Patent Application
20150272601
The present invention relates to apparatus, systems and methods for dissolving blood clots. In one particular aspect the present invention relates to dissolution of blood clots in the brain.
Stroke is the third leading cause of death (after heart disease and cancer) and the leading cause of disability, as reported by Ingall: Stroke-incidence, mortality, morbidity and risk. J Insur Med 36(2):143-152 (2004). The annual total economic cost of stroke is estimated at $68.9 billion, as of 2004. There are 795,000 strokes annually in the United State of America, according to Lloyd-Jones et al.: Heart disease and stroke statistics—2009 update. Circulation 119(3):480-486 (2009). First strokes account for 75% of these strokes and 18% of stroke victims die from their stroke. Death resultant from stroke is greater among women (61% women, 39% men). The World Health Organization estimates that there are 15 million strokes annually worldwide and approximately 5 million of these stroke victims die and another 5 million are permanently disabled.
Problem to be solved: The current standard of care for stroke patients is admittance to the Emergency Room or other emergency treatment facility followed immediately by a computed tomography (CT) scan to determine whether the stroke is ischemic (blockage) or hemorrhagic (ruptured) and to assess the location and extent of ischemia in the brain. If the patient is admitted soon enough after the onset of ischemic stroke (<3 hours generally, <4.5 hours in some cases), then tissue Plasminogen Activator (tPA) is administered. Beyond this time “window” (i.e., 3 to 4.5 hours), the FDA does not approve tPA administration due to the risk of hemorrhagic damage to the brain. Unfortunately, tPA administration in patients with ischemic stroke results in only a 30% greater chance of little, or no disability, compared with no tPA at 3 months, as reported by Marler: Tissue plasminogen activator for acute ischemic stroke. N Engl J Med. 333:1581-1587 (1995). Additionally, intracerebral hemorrhage occurs at a 6.4% incidence rate among patients receiving tPA therapy.
The narrow therapeutic time-window and complications associated with tPA administration have driven the development of other approaches for managing ischemic stroke. Beyond 3 or 4.5 hours, and up to 8 hours, mechanical thrombectomy is performed to recannulate the occluded (blocked) blood vessel, but recent trials failed to demonstrate a clinical benefit from the first generation of mechanical devices, see Smith et al., Safety and efficacy of mechanical embolectomy in acute ischemic stroke: results of the MERCI trial. Stroke. 2005 July; 36(7):1432-8. Epub 2005 Jun. 16.(2005). In comparison, the addition of adjuvant ultrasound (with or without microbubbles) has been shown in multiple studies to improve tPA efficacy, as reported by 5. Alexandrov et al: CLOTBUST Investigators: Ultrasound-enhanced systemic thrombolysis for acute ischemic stroke. N Engl J Med 351:2170-2178, (2004); Alexandrov et al.: A pilot randomized clinical safety study of sonothrombolysis. Stroke 39:1464-1469, (2008); Dinia et al.: Timing of microbubble enhanced sonothrombolysis strongly predicts . . . . Stroke 39:559, (2008) (abstr); and Molina et al.: Microbubble administration accelerates clot lysis during continuous 2-MHz ultrasound monitoring in stroke patients treated with intravenous tissue plasminogen activator. Stroke 37:425-429, (2006).
In a recent clinical trial, ischemic stroke patients that were treated with tPA, transcranial ultrasound, and microbubbles had significantly higher rates of recanalization and greater clinical improvement compared with patients who received tPA alone (54.9% versus 31.1%, n=128), see Dinia et al., cited above. Although this represents a significant improvement, tPA administration was still linked to intracerebral hemorrhage, and the combined tPA/US/MB therapy was ineffective in over 30% of patients. Thus, there is a clear need to develop technologies that further enhance tPA efficacy at lower doses and reduce the incidence of intracerebral hemorrhage. Even small improvements in patient outcomes will be impactful based on the large scale of the clinical problem.
In one aspect of the present invention, a method of treating a blood clot in a patient is provided including: delivering a thrombolytic agent toward the blood clot; and applying ultrasonic energy to the microbubbles to vibrate the microbubbles.
In at least one embodiment, at least 50 percent of the microbubbles dissolve within 120 seconds after production of the microbubbles.
In at least one embodiment, at least 80 percent of a total volume of the microbubbles vanishes after 120 seconds after production of the microbubbles.
In at least one embodiment, at least 50 percent of a total volume of the microbubbles vanishes after 120 seconds after production of the microbubbles.
In at least one embodiment, at least 30 percent of a total volume of the microbubbles vanishes after 120 seconds after production of the microbubbles.
In at least one embodiment, at least 90 percent of the microbubbles dissolve within 120 seconds after production of the microbubbles.
In at least one embodiment, at least 80 percent of the microbubbles dissolve within a time period in the range of from about 30 seconds to about 180 seconds after production of the microbubbles.
In at least one embodiment, at least 80 percent of the microbubbles dissolve within 120 seconds after production of the microbubbles.
In at least one embodiment, at least 30 percent of the microbubbles dissolve within 120 seconds after production of the microbubbles.
In at least one embodiment, at least 50 percent of the microbubbles dissolve within a predetermined time period after production of the microbubbles, wherein the predetermined time period is in the range of 30 seconds to 180 seconds.
In at least one embodiment, all of the microbubbles dissolve within ninety seconds after production of the microbubbles.
In at least one embodiment, the microbubbles have an average diameter greater than or equal to about eight micrometers.
In at least one embodiment, the microbubbles have an average diameter greater than or equal to about twenty-five micrometers.
In at least one embodiment, the average diameter is in the range of twenty-five to thirty-five micrometers.
In at least one embodiment, the microbubbles have an average diameter in the range of about eight micrometers to about twenty-five micrometers.
In at least one embodiment, the microbubbles have an average diameter in the range of about ten micrometers to about twenty micrometers.
In at least one embodiment, the microbubbles have an average diameter in the range of about eight micrometers to about twenty-five micrometers.
In at least one embodiment, the microbubbles each have a shell comprising albumin and a core comprising nitrogen.
In at least one embodiment, the microbubbles each have a shell and a core, wherein the core comprises an unstable gas.
In at least one embodiment, the core further comprises a stable gas.
In at least one embodiment, the core comprises a neuroprotective gas.
In at least one embodiment, the blood clot is in the brain of the patient and the ultrasound energy is delivered trans-cranially.
