plurality of electrodes.
  • 13. The electrical ablation apparatus of claim 1, wherein the second electrode comprises a plurality of electrodes.
  • 14. The electrical ablation apparatus of claim 1, wherein: the first selectably deployable electrode may be retracted to allow the electrical ablation apparatus to pivot about a pivot point defined by the second selectably deployable electrode; andthe second selectably deployable electrode may be retracted to allow the electrical ablation apparatus to pivot about a point defined by the first selectably deployable electrode.
US Referenced Citations (913)
Number Name Date Kind
645576 Telsa Mar 1900 A
649621 Tesla May 1900 A
787412 Tesla Apr 1905 A
1127948 Wappler Feb 1915 A
2028635 Wappler Jan 1936 A
2031682 Wappler et al. Feb 1936 A
2113246 Wappler Apr 1938 A
2196620 Attarian Apr 1940 A
2952206 Becksted Sep 1960 A
3435824 Gamponia Apr 1969 A
3470876 Barchilon Oct 1969 A
3595239 Petersen Jul 1971 A
3946740 Bassett Mar 1976 A
3994301 Agris Nov 1976 A
4011872 Komiya Mar 1977 A
4012812 Black Mar 1977 A
4085743 Yoon Apr 1978 A
4178920 Cawood, Jr. et al. Dec 1979 A
4207873 Kruy Jun 1980 A
4235238 Ogiu et al. Nov 1980 A
4258716 Sutherland Mar 1981 A
4269174 Adair May 1981 A
4278077 Mizumoto Jul 1981 A
4285344 Marshall Aug 1981 A
4311143 Komiya Jan 1982 A
4396021 Baumgartner Aug 1983 A
4406656 Hattler et al. Sep 1983 A
4452246 Bader et al. Jun 1984 A
4461281 Carson Jul 1984 A
4491132 Aikins Jan 1985 A
4527331 Lasner et al. Jul 1985 A
4538594 Boebel et al. Sep 1985 A
D281104 Davison Oct 1985 S
4580551 Siegmund et al. Apr 1986 A
4646722 Silverstein et al. Mar 1987 A
4653476 Bonnet Mar 1987 A
4655219 Petruzzi Apr 1987 A
4669470 Brandfield Jun 1987 A
4671477 Cullen Jun 1987 A
4685447 Iversen et al. Aug 1987 A
4711240 Goldwasser et al. Dec 1987 A
4712545 Honkanen Dec 1987 A
4721116 Schintgen et al. Jan 1988 A
D295894 Sharkany et al. May 1988 S
4763669 Jaeger Aug 1988 A
4770188 Chikama Sep 1988 A
4823794 Pierce Apr 1989 A
4829999 Auth May 1989 A
4867140 Hovis et al. Sep 1989 A
4873979 Hanna Oct 1989 A
4880015 Nierman Nov 1989 A
4911148 Sosnowski et al. Mar 1990 A
4926860 Stice et al. May 1990 A
4938214 Specht et al. Jul 1990 A
4950273 Briggs Aug 1990 A
4950285 Wilk Aug 1990 A
4960133 Hewson Oct 1990 A
4979950 Transue et al. Dec 1990 A
4984581 Stice Jan 1991 A
5007917 Evans Apr 1991 A
5020514 Heckele Jun 1991 A
5020535 Parker et al. Jun 1991 A
5025778 Silverstein et al. Jun 1991 A
5033169 Bindon Jul 1991 A
5037433 Wilk et al. Aug 1991 A
5041129 Hayhurst et al. Aug 1991 A
5046513 Gatturna et al. Sep 1991 A
5050585 Takahashi Sep 1991 A
5065516 Dulebohn Nov 1991 A
5066295 Kozak et al. Nov 1991 A
5123913 Wilk et al. Jun 1992 A
5123914 Cope Jun 1992 A
5133727 Bales et al. Jul 1992 A
5174300 Bales et al. Dec 1992 A
5176126 Chikama Jan 1993 A
5190555 Wetter et al. Mar 1993 A
5192284 Pleatman Mar 1993 A
5201752 Brown et al. Apr 1993 A
5201908 Jones Apr 1993 A
5203785 Slater Apr 1993 A
5203787 Noblitt et al. Apr 1993 A
5209747 Knoepfler May 1993 A
5219357 Honkanen et al. Jun 1993 A
5219358 Bendel et al. Jun 1993 A
5222965 Haughton Jun 1993 A
5234453 Smith et al. Aug 1993 A
5235964 Abenaim Aug 1993 A
5246424 Wilk Sep 1993 A
5259366 Reydel et al. Nov 1993 A
5263958 deGuillebon et al. Nov 1993 A
5273524 Fox et al. Dec 1993 A
5275607 Lo et al. Jan 1994 A
5284128 Hart Feb 1994 A
5290302 Pericic Mar 1994 A
5295977 Cohen et al. Mar 1994 A
5297536 Wilk Mar 1994 A
5312351 Gerrone May 1994 A
5312416 Spaeth et al. May 1994 A
5318589 Lichtman Jun 1994 A
5320636 Slater Jun 1994 A
5325845 Adair Jul 1994 A
5330471 Eggers Jul 1994 A
5330488 Goldrath Jul 1994 A
5330496 Alferness Jul 1994 A
5330502 Hassler et al. Jul 1994 A
5331971 Bales et al. Jul 1994 A
5334198 Hart et al. Aug 1994 A
5344428 Griffiths Sep 1994 A
5350391 Iacovelli Sep 1994 A
5352184 Goldberg et al. Oct 1994 A
5352222 Rydell Oct 1994 A
5354302 Ko Oct 1994 A
5354311 Kambin et al. Oct 1994 A
5356408 Rydell Oct 1994 A
5364410 Failla et al. Nov 1994 A
5366466 Christian et al. Nov 1994 A
5366467 Lynch et al. Nov 1994 A
5368605 Miller, Jr. Nov 1994 A
5370647 Graber et al. Dec 1994 A
5370679 Atlee, III Dec 1994 A
5374273 Nakao et al. Dec 1994 A
5383877 Clarke Jan 1995 A
5383888 Zvenyatsky et al. Jan 1995 A
5386817 Jones Feb 1995 A
5391174 Weston Feb 1995 A
5392789 Slater et al. Feb 1995 A
5395386 Slater Mar 1995 A
5401248 Bencini Mar 1995 A
5403342 Tovey et al. Apr 1995 A
5403348 Bonutti Apr 1995 A
5405073 Porter Apr 1995 A
5405359 Pierce Apr 1995 A
5423821 Pasque Jun 1995 A
5433721 Hooven et al. Jul 1995 A
5439471 Kerr Aug 1995 A
5439478 Palmer Aug 1995 A
5441059 Dannan Aug 1995 A
5443463 Stern et al. Aug 1995 A
5445638 Rydell et al. Aug 1995 A
5449021 Chikama Sep 1995 A
5456684 Schmidt et al. Oct 1995 A
5458131 Wilk Oct 1995 A
5458583 McNeely et al. Oct 1995 A
5460168 Masubuchi et al. Oct 1995 A
5465731 Bell et al. Nov 1995 A
5467763 McMahon et al. Nov 1995 A
5468250 Paraschac et al. Nov 1995 A
5470308 Edwards et al. Nov 1995 A
5470320 Tiefenbrun et al. Nov 1995 A
5478347 Aranyi Dec 1995 A
5480404 Kammerer et al. Jan 1996 A
5482054 Slater et al. Jan 1996 A
5484451 Akopov et al. Jan 1996 A
5489256 Adair Feb 1996 A
5496347 Hashiguchi et al. Mar 1996 A
5499992 Meade et al. Mar 1996 A
5503616 Jones Apr 1996 A
5505686 Willis et al. Apr 1996 A
5511564 Wilk Apr 1996 A
5514157 Nicholas et al. May 1996 A
5522829 Michalos Jun 1996 A
5522830 Aranyi Jun 1996 A
5536248 Weaver et al. Jul 1996 A
5554151 Hinchliffe Sep 1996 A
5558133 Bortoli et al. Sep 1996 A
5562693 Devlin et al. Oct 1996 A
5569243 Kortenbach et al. Oct 1996 A
5569298 Schnell Oct 1996 A
5578030 Levin Nov 1996 A
5582611 Tsuruta et al. Dec 1996 A
5582617 Klieman et al. Dec 1996 A
5584845 Hart Dec 1996 A
5593420 Eubanks, Jr et al. Jan 1997 A
5595562 Grier Jan 1997 A
