Patent Grant
9415195
1. Field of the Invention
Medical apparatus and methods for treatment related to expandable prosthesis and methods for treating abdominal and other aneurysms are disclosed.
Aneurysms are enlargements or “bulges” in blood vessels which are often prone to rupture and which therefore present a serious risk to the patient. Aneurysms may occur in any blood vessel but are of particular concern when they occur in the cerebral vasculature or the patient's aorta.
There is concern about aneurysms occurring in the aorta, particularly those referred to as aortic aneurysms. Abdominal aortic aneurysms (AAA's) are classified based on their location within the aorta as well as their shape and complexity. Aneurysms which are found below the renal arteries are referred to as infrarenal abdominal aortic aneurysms. Suprarenal abdominal aortic aneurysms occur above the renal arteries, while thoracic aortic aneurysms (TAA's) occur in the ascending, transverse, or descending part of the upper aorta.
Infrarenal aneurysms are the most common, representing about seventy percent (70%) of all aortic aneurysms. Suprarenal aneurysms are less common, representing about 20% of the aortic aneurysms. Thoracic aortic aneurysms are the least common and often the most difficult to treat. Most endovascular systems are also too large (above 12 F) for percutaneous introduction.
The most common form of aneurysm is “fusiform,” where the enlargement extends about the entire aortic circumference. Less commonly, the aneurysms may be characterized by a bulge on one side of the blood vessel attached at a narrow neck. Thoracic aortic aneurysms are often dissecting aneurysms caused by hemorrhagic separation in the aortic wall, usually within the medial layer. The most common treatment for each of these types and forms of aneurysm is open surgical repair. Open surgical repair is quite successful in patients who are otherwise reasonably healthy and free from significant co-morbidities. Such open surgical procedures are problematic, however, since access to the abdominal and thoracic aortas is difficult to obtain and because the aorta must be clamped off, placing significant strain on the patient's heart.
Over the past decade, endoluminal grafts have come into widespread use for the treatment of aortic aneurysm in patients who cannot undergo open surgical procedures. In general, endoluminal repairs access the aneurysm “endoluminally” through either or both iliac arteries in the groin. The grafts, which typically have been fabric or membrane tubes supported and attached by various stent structures, are then implanted, typically requiring several pieces or modules to be assembled in situ. Successful endoluminal procedures have a much shorter recovery period than open surgical procedures.
Present endoluminal aortic aneurysm repairs, however, suffer from a number of limitations. A significant number of endoluminal repair patients experience leakage at the proximal juncture (attachment point closest to the heart) within two years of the initial repair procedure. While such leaks can often be fixed by further endoluminal procedures, the need to have such follow-up treatments significantly increases cost and is certainly undesirable for the patient. A less common but more serious problem has been graft migration. In instances where the graft migrates or slips from its intended position, open surgical repair is required. This is a particular problem since the patients receiving the endoluminal grafts are those who are not considered good candidates for open surgery. Further shortcomings of the present endoluminal graft systems relate to both deployment and configuration. Multiple component treatment systems require additional procedure time to allow for introduction of each piece and even more time for assembling the pieces in situ. Such techniques are not only more time consuming, they are also more technically challenging, increasing the risk of failure. Current devices are also unsuitable for treating many geometrically complex aneurysms, particularly infrarenal aneurysms with little space between the renal arteries and the upper end of the aneurysm, referred to as short-neck or no-neck aneurysms. Aneurysms having torturous geometries, are also difficult to treat.
For these reasons, it would desirable to provide improved methods, systems, and prosthesis for the endoluminal treatment of aortic aneurysms. Such improved methods, systems, and treatments should provide implanted prosthesis which result in minimal or no endoleaks, which resist migration, which are relatively easy to deploy, which have a low introduction profile (preferably below 12 F), and which can treat most or all aneurysmal configurations, including short-neck and no-neck aneurysms as well as those with highly irregular and asymmetric geometries.
2. Description of the Background Art
Grafts and endografts having fillable components are described in U.S. Pat. Nos. 4,641,653; 5,530,528; 5,665,117; 5,769,882; and 7,530,988; U.S. Patent Publication 2004/0116997; and PCT Publications WO 00/51522 and WO 01/66038.
Methods, systems, and apparatuses for the endoluminal treatment of aneurysms, particularly abdominal aortic aneurysms (AAA's) and thoracic aortic aneurysms (TAA's) are provided herein. Generally, the prostheses comprise double-walled filling structures which have outside walls that are compliant or otherwise adapted to substantially fill the enlarged bulk volume of an aneurysm, particularly a fusiform aneurysm, leaving a lumen in place for blood flow.
The double-walled filling structures will thus usually have a generally toroidal structure with an outer wall, an inner wall, a potential space or volume between the outer and inner walls to be filled with a filling medium, and a generally tubular lumen inside of the inner wall which provides the blood flow lumen after the prosthesis has been deployed. The shape of the filling structure is adapted to conform to the aneurysm being treated during deployment. The filling structure size can be chosen from among a few sizes to match the needs and dimensions that might be needed by nearly all patients for treating their particular aneurysmal as determined by using imaging and computer-aided diagnostic techniques. A family or collection of available filling structures may include different geometries and sizes (lengths and lumen diameters) so that a treating physician may select a specific filling structure to treat a particular patient based on the size and geometry of that patient's aneurysm. By using the method and apparatuses described herein, each device can treat a large range of different sized anatomies, such that only a few different size devices need be kept in inventory to be prepared to treat the full range of approved aortic aneurysmal disease indications. Generally, the outer wall of the filling structure conforms or is conformable to the inner surface of the aneurysm being treated, while the inner wall of the structure is substantially aligned with lumens of the blood vessels upstream and downstream of the prosthesis after the prosthesis has been deployed.