In at least one embodiment, the blood clot is in a cerebral artery and the catheter is inserted into the cerebral artery.
In at least one embodiment, the blood clot is in a blood vessel, having caused an ischemic stroke.
In at least one embodiment, the blood clot comprises congealed blood resulting from a hemorrhage.
In at least one embodiment, the blood clot is in a vein, having caused deep vein thrombosis.
In at least one embodiment, the blood clot is in a pulmonary artery, having caused a pulmonary embolism.
In at least one embodiment, the thrombolytic agent is delivered intravenously.
In at least one embodiment, the delivery of the thrombolytic agent comprises introducing the thrombolytic agent into a carotid artery of the patient.
In at least one embodiment, the delivery of the thrombolytic agent comprises delivering the thrombolytic agent from a distal end portion of the catheter.
In at least one embodiment, the microbubbles are produced by a microfluidics device.
In at least one embodiment, the microfluidics device is provided in the catheter, and inserted into the patient along with the catheter.
In at least one embodiment, the thrombolytic agent comprises tissue Plasminogen Activator (tPA).
In at least one embodiment, the blood clot is in the brain of the patient and the ultrasound energy is delivered from the catheter.
In at least one embodiment, the ultrasound energy is delivered from a location outside the body of the patient to a location inside the patient at or near a location of the blood clot.
In at least one embodiment, the ultrasound energy is delivered from the catheter.
In at least one embodiment, the method further includes real-time monitoring at least one of production rate and size of microbubbles produced.
In at least one embodiment, the real-time monitoring is performed in an automatic feedback loop, the method further comprising automatically adjusting at least one of gas pressure, gas flow rate, liquid pressure and liquid flow rate to maintain stable production rate and size of the microbubbles.
In at least one embodiment, the method further includes concurrent or adjacent use of a thrombectomy device to assist in at least one of breaking up and removing the blood clot.
In at least one embodiment, delivering low stability microbubbles and applying ultrasonic energy comprise: initially delivering a microdose of the microbubbles; receiving ultrasound echo signals from one or more isolated microbubbles; calculating aberrating delays based upon the ultrasound echo signals received from the one or more isolated microbubbles; and superimposing the aberrating delays on at least one of transmit and receive phases of the ultrasound energy.
In at least one embodiment, the method further includes: incrementally increasing power of the transmit ultrasound energy to determine a threshold power level where microbubble destruction, such as by cavitation or other form of destruction is observed to start occurring; reducing the power of the transmit ultrasound energy to a reduced power level comprising a predetermined percentage of the threshold power level; and delivering the microbubbles at full dose and applying the ultrasound energy to the microbubbles at the reduced power level.
In at least one embodiment, a frequency of the transmit ultrasound energy is matched to a resonance frequency of the microbubbles.
In at least one embodiment, a frequency of the transmit ultrasound energy is off-resonance relative to a resonance frequency of the microbubbles.
In at least one embodiment, the method is carried out and monitored using ultrasound imaging, without any use of fluoroscopy or X-ray imaging.
In at least one embodiment, the low stability microbubbles are outputted from a microfluidics device in the catheter, the microfluidics device comprising an outlet port from which the low stability microbubbles are outputted, and wherein a distance from the outlet port to the clot is 5 cm or less.
In at least one embodiment, the distance is in the range of 2 cm to 4 cm.
In another aspect of the present invention, a system for treating a blood clot is provided, including: a catheter configured to be inserted into a patient; low stability microbubbles; the catheter configured to deliver the microbubbles toward the blood clot in the patient; and an ultrasonic energy device configured to apply ultrasonic energy to the microbubbles to vibrate the microbubbles.
In at least one embodiment, at least fifty percent of the microbubbles dissolve within one hundred twenty seconds after production of the microbubbles.
In at least one embodiment, all of the microbubbles dissolve within ninety seconds after production of the microbubbles.
In at least one embodiment, the microbubbles have an average diameter greater than or equal to about eight micrometers.
In at least one embodiment, the microbubbles have an average diameter greater than or equal to about twenty-five micrometers.
In at least one embodiment, the average diameter is in the range of twenty-five to thirty five micrometers.
In at least one embodiment, the microbubbles have an average diameter in the range of about eight micrometers to about twenty-five micrometers.
In at least one embodiment, the microbubbles have an average diameter in the range of about ten micrometers to about twenty micrometers.
In at least one embodiment, the microbubbles have an average diameter in the range of about eight micrometers to about twenty-five micrometers.
In at least one embodiment, the microbubbles are polydisperse, with a minimum diameter of about one micrometer and a maximum diameter of about one hundred micrometers.
In at least one embodiment, the microbubbles each have a shell comprising albumin and a core comprising nitrogen.
In at least one embodiment, the microbubbles each have a shell and a core, wherein the core comprises an unstable gas.
In at least one embodiment, the core further comprises a stable gas.
In at least one embodiment, the core further comprises a neuroprotective gas.
In at least one embodiment, the core comprises an unstable gas and a neuroprotective gas.
In at least one embodiment, the core comprises an unstable gas a stable gas and a neuroprotective gas.
In at least one embodiment, the blood clot is in the brain of the patient and the ultrasound energy device is configured to apply ultrasound energy from outside the patient's body, trans-cranially to the microbubbles.
In at least one embodiment, the blood clot is in a cerebral artery and the catheter is configured and dimensioned to be inserted into the cerebral artery.
In at least one embodiment, the blood clot is in a femoral vein and the catheter is configured and dimensioned to be inserted into the femoral vein.
In at least one embodiment, the blood clot is in an iliofemoral vein and the catheter is configured and dimensioned to be inserted into the iliofemoral vein.
In at least one embodiment, the blood clot is in a popliteal vein and the catheter is configured and dimensioned to be inserted into the popliteal vein.
In at least one embodiment, the blood clot is in an iliac vein and the catheter is configured and dimensioned to be inserted into the iliac vein.
In at least one embodiment, the blood clot is in an inferior vena cava and the catheter is configured and dimensioned to be inserted into the inferior vena cava.
In at least one embodiment, the blood clot is in an axillary vein and the catheter is configured and dimensioned to be inserted into the axillary vein.
In at least one embodiment, the blood clot is in a subclavian vein and the catheter is configured and dimensioned to be inserted into the subclavian vein.