5597378 Jervis Jan 1997 A
5601573 Fogelberg et al. Feb 1997 A
5601588 Tonomura et al. Feb 1997 A
5604531 Iddan et al. Feb 1997 A
5607389 Edwards et al. Mar 1997 A
5607450 Zvenyatsky et al. Mar 1997 A
5618303 Marlow et al. Apr 1997 A
5620415 Lucey et al. Apr 1997 A
5624399 Ackerman Apr 1997 A
5626578 Tihon May 1997 A
5628732 Antoon, Jr. et al. May 1997 A
5630782 Adair May 1997 A
5643283 Younker Jul 1997 A
5643294 Tovey et al. Jul 1997 A
5645083 Essig et al. Jul 1997 A
5645565 Rudd et al. Jul 1997 A
5649372 Souza Jul 1997 A
5653677 Okada et al. Aug 1997 A
5653690 Booth et al. Aug 1997 A
5662663 Shallman Sep 1997 A
5669875 van Eerdenburg Sep 1997 A
5681324 Kammerer et al. Oct 1997 A
5681330 Hughett et al. Oct 1997 A
5685820 Riek et al. Nov 1997 A
5690660 Kauker et al. Nov 1997 A
5695448 Kimura et al. Dec 1997 A
5695511 Cano et al. Dec 1997 A
5702438 Avitall Dec 1997 A
5709708 Thal Jan 1998 A
5716326 Dannan Feb 1998 A
5730740 Wales et al. Mar 1998 A
5735849 Baden et al. Apr 1998 A
5741234 Aboul-Hosn Apr 1998 A
5741278 Stevens Apr 1998 A
5741285 McBrayer et al. Apr 1998 A
5746759 Meade et al. May 1998 A
5749881 Sackier et al. May 1998 A
5749889 Bacich et al. May 1998 A
5752951 Yanik May 1998 A
5766167 Eggers et al. Jun 1998 A
5766170 Eggers Jun 1998 A
5766205 Zvenyatsky et al. Jun 1998 A
5769849 Eggers Jun 1998 A
5779701 McBrayer et al. Jul 1998 A
5779716 Cano et al. Jul 1998 A
5779727 Orejola Jul 1998 A
5782859 Nicholas et al. Jul 1998 A
5782866 Wenstrom, Jr. Jul 1998 A
5791022 Bohman Aug 1998 A
5792113 Kramer et al. Aug 1998 A
5792153 Swain et al. Aug 1998 A
5792165 Klieman et al. Aug 1998 A
5797835 Green Aug 1998 A
5797928 Kogasaka Aug 1998 A
5797939 Yoon Aug 1998 A
5797941 Schulze et al. Aug 1998 A
5803903 Athas et al. Sep 1998 A
5808665 Green Sep 1998 A
5810806 Ritchart et al. Sep 1998 A
5810865 Koscher et al. Sep 1998 A
5810876 Kelleher Sep 1998 A
5810877 Roth et al. Sep 1998 A
5813976 Filipi et al. Sep 1998 A
5814058 Carlson et al. Sep 1998 A
5817061 Goodwin et al. Oct 1998 A
5817107 Schaller Oct 1998 A
5817119 Klieman et al. Oct 1998 A
5819736 Avny et al. Oct 1998 A
5824071 Nelson et al. Oct 1998 A
5827281 Levin Oct 1998 A
5830231 Geiges, Jr. Nov 1998 A
5833700 Fogelberg et al. Nov 1998 A
5833703 Manushakian Nov 1998 A
5843017 Yoon Dec 1998 A
5843121 Yoon Dec 1998 A
5849022 Sakashita et al. Dec 1998 A
5853374 Hart et al. Dec 1998 A
5860913 Yamaya et al. Jan 1999 A
5860995 Berkelaar Jan 1999 A
5882331 Sasaki Mar 1999 A
5882344 Stouder, Jr. Mar 1999 A
5893846 Bales et al. Apr 1999 A
5893874 Bourque et al. Apr 1999 A
5893875 O'Connor et al. Apr 1999 A
5899919 Eubanks, Jr. et al. May 1999 A
5904702 Ek et al. May 1999 A
5908420 Parins et al. Jun 1999 A
5911737 Lee et al. Jun 1999 A
5916147 Boury Jun 1999 A
5921997 Fogelberg et al. Jul 1999 A
5922008 Gimpelson Jul 1999 A
5925052 Simmons Jul 1999 A
5928255 Meade et al. Jul 1999 A
5944718 Austin et al. Aug 1999 A
5951549 Richardson et al. Sep 1999 A
5954720 Wilson et al. Sep 1999 A
5954731 Yoon Sep 1999 A
5957943 Vaitekunas Sep 1999 A
5957953 DiPoto et al. Sep 1999 A
5971995 Rousseau Oct 1999 A
5976074 Moriyama Nov 1999 A
5976075 Beane et al. Nov 1999 A
5976130 McBrayer et al. Nov 1999 A
5980556 Giordano et al. Nov 1999 A
5984938 Yoon Nov 1999 A
5984939 Yoon Nov 1999 A
5989182 Hori et al. Nov 1999 A
5993447 Blewett et al. Nov 1999 A
6001120 Levin Dec 1999 A
6004269 Crowley et al. Dec 1999 A
6004330 Middleman et al. Dec 1999 A
6007566 Wenstrom, Jr. Dec 1999 A
6010515 Swain et al. Jan 2000 A
6017356 Frederick et al. Jan 2000 A
6019770 Christoudias Feb 2000 A
6024708 Bales et al. Feb 2000 A
6027522 Palmer Feb 2000 A
6030365 Laufer Feb 2000 A
6030634 Wu et al. Feb 2000 A
6033399 Gines Mar 2000 A
6036685 Mueller Mar 2000 A
6053927 Hamas Apr 2000 A
6066160 Colvin et al. May 2000 A
6068629 Haissaguerre et al. May 2000 A
6071233 Ishikawa et al. Jun 2000 A
6090108 McBrayer et al. Jul 2000 A
6096046 Weiss Aug 2000 A
6102926 Tartaglia et al. Aug 2000 A
6106473 Violante et al. Aug 2000 A
6109852 Shahinpoor et al. Aug 2000 A
6110183 Cope Aug 2000 A
6139555 Hart et al. Oct 2000 A
6146391 Cigaina Nov 2000 A
6148222 Ramsey, III Nov 2000 A
6149653 Deslauriers Nov 2000 A
6149662 Pugliesi et al. Nov 2000 A
6159200 Verdura et al. Dec 2000 A
6165184 Verdura et al. Dec 2000 A
6168605 Measamer et al. Jan 2001 B1
6170130 Hamilton et al. Jan 2001 B1
6179776 Adams et al. Jan 2001 B1
6179837 Hooven Jan 2001 B1
6190353 Makower et al. Feb 2001 B1
6190384 Ouchi Feb 2001 B1
6203533 Ouchi Mar 2001 B1
6206872 Lafond et al. Mar 2001 B1
6206877 Kese et al. Mar 2001 B1
6234958 Snoke et al. May 2001 B1
6258064 Smith et al. Jul 2001 B1
6261242 Roberts et al. Jul 2001 B1
6264664 Avellanet Jul 2001 B1
6270497 Sekino et al. Aug 2001 B1
6270505 Yoshida et al. Aug 2001 B1
6277136 Bonutti Aug 2001 B1
6283963 Regula Sep 2001 B1
6293909 Chu et al. Sep 2001 B1
6293952 Brosens et al. Sep 2001 B1
6296630 Altman et al. Oct 2001 B1
6322578 Houle et al. Nov 2001 B1
6326177 Schoenbach et al. Dec 2001 B1
6350267 Stefanchik Feb 2002 B1
6352503 Matsui et al. Mar 2002 B1
6355035 Manushakian Mar 2002 B1
6361534 Chen et al. Mar 2002 B1
6371956 Wilson et al. Apr 2002 B1
6379366 Fleischman et al. Apr 2002 B1
6383195 Richard May 2002 B1
6383197 Conlon et al. May 2002 B1
6391029 Hooven et al. May 2002 B1
6406440 Stefanchik Jun 2002 B1
6409727 Bales et al. Jun 2002 B1
6409733 Conlon et al. Jun 2002 B1
6427089 Knowlton Jul 2002 B1
6431500 Jacobs et al. Aug 2002 B1
6443970 Schulze et al. Sep 2002 B1
6443988 Felt et al. Sep 2002 B2
6447511 Slater Sep 2002 B1
6447523 Middleman et al. Sep 2002 B1
6454783 Piskun Sep 2002 B1
6454785 De Hoyos Garza Sep 2002 B2
6458076 Pruitt Oct 2002 B1
6464701 Hooven et al. Oct 2002 B1
6464702 Schulze et al. Oct 2002 B2
6475104 Lutz et al. Nov 2002 B1
6485411 Konstorum et al. Nov 2002 B1