The filling structures of the prosthesis will usually be formed from a compliant material, such as silicone, polyurethane, latex, or combinations thereof.
The walls of the filling structures may consist of a single layer or may comprise multiple layers which are laminated or otherwise formed together. Different layers may comprise different materials, including both compliant and/or non-compliant materials. The walls may also be structurally reinforced in various ways, including use of braided reinforcement layers, filament reinforcement layers, and the like. In some embodiments, the system may include self-expanding scaffolds within the filling structures so that the structures can be initially delivered and allowed to self-expand at the treatment site, thus obviating the need for the structures associated with a balloon delivery catheter as described below.
In many embodiments, delivery protocols described utilize delivery catheters having a balloon or other expandable support for carrying the filling structure. When using balloons, the balloons may be substantially or entirely compliant, although non-compliant and combination compliant/non-compliant balloons may also be used. The balloon or other mechanical expansion components of the delivery catheter will initially be disposed within the inner tubular lumen of the filling structure, with the filling structure generally being collapsed into a low width or low profile configuration over the expansion element. The delivery catheter may then be introduced intraluminally, typically into each iliac artery and upwardly to the region within the aorta to be treated. Such delivery catheters may also include one or more lumens, tubes, or other components or structures for delivering the filling medium in a fluid form to an internal filling cavity of the filling structure. Thus, the delivery catheters can be used to both initially place and locate the filling structure of the prosthesis at the aneurysmal site. Once at the aneurysmal site, the internal tubular lumens of the structures can be expanded simultaneously using the balloons or other expandable elements on the delivery catheters. The filling structures (separate from the expansion of the tubular lumen) will be filled and expanded by delivering the filling medium via the catheters into the internal volume of the filling structures. Generally, both expansion and filling operations are performed simultaneously for a reliable and consistently predictable treatment result, or can be individually expanded in either order, e.g. the filling structure may be filled first with the delivery catheter balloon being expanded second, or vice versa, as desired or if simultaneous expansion and filling can for some reason not be performed. The filling structure(s) and/or delivery balloons may have radiopaque markers to facilitate placement and/or pressure sensors for monitoring filling and inflation pressures during deployment. The simultaneous filling allows structures to automatically accommodate one another and does not require the operator take extra special care as is often necessary when pressurization of adjacent separate structures is done separately and not simultaneously from a common source.
As described below, the filling structure may be filled with filling medium at a pressure from 100 mm of Hg to 330 mm of Hg, as needed to achieve or slightly exceed the patient's systolic blood pressure to have the fill bag displace the blood already in the circulatory system; too high a pressure in a compliant balloon can create excess stress on the already weakened aneurysmal wall, thus should be avoided. The above pressures are gage pressures, i.e. measured relative to atmospheric pressure.
The sequential delivery of two prostheses and their respective filling structures may be utilized to initiate treatment of aneurysms located adjacent a vessel bifurcation, such as infrarenal abdominal aortic aneurysms. Two filling structures are introduced in a generally adjacent, parallel arrangement within and substantially spanning the aneurysmal volume and sac. In the specific case of infrarenal aneurysms, each prosthesis is typically delivered separately, one through each of the two iliac arteries. After locating the filling structures of the prosthesis within the aneurysmal space, to achieve an optimal result, they can be filled simultaneously using a pressurization manifold console, particularly a single operator pressurization manifold console, so as to fill and occupy substantially the entire aneurysmal volume, forming a pair of blood flow lumens spanning the aneurysmal sac.
Suitable filling materials typically include a fluid (often having a low viscosity), at least initially, to permit delivery through connected piping in the delivery catheter and may be curable or otherwise hardenable so that, once in place, the filling structure forms a final shape which will remain after the delivery catheter is removed. The fillable materials will usually be curable polymers which, after curing, will have a fixed shape with a Shore hardness typically in the range from 10 durometer to 140 durometer. The polymers may be delivered as liquids, gels, foams, slurries, or the like. The polymers may be epoxies or other curable two-part systems. In other embodiments, the polymer may comprise a single material which when exposed to the vascular environment within the filling structure changes state over time, typically from zero to ten minutes.
After curing, the filling material may have a specific gravity, typically in the range from 0.1 to 5, more typically from 0.8 to 1.2 which is generally the same as blood or thrombus. The filling material may also include bulking and other agents to modify density, viscosity, mechanical characteristics or the like, including microspheres, fibers, powders, gasses, radiopaque materials, drugs, and the like. Exemplary filling materials include polyurethanes, collagen, polyethylene glycols, microspheres, and the like.
Preferably, the filling structures of the prosthesis will require no additional sealing or anchoring means to hold them in place within the aneurysm. In some instances, however, it may be desirable to employ additional sealing or anchoring mechanisms, such as stents, scaffolds, hooks, barbs, sealing cuffs, and the like. For sealing cuffs or stents which extend proximally of infrarenal prosthesis, it may be desirable to provide openings or ports to allow the anchoring or sealing devices to extend over the renal ostia while penetrating blood flow into the renal arteries. The sealing or anchoring devices typically attach to and/or overlap with the filling structure of the prosthesis and provide for a smooth transition from the aortic and/or iliac lumens into the tubular lumens provided by the deployed filling structures.