In at least one embodiment, the blood clot is in the microvasculature, having caused microvascular obstruction (MVO) and the catheter is configured and dimensioned to be inserted into an artery that feeds the microvasculature having been obstructed.
In at least one embodiment, the system further includes a delivery tube configured to delivering a thrombolytic agent toward the blood clot.
In at least one embodiment, the system further includes a thrombolytic agent to be applied to the blood clot.
In at least one embodiment, the catheter comprises a delivery channel configured to deliver a thrombolytic agent from a distal end portion of the catheter toward the blood clot.
In at least one embodiment, the system further includes the thrombolytic agent in the delivery channel.
In at least one embodiment, the catheter includes a microfluidics flow-focusing device contained within the catheter and configured to produce the low stability microbubbles.
In at least one embodiment, the microfluidics flow-focusing device is flexible and capable of being deformed for insertion into the catheter.
In at least one embodiment, the microfluidics flow-focusing device comprises a lamination of polymer layers and can be rolled up to be received within a cylindrical void of the catheter.
In at least one embodiment, the microfluidics flow-focusing device is rigid and comprises glass.
In at least one embodiment, the microfluidics flow-focusing device comprises electrodes configured to operate as a micro Coulter device to measure changes in impedance as the low stability microbubbles flow past the electrodes.
In at least one embodiment, the microfluidics flow-focusing device comprises at least one liquid input channel, a gas input channel, and electrodes positioned in the gas input channel and at least one of the at least one liquid input channel, the electrodes being configured to detect electrical conductivity.
In at least one embodiment, the catheter further comprises a microfluidics flow-focusing device configured to produce the low stability microbubbles.
In at least one embodiment, the catheter comprises a microfluidics T-junction device configured to produce the low stability microbubbles.
In at least one embodiment, the catheter comprises a microfluidics co-flow device configured to produce the low-stability microbubbles.
In at least one embodiment, the ultrasonic energy device comprises a transducer contained within the catheter.
In at least one embodiment, the blood clot is in the brain of the patient and the catheter and transducer are configured and dimensioned to be inserted into a blood vessel in the brain.
In at least one embodiment, the blood vessel is a cerebral artery.
In at least one embodiment, the system further includes a tube in fluid communication with and extending distally from a distal tip of the catheter; wherein the catheter has a first outside diameter and the tube has a second outside diameter, the second outside diameter being less than the first outside diameter; and wherein the tube is configured and dimensioned to deliver the microbubbles distally of the catheter.
In at least one embodiment, the tube is configured and dimensioned to deliver the microbubbles into a vessel that is too small for the catheter to be inserted into.
In at least one embodiment, the system further includes at least one sensor configured for real-time monitoring at least one of production rate and size of microbubbles produced.
In at least one embodiment, the microfluidics device further comprises at least one sensor configured for real-time monitoring at least one of production rate and size of microbubbles produced.
In at least one embodiment, the at least one sensor comprises multiple non-polarizing electrodes.
In at least one embodiment, the at least one sensor comprises multiple optical waveguides.
In at least one embodiment, the real-time monitoring is performed in an automatic feedback loop, the system further comprising an automatic control system configured to automatically adjust at least one of gas pressure and liquid flow rate to maintain stable production rate and size of the microbubbles.
In at least one embodiment, the real-time monitoring is performed in an automatic feedback loop, the system further comprising an automatic control system configured to automatically adjust at least one of gas pressure and liquid flow rate to temporarily stop microbubble production or to resume microbubble production from an off state.
In at least one embodiment, the system further includes a thrombectomy device to assist in breaking up the blood clot.
In at least one embodiment, the transducer comprises one or more transducers configured for ultrasonic imaging as well as for the applying ultrasonic energy to vibrate the microbubbles.
In another aspect of the present invention, a method of treating a blood clot is provided, including: inserting a catheter into a patient; delivering low stability microbubbles toward the blood clot in the patient; measuring the diameters of the low stability microbubbles in real time; and changing the diameters of microbubbles produced by varying at least one of gas pressure and liquid flow rate input to a microfluidics device the produces the microbubbles.
In at least one embodiment, the microfluidics device comprises electrodes configured to operate as a micro Coulter device to measure changes in impedance as the microbubbles flow past the electrodes.
In at least one embodiment, the microfluidics device comprises optical waveguides configured to operate as a micro particle sizer to measure changes in optical transmission and reflections as microbubbles flow past the waveguides.
In at least one embodiment, the method further includes changing at least one of: liquid composition or gas composition to alter a half-life of the low stability microbubbles produced.
In another aspect of the present invention, a system for treating a blood clot is provided, including: a catheter configured to be inserted into a patient; and a microfluidics device contained in a distal end portion of the catheter, the microfluidics device configured to produce low stability microbubbles, the microfluidics device comprising electrodes configured to operate as a micro Coulter device to measure changes in impedance as the low stability microbubbles flow past the electrodes.
In at least one embodiment, the microfluidics device is configured to produce the low stability microbubbles having a diameter in the range of 10 μm to 35 μm.
In at least one embodiment, the microfluidics device comprises an outlet port from which the microbubbles are outputted, the catheter comprising a distal end; and wherein the outlet port is positioned at a distance in the range of from 0 mm to 3 mm from the distal end.
In at least one embodiment, the distance is in the range of from 0.5 mm to 1 mm.
In at least one embodiment, the distance is about 1 mm.
In at least one embodiment, the outlet port is positioned at a distance from the clot in the range of from about 0 mm to 5 cm.
In at least one embodiment, the outlet port is positioned at a distance from the clot in the range of from about 0 mm to 10 mm.
These and other advantages and features of the invention will become apparent to those persons skilled in the art upon reading the details of the invention as more fully described below.
Before the present methods and apparatus are described, it is to be understood that this invention is not limited to particular embodiments described, as such may, of course, vary. It is also to be understood that the terminology used herein is for the purpose of describing particular embodiments only, and is not intended to be limiting, since the scope of the present invention will be limited only by the appended claims.
Where a range of values is provided, it is understood that each intervening value, to the tenth of the unit of the lower limit unless the context clearly dictates otherwise, between the upper and lower limits of that range is also specifically disclosed. Each smaller range between any stated value or intervening value in a stated range and any other stated or intervening value in that stated range is encompassed within the invention. The upper and lower limits of these smaller ranges may independently be included or excluded in the range, and each range where either, neither or both limits are included in the smaller ranges is also encompassed within the invention, subject to any specifically excluded limit in the stated range. Where the stated range includes one or both of the limits, ranges excluding either or both of those included limits are also included in the invention.