6489745 Koreis Dec 2002 B1
6491626 Stone et al. Dec 2002 B1
6491627 Komi Dec 2002 B1
6491691 Morley et al. Dec 2002 B1
6494893 Dubrul et al. Dec 2002 B2
6500176 Truckai et al. Dec 2002 B1
6503192 Ouchi Jan 2003 B1
6506190 Walshe Jan 2003 B1
6508827 Manhes Jan 2003 B1
6514239 Shimmura et al. Feb 2003 B2
6520954 Ouchi Feb 2003 B2
6543456 Freeman Apr 2003 B1
6551270 Bimbo et al. Apr 2003 B1
6554829 Schulze et al. Apr 2003 B2
6558384 Mayenberger May 2003 B2
6562035 Levin May 2003 B1
6569159 Edwards et al. May 2003 B1
6572629 Kalloo et al. Jun 2003 B2
6572635 Bonutti Jun 2003 B1
6575988 Rousseau Jun 2003 B2
6587750 Gerbi et al. Jul 2003 B2
6592559 Pakter et al. Jul 2003 B1
6592603 Lasner Jul 2003 B2
6602262 Griego et al. Aug 2003 B2
6605105 Cuschieri et al. Aug 2003 B1
6610074 Santilli Aug 2003 B2
6620193 Lau et al. Sep 2003 B1
6623448 Slater Sep 2003 B2
6626919 Swanstrom Sep 2003 B1
6632229 Yamanouchi Oct 2003 B1
6652521 Schulze Nov 2003 B2
6652551 Heiss Nov 2003 B1
6656194 Gannoe et al. Dec 2003 B1
6663641 Kovac et al. Dec 2003 B1
6666854 Lange Dec 2003 B1
6672338 Esashi et al. Jan 2004 B1
6673058 Snow Jan 2004 B2
6673087 Chang et al. Jan 2004 B1
6679882 Kornerup Jan 2004 B1
6685628 Vu Feb 2004 B2
6685724 Haluck Feb 2004 B1
6692445 Roberts et al. Feb 2004 B2
6692462 Mackenzie et al. Feb 2004 B2
6699180 Kobayashi Mar 2004 B2
6699256 Logan et al. Mar 2004 B1
6699263 Cope Mar 2004 B2
6706018 Westlund et al. Mar 2004 B2
6709445 Boebel et al. Mar 2004 B2
6716226 Sixto, Jr. et al. Apr 2004 B2
6736822 McClellan et al. May 2004 B2
6740030 Martone et al. May 2004 B2
6743240 Smith et al. Jun 2004 B2
6749560 Konstorum et al. Jun 2004 B1
6749609 Lunsford et al. Jun 2004 B1
6752768 Burdorff et al. Jun 2004 B2
6752811 Chu et al. Jun 2004 B2
6752822 Jespersen Jun 2004 B2
6761685 Adams et al. Jul 2004 B2
6761722 Cole et al. Jul 2004 B2
6773434 Ciarrocca Aug 2004 B2
6780151 Grabover et al. Aug 2004 B2
6780352 Jacobson Aug 2004 B2
6783491 Saadat et al. Aug 2004 B2
6786864 Matsuura et al. Sep 2004 B2
6790173 Saadat et al. Sep 2004 B2
6795728 Chornenky et al. Sep 2004 B2
6800056 Tartaglia et al. Oct 2004 B2
6808491 Kortenbach et al. Oct 2004 B2
6824548 Smith et al. Nov 2004 B2
6836688 Ingle et al. Dec 2004 B2
6837847 Ewers et al. Jan 2005 B2
6843794 Sixto, Jr. et al. Jan 2005 B2
6861250 Cole et al. Mar 2005 B1
6866627 Nozue Mar 2005 B2
6878106 Herrmann Apr 2005 B1
6878110 Yang et al. Apr 2005 B2
6881216 Di Caprio et al. Apr 2005 B2
6884213 Raz et al. Apr 2005 B2
6887255 Shimm May 2005 B2
6889089 Behl et al. May 2005 B2
6896683 Gadberry et al. May 2005 B1
6896692 Ginn et al. May 2005 B2
6908476 Jud et al. Jun 2005 B2
6916284 Moriyama Jul 2005 B2
6918871 Schulze Jul 2005 B2
6932810 Ryan Aug 2005 B2
6932824 Roop et al. Aug 2005 B1
6932827 Cole Aug 2005 B2
6932834 Lizardi et al. Aug 2005 B2
6942613 Ewers et al. Sep 2005 B2
6945979 Kortenbach et al. Sep 2005 B2
6955683 Bonutti Oct 2005 B2
6958035 Friedman et al. Oct 2005 B2
6960162 Saadat et al. Nov 2005 B2
6960163 Ewers et al. Nov 2005 B2
6962587 Johnson et al. Nov 2005 B2
6964662 Kidooka Nov 2005 B2
6966909 Marshall et al. Nov 2005 B2
6967462 Landis Nov 2005 B1
6971988 Orban, III Dec 2005 B2
6972017 Smith et al. Dec 2005 B2
6974411 Belson Dec 2005 B2
6976992 Sachatello et al. Dec 2005 B2
6984205 Gazdzinski Jan 2006 B2
6986774 Middleman et al. Jan 2006 B2
6988987 Ishikawa et al. Jan 2006 B2
6991627 Madhani et al. Jan 2006 B2
6991631 Woloszko et al. Jan 2006 B2
6994708 Manzo Feb 2006 B2
6997931 Sauer et al. Feb 2006 B2
7000818 Shelton, IV et al. Feb 2006 B2
7001341 Gellman et al. Feb 2006 B2
7008375 Weisel Mar 2006 B2
7009634 Iddan et al. Mar 2006 B2
7010340 Scarantino et al. Mar 2006 B2
7029435 Nakao Apr 2006 B2
7029438 Morin et al. Apr 2006 B2
7029450 Gellman Apr 2006 B2
7035680 Partridge et al. Apr 2006 B2
7037290 Gardeski et al. May 2006 B2
7041052 Saadat et al. May 2006 B2
7052489 Griego et al. May 2006 B2
7060024 Long et al. Jun 2006 B2
7060025 Long et al. Jun 2006 B2
7063697 Slater Jun 2006 B2
7066879 Fowler et al. Jun 2006 B2
7066936 Ryan Jun 2006 B2
7070602 Smith et al. Jul 2006 B2
7076305 Imran et al. Jul 2006 B2
7083618 Couture et al. Aug 2006 B2
7083620 Jahns et al. Aug 2006 B2
7083629 Weller et al. Aug 2006 B2
7083635 Ginn Aug 2006 B2
7087071 Nicholas et al. Aug 2006 B2
7090673 Dycus et al. Aug 2006 B2
7090685 Kortenbach et al. Aug 2006 B2
7101371 Dycus et al. Sep 2006 B2
7101372 Dycus et al. Sep 2006 B2
7101373 Dycus et al. Sep 2006 B2
7105000 McBrayer Sep 2006 B2
7105005 Blake Sep 2006 B2
7108703 Danitz et al. Sep 2006 B2
7112208 Morris et al. Sep 2006 B2
7117703 Kato et al. Oct 2006 B2
7118531 Krill Oct 2006 B2
7118587 Dycus et al. Oct 2006 B2
7128708 Saadat et al. Oct 2006 B2
RE39415 Bales et al. Nov 2006 E
7131978 Sancoff et al. Nov 2006 B2
7137980 Buysse et al. Nov 2006 B2
7137981 Long Nov 2006 B2
7147650 Lee Dec 2006 B2
7150097 Sremcich et al. Dec 2006 B2
7150655 Mastrototaro et al. Dec 2006 B2
7152488 Hedrich et al. Dec 2006 B2
7153321 Andrews Dec 2006 B2
7163525 Franer Jan 2007 B2
7172714 Jacobson Feb 2007 B2
7179254 Pendekanti et al. Feb 2007 B2
7188627 Nelson et al. Mar 2007 B2
7195612 Van Sloten et al. Mar 2007 B2
7195631 Dumbauld Mar 2007 B2
7204820 Akahoshi Apr 2007 B2
7208005 Frecker et al. Apr 2007 B2
7220227 Sasaki et al. May 2007 B2
7223272 Francese et al. May 2007 B2
7232445 Kortenbach et al. Jun 2007 B2
7241290 Doyle et al. Jul 2007 B2
7244228 Lubowski Jul 2007 B2
7250027 Barry Jul 2007 B2
7252660 Kunz Aug 2007 B2
7255675 Gertner et al. Aug 2007 B2
7270663 Nakao Sep 2007 B2
7294139 Gengler Nov 2007 B1
7306597 Manzo Dec 2007 B2
7308828 Hashimoto Dec 2007 B2
7320695 Carroll Jan 2008 B2
7329256 Johnson et al. Feb 2008 B2
7329257 Kanehira et al. Feb 2008 B2
7329383 Stinson Feb 2008 B2
7344536 Lunsford et al. Mar 2008 B1
7364582 Lee Apr 2008 B2