The filling structures may be modified in a variety of ways. For example, the external surfaces of the filling structures may be partially or entirely modified to enhance placement within the aneurysmal space, typically by promoting tissue ingrowth or mechanically interlocking with the inner surface of the aneurysm. Such surface modifications include surface roughening, surface stippling, surface flocking, fibers disposed over the surface, foam layers disposed over the surface, rings, and the like. The filling structures may also include biologically active substances over all or a portion of the external surface of the filling structure, such as thrombogenic substances, tissue growth promotants, biological adhesives, and the like. The filling structures may further include synthetic adhesives, such as polyacrylamides, over the surface to enhance adherence.
In some applications, it may be desirable to modify all or a portion of the internal surface of the filling cavity of the filling structure. Such surface modifications may comprise surface roughening, rings, stipples, flocking, foam layers, fibers, adhesives, and the like. The purpose of such surface modification is usually be to enhance the filling and bonding to the filling material, and to control the minimum wall thickness when the structure is filled particularly after the filling material has been cured. In particular instances, such as in locations of the filling structure which are pressed together when the structure is deployed, thus potentially excluding filling material, it may be desirable if the surfaces of the filling structure adhere directly to each other.
In view of the above general description, specific embodiments are described and discussed herein. Methods for treating an aneurysm comprise positioning at least two double-walled filling structures across the aneurysm. By “across” the aneurysm, it is meant generally that the filling structure will extend axially from one anatomical location which has been identified by imaging or otherwise as being the beginning of the aneurysm to a second location (or locations in the case of bifurcated aneurysm) where it has been similarly established that the aneurysm ends. After positioning, the two filling structures are filled simultaneous by using a manifold console, particularly a single operator manifold console, to which the filling lines for the structures are securely coupled so that a fluid filling medium is supplied and causes an outer wall of the structure to expand and conform to the inside of the aneurysm and its complementary companion structure and an inner wall of the structures form generally tubular lumens to provide for blood flow after the filling structures have been deployed. The tubular lumens will preferably be supported, typically by a balloon or mechanically expansible element, while the filling structures are being filled, after the filling structures have been filled, or during both periods. After the filling structures have been filled, the filling material or medium is hardened while the tubular lumens remain supported. Supporting the tubular lumens during hardening assures that the lumens have a desired geometry, properly align with adjacent vascular lumens, and that the tubular lumens being formed remains aligned with the native aortic and/or iliac artery lumens after the prostheses have been fully implanted. The support may be provided by a balloon which extends proximally and distally of the filling structure where the balloon may slightly “overexpand” in order to assure the desired smooth transition and conformance of the tubular lumen provided by the filling structure with the native vessel lumens.
After hardening, the support (such as an endoframe) may be left in place, (if not obstructing blood flow) or may be removed, leaving the filling structure in place. In most instances, however, prior to hardening, it will be desirable to confirm proper placement of the filling structure. This can be done using imaging techniques or otherwise testing for patency and continuity. In some instances, it may be desirable to first fill the filling structure with saline or other non-hardenable substance to make sure that the geometry of the filling structure is appropriate for the patient being treated. After testing, the saline may be removed and replaced with the hardenable filler. Through the use of only a few sizes to cover most aneurysmal configurations, the use of a step of prefilling the filling structure with saline and the time expenditure associated with such a step can be avoided.
Treating abdominal aortic aneurysms may comprise use of a first double-walled filling structure and a second double-walled filling structure. The first and second filling structures are adapted to be simultaneously filled with a hardenable filling medium while they positioned adjacent to each other within the aneurysm. The systems further comprise first and second delivery catheters which can be used to align each of the first and second filling structures properly with the right and left iliacs and the infrarenal aorta as they are being deployed, filled, and hardened.
Thus a method for treating an aneurysm includes the steps of: positioning at least two double-walled filling structures having an aneurysm conforming outer wall and a blood transit lumen creating inner wall through two separate arteries across the one aneurysm to be treated; supporting the inner walls of the blood transit lumens with a support structure; causing the support structure to expand wherein each expanded support structure defines the shape of a corresponding expanded blood transit lumen; simultaneously filling the filling structures with a fluid filling medium so that their outer walls conform to the inside of the aneurysm and to each other thereby creating a blood transit barrier substantially filling the bulk volume of the aneurysm and substantially preventing blood transit between the aneurysm conforming outer wall and the inside of the aneurysm and the inner walls surround the expanded support structure to contain blood in each corresponding expanded blood transit lumen; hardening the filling medium; and removing fill lines connected to each of the double-walled filling structures after the fluid filling medium has hardened, wherein the fluid filling structure is filled with fluid filling medium at a filling pressure exceeding the systolic blood pressure experienced by the aneurysm and wherein the expanded support structure provides an outward force which is greater than the inward force applied by the filling pressure. The support structure may be an endoframe. The filling pressure may be in the range from 100 mm Hg to 330 mm Hg. The fluid filling medium can be a flowable polymer which is curable in situ. The polymer can be a polyurethane, a polyethylene glycol, or a collagen. The fluid filling medium can have a density in the range from 0.1 gm/cc to 5 gm/cc when hardened. The fluid filling medium comprises a two-part curable material which hardens after mixing. The method may include positioning an anchor or sealing element within at least one opening of the tubular lumen of the filling structure, wherein the anchor or sealing element extends from the lumen of the filling structure into a lumen of the blood vessel and/or positioning an anchor or sealing element at each opening.