Unless defined otherwise, all technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art to which this invention belongs. Although any methods and materials similar or equivalent to those described herein can be used in the practice or testing of the present invention, the preferred methods and materials are now described. All publications mentioned herein are incorporated herein by reference, in their entireties, to disclose and describe the methods and/or materials in connection with which the publications are cited.
It must be noted that as used herein and in the appended claims, the singular forms “a”, “an”, and “the” include plural referents unless the context clearly dictates otherwise. Thus, for example, reference to “a microbubble” includes a plurality of such microbubbles and reference to “the electrode” includes reference to one or more electrodes and equivalents thereof known to those skilled in the art, and so forth.
The publications discussed herein are provided solely for their disclosure prior to the filing date of the present application. The dates of publication provided may be different from the actual publication dates which may need to be independently confirmed.
“Erosion” as used herein, refers to the rate of removal of clot volume, expressed either in percentage per time or volume per time.
“Dissolution” as used herein refers to the gas inside a microbubble being lost through the microbubble shell or membrane.
“Low stability” as used herein, refers to having lifetime (measured by half-life, for example) being less than three minutes, possibly as little as 5-10 seconds. Examples of low stability microbubbles include those formed with an unstable shell formulation (i.e. contrary to the common goal of currently known microbubble design) and unstable gas (e.g., a gas chosen for its rapid rate of diffusion out of the shell and into the blood plasma). Examples of unstable gases include, but are not limited to: O2, N2, CO2, or blends thereof, with or without a portion of a stable gas such as C4F10 or C3F8 or SF6.
An “unstable gas”, as used herein, refers to a gas with a solubility in water that is higher than 10 mg gas per 1 L of water at 25 C. High solubility gases diffuse into water quickly and yield a microbubble with short lifetimes, i.e. an “unstable microbubble”. Examples of unstable gases include, but are not limited to: O2, N2 and CO2.
An “unstable shell formulation” or “unstable shell”, as used herein, refers to a shell formulation that forms a shell or coating at the liquid/gas interface of the microbubble that provides a weak barrier to gas diffusion out of the microbubble and into the aqueous medium. An unstable shell formulation includes one or more of the following characteristics: (1) a protein-based surfactant that is not cross-linked; (2) a lipid-based surfactant used above the melt temperature (Tm) of the lipid; (3) a lipid-based surfactant that is comprised of lipids with a single hydrophobic tail; and/or (4) a lipid-based surfactant with no pegylation.
A “stable gas”, as used herein, refers to a gas with a solubility in water that is less than 10 mg gas per 1 L of water at 25 C. Examples of stable gases, include, but are not limited to: C4F10 and SF6.
A “stable shell formulation” or “stable shell”, as used herein, refers to one or more of the following: (1) a protein-based shell material that is cross-linked; (2) a lipid-based shell material that is below its lipid melt temperature (Tm); (3) a lipid-based shell material that is comprised of lipids with two hydrophobic tails; and/or (4) a shell material that has been pegylated.
A “neuroprotective gas” as used herein, refers to one or more of a set of gases that confer neuroprotection during ischemic stroke events and reduce tissue loss due to ischemia. Examples of neuroprotective gases include, but are not limited to: hydrogen (H2), nitrous oxide (N2O), xenon, isofluorane, sevofluorane, halothane, nitric oxide (NO), or blends thereof.
The term blood clot refers to a gelatinous or semisolid mass of coagulated blood, including, but not limited to those that form a complete or partial blockage of a blood vessel, such as those blood clots that cause ischemic stroke, heart attack, etc. A “blood clot” may refer to congealed blood, for example, as occurs in hemorrhagic stroke or other cause of blood leaking from a vessel, pooling and congealing. The present invention can facilitate liquifying of the congealed blood to facility its extraction.
A purpose of the present invention is to extend the efficacious and safe window for clinical use of tPA-based therapy or other thrombolytic agent-based therapy. Microbubble fabrication techniques are used to design and provide novel microbubbles with properties specifically tailored to further enhance the adjuvant provided will permit the use of a lower dosage of thrombolytic agent compared to that applied in current techniques and thereby implicitly reduce risk of hemorrhage and/or extend the time window for safe tPA-based (or other thrombolytic agent-based) therapy. Consequently, the number of patients safely and successfully treated may be significantly increased.
Apparatus 100 includes a minimally-invasive intravascular device that applies a stream of microbubbles 30 to a target location within a vessel of the patient adjacent to a blockage/blood clot. In the embodiment shown in
A microbubble source 12 is provided in catheter 10 (preferably, but not necessarily limited to the distal end portion or distal tip of the catheter 10) to supply a stream of microbubbles that are delivered out of the distal end portion of the catheter 10 toward the blockage. Alternatively, microbubble source can be located at or in hydraulic communication with a proximal end portion of the catheter 10.
An ultrasound source (transducer or transducer array) 14 is provided in the embodiment of
An optimal therapeutic mode in one embodiment includes a 500 kHz center frequency, a 500 kPa peak negative pressure, with an on period of 1-5 s and an off period of 1-10 s, corresponding to a total duty cycle of approximately 30%. However, each of frequency, pressure and ‘on’/‘off’ times may vary. For example, frequency may range from 100 kHz to 10 MHz (although most in the 1 MHz region), peak pressure may vary from 100 kPa to 1 MPa and the on/off periods may vary extensively (e.g., 0.1-20 s with many permutations of on/off ratio). Anatomic (B-Mode) imaging is used to observe the anatomy in question. B-Mode provides cross-sectional information and assists with placing the therapeutic focus centered upon the intended target zone. Typically, the therapeutic zone will lie central in the imaging plane at some depth. When using an array-based system, the therapeutic focus can be user selected. In a simpler system, the therapeutic source may be a fixed focal depth single element transducer. Thus, the user can manipulate the imaging plane until the focal zone of the therapeutic transducer is located right over the intended anatomy—e.g. the blood clot in a blood vessel.