7402162 Ouchi Jul 2008 B2
7422590 Kupferschmid et al. Sep 2008 B2
7488295 Burbank et al. Feb 2009 B2
7497867 Lasner et al. Mar 2009 B2
7524281 Chu et al. Apr 2009 B2
7540872 Schechter et al. Jun 2009 B2
7544203 Chin et al. Jun 2009 B2
7548040 Lee et al. Jun 2009 B2
7549564 Boudreaux Jun 2009 B2
7559887 Dannan Jul 2009 B2
7559916 Smith et al. Jul 2009 B2
7575548 Takemoto et al. Aug 2009 B2
7579550 Dayton et al. Aug 2009 B2
7588557 Nakao Sep 2009 B2
7618398 Holman et al. Nov 2009 B2
7674259 Shadduck Mar 2010 B2
7713189 Hanke May 2010 B2
7744615 Couture Jun 2010 B2
7758577 Nobis et al. Jul 2010 B2
7780691 Stefanchik Aug 2010 B2
7794409 Damarati Sep 2010 B2
7828186 Wales Nov 2010 B2
7846171 Kullas et al. Dec 2010 B2
7892220 Faller et al. Feb 2011 B2
7909809 Scopton et al. Mar 2011 B2
7914513 Voorhees, Jr. Mar 2011 B2
7945332 Schechter May 2011 B2
7988685 Ziaie et al. Aug 2011 B2
8075587 Ginn Dec 2011 B2
20010049497 Kalloo et al. Dec 2001 A1
20020022857 Goldsteen et al. Feb 2002 A1
20020023353 Ting-Kung Feb 2002 A1
20020029055 Bonutti Mar 2002 A1
20020042562 Meron et al. Apr 2002 A1
20020068945 Sixto, Jr. et al. Jun 2002 A1
20020078967 Sixto, Jr. et al. Jun 2002 A1
20020082516 Stefanchik Jun 2002 A1
20020107530 Sauer et al. Aug 2002 A1
20020138086 Sixto, Jr. et al. Sep 2002 A1
20020147456 Diduch et al. Oct 2002 A1
20020183591 Matsuura et al. Dec 2002 A1
20030036679 Kortenbach et al. Feb 2003 A1
20030083681 Moutafis et al. May 2003 A1
20030114732 Webler et al. Jun 2003 A1
20030124009 Ravi et al. Jul 2003 A1
20030130564 Martone et al. Jul 2003 A1
20030130656 Levin Jul 2003 A1
20030167062 Gambale et al. Sep 2003 A1
20030171651 Page et al. Sep 2003 A1
20030176880 Long et al. Sep 2003 A1
20030216611 Vu Nov 2003 A1
20030216615 Ouchi Nov 2003 A1
20030225312 Suzuki et al. Dec 2003 A1
20030229269 Humphrey Dec 2003 A1
20030229371 Whitworth Dec 2003 A1
20030236549 Bonadio et al. Dec 2003 A1
20040002683 Nicholson et al. Jan 2004 A1
20040098007 Heiss May 2004 A1
20040116948 Sixto, Jr. et al. Jun 2004 A1
20040127940 Ginn et al. Jul 2004 A1
20040133089 Kilcoyne et al. Jul 2004 A1
20040136779 Bhaskar Jul 2004 A1
20040138525 Saadat et al. Jul 2004 A1
20040138529 Wiltshire et al. Jul 2004 A1
20040138587 Lyons, IV Jul 2004 A1
20040161451 Pierce et al. Aug 2004 A1
20040186350 Brenneman et al. Sep 2004 A1
20040193146 Lee et al. Sep 2004 A1
20040193186 Kortenbach et al. Sep 2004 A1
20040193188 Francese Sep 2004 A1
20040193189 Kortenbach et al. Sep 2004 A1
20040193200 Dworschak et al. Sep 2004 A1
20040199052 Banik et al. Oct 2004 A1
20040206859 Chong et al. Oct 2004 A1
20040210245 Erickson et al. Oct 2004 A1
20040215058 Zirps et al. Oct 2004 A1
20040225186 Horne, Jr. et al. Nov 2004 A1
20040230095 Stefanchik et al. Nov 2004 A1
20040230096 Stefanchik et al. Nov 2004 A1
20040230097 Stefanchik et al. Nov 2004 A1
20040249367 Saadat et al. Dec 2004 A1
20040249394 Morris et al. Dec 2004 A1
20050004515 Hart et al. Jan 2005 A1
20050033277 Clague et al. Feb 2005 A1
20050033319 Gambale et al. Feb 2005 A1
20050033333 Smith et al. Feb 2005 A1
20050049616 Rivera et al. Mar 2005 A1
20050065397 Saadat et al. Mar 2005 A1
20050065517 Chin Mar 2005 A1
20050070754 Nobis et al. Mar 2005 A1
20050070763 Nobis et al. Mar 2005 A1
20050070764 Nobis et al. Mar 2005 A1
20050080413 Canady Apr 2005 A1
20050090837 Sixto, Jr. et al. Apr 2005 A1
20050090838 Sixto, Jr. et al. Apr 2005 A1
20050101837 Kalloo et al. May 2005 A1
20050101838 Camillocci et al. May 2005 A1
20050107664 Kalloo et al. May 2005 A1
20050110881 Glukhovsky et al. May 2005 A1
20050113847 Gadberry et al. May 2005 A1
20050119613 Moenning et al. Jun 2005 A1
20050124855 Jaffe et al. Jun 2005 A1
20050125010 Smith et al. Jun 2005 A1
20050131279 Boulais et al. Jun 2005 A1
20050131457 Douglas et al. Jun 2005 A1
20050137454 Saadat et al. Jun 2005 A1
20050143690 High Jun 2005 A1
20050143774 Polo Jun 2005 A1
20050149087 Ahlberg et al. Jul 2005 A1
20050149096 Hilal et al. Jul 2005 A1
20050159648 Freed Jul 2005 A1
20050165272 Okada et al. Jul 2005 A1
20050165378 Heinrich et al. Jul 2005 A1
20050165411 Orban, III Jul 2005 A1
20050165429 Douglas et al. Jul 2005 A1
20050192598 Johnson et al. Sep 2005 A1
20050192602 Manzo Sep 2005 A1
20050209624 Vijay Sep 2005 A1
20050215858 Vail, III Sep 2005 A1
20050216050 Sepetka et al. Sep 2005 A1
20050228406 Bose Oct 2005 A1
20050234297 Devierre et al. Oct 2005 A1
20050250990 Le et al. Nov 2005 A1
20050251176 Swanstrom et al. Nov 2005 A1
20050261674 Nobis et al. Nov 2005 A1
20050267492 Poncet et al. Dec 2005 A1
20050272975 McWeeney et al. Dec 2005 A1
20050272977 Saadat et al. Dec 2005 A1
20050273084 Hinman et al. Dec 2005 A1
20050277945 Saadat et al. Dec 2005 A1
20050277951 Smith et al. Dec 2005 A1
20050277952 Arp et al. Dec 2005 A1
20050277954 Smith et al. Dec 2005 A1
20050277955 Palmer et al. Dec 2005 A1
20050277956 Francese et al. Dec 2005 A1
20050277957 Kuhns et al. Dec 2005 A1
20050283118 Uth et al. Dec 2005 A1
20050288555 Binmoeller Dec 2005 A1
20060004406 Wehrstein et al. Jan 2006 A1
20060004409 Nobis et al. Jan 2006 A1
20060004410 Nobis et al. Jan 2006 A1
20060015009 Jaffe et al. Jan 2006 A1
20060020167 Sitzmann Jan 2006 A1
20060020247 Kagan et al. Jan 2006 A1
20060025654 Suzuki et al. Feb 2006 A1
20060025819 Nobis et al. Feb 2006 A1
20060036267 Saadat et al. Feb 2006 A1
20060041188 Dirusso et al. Feb 2006 A1
20060058582 Maahs et al. Mar 2006 A1
20060058776 Bilsbury Mar 2006 A1
20060069425 Hillis et al. Mar 2006 A1
20060079890 Guerra Apr 2006 A1
20060089528 Tartaglia et al. Apr 2006 A1
20060095031 Ormsby May 2006 A1
20060095060 Mayenberger et al. May 2006 A1
20060106423 Weisel et al. May 2006 A1
20060111209 Hinman et al. May 2006 A1
20060111704 Brenneman et al. May 2006 A1
20060129166 Lavelle Jun 2006 A1
20060135971 Swanstrom et al. Jun 2006 A1