Another method for treating an abdominal aortic aneurysm between the iliacs and the renal arteries, includes: positioning a first double-walled filling structure on a first endoframe from one iliac artery and artery access site, across the aneurysm, and into the aorta beneath the renal arteries, wherein the first endoframe shapes the entire length of a first tubular lumen; positioning a second double-walled filling structure on a second endoframe from the other iliac artery and artery access site, across the aneurysm, and into the aorta beneath the renal arteries and adjacent to the first double-walled filling structure, wherein the second endoframe shapes the entire length of a second tubular lumen; causing the first endoframe and the second endoframe to be expanded to create a first expanded tubular lumen and a second expanded tubular lumen; simultaneously filling the first filling structure and the second filling structure with a fluid filling medium so that an outer wall of the first filling structure and the second filling structure conform to an inside surface of the aneurysm and the first filling structure and second filling structure conform to each other and an inner wall of the first filling structure and the second filling structure each form a generally tubular lumen with a shape defined by the expanded first tubular lumen and the expanded second tubular lumen from the first iliac and the second iliac to the aorta beneath the renal arteries; simultaneously hardening the fluid filling medium in the first filling structure and the second filling structure while the first endoframe continues to define the shape of the expanded first tubular lumen and the second endoframe continues to define the shape of the expanded second tubular lumen. The first and the second endoframes may extend upstream and downstream from each double-walled filling structure of the first filling structure and the second filling structure so that each endoframe aligns and conforms each end of the filling structure with the iliac and aorta. An outer wall of the first filling structure or the second filling structure may be formed from a compliant material and/or from a non-compliant material or a combination thereof. Each endoframe can include a mechanical structure expandable to one or more fixed diameters. Each filling structure can be filled with fluid filling medium at filling pressure and each expanded endoframe resists the force of the filling pressure surrounding it and maintains the expanded shapes of the first and second tubular lumens. The filling pressure may be in the range from 100 mm Hg to 330 mm Hg. An anchor or sealing element may be positioned at one or more openings from the tubular lumen of at least one of the filling structures to a lumen of the iliac or aorta.
Another method of treating an aortic aneurysm using two catheters each having a sheath holding compressed within one or more expandable endobags in fluid communication with one another and an endobag fill line surrounding a compressed endoframe includes the steps of: threading a catheter into each of two separate femoral arteries of a patient to be treated and into the aorta with a common end of each endoframe of the catheters being positioned near a proximal end of an aneurysmal sac of the aneurysm to be treated, wherein the proximal ends of the endoframes of each of the catheters are positioned adjacent one another in anticipation of expansion of the endoframes of each of the adjacent catheters in a configuration ensuring substantially unobstructed blood flow through each lumen of the expanded endoframes; wherein the common end of the endoframes are at the substantially the same level and at a location in the aorta adjacent to where landing of the common ends of the endoframes is intended; removing the sheath exposing the expandable endobag and expanding the compressed endoframe of each of the two catheters; establishing communication between a fill line for an expandable endobag of a first of the two catheters and a fill line for an expandable endobag of a second of the two catheters and a curable filler material source to form an endobag filler circuit; monitoring and controlling the pressure within the endobag filler circuit while using one source of curable filler material to pressurize the endobag filler circuit thereby simultaneously pressurizing the fill line for each expandable endobag of the two catheters causing the expandable endobags disposed across the aneurysm within the patient to inflate to fill the aneurysm and press against each other and the aneurysmal wall, wherein controlling the pressure within the endobag filler circuit consists of filling of the endobag filler circuit until the maximum pressure reading monitored during pressurization is at least equal to the systolic blood pressure of the patient being treated, wherein the maximum pressure reading monitored during pressurization is established when curable filler material injection causing the pressurizing of the endobag filler circuit is stopped and steady state endobag circuit pressure is measured; maintaining the pressure within the endobag filler circuit for a curing time allowing the curable filler material to cure; detaching the endobag fill lines from their respective endobags and removing the two catheters from the patient.