Doppler modes—especially Color Doppler—can be used to observe or sense the presence of blood flow. For example, during the process of opening a blood vessel previously occluded by clot, the increasing presence of blood flow indicates a positive therapeutic result. Other Doppler modes are possible—e.g. audible (PW) Doppler gives an audible indication of blood flow. Doppler, in various modes, gives an indication of velocity of flow and volume (or area) of flow. Both of these have value in guiding the procedure. PW Doppler (audible or video) provides an indication of peak blood velocity and also the approximate volumetric flow character of the blood. As blood flow is recovered as the procedure is successful in removing a clot, it is anticipated that small high velocity blood “jets” may be replaced by a wider cross-section of blood that may move a more uniform velocity. Notice that a “jet” may or may not occur in the case of a partial occlusion depending on the degree of restriction and any downstream resistance to flow. In any event, changes in blood flow quality (velocity or cross-sectional area of flowing blood) are of diagnostic and therapy guidance value. Color Doppler is usually implemented as an extension of PW Doppler. In effect PW Doppler signals are acquired across a range of lateral and depth locations according to a user selected “Color Box” that defines the region of interest to be interrogated. Peak or average velocity values are color coded and displayed. i.e. various shades of red and blue denote varying velocities of blood flowing towards or away from the transducer. Color Doppler is, by nature, more graphical than PW Doppler used to produce an audible or a velocity time varying “strip” (i.e. a moving strip showing the variance of various PW Doppler detected velocities as a function of time—typically called PW Spectral Doppler)
At the same time (or slightly prior to or slightly after) microbubbles are being streamed to the blockage and ultrasound is directed to the blockage, a thrombolytic agent is systemically introduced and delivered to the blockage in the location of surgical target area. In the embodiment shown in
Alternatively, the thrombolytic agent may be administered more locally, such as through the carotid artery, or still more locally, from the distal end portion of catheter 10. This further reduces the dosage required to be applied for efficacy and further reduces the risk of intracerebral hemorrhage. The highly localized nature of thrombolytic agent delivery from catheter 10 may enable the use of one or more thrombolytic agents that have previously failed in drug trials for treatment of blockages due to side effect risks of hemorrhage when applied systemically in doses necessarily larger than those required when delivered in a highly localized manner as described.
In the embodiment of
Using a trans-cranial, Doppler compatible, transducer and programmable scanner allows for interleaving drug delivery with anatomic and Color Doppler imaging so as to observe increasing blood flow resulting from a successful clot dissolution exercise. Consistent with previous uses of trans-cranial ultrasound for sonothrombolysis, the trans-cranial transducer may be held in a position via a head-frame positioned rigidly with respect to the head surface. Significantly, the approaches described herein enable real-time, non-invasive, radiation-free, guidance of the procedure.
The application of ultrasound agitates and/or mixes the microbubbles and thrombolytic agent and facilitates more active transport of the thrombolytic agent into the clot. The microbubbles are typically not designed to be burst by the application of ultrasound, but in the event that one or more microbubbles does burst under application of ultrasound, this may further contribute to lysis of the clot. “Anatomic” mode ultrasound is used to provide conventional ultrasound imaging of structure. No information about organ function (e.g., blood flow, etc.) is provided by anatomic mode, but a geometric map of the underlying tissue structure is provided. “Color Doppler” mode ultrasound is used to image the blood flow to show its increase as the blood clot is lysed. Also, this imaging of the flow shows where the blood clot is lysed. Further, Color Doppler mode pulses may provide some therapeutic effect. “Radiation force” ultrasound can optionally be used, as described in U.S. Pat. No. 8,622,911. However, a preferred embodiment relies on residual blood flow to carry microbubbles and drug to the clot. As the clot is lysed by application of thrombolytic agent, microbubbles and, optionally, ultrasound energy, thereto, increase of blood flow past the location of the clot can be monitored visually using the Color Doppler mode of ultrasound. Once the lysis of the blood clot has been completed, ultrasound application is discontinued and application of microbubbles is discontinued. Application of thrombolytic agent may be discontinued at this time if it has not already been discontinued (which is more typically the case) after a predetermined dosage has been applied. Catheter 10 can then be removed from the patient and the entrance opening(s) for the catheter 10 (and introduction of thrombolytic agent, when it is applied separately) is/are closed to complete the procedure.
Microbubbles can be produced by a flow-focusing microfluidic device 12′ incorporated into the distal tip of the catheter 10. Flow-focusing microfluidic devices contain micro-channels that direct the flow of gas and liquid towards a nozzle to produce micrometer sized microbubbles 30. This microbubble fabrication approach enables the production of microbubbles with diameters 36 (see
This approach has many features and characteristics: (1) increased versatility, as the composition and size can be varied “on the fly”; and (2) enables otherwise unfeasible microbubbles. Making the microbubbles at the distal tip portion 10D mitigates stability problems, as the microbubbles only have to survive a few seconds before therapeutic delivery. This may enable focal delivery of neuroprotective gases that otherwise cannot be encapsulated within conventional microbubble formulations. Further, this may enable less stable chemical formulations or less stable bubble (i.e. shell/gas) permutations and is advantageous in that relatively large microbubbles may be produced. The relatively larger microbubbles are discussed in greater detail below and are more effective in facilitating lysis than relatively smaller microbubbles. The microfluidic device 12′ may be less than about 1 mm in largest transverse cross-section and therefore can be fit inside catheter 10, for example. The arrows indicate direction of flow of liquid 28A, 28B and gas 24. In at least one embodiment, microfluidic device 12′ is manufactured using a lamination of polydimethylsiloxane (PDMS) (or similar silicone compositions), polymethylmethacrylate (PMMA), polyacrylamide, or polyimide layers making it flexible and capable of being rolled up within the tight cylindrical void of the catheter 10. In another embodiment, microfluidic device 12′ is made of glass (e.g., Schott Borofloat 33), quartz or fused silica and is small enough that it does not need to be rolled to be placed into the void of the catheter distal tip portion 10D. The glass version is capable of operating at relatively higher pressures (compared to the PDMS embodiment) and therefore provides a relatively higher rate of production of microbubbles without the need for incorporating multiple microfluidic devices 12′ in the catheter 10. In another embodiment, the microfluidic device 12′ is manufactured using photoresist (SU-8, or similar) deposited on a solid substrate (glass, sapphire, silicon, etc.) and integrated directly into the catheter, thereby forgoing the need for additional process steps such as soft photolithography (as is required for polydimethylsiloxane (PDMS) device fabrication) or glass etching.