20060135984 Kramer et al. Jun 2006 A1
20060142644 Mulac et al. Jun 2006 A1
20060142790 Gertner Jun 2006 A1
20060149131 Or Jul 2006 A1
20060149132 Iddan Jul 2006 A1
20060149135 Paz Jul 2006 A1
20060161190 Gadberry et al. Jul 2006 A1
20060167416 Mathis et al. Jul 2006 A1
20060167482 Swain et al. Jul 2006 A1
20060178560 Saadat et al. Aug 2006 A1
20060183975 Saadat et al. Aug 2006 A1
20060189844 Tien Aug 2006 A1
20060189845 Maahs et al. Aug 2006 A1
20060190027 Downey Aug 2006 A1
20060195084 Slater Aug 2006 A1
20060200005 Bjork et al. Sep 2006 A1
20060200169 Sniffin Sep 2006 A1
20060200170 Aranyi Sep 2006 A1
20060200199 Bonutti et al. Sep 2006 A1
20060217697 Lau et al. Sep 2006 A1
20060217742 Messerly et al. Sep 2006 A1
20060217743 Messerly et al. Sep 2006 A1
20060229639 Whitfield Oct 2006 A1
20060229640 Whitfield Oct 2006 A1
20060237022 Chen et al. Oct 2006 A1
20060237023 Cox et al. Oct 2006 A1
20060253004 Frisch et al. Nov 2006 A1
20060253039 McKenna et al. Nov 2006 A1
20060258907 Stefanchik et al. Nov 2006 A1
20060258908 Stefanchik et al. Nov 2006 A1
20060258910 Stefanchik et al. Nov 2006 A1
20060258954 Timberlake et al. Nov 2006 A1
20060258955 Hoffman et al. Nov 2006 A1
20060259010 Stefanchik et al. Nov 2006 A1
20060264752 Rubinsky et al. Nov 2006 A1
20060264930 Nishimura Nov 2006 A1
20060271102 Bosshard et al. Nov 2006 A1
20060276835 Uchida Dec 2006 A1
20060285732 Horn et al. Dec 2006 A1
20060287644 Inganas et al. Dec 2006 A1
20060287666 Saadat et al. Dec 2006 A1
20070002135 Glukhovsky Jan 2007 A1
20070005019 Okishige Jan 2007 A1
20070010801 Chen et al. Jan 2007 A1
20070015965 Cox et al. Jan 2007 A1
20070016255 Korb et al. Jan 2007 A1
20070032700 Fowler et al. Feb 2007 A1
20070032701 Fowler et al. Feb 2007 A1
20070043345 Davalos et al. Feb 2007 A1
20070049800 Boulais Mar 2007 A1
20070051375 Milliman Mar 2007 A1
20070060880 Gregorich et al. Mar 2007 A1
20070079924 Saadat et al. Apr 2007 A1
20070100376 Mikkaichi et al. May 2007 A1
20070106118 Moriyama May 2007 A1
20070112331 Weber et al. May 2007 A1
20070112342 Pearson et al. May 2007 A1
20070112383 Conlon et al. May 2007 A1
20070112384 Conlon et al. May 2007 A1
20070112385 Conlon May 2007 A1
20070112425 Schaller et al. May 2007 A1
20070118115 Artale et al. May 2007 A1
20070123840 Cox May 2007 A1
20070129719 Kendale et al. Jun 2007 A1
20070129760 Demarais et al. Jun 2007 A1
20070135709 Rioux et al. Jun 2007 A1
20070135803 Belson Jun 2007 A1
20070142780 Van Lue Jun 2007 A1
20070154460 Kraft et al. Jul 2007 A1
20070156028 Van Lue et al. Jul 2007 A1
20070156127 Rioux et al. Jul 2007 A1
20070162101 Burgermeister et al. Jul 2007 A1
20070173869 Gannoe et al. Jul 2007 A1
20070173870 Zacharias Jul 2007 A2
20070173872 Neuenfeldt Jul 2007 A1
20070179525 Frecker et al. Aug 2007 A1
20070179530 Tieu et al. Aug 2007 A1
20070198057 Gelbart et al. Aug 2007 A1
20070203487 Sugita Aug 2007 A1
20070208336 Kim et al. Sep 2007 A1
20070208364 Smith et al. Sep 2007 A1
20070213754 Mikkaichi et al. Sep 2007 A1
20070225554 Maseda et al. Sep 2007 A1
20070233040 Macnamara et al. Oct 2007 A1
20070244358 Lee Oct 2007 A1
20070250038 Boulais Oct 2007 A1
20070250057 Nobis et al. Oct 2007 A1
20070255096 Stefanchik et al. Nov 2007 A1
20070255100 Barlow et al. Nov 2007 A1
20070255273 Fernandez et al. Nov 2007 A1
20070255303 Bakos et al. Nov 2007 A1
20070255306 Conlon et al. Nov 2007 A1
20070260112 Rahmani Nov 2007 A1
20070260117 Zwolinski et al. Nov 2007 A1
20070260121 Bakos et al. Nov 2007 A1
20070260273 Cropper et al. Nov 2007 A1
20070270629 Charles Nov 2007 A1
20070270889 Conlon et al. Nov 2007 A1
20070270907 Stokes et al. Nov 2007 A1
20070282371 Lee et al. Dec 2007 A1
20070293727 Goldfarb et al. Dec 2007 A1
20080004650 George Jan 2008 A1
20080015409 Barlow et al. Jan 2008 A1
20080015552 Doyle et al. Jan 2008 A1
20080021416 Arai et al. Jan 2008 A1
20080022927 Zhang et al. Jan 2008 A1
20080027387 Grabinsky Jan 2008 A1
20080051735 Measamer et al. Feb 2008 A1
20080058586 Karpiel Mar 2008 A1
20080071264 Azure Mar 2008 A1
20080086172 Martin et al. Apr 2008 A1
20080097159 Ishiguro Apr 2008 A1
20080097483 Ortiz et al. Apr 2008 A1
20080103527 Martin et al. May 2008 A1
20080119870 Williams May 2008 A1
20080119891 Miles et al. May 2008 A1
20080125796 Graham May 2008 A1
20080132892 Lunsford et al. Jun 2008 A1
20080139882 Fujimori Jun 2008 A1
20080147113 Nobis et al. Jun 2008 A1
20080171907 Long et al. Jul 2008 A1
20080177135 Muyari et al. Jul 2008 A1
20080200755 Bakos Aug 2008 A1
20080200762 Stokes et al. Aug 2008 A1
20080200911 Long Aug 2008 A1
20080200912 Long Aug 2008 A1
20080200933 Bakos et al. Aug 2008 A1
20080200934 Fox Aug 2008 A1
20080221619 Spivey et al. Sep 2008 A1
20080228213 Blakeney et al. Sep 2008 A1
20080230972 Ganley Sep 2008 A1
20080243106 Coe et al. Oct 2008 A1
20080249567 Kaplan Oct 2008 A1
20080269782 Stefanchik et al. Oct 2008 A1
20080269783 Griffith Oct 2008 A1
20080275474 Martin et al. Nov 2008 A1
20080275475 Schwemberger et al. Nov 2008 A1
20080287983 Smith et al. Nov 2008 A1
20080300547 Bakos Dec 2008 A1
20080312496 Zwolinski Dec 2008 A1
20080312506 Spivey et al. Dec 2008 A1
20090054728 Trusty Feb 2009 A1
20090062788 Long et al. Mar 2009 A1
20090062792 Vakharia et al. Mar 2009 A1
20090062795 Vakharia et al. Mar 2009 A1
20090078736 Van Lue Mar 2009 A1
20090112059 Nobis Apr 2009 A1
20090112062 Bakos Apr 2009 A1
20090112063 Bakos et al. Apr 2009 A1
20090125042 Mouw May 2009 A1
20090131751 Spivey et al. May 2009 A1
20090131932 Vakharia et al. May 2009 A1
20090131933 Ghabrial et al. May 2009 A1
20090143639 Stark Jun 2009 A1
20090143794 Conlon et al. Jun 2009 A1
20090143818 Faller et al. Jun 2009 A1
20090149710 Stefanchik et al. Jun 2009 A1
20090177219 Conlon Jul 2009 A1
20090182332 Long et al. Jul 2009 A1
20090192344 Bakos et al. Jul 2009 A1
20090192534 Ortiz et al. Jul 2009 A1