A system for treating an aneurysm includes: a first catheter and a second catheter each catheter having a double-walled filling structure with an aneurysm conforming outer wall and a blood transit lumen creating inner wall, known as an endobag, surrounding an endoframe releasably coupled to the catheter and held compressed in an unexpanded configuration by a retractable sheath, wherein an endobag pressurization piping has one end releasably coupled to the endobag and has an inner lumen in communication with the inside of the endobag with the other end of the endobag pressurization piping extending within the sheath and in communication with endobag pressurization tubing outside the catheter, wherein an inside of an endoframe expanding substantially non-compliant balloon is in communication with endoframe pressurization tubing outside of the catheter, and wherein a guidewire lumen of the catheter is in communication with guidewire lumen pressurization tubing extending outside of the catheter; a single operator sequential manifold console having two endobag pressurization tubing outlet ports, two endoframe pressurization tubing outlet ports, and two guidewire lumen pressurization outlet ports wherein one of the two ports are connectable to the ends of the corresponding pressurization tubing outside of both the first catheter and the second catheter; the manifold console further having sequential inlet ports, wherein a first inlet port communicates with the two endobag pressurization tubing outlet ports, wherein a second inlet port communicates with the two endoframe pressurization tubing outlet ports, and wherein a third inlet port communicates with the two guidewire lumen pressurization outlet ports, wherein when the tubing ends from the first and the second catheters are connected to the corresponding manifold console outlet ports, pressurization of the corresponding inlet port equally pressurizes the corresponding pressure containing passage in both the first catheter and the second catheter simultaneously; wherein the first, second, and third inlet ports are configured in a side by side sequential configuration, where the sequential configuration of first, second, and third ports is arranged to match a recommended sequence of an operator's steps of pressure application to the first and second catheter endobag pressurization, endoframe pressurization, and guidewire lumen pressurization tubing. The single operator sequential manifold console may include a polymer cured indicator comprising a colored surface facing a light transmissive section of the endobag pressurization piping along the polymer flow path of the piping between the endobag pressurization inlet port and the two endobag pressurization outlet ports, such that the color of the colored surface can be seen through the light transmissive section of the piping when the piping is empty or is pressurized to contain uncured polymer and that the color of the colored surface is at least partially obstructed by a change in light transmissivity of the polymer as it cures thereby providing a visual confirmation, by the obstruction of viewing of the colored surface to the operator of the state of cure of the polymer. The single operator sequential manifold console may also include a fourth inlet port, which is also in communication with the endobag pressurization piping in the manifold console, where the fourth port is not located adjacent the first inlet port. The single operator sequential manifold console may include a fourth inlet port flow valve which when closed prevents flow between the endobag pressurization piping in the sequential manifold console and the fourth inlet port. The single operator sequential manifold console includes a third inlet port flow valve which when closed prevents flow between the guidewire lumen pressurization piping in the sequential manifold console and the third inlet port.
A single operator sequential manifold console may include two endobag pressurization tubing outlet ports, two endoframe pressurization tubing outlet ports, and two guidewire lumen pressurization outlet ports wherein one of the two ports are connectable to ends of corresponding pressurization tubing outside of both a first catheter and a second catheter; the manifold console further having sequential inlet ports, wherein a first inlet port communicates with the two endobag pressurization tubing outlet ports, wherein a second inlet port communicates with the two endoframe pressurization tubing outlet ports, and wherein a third inlet port communicates with the two guidewire lumen pressurization outlet ports, wherein when the tubing ends from the first and the second catheters are connected to the corresponding manifold console outlet ports, pressurization of the corresponding inlet port equally pressurizes the corresponding pressure containing passage leading to both the first catheter and the second catheter simultaneously; wherein the first, second, and third inlet ports are configured in a side by side sequential configuration, where the sequential configuration of first, second, and third ports is arranged to match a recommended sequence of an operator's steps of pressure application to the connectable first and second catheter endobag pressurization, endoframe pressurization, and guidewire lumen pressurization tubing. The single operator sequential manifold console may include a polymer cured indicator comprising a colored surface facing a light transmissive section of the endobag pressurization piping along the polymer flow path of the piping between the endobag pressurization inlet port and the two endobag pressurization outlet ports, such that the color of the colored surface can be seen through the light transmissive section of the piping when the piping is empty or is pressurized to contain uncured polymer and that the color of the colored surface is at least partially obstructed by a change in light transmissivity of the polymer as it cures thereby providing a visual confirmation, by the obstruction of viewing of the colored surface to the operator of the state of cure of the polymer. The single operator sequential manifold console may also include a fourth inlet port, which is also in communication with the endobag pressurization piping in the manifold console, where the fourth port is not located adjacent the first inlet port and which when closed prevents flow between the endobag pressurization piping in the sequential manifold console and the fourth inlet port. The single operator sequential manifold may include a third inlet port flow valve which when closed prevents flow between the guidewire lumen pressurization piping in the sequential manifold console and the third inlet port.
A system 10 is for delivering a double-walled filling structure 12 to an aneurysm includes the filling structure and a delivery catheter 14 having an expandable element, typically an inflatable balloon 16, at its distal end. The catheter 14 will comprise a guidewire lumen 18, a balloon inflation lumen (not illustrated) or other structure for expanding other expandable components, and a filling tube 20 for delivering a filling medium or material to an internal space 22 of the double-walled filling structure 12. The internal space 22 is defined between an outer wall 24 and inner wall 26 of the filling structure. Upon inflation with the filling material or medium, the outer wall will expand radially outwardly, as shown in broken line, as will the inner wall 26, also shown in broken line. Expansion of the inner wall 26 defines an internal lumen 28. The expandable balloon 16 or other structure will be expandable to support an inner surface of the lumen 28, as also in broken line in
Referring now to
The inner surface 30 of the filling volume 22 may also be modified by providing features 26′, coatings, surface roughening, coated with materials 29, or a variety of other modifications. The purpose of such internal features is typically to enhance adherence of the walls to the filling material or medium as the medium is cured or otherwise hardened. In some instances, materials may be coated on all or a portion of the inside surface 30 to induce or catalyze hardening of the filling material as it is being introduced.
The double-walled filling structure 12 will typically comprise at least one valve 35 to permit the introduction of the filling material or medium into the internal volume 22 using filling tube 20. As illustrated, the valve 35 may be a simple flap valve. Other more complex ball valves, and other one-way valve structures may be provided. In other instances, two-way valve structures may be provided to permit both filling and selective emptying of the internal volume 22. In other instances, the filling tube may comprise a needle or other filling structure to pass through the valve 35 to permit both filling and removal of filling medium.