In the embodiments shown in
Microbubbles 30 are produced with larger diameters than those that have been experimented with in the past. As noted above, microbubbles 30 preferably have diameters 30 in the range of about 8 to 25 micrometers. The ratio of microbubbles 30 having diameters in the range of about 8 to 25 micrometers to microbubbles having diameters less than about 8 micrometers should be at least 2.5/1. Ideally the microbubbles should be all the same size, which provides a more reliable and predictable response to a particular ensonification waveform. In reality, the microbubbles vary in size during initialization but once the system is initialized, it forms a steady stream of microbubbles all the same size, typically within about a 5% range of size variability. The present invention produces a stream of microbubbles of substantially the same size. However, the size of the microbubbles produced is programmable to a degree. The size of the microbubbles produced is a function of: the physical aperture size of the nozzle 26 in the microfluidics device 12′ (foremost effect), the gas pressure and the liquid flow rate. Broadly speaking, increasing gas pressure increases microbubble size and increasing liquid flow rate reduces microbubble size, given a fixed aperture size. The larger diameters result in larger driving velocities of the microbubbles 30, compared to the velocities of smaller microbubbles driven by the same ultrasonic force. Further, the larger microbubbles are only problematic if they aggregate downstream after dissolution of the clot. By designing the microbubbles so that they dissolve or disintegrate within a short time after their production, this ensures that the microbubbles, after being applied to the clot, will dissolve or disintegrate shortly thereafter to as to eliminate the risk of accumulating downstream and causing problems. In one embodiment, microbubbles 30 comprising shells made from 3% albumin, 10% dextrose in 0.9% saline (i.e., 0.9% NaCl in water with 3% by weight albumin), the remaining 87% being 0.9% saline) and filled with N2 gas yields a microbubble half-life of approximately twenty seconds. Replacing the N2 with CO2 shortens the half-life of the microbubble. The half-life values have been measured in the following ways: (1) direct observation of microbubble dissolution via light microscopy, (2) measuring microbubble concentration and size using a Coulter counter, (3) monitoring the intensity of the backscattered acoustic signal produced by a population of microbubbles as they dissolve. The term “half-life” is used here to denote the time it takes for half of the microbubbles to vanish and is independent of the method used to measure vanishment of the microbubbles.
The erosion (rate of removal) of a clot is dependent upon the amount of thrombolytic agent applied and the characteristics of the microbubbles and, optionally, ultrasonic driving force applied thereto. In general, as the concentration of thrombolytic agent increases, the erosion increases. However, the risk of hemorrhage also increases. The large microbubbles provided by the present invention increase the erosion of a clot, relative to application of smaller microbubbles using the same ultrasonic energy and concentration of thrombolytic agent.
Because of the design of the microbubbles of the present invention to dissolve shortly after use, these larger microbubbles can be effectively used to erode a clot. Because they are more effective, a relatively lower amount/concentration of thrombolytic agent can be used effectively, thereby lowering the risk of hemorrhage.
The microbubble gaseous core 34 (see
The dissolution of the microbubbles is designed to occur as quickly as possible once the microbubbles 30 have passed the surgical target area, e.g., after erosion of the clot to the extent that the microbubble flows downstream thereof. Depending upon the blood flow conditions, the dissolution rate designed into the microbubbles can vary. For example, the half-life of the microbubbles is preferably less than thirty seconds, more preferably less than twenty seconds.
Real-time feedback regarding the production rate and size of the microbubbles 30 may be achieved by incorporating monitoring technology directly into the microfluidic chip 12′. One preferred embodiment uses multiple nonpolarizing (e.g. AgCl) electrodes 46 (see
Real-time feedback supplied by the monitoring electrodes 46 may be incorporated into an automated feedback loop to adjust gas pressure and liquid flow rates to maintain stable microfluidic device operation. In addition, monitoring production rate will provide guidance on how many microbubbles 30 have been administered to the patient for dose reporting purposes.
As noted above, as an alternative to the embodiment described with regard to
Any of the embodiments described in U.S. patent application Ser. No. 12/739,128 (Now U.S. Pat. No. 8,622,911), Ser. Nos. 13/306,391 and 14/063,830 can be used in the present invention as an alternative to that described with regard to
Still referring to
It should be appreciated that the aforementioned catheter 10, microbubble reservoir or channel 12, 12′ ultrasound transducer(s) 50, and controller may be disposed entirely inside the patient 1, or some components may be located outside of the patient 1, as already noted. The surgical target area is preferably within a cerebral artery, but could additionally or alternatively be in one or more arteries downstream of cerebral arteries; other blood vessels; an organ, including hollow organs and/or, solid organs; parenchymal tissue; stromal tissue; a tubular anatomical structure, including, but not limited to ducts.
The imaging transducer/transducer array 54 and the delivery/radiation force transducer/transducer array 52 may be identical. Whereas it is sometimes necessary to optimize two transducers for two functions it is also feasible, if the transducer possesses sufficient performance versatility (e.g. high frequency bandwidth and high power capability) to use the same transducer for both imaging and therapeutic function.
Another alternative that may be employed with any of the systems 100 described above, is to deliver the antithrombolytic agent directly from the catheter 10 rather than introducing the antithrombolytic agent systemically, such as through an intravenous drip. Further alternatively, rather than an IV drip or delivery directly from the catheter 10, the antithrombolytic agent can be dispensed into the carotid artery. These alternative approaches, involving dispensation of the antithrombolytic agent in the carotid artery or within the occluded vessel, will enable a further, potentially very significant, reduction in dosage of antithrombolytic agent that is required to be effective, with consequent reduced risk of intracerebral hemorrhage. The highly localized nature of drug delivery (using administration from the catheter 10) may enable the use of alternative antithrombolytic agents, such as previously investigated drugs that failed in trials due to side-effect risk (e.g. hemorrhage). Thus, “failed” drugs may potentially be resurrected if they are found to be relatively safe and effective at the lower dosage levels permitted by direct delivery through the catheter 10.
In at least one embodiment, any of the embodiments of system 100 described herein can be used in combination with a thrombectomy device. Examples of thrombectomy devices that can be used include, but are not limited to: the MERCI® retriever (Stryker Corporation, Kalamazoo, Mich.) (a shape metal alloy corkscrew-like device) and the PENUMBRA™ devices (Penumbra, Inc., Alameda, Calif.) (based upon an aspirator in combination with a small metal hook-like device to break apart a clot). During deployment of each of these devices, arterial flow is restricted by a proximally placed balloon—to minimize risk of embolism resulting from clot fragment being swept distal with respect to original clot position. Furthermore, the present systems 100 can be paired with other devices currently in development.