20090198231 Esser et al. Aug 2009 A1
20090198253 Omori Aug 2009 A1
20090216248 Uenohara et al. Aug 2009 A1
20090227828 Swain et al. Sep 2009 A1
20090248055 Spivey et al. Oct 2009 A1
20090269317 Davalos Oct 2009 A1
20090281559 Swain et al. Nov 2009 A1
20090287206 Jun Nov 2009 A1
20090287236 Bakos et al. Nov 2009 A1
20090299135 Spivey Dec 2009 A1
20090299143 Conlon et al. Dec 2009 A1
20090299362 Long et al. Dec 2009 A1
20090299385 Stefanchik et al. Dec 2009 A1
20090299406 Swain et al. Dec 2009 A1
20090299409 Coe et al. Dec 2009 A1
20090306658 Nobis et al. Dec 2009 A1
20090306683 Zwolinski et al. Dec 2009 A1
20090326561 Carroll, II et al. Dec 2009 A1
20100010294 Conlon et al. Jan 2010 A1
20100010298 Bakos et al. Jan 2010 A1
20100010299 Bakos et al. Jan 2010 A1
20100010303 Bakos Jan 2010 A1
20100010510 Stefanchik Jan 2010 A1
20100010511 Harris et al. Jan 2010 A1
20100030211 Davalos et al. Feb 2010 A1
20100036198 Tacchino et al. Feb 2010 A1
20100042045 Spivey Feb 2010 A1
20100048990 Bakos Feb 2010 A1
20100049190 Long et al. Feb 2010 A1
20100056861 Spivey Mar 2010 A1
20100056862 Bakos Mar 2010 A1
20100057085 Holcomb et al. Mar 2010 A1
20100057108 Spivey et al. Mar 2010 A1
20100063538 Spivey et al. Mar 2010 A1
20100076451 Zwolinski et al. Mar 2010 A1
20100081877 Vakharia Apr 2010 A1
20100087813 Long Apr 2010 A1
20100130817 Conlon May 2010 A1
20100130975 Long May 2010 A1
20100131005 Conlon May 2010 A1
20100152539 Ghabrial et al. Jun 2010 A1
20100152609 Zwolinski et al. Jun 2010 A1
20100179510 Fox et al. Jul 2010 A1
20100261994 Davalos et al. Oct 2010 A1
20100331758 Davalos et al. Dec 2010 A1
20110106221 Neal, II et al. May 2011 A1
20110190659 Long et al. Aug 2011 A1
20110190764 Long et al. Aug 2011 A1
20110245619 Holcomb Oct 2011 A1
20110306971 Long Dec 2011 A1
20120004502 Weitzner et al. Jan 2012 A1
Foreign Referenced Citations (130)
Number Date Country
3008120 Sep 1980 DE
4323585 Jan 1995 DE
19713797 Oct 1997 DE
19757056 Aug 2008 DE
102006027873 Oct 2009 DE
0086338 Aug 1983 EP
0286415 Oct 1988 EP
0589454 Mar 1994 EP
0464479 Mar 1995 EP
0529675 Feb 1996 EP
0724863 Jul 1999 EP
0760629 Nov 1999 EP
0818974 Jul 2001 EP
1281356 Feb 2003 EP
0947166 May 2003 EP
0836832 Dec 2003 EP
1402837 Mar 2004 EP
0744918 Apr 2004 EP
0931515 Aug 2004 EP
0941128 Oct 2004 EP
1411843 Oct 2004 EP
1150614 Nov 2004 EP
1477104 Nov 2004 EP
1481642 Dec 2004 EP
1493391 Jan 2005 EP
0848598 Feb 2005 EP
1281360 Mar 2005 EP
1568330 Aug 2005 EP
1452143 Sep 2005 EP
1616527 Jan 2006 EP
1006888 Mar 2006 EP
1013229 Jun 2006 EP
1721561 Nov 2006 EP
1153578 Mar 2007 EP
1334696 Mar 2007 EP
1769766 Apr 2007 EP
1836971 Sep 2007 EP
1854421 Nov 2007 EP
1857061 Nov 2007 EP
1875876 Jan 2008 EP
1891881 Feb 2008 EP
1902663 Mar 2008 EP
1477106 Jun 2008 EP
1949844 Jul 2008 EP
1518499 Aug 2008 EP
1709918 Oct 2008 EP
1994904 Nov 2008 EP
1707130 Dec 2008 EP
0723462 Mar 2009 EP
1769749 Nov 2009 EP
1493397 Sep 2011 EP
2731610 Sep 1996 FR
2335860 Oct 1999 GB
2403909 Jan 2005 GB
63309252 Dec 1988 JP
4038960 Feb 1992 JP
2000245683 Sep 2000 JP
2002-369791 Dec 2002 JP
2003-088494 Mar 2003 JP
2003-235852 Aug 2003 JP
2004-33525 Feb 2004 JP
2004-065745 Mar 2004 JP
2005-121947 May 2005 JP
2005-261514 Sep 2005 JP
2006297005 Nov 2006 JP
1021295 Feb 2004 NL
194230 May 1967 SU
980703 Dec 1982 SU
WO 8401707 May 1984 WO
WO 9213494 Aug 1992 WO
WO 9310850 Jun 1993 WO
WO 9320760 Oct 1993 WO
WO 9320765 Oct 1993 WO
WO 9509666 Apr 1995 WO
WO 9622056 Jul 1996 WO
WO 9627331 Sep 1996 WO
WO 9639946 Dec 1996 WO
WO 9712557 Apr 1997 WO
WO 9900060 Jan 1999 WO
WO 9909919 Mar 1999 WO
WO 9917661 Apr 1999 WO
WO 9930622 Jun 1999 WO
WO 0035358 Jun 2000 WO
WO 0126708 Apr 2001 WO
WO 0158360 Aug 2001 WO
WO 0211621 Feb 2002 WO
WO 0234122 May 2002 WO
WO 02094082 Nov 2002 WO
WO 03045260 Jun 2003 WO
WO 03059412 Jul 2003 WO
WO 03078721 Sep 2003 WO
WO 03081761 Oct 2003 WO
WO 03082129 Oct 2003 WO
WO 2004006789 Jan 2004 WO
WO 2004028613 Apr 2004 WO
WO 2004037123 May 2004 WO
WO 2004037149 May 2004 WO
WO 2004052221 Jun 2004 WO
WO 2004086984 Oct 2004 WO
WO 2005009211 Feb 2005 WO
WO 2005018467 Mar 2005 WO
WO 2005037088 Apr 2005 WO
WO 2005065284 Jul 2005 WO
WO 2005112810 Dec 2005 WO
WO 2005120363 Dec 2005 WO
WO 2006007399 Jan 2006 WO
WO 2006012630 Feb 2006 WO
WO 2006040109 Apr 2006 WO
WO 2006041881 Apr 2006 WO
WO 2006060405 Jun 2006 WO
WO 2006110733 Oct 2006 WO
WO 2006113216 Oct 2006 WO
WO 2007013059 Feb 2007 WO
WO 2007048085 Apr 2007 WO
WO 2007063550 Jun 2007 WO
WO 2007100067 Sep 2007 WO
WO 2007109171 Sep 2007 WO
WO 2008033356 Mar 2008 WO
WO 2008076337 Jun 2008 WO
WO 2008076800 Jun 2008 WO
WO 2008079440 Jul 2008 WO
WO 2008101075 Aug 2008 WO
WO 2008102154 Aug 2008 WO
WO 2008108863 Sep 2008 WO
WO 2008151237 Dec 2008 WO
WO 2009027065 Mar 2009 WO
WO 2009032623 Mar 2009 WO
WO 2009121017 Oct 2009 WO
WO 2010027688 Mar 2010 WO
WO 2010080974 Jul 2010 WO
Non-Patent Literature Citations (133)
Entry
International Search Report for PCT/US2010/020465, Jun. 30, 2010 (4 pages).
D. Wilhelm et al., “An Innovative, Safe and Sterile Sigmoid Access (ISSA) for Notes,” Endoscopy 2007, vol. 39, pp. 401-406.
Nakazawa et al., “Radiofrequency Ablation of Hepatocellular Carcinoma: Correlation Between Local Tumor Progression After Ablation and Ablative Margin,” AJR, 188, pp. 480-488 (Feb. 2007).
Miklav{hacek over (c)}i{hacek over (c)} et al., “A validated model of in vivo electric field distribution in tissues for electrochemotherapy and for DNA electrotransfer for gene therapy,” Biochimica et Biophysica Acta, 1523, pp. 73-83 (2000).
Evans, “Ablative and cathether-delivered therapies for colorectal liver metastases (CRLM),” EJSO, 33, pp. S64-S75 (2007).
Wong et al., “Combined Percutaneous Radiofrequency Ablation and Ethanol Injection for Hepatocellular Carcinoma in High-Risk Locations,” AJR, 190, pp. W187-W195 (2008).