As illustrated in
Referring now to
Referring to
After the double-walled filling structure 12 is properly positioned, a hardenable inflation medium is introduced into the internal space 22 filling of the inner space 22 and expands the outer wall 24 of the structure outwardly so that it conforms to the inner surface (S) of the aneurysmal space.
Before, during, or after filling of the double-walled filling structure 12 with inflation medium, as illustrated in
After the filling material has been introduced to the filling structure 12, typically through the filling tube 20, the fluid filling material must be cured or otherwise hardened to provide for the permanent implant having a generally fixed structure which will remain in place in the particular aneurysmal geometry. Methods for curing or hardening the filling material will depend on the nature of the filling material. For example, certain polymers may be cured by the application of energy, such as heat energy or ultraviolet light. Other polymers may be cured when exposed to body temperature, oxygen, or other conditions which cause polymerization of the fluid filling material. Still others may be mixed immediately prior to use and simply cure after a fixed time, typically minutes. Often, after the filling material has been hardened, the delivery catheter 14 may be removed and the filling structure left in place as the completed prosthetic implant.
In other cases, however, it may be desirable to further position certain seals, anchors, stents, or other additional prosthetic components at either the proximal end 52 or distal end 50 of the graft. As illustrated in
In a particular, a pair of double-walled filling structures will simultaneously be used to treat infrarenal abdominal aortic aneurysms, instead of only a single filling structure as illustrated in
In treating an infrarenal abdominal aortic aneurysm using the pair of filling structures 112 and 212 illustrated in
As discussed herein below the two filling structures and associated balloons will be expanded simultaneously, a partially filled (in process) filling condition is illustrated in
After filling the filling structures 112 and 212 as illustrated in
Referring now to
The catheter 14 will comprise a guidewire lumen (not shown), a balloon inflation lumen (not shown) or other structure for expanding other expandable components, and a filling tube 20 for delivering a filling medium or material to an internal space 22 of the double-walled filling structure 12. The internal space 22 is defined between an outer wall 24 and inner wall 26 of the filling structure. Upon inflation with the filling material or medium, the outer wall 24 will expand radially outwardly (expanded outer wall 24 shown in broken line) as will the inner wall 26 (expanded inner wall 26′ shown in broken line). Expansion of the inner wall 26 defines an internal generally tubular lumen 28 through which blood flows after deployment of the filling structure in the aneurysm. The expandable balloon 16 or other structure will be expandable to correspondingly expand the endoframe 19 to provide support and to shape an inner surface of the lumen 28. In this embodiment, the expandable balloon is cylindrically shaped and therefore the generally tubular lumen 28 will also be cylindrically shaped. In other embodiments, the balloon may be pre-shaped to more precisely match the curvature of the vessel. For example, when treating an aortic aneurysm, a tapered, pre-shaped or curved balloon may be used so that the lumen substantially matches the aorta. Various balloon configurations may be used in order to match vessel tortuosity. Pre-shaped, curved or tapered balloons may be used in any of the embodiments disclosed herein in order to obtain a desired lumen shaped.
In a particular, a pair of double-walled filling structures will be used to treat infrarenal abdominal aortic aneurysms, instead of only a single filling structure as illustrated in
In an exemplary method, first, the balloon 116 or 216 is expanded. Expanding the balloon 116 or 216 expands the corresponding filling structure 112 or 212 and endoframe 127, 227 disposed thereon. Next, the expanded filling structure 112 or 212 is filled with the fluid filling medium. Then, the balloon 116 or 216 is deflated to allow a flow of blood through the filling structure 112, 212 filled with the fluid filling medium, while the expanded endoframe 127, 227 maintains the patency of the generally tubular lumen within the expanded filled filling structure 112 or 212. In another embodiment, one or both of filling structures 112 or 212 are be filled with the fluid filling medium first, then the balloon 116 or 216 expanded to expand the endoframe 127 or 227 to form a generally tubular lumen in the corresponding filling structure 112 or 212. In still another embodiment, filling structure 112 or 212 is filled with the fluid filling medium simultaneously with expanding the balloon 116 or 216 disposed therein. Typical variations of deployment procedures may include: one of the filling structures 112, 212 and associated balloons 116, 216 being expanded first along with the corresponding endoframe 127, 227, followed by the other filling structure, endoframe and balloon. As discussed in the configurations described below, both balloons are radially expanded simultaneously thereby also expanding the filling structures and endoframes simultaneously.
Alternatively, one or both filling structures 112, 212 may be filled with a hardenable material and then the filling structures 112, 212 are radially expanded along with the corresponding endoframe 127, 227. In still other embodiments, combinations of filling and expanding may be performed in different order depending on physician preference and aneurysm anatomy. In some embodiments, an optional pre-filling step may be performed prior to filling with the hardenable filling medium. In this optional step, once the delivery system is positioned across the aneurysm, the filling structure may be filled with CO2 gas, contrast media, saline or other fluids to unfurl the filling structure 12 away from the delivery catheter thereby helping to ensure more uniform filling later on and reduce or eliminate stiction between folds of the filling structure that may be present. During unfurling, the filling structure may be partially filled or fully filled so that it conforms to the inner aneurysm wall. Once unfurled, angiography may be performed through a fenestrated nosecone 133 or 233 on the inner catheters shafts 114 or 214 upstream of the aneurysm to detect leaks in the deployed filling structure 12. Once an optimal filling volume and pressure is determined to prevent the occurrence of endoleaks, the fluid may be removed from the filling structure and it may be filled with the hardenable material to expand and conform to the aneurysmal space between the lumens and the inner aneurysm wall. Pressure relief valves such as those described herein may also be used to ensure that the filling structure is not over filled. In order to prevent overfilling of the filling structure, any of the pressure relief valves disclosed below may also be used to bleed off excess fluid from the filling structure.