When applying ultrasound trans-cranially, optimum intensity of ultrasound energy applied to the microbubbles 30 to effect erosion of the clot will vary, depending upon the thickness of the patient's skull and the anatomy of the target region. In many cases, it is possible to cause a cavitation event to occur—i.e. to cause one or more microbubbles 30 to “explode”. The sound produced by the explosion provides a one-way sound source from a single target location. The sound associated with the cavitation is akin to an ideal point acoustic source making it near perfect as a unique source upon which receive channel data can be processed. In this model, a single target source signal is known to come from a single point in the brain. However, the signal will be aberrated (time shifted) due to different path lengths in materials possessing different speeds of sound. The bone of the skull has a far higher speed of sound than soft tissue, and it is non-uniformly thick. Methods for processing the detected time of arrivals to calculate the required aberrating delay corrections (to be applied in either or both transmit and receive mode) are well known. For example, refer to: Dorny, “A self-survey technique for self-cohering of antenna systems” Antennas and Propagation, IEEE Transactions on (Volume: 26, Issue: 6) pp 877-881 1978, which is hereby incorporated herein, in its entirety, by reference thereto. More advanced phase aberration corrections approaches may also be used. These latter approaches are less onerous in terms of their need for a “beacon”. For example, refer to the following article incorporated herein, in its entirety, by reference thereto: Flax and O'Donnell “Phase-aberration correction using signals from point reflectors and diffuse scatterers: basic principles” IEEE Trans Ultrason Ferroelectr Freq Control. 1988; 35(6):758-67.)
By applying a “micro dose” comprising a very small percentage of a conventional dose (e.g., a few thousands or a few tens of thousands) of microbubbles 30, there will be sufficient single microbubbles 30 in the field of view that each can be clearly differentiated—especially if using a nonlinear sensitive imaging technique such as those widely known in the field—e.g. pulse inversion, amplitude modulation or the combination “contrast pulse sequences”. Once the signals from isolated microbubbles 30 are used as a beacon to calculate aberrating delays and these delays are superimposed in either or both transmit and receive modes, the system 100 can step into a mode wherein it incrementally increases transmit power until microbubble 30 destruction is observed to start occurring—i.e. a threshold effect. Since, as noted, destruction/explosion of microbubbles 20 is not preferred for the erosion applications described herein, the detection of the destruction threshold (the intensity level at which destruction/explosion of microbubbles substantially begins) allows the system 100 to back off from this threshold to some determined optimal level. For example, it may back off to 50% of the transmit power required to induce immediate microbubble 30 destruction, although some other predetermined percentage less than one hundred percent may be alternately programmed into the system 100, such as, but not limited to: 90%, 80%, 70%, 60%, etc. In this way, the system 100 rapidly determines an optimal phase aberrating correction and power setting that is precisely adaptive to a particular patient 1 and skull/target geometry. Once this calibration exercise is complete, the system 100 displays an indication that this step is complete (e.g. a “ready” light) and the user can dispense a full dose of microbubbles 30. At this time, the system 100 will operate at the optimal aberrating correction and power level to effect optimal, yet safe, thrombolytic drug delivery and clot lysis.
In at least one embodiment, side and/or forward-looking ultrasound imaging may be used to facilitate a fluoroscopy-free procedure. As one non-limiting example, transducer 50 of the embodiments of
The system may be provided with dedicated ultrasound hardware. This is particularly relevant for embodiments where non ultrasound imaging is performed, but only driving, acoustic force is applied for microbubble and drug delivery. In these cases, the ultrasound instrumentation may comprise relatively inexpensive hardware to generate the requisite simple pulse shapes and intensities.
Catheter 10′ is configured to produce and deliver microbubbles 30 via microfluidics device 12′ at a rate of greater than or equal to 100,000 microbubbles per second, up to tens of millions of microbubbles per second, preferably in a range of 100,000 to 1,000,000 microbubbles per second, and having a diameter in the range of 10 μm-35 μm. Preliminary experimentation has indicated that 100,000 microbubbles/second is a sufficient production rate to produce a saturation level of microbubble deposition on a realistic size clot target (e.g., a clot target having a cross sectional dimension in the range from about 0.3 mm to about 3 mm, typically in the range from about 0.5 mm to about 2 mm). The microbubbles 30 can be assessed in terms of diameter and production rate using electrical impedance monitoring (“micro Coulter”). Microfluidics device 12′ includes electrodes 1146 placed in the inlet ports (see
When using a voltage >0.5 V, irreversible electrolysis can occur in the microchannels of the device 12′, but higher frequencies (>500 kHz) can be used to avoid gas bubble formation in the microchannels. Additionally, platinum black can be used on the electrodes to decrease the double layer capacitance to diminish electrolytic effects.
Alternatively, optical waveguides operating in either transmission or reflection mode may be used to measure microbubble diameter and production rate.
The following examples are put forth so as to provide those of ordinary skill in the art with a complete disclosure and description of how to make and use the present invention, and are not intended to limit the scope of what the inventors regard as their invention nor are they intended to represent that the experiments below are all or the only experiments performed. Efforts have been made to ensure accuracy with respect to numbers used (e.g. amounts, temperature, etc.) but some experimental errors and deviations should be accounted for. Unless indicated otherwise, parts are parts by weight, molecular weight is weight average molecular weight, temperature is in degrees Centigrade, and pressure is at or near atmospheric.
A catheter based-system employing a microfluidics device 12′ in a catheter having an outside diameter of 2 mm and a length of 2 m, with the tubing of the catheter being made of PE50 and having a 250 um inside diameter was developed and tested. The microfluidics flow-focusing device 12′ produced microbubbles 30 having albumin shells and nitrogen cores, using 3% albumin, 10% dextrose in 0.9% saline with N2 gas. The microbubbles 30 were delivered out of the port 26 of the microfluidics device 12′ and out of the catheter for over thirty minutes. It is believed that thirty minutes should be a good approximation of the time required for a catheter based clot disintegration procedure in vivo. The microbubbles produced were large, having diameters in the range of about 5 μm to about 20 μm that, by design, dissolved rapidly after production. For in vivo administration, this will mitigate the risk of emboli in small, downstream capillary blood vessels and/or other downstream vessels or locations.