Heller et al., “Electrically mediated plasmid DNA delivery to hepatocellular carcinomas in vivo,” Gene Therapy, 7, pp. 826-829 (2000).
Widera et al., “Increased DNA Vaccine Delivery and Immunogenicity by Electroporation In Vivo,” The Journal of Immunology, 164, pp. 4635-4640 (2000).
Weaver et al., “Theory of electroporation: A review,” Bioelectrochemistry and Bioenergetics, 41, pp. 135-160 (1996).
Mulier et al., “Radiofrequency Ablation Versus Resection for Resectable Colorectal Liver Metastases: Time for a Randomized Trial?” Annals of Surgical Oncology, 15(1), pp. 144-157 (2008).
Link et al., “Regional Chemotherapy of Nonresectable Colorectal Liver Metastases with Mitoxanthrone, 5-Fluorouracil, Folinic Acid, and Mitomycin C May Prolong Survival,” Cancer, 92, pp. 2746-2753 (2001).
Guyton et al., “Membrane Potentials and Action Potentials,” W.B. Sanders, ed. Textbook of Medical Physiology, p. 56 (2000).
Guyton et al., “Contraction of Skeletal Muscle,” Textbook of Medical Physiology, pp. 82-84 (2000).
“Ethicon Endo-Surgery Novel Investigational Notes and SSL Devices Featured in 15 Presentations at Sages,” Apr. 22, 2009 Press Release; URL http://www.jnj.com/connect/news/all/20090422—152000; accessed Aug. 28, 2009 (3 pages).
“Ethicon Endo-Surgery Studies Presented at DDW Demonstrate Potential of Pure NOTES Surgery With Company's Toolbox,” Jun. 3, 2009 Press Release; URL http://www.jnj.com/connect/news/product/20090603—120000; accessed Aug. 28, 2009 (3 pages).
Castellvi et al., “Hybrid Transvaginal NOTES Sleeve Gastrectomy in a Porcine Model Using a Magnetically Anchored Camera and Novel Instrumentation,” Abstract submitted along with Poster at SAGES Annual Meeting in Phoenix, AZ, Apr. 22, 2009 (1 page).
Castellvi et al., “Hybrid Transvaginal NOTES Sleeve Gastrectomy in a Porcine Model Using a Magnetically Anchored Camera and Novel Instrumentation,” Poster submitted along with Abstract at SAGES Annual Meeting in Phoenix, AZ, Apr. 22, 2009 (1 page).
OCTO Port Modular Laparoscopy System for Single Incision Access, Jan. 4, 2010; URL http://www.medgadget.com/archives/2010/01/octo—port—modular—laparo . . . ; accessed Jan. 5, 2010 (4 pages).
Hakko Retractors, obtained Aug. 25, 2009 (5 pages).
Zadno et al., “Linear Superelasticity in Cold-Worked NI-TI,” Engineering Aspects of Shape Memory Alloys, pp. 414-419.
U.S. Appl. No. 12/607,252, filed Oct. 28, 2009.
U.S. Appl. No. 12/580,400, filed Oct. 16, 2009.
U.S. Appl. No. 12/607,388, filed Oct. 28, 2009.
U.S. Appl. No. 12/612,911, filed Nov. 5, 2009.
U.S. Appl. No. 12/614,143, filed Nov. 6, 2009.
U.S. Appl. No. 12/617,998, filed Nov. 13, 2009.
U.S. Appl. No. 12/640,440, filed Dec. 17, 2009.
U.S. Appl. No. 12/640,469, filed Dec. 17, 2009.
U.S. Appl. No. 12/640,476, filed Dec. 17, 2009.
U.S. Appl. No. 12/640,492, filed Dec. 17, 2009.
U.S. Appl. No. 12/641,823, filed Dec. 18, 2009.
U.S. Appl. No. 12/641,853, filed Dec. 18, 2009.
U.S. Appl. No. 12/641,837, filed Dec. 18, 2009.
U.S. Appl. No. 12/651,181, filed Dec. 31, 2009.
U.S. Appl. No. 12/696,598, filed Jan. 29, 2010.
U.S. Appl. No. 12/696,626, filed Jan. 29, 2010.
U.S. Appl. No. 12/752,701, filed Apr. 1, 2010.
U.S. Appl. No. 11/897,676, filed Aug. 31, 2007.
Michael S. Kavic, M.D., “Natural Orifice Translumenal Endoscopic Surgery: “NOTES””, JSLS, vol. 10, pp. 133-134 (2006).
Ethicon, Inc., “Wound Closure Manual: Chapter 3 (The Surgical Needle),” 15 pages, (publication date unknown).
Guido M. Sclabas, M.D., et al., “Endoluminal Methods for Gastrotomy Closure in Natural Orifice TransEnteric Surgery (NOTES),” Surgical Innovation, vol. 13, No. 1, pp. 23-30, Mar. 2006.
Fritscher-Ravens, et al., “Transgastric Gastropexy and Hiatal Hernia Repair for GERD Under EUS Control: a Porcine Model,” Gastrointestinal Endoscopy, vol. 59, No. 1, pp. 89-95, 2004.
Ogando, “Prototype Tools That Go With the Flow,” Design News, 2 pages, Jul. 17, 2006.
Edd, et al., “In Vivo Results of a New Focal Tissue Ablation Technique: Irreversible Electroporation,” IEEE Trans Biomed Eng, vol. 53, pp. 1409-1415, 2006.
Kennedy, et al., “High-Burst-Strength, Feedback-Controlled Bipolar Vessel Sealing,” Surgical Endoscopy, vol. 12, pp. 876-878 (1998).
Collins et al., “Local Gene Therapy of Solid Tumors with GM-CSF and B7-1 Eradicates Both Treated and Distal Tumors,” Cancer Gene Therapy, vol. 13, pp. 1061-1071 (2006).
K. Sumiyama et al., “Transesophageal Mediastinoscopy by Submucosal Endoscopy With Mucosal Flap Safety Value Technique,” Gastrointest Endosc., Apr. 2007, vol. 65(4), pp. 679-683 (Abstract).
K. Sumiyama et al., “Submucosal Endoscopy with Mucosal Flap Safety Valve,” Gastrointest Endosc. Apr. 2007, vol. 65(4) pp. 694-695 (Abstract).
K. Sumiyama et al., “Transgastric Cholecystectomy: Transgastric Accessibility to the Gallbladder Improved with the SEMF Method and a Novel Multibending Therapeutic Endoscope,” Gastrointest Endosc., Jun. 2007, vol. 65(7), pp. 1028-1034 (Abstract).
K. Sumiyama et al., “Endoscopic Caps,” Tech. Gastrointest. Endosc., vol. 8, pp. 28-32, 2006.
“Z-Offset Technique Used in the Introduction of Trocar During Laparoscopic Surgery,” M.S. Hershey NOTES Presentation to EES NOTES Development Team, Sep. 27, 2007.
F.N. Denans, Nouveau Procede Pour La Guerison Des Plaies Des Intestines. Extrait Des Seances De La Societe Royale De Medecine De Marseille, Pendant Le Mois De Decembre 1825, et le Premier Tremestre De 1826, Séance Du 24 Fevrier 1826. Recueil De La Societe Royale De Medecin De Marseille. Marseille: Impr. D'Achard, 1826; 1:127-31. (with English translation).
I. Fraser, “An Historical Perspective on Mechanical Aids in Intestinal Anastamosis,” Surg. Gynecol. Obstet. (Oct. 1982), vol. 155, pp. 566-574.
M.E. Ryan et al., “Endoscopic Intervention for Biliary Leaks After Laparoscopic Cholecystectomy: A Multicenter Review,” Gastrointest. Endosc., vol. 47(3), 1998, pp. 261-266.
C. Cope, “Creation of Compression Gastroenterostomy by Means of the Oral, Percutaneous, or Surgical Introduction of Magnets: Feasibility Study in Swine,” J. Vasc Intery Radiol, (1995), vol. 6(4), pp. 539-545.
J.W. Hazey et al., “Natural Orifice Transgastric Endoscopic Peritoneoscopy in Humans: Initial Clinical Trial,” Surg Endosc, (Jan. 2008), vol. 22(1), pp. 16-20.
N. Chopita et al., “Endoscopic Gastroenteric Anastamosis Using Magnets,” Endoscopy, (2005), vol. 37(4), pp. 313-317.
C. Cope et al., “Long Term Patency of Experimental Magnetic Compression Gastroenteric Anastomoses Achieved with Covered Stents,” Gastrointest Endosc, (2001), vol. 53, pp. 780-784.