After filling the filling structures 112 and 212 as illustrated in
The double filling structure embodiments may include at least one endoframe deployed within each of the tubular blood flow lumens. The endoframes will generally be endoskeletal structures that lay the foundation for new lumens, and will be deployed within the tubular lumens of the double-walled filling structures using balloon or other expansion catheters (in the case of malleable or balloon-expandable endoframes) and an optional retractable constraining sheath.
Referring now to
In the exemplary embodiment of
It would therefore be advantageous an integrated system provide a system that can perform an angiography procedure without substantially increasing the profile of the delivery system or over complicating the procedure. It would be further advantageous for such a system to provide more effective ways of coupling the filling structure and endoframe to the delivery catheter to inhibit movement and facilitate more accurate delivery of the endoframe and endograft to the treatment site.
Fenestrated Nosecone
To facilitate both advancement of the system and deployment of the filling structure, fenestrated nosecone 33 releasably couples or interfaces with the distal end of outer sheath 40. In an exemplary embodiment, nosecone 33 includes an isodiametric portion 36 which is isodiametric with the outer diameter of the distal end of outer sheath 40 so as to create a smooth transition at the interface and prevent “snowplowing” against a vessel wall as the system advances through the patient's vasculature. Isodiametric portion 36 extends a distance distal of the interface so as to increase the stiffness of the nosecone near the interface and prevent flexure of the nosecone and/or outer sheath at the interface during advancement of the system. Nosecone 33 may also include a portion 37 having an outside diameter slightly smaller than the inside diameter of the distal end of outer sheath 40; thus, portion 37 is disposed within the outer sheath 40 such that the outer sheath 40 fittingly receives portion 37 so as to releasably couple with the nosecone 33. Portion 37 may extend a distance proximal of the interface so as to increase the stability of the coupling and to increase the stiffness near the interface to prevent separation between the nosecone and outer sheath 40 as the system winds through complex or tortuous vasculature, thereby further reinforcing the smooth transition between the nosecone 33 and the outer sheath 40 to reduce the likelihood of “snowplowing” against the vessel wall. The nosecone 33 and/or the outer sheath 40 may further include a radiopaque marker band 31 near the interface to allow a physician to image the location of the distal end of the outer sheath 40 relative to nosecone 33. The resin to manufacture the nosecone may also include a radiopaque filler to facilitate imaging during the procedure.
Nosecone 33 is dimensioned to facilitate advancement in a patient's vasculature. An exemplary nosecone may be between 1 to 4 inches in length, preferably 2.5 to 3 inches, and have an outside diameter tapering from about 0.25 inches at a proximal end to about 0.050 inches at a distal end. The through lumen 18 extending through the nosecone 33 may also reduce in size as the outside diameter tapers down. For example, the through lumen at the proximal end 32B may be between 0.05 and 0.1 inches, preferably about 0.08 inches, and reduce in size gradually or incrementally to 0.02 to 0.04 inches, preferably about 0.05 inches at the distal portion 32A of nosecone 33.
Angiography may be performed by injecting a contrast media through the guidewire lumen of the inner shaft 17, which then flow into the through lumen 18 of nosecone 33 and out the side ports 34, preferably while the guidewire GW is disposed within the guidewire lumen and through lumen 18. Angiography may be performed through nosecone 33 before, during, or after treatment of the aneurysm, and is useful for imaging the flow of blood, particularly for detecting leaks in an endograft deployed in an aneurysm. In an angiography procedure, a radiopaque contrast media is delivered into a blood vessel and an X-ray based imaging technique, such as fluoroscopy, is used to image the flow of the contrast media as it flows through the blood vessel. Thus, the contrast media is released uniformly into the blood vessel so that the imaging produces a more accurate representation of blood flow through the vessel.
In an many embodiments, fenestrated nosecone 33 includes pairs of side ports 34 arranged in a series equally distributed along the nosecone in a helical fashion so as to evenly distribute the contrast media into the vasculature. Preferably, each of side ports 34 extends in an orthogonal direction from the longitudinal axis of the nosecone 33. In an exemplary embodiment, the nosecone 33 comprises a series of 4 to 10 pairs of side ports 34, preferably 5 to 7 pairs of side ports, arranged in a helical fashion as described above. Typically, a side port 34 has a diameter within a range of 0.01 inches to 0.05 inches, and more preferably within a range of 0.03 to 0.04 inches.
Annular Knob
Carrier knob 57 may include an internal seal 56, such as an silicone O-ring, to prevent fluid outflow from between the distal and proximal segments of the outer sheath 40. Typically, the blood pressure of the patient against internal seal 56 is sufficient to prevent fluid outflow from the body between outer sheath 40 and hypotube 41. As the carrier knob 57 is pulled proximally internal seal 56 slides proximally contacting the outer surface of the hypotube 41 and inside the annular knob 57.