The large microbubbles produced yield greater bioeffects than those of smaller diameter (e.g., 2 μm average), and, because of their predesigned low stability (rapid dissolution after production) will increase the rate of clot lysis (relative to a similar treatment using 2 μm average diameter microbubbles), without the increased risk of embolism downstream.
In a prior art example, microbubbles having a lipid shell and sulfurhexafluouride gas with a concentration in the range of 2 to 5×108 microbubbles/ml and mean diameter of 2.5 μm and recombinant tissue plasminogen activator (rt-PA) at a concentration of 0.3 mg/ml were delivered through a 140 cm long catheter having 0.45 mm diameter inner lumen, to a clot formed in a polyimide tube having a 6 mm inner diameter. Ultrasound was delivered to the clot over a ten minute treatment period with peak rarefaction acoustic pressure of 2.1 MPa and a duty cycle of 4%. The microbubbles and rt-PA were concurrently delivered over a period of two
minutes at a flow rate of 18 ml/h. After the treatment period, the clot was removed and weighed to determine a clot lysis percentage expressed as a percentage of the clot weight after the procedure, as compared to the clot weight prior to the procedure. Clot lysis percentage approached 60%. Further details of this example can be found in Soltani et al., “Potentiating intra-arterial sonothrombolysis for acute ischemic stroke by the addition of the ultrasound contrast agents”, J Thromb Thrombolysis, 2011 January; 31(1):71-84, which is incorporated herein, in its entirety, by reference thereto.
In an example according to an embodiment of the present invention, microbubbles having a 3% albumin and 10% dextrose shell and N2 gas with a concentration in the range of 50,000 microbubbles/ml and mean diameter of 20 μm and recombinant tissue plasminogen activator (rt-PA) at a concentration of 3 mg/ml were delivered through a 20 cm long catheter comprised of PE50 tubing, to a clot formed in a transparent PTFE tube having a 4 mm inner diameter. Ultrasound was delivered to the clot over a 30 minute treatment period with 200 kPA peak negative pressure, frequency of 1 Mhz and duty cycle of 30%. The microbubbles and rt-PA were concurrently delivered over a period of 30 minutes at a flow rate of 12 ml/min Throughout the treatment period, clot diameter was monitored microscopically. Peak clot erosion rates of approximately 30 um/min were recorded, as compared to 10 um/min when using 3 mg/ml (rt-PA) alone.
Color Doppler imaging using a high frequency clinical scanner provides valuable real-time guidance on the evolution and location of a stroke in the rat brain.
Preliminary clot erosion data was obtained using an Olympus/Panametrics 1 MHz V303-SU transducer. For determining clot erosion according to an embodiment of the present invention, a 5 mm diameter, 1 MHz transducer with a 15 mm nominal focus will be used. The offset from the center of the imaging plane from the center of the delivery transducer will be recorded and used so that once a desired image plane (or sequence of planes) is established, the translation offset is compensated for precisely to assure reliable ensonification of the desired tissue region. A stepper-controlled translation stage will be used to enable precise, repeatable, scanning of the high frequency imaging array. The paired imaging and Panametrics transducers will be mounted in a 3D printed plastic holder.
Varying gas composition of the microbubbles 30, versus the gas in surrounding liquid, affects microbubble 30 stability. Currently, the least stable microbubbles of the present invention have a half-life of <20 s. The stability can be varied, as noted above, by modifying the gas composition inside the microbubbles. For example, by choosing a highly stable gas with low rate of diffusion (e.g., C4F10), longevity of several minutes is achievable. Adding O2, or N2, will decrease longevity. Adding or increasing CO2 will provide microbubbles 30 having the shortest half-lives. Increasing C4F10, (or C3F8) will increase half-life. The shell composition can also be altered to change half-life performance. In one example, shell composition contains 3% albumin, 10% dextrose.
The clot formation and erosion process is highly complex and dependent on many interconnected factors. An in vitro human blood clot model was developed to assess clot erosion based on the following measurements: (1) linear erosion rate (μm/min) derived from microscopic images; (2) relative volumetric erosion rate derived from colorimetric quantification of red blood cells released from the clot; (3) fibrinolysis rates derived from the release of Fluorescein isothiocyanate (FITC_-labeled fibrinogen incorporated within the clot, and (4) microscopic video evaluation of clot “break-off” fragment size. The in vitro experimental apparatus 1300 is shown in
While the present invention has been described with reference to the specific embodiments thereof, it should be understood by those skilled in the art that various changes may be made and equivalents may be substituted without departing from the true spirit and scope of the invention. In addition, many modifications may be made to adapt a particular situation, material, composition of matter, process, process step or steps, to the objective, spirit and scope of the present invention. All such modifications are intended to be within the scope of the claims appended hereto.
This application is a continuation-in-part application of co-pending application Ser. No. 14/063,830, filed on Oct. 25, 2013, which is a continuation application of application Ser. No. 12/739,128, filed on Aug. 9, 2010, now U.S. Pat. No. 8,622,911, issued on Jan. 7, 2014. Application Ser. No. 12/739,128 is an application that was filed under 35 U.S.C. 371 claiming priority to International Application PCT/US2008/081189, filed Oct. 24, 2008, which claims priority to U.S. Provisional Application Ser. No. 61/000,632, filed Oct. 26, 2007, entitled “Molecular Targeted Microbubbles for Enhanced Blood Vessel Imaging and Therapeutic Treatment of Neointimal Hyperplasia;” and U.S. Provisional Application Ser. No. 61/099,025, filed Sep. 22, 2008, entitled “Molecular Targeted Microbubbles for Enhanced Blood Vessel Imaging and Therapeutic Treatment of Neointimal Hyperplasia”. Each of the aforementioned applications and patent is hereby incorporated herein, in its entirety, by reference thereto, and we claim priority to each of the aforementioned applications.
This invention was made with government support under Federal Grant No. HL090700 and Federal Grant No. 5R01EB002185-7, awarded by The National Institutes of Health. The Government has certain rights in the invention.
| Number | Date | Country | |
|---|---|---|---|
| 61000632 | Oct 2007 | US | |
| 61099025 | Sep 2008 | US |
| Number | Date | Country | |
|---|---|---|---|
| Parent | 12739128 | Aug 2010 | US |
| Child | 14063830 | US |
| Number | Date | Country | |
|---|---|---|---|
| Parent | 14063830 | Oct 2013 | US |
| Child | 14736191 | US |