H. Okajima et al., “Magnet Compression Anastamosis for Bile Duct Stenosis After Duct to Duct Biliary Reconstruction in Living Donor Liver Transplantation,” Liver Transplantation (2005), pp. 473-475.
A. Fritscher-Ravens et al., “Transluminal Endosurgery: Single Lumen Access Anastamotic Device for Flexible Endoscopy,” Gastrointestinal Endosc, (2003), vol. 58(4), pp. 585-591.
G.A. Hallenbeck, M.D. et al., “An Instrument for Colorectal Anastomosis Without Sutrues,” Dis col. Rectum, (1963), vol. 5, pp. 98-101.
T. Hardy, Jr., M.D. et al., “A Biofragmentable Ring for Sutureless Bowel Anastomosis. An Experimental Study,” Dis Col Rectum, (1985), vol. 28, pp. 484-490.
P. O'Neill, M.D. et al., “Nonsuture Intestinal Anastomosis,” Am J. Surg, (1962), vol. 104, pp. 761-767.
C.P. Swain, M.D. et al., “Anastomosis at Flexible Endoscopy: An Experimental Study of Compression Button Gastrojejunostomy,” Gastrointest Endosc, (1991), vol. 37, pp. 628-632.
J.B. Murphy, M.D., “Cholecysto-Intestinal, Gastro-Intestinal, Entero-Intestinal Anastomosis, and Approximation Without Sutures (original research),” Med Rec, (Dec. 10, 1892), vol. 42(24), pp. 665-676.
USGI® EndoSurgical Operating System—g-Prox® Tissue Grasper/Approximation Device; [online] URL: http://www.usgimedical.com/eos/components-gprox.htm—accessed May 30, 2008 (2 pages).
Printout of web page—http://www.vacumed.com/zcom/product/Product.do?compid=27&prodid=852, #51XX Low-Cost Permanent Tubes 2MM ID, Smooth Interior Walls, VacuMed, Ventura, California, Accessed Jul. 24, 2007.
Endoscopic Retrograde Cholangiopancreatogram (ERCP); [online] URL: http://www.webmd.com/digestive-disorders/endoscopic-retrograde-cholangiopancreatogram-ercp.htm; last updated: Apr. 30, 2007; accessed: Feb. 21, 2008 (6 pages).
ERCP; Jackson Siegelbaum Gastroenterology; [online] URL: http://www.gicare.com/pated/epdgs20.htm; accessed Feb. 21, 2008 (3 pages).
D.G. Fong et al., “Transcolonic Ventral Wall Hernia Mesh Fixation in a Porcine Model,” Endoscopy 2007; 39: 865-869.
B. Rubinsky, Ph.D., “Irreversible Electroporation in Medicine,” Technology in Cancer Research and Treatment, vol. 6, No. 4, Aug. 2007, pp. 255-259.
D.B. Nelson, MD et al., “Endoscopic Hemostatic Devices,” Gastrointestinal Endoscopy, vol. 54, No. 6, 2001, pp. 833-840.
CRE™ Pulmonary Balloon Dilator; [online] URL: http://www.bostonscientific.com/Device.bsci?page=HCP—Overview&navRe1Id=1000.1003&method=D . . . , accessed Jul. 18, 2008 (4 pages).
J.D. Paulson, M.D., et al., “Development of Flexible Culdoscopy,” The Journal of the American Association of Gynecologic Laparoscopists, Nov. 1999, vol. 6, No. 4, pp. 487-490.
H. Seifert, et al., “Retroperitoneal Endoscopic Debridement for Infected Peripancreatic Necrosis,” The Lancet, Research Letters, vol. 356, Aug. 19, 2000, pp. 653-655.
K.E. Mönkemüller, M.D., et al., “Transmural Drainage of Pancreatic Fluid Collections Without Electrocautery Using the Seldinger Technique,” Gastrointestinal Endoscopy, vol. 48, No. 2, 1998, pp. 195-200.
U.S. Appl. No. 12/019,461, filed Jan. 24, 2008.
U.S. Appl. No. 12/045,318, filed Mar. 10, 2008.
U.S. Appl. No. 12/115,916, filed May 6, 2008.
U.S. Appl. No. 12/122,031, filed May 16, 2008.
U.S. Appl. No. 12/129,784, filed May 30, 2008.
U.S. Appl. No. 12/129,880, filed May 30, 2008.
U.S. Appl. No. 12/130,010, filed May 30, 2008.
U.S. Appl. No. 12/130,023, filed May 30, 2008.
U.S. Appl. No. 12/130,224, filed May 30, 2008.
U.S. Appl. No. 12/130,652, filed May 30, 2008.
U.S. Appl. No. 12/133,109, filed Jun. 4, 2008.
U.S. Appl. No. 12/133,953, filed Jun. 5, 2008.
U.S. Appl. No. 12/163,255, filed Jun. 27, 2008.
U.S. Appl. No. 12/169,868, filed Jul. 9, 2008.
U.S. Appl. No. 12/170,862, filed Jul. 10, 2008.
U.S. Appl. No. 12/172,752, filed Jul. 14, 2008.
U.S. Appl. No. 12/172,766, filed Jul. 14, 2008.
U.S. Appl. No. 12/172,782, filed Jul. 14, 2008.
U.S. Appl. No. 12/192,372, filed Aug. 15, 2008.
U.S. Appl. No. 12/203,330, filed Sep. 3, 2008.
U.S. Appl. No. 12/197,749, filed Aug. 25, 2008.
U.S. Appl. No. 12/197,653, filed Aug. 25, 2008.
U.S. Appl. No. 12/202,740, filed Sep. 2, 2008.
U.S. Appl. No. 12/203,458, filed Sep. 3, 2008.
U.S. Appl. No. 12/201,812, filed Aug. 29, 2008.
U.S. Appl. No. 12/207,306, filed Sep. 9, 2008.
U.S. Appl. No. 12/243,334, filed Oct. 1, 2008.
U.S. Appl. No. 12/234,425, filed Sep. 19, 2008.
U.S. Appl. No. 12/060,601, filed Apr. 1, 2008.
U.S. Appl. No. 12/277,975, filed Nov. 25, 2008.
U.S. Appl. No. 12/277,957, filed Nov. 25, 2008.
U.S. Appl. No. 12/332,938, filed Dec. 11, 2008.
U.S. Appl. No. 12/337,340, filed Dec. 17, 2008.
U.S. Appl. No. 12/352,451, filed Jan. 12, 2009.
U.S. Appl. No. 12/359,824, filed Jan. 26, 2009.
U.S. Appl. No. 12/359,053, filed Jan. 23, 2009.
U.S. Appl. No. 12/362,826, filed Jan. 30, 2009.
U.S. Appl. No. 12/363,137, filed Jan. 30, 2009.
U.S. Appl. No. 12/364,172, filed Feb. 2, 2009.
U.S. Appl. No. 12/364,256, filed Feb. 2, 2009.
U.S. Appl. No. 12/413,479, filed Mar. 27, 2009.
U.S. Appl. No. 12/468,462, filed May 19, 2009.
Written Opinion for PCT/US2010/020465, Jun. 30, 2010 (10 pages).
How Stuff Works “How Smart Structures Will Work,” http://science.howstuffworks.com/engineering/structural/smart-structure1.htm; accessed online Nov. 1, 2011 (3 pages).
Instant Armor: Science Videos—Science News—ScienCentral; http://www.sciencentral.com/articles./view.php3?article—id=218392121; accessed online Nov. 1, 2011 (2 pages).
Stanway, Smart Fluids: Current and Future Developments. Material Science and Technology, 20, pp. 931-939, 2004; accessed online Nov. 1, 2011 at http://www.dynamics.group.shef.ac.uk/smart/smart.html (7 pages).
Jolly et al., Properties and Applications of Commercial Magnetorheological Fluids. SPIE 5th Annual Int. Symposium on Smart Structures and Materials, 1998 (18 pages).
U.S. Appl. No. 13/036,895, filed Feb. 28, 2011.
U.S. Appl. No. 13/036,908, filed Feb. 28, 2011.
U.S. Appl. No. 13/218,221, filed Aug. 25, 2011.
U.S. Appl. No. 13/267,251, filed Oct. 6, 2011.
U.S. Appl. No. 13/325,791, filed Dec. 14, 2011.
U.S. Appl. No. 13/352,495, filed Jan. 18, 2012.
U.S. Appl. No. 13/399,358, filed Feb. 17, 2012.
U.S. Appl. No. 13/420,805, filed Mar. 15, 2012.
U.S. Appl. No. 13/420,818 filed Mar. 15, 2012.
U.S. Appl. No. 13/425,103, filed Mar. 20, 2012.
Related Publications (1)
Number Date Country
20100179530 A1 Jul 2010 US