Carrier knob 57 may be heat bonded to the outer sheath 40 by covering the proximal end of outer sheath 40 by a laminate material, preferably a polymer material such as Pebax®, placing a cavity in the knob 57 over the laminate covered outer sheath 40, and heating the assembly so that the laminate bonds to the outer shaft 40 and/or the knob 57, preferably bonding with both the outside surface of outer sheath 40 and the inside surface of the knob 57. The system may further include a retaining mechanism to prevent the hypotube 41 from slipping out of the knob 57 when the outer sheath 40 is advanced. The retaining mechanism may comprise a collar, a ring, a pin, a screw or any mechanism suitable to maintain a slidable coupling between the hypotube 41 and the annular knob 57. The system may also include a keying mechanism to prevent rotation between hypotube 41 (main catheter shaft) and sheath 40. Knob 57 include a sheath flush line 63, to allows flushing of the sheath or shooting contract through the sheath during the treatment procedure.
Handle
These pressures may potentially cause the guidewire to “shoot” out of the guidewire lumen. To prevent this from happening, the guidewire access port 61 may include a locking mechanism for locking guidewire GW to the handle during the angiography process. Thus, angiography line 62 provides access to the guidewire lumen, while the guidewire access 61 may seal and lock the guidewire GW into place. Release wire access port/connector 66 provides access for removal of the release wire so as to decouple the coupling mechanisms and release the deployed filling structure from the inner shaft 17. Release wire access port/connector 66 may include a threaded luer type connector, which is fixed to the proximal end of the release wire, such that removing the port connector (along with the filling structure fill tube 64) and pulling in the proximal direction will retract the release wire and decouple the coupling mechanisms. Optionally, handle 60 may rotate on its inner and outer shafts to prevent undesired transfer of torque to the catheter shafts. The descriptions of additional components depicted are included in the descriptions of
A pressure monitor 69 is utilized to monitor the filling structure filling pressure during the treatment procedure. Typically, the pressure monitor is fluidly coupled with the filling tube circuit so as to monitor the system filling pressure during filling of the filling structure 12 with the hardenable medium.
Pressure Monitoring
In an exemplary method of simultaneous action in deploying filling structures and endoframes in separate catheters, pressure monitoring may be utilized in the following way.
After two filling structures have been delivered to the treatment site, both endoframes are radially expanded to help create a lumen for blood flow through the filling structure across the aneurysm. Using data from a patient's computerized tomography (CT) scans, a fill volume of the aneurysm treatment site may be estimated. This represents the baseline filling volume for both filling structure and is the minimum expected volume of filling material to be injected into the filling structure feed circuitry. Syringes or other injection devices coupled with a pressure gage may be used to optionally pre-fill each filling structure with contrast material using the baseline volume and the resulting baseline fill pressure may be noted. In addition, the pressure monitoring system may include a pop-off valve to relieve excess pressure in the event of overfilling. The pressure monitoring system may include a sensor inside the filling structure and a sensor monitoring the patient's systolic and or diastolic blood pressure used for calculating the patient's differential blood pressure. A differential blood pressure reading between the filling structure and the patient's systolic and or diastolic pressure simplifies the process of filling the structures as this allows the physician to accurately target the pressure inside the filling structure. This allows unfurling of the filling structure and provides a preliminary assessment of how the expanded filling structures fit into the aneurysmal space. Once this is accomplished, the contrast material is removed from the filling structures (in a method utilizing a pre-filling step). Again using the patient CT data, a functional fill volume may be determined. This volume is a percentage of the aneurysm volume obtained from the CT data, or it may be a predetermined number and is the volume of filling material that effectively seals and excludes the aneurysm.
Functional fill pressure will be the pressure at which the functional fill volume is attained. A polymer fill dispenser may then be used to fill each filling structure with the functional fill volume and the functional fill pressure is noted. While holding the functional fill volume and pressure, the filling structure may be observed under fluoroscopy to check for proper positioning, filling and the absence of leakage across the aneurysm. If leaks are observed, additional polymer may be added to the filling structures until the leaks are prevented or minimized. Excessive additional polymer should not be added to the filling structure in order to avoid exceeding a safe fill volume or safe fill pressure. Once the physician is satisfied with the filling and positioning of the filling structures, stopcocks to the filling structures may be closed to allow the polymer to harden and then the delivery devices may be removed from the patient.
The methods may also include use of a pressure monitoring system that allows a physician to monitor the pressure before, during or after filling the filling structure. The system may include a user interface for displaying the pressure output and may optionally include a time output displayed in conjunction with the pressure output. The monitoring system may also include a processor for analyzing the pressure data. The processor may be programmed to normalize the pressure data. The pressure monitoring system enables the physician to closely monitor the filling pressure during deployment of the filling structure and may include additional functions to facilitate proper deployment, including: pressure cut-off switches, warning indicators if the measured filling pressure is outside an acceptable range, and pressure bleed off switches to optimize filling pressure and compensate for fluctuations in pressure during filling.
The monitoring system may also record the pressure data during deployment. Additionally, in embodiments deploying two filling structures, the monitoring systems may be operatively coupled such that the system or a physician may monitor pressures during filling of one filling structure in response to pressure output readings from the other adjacent filling structures.
Pressure monitoring can also be performed at various stages of the aneurysm repair procedure to help control the filling process of the filling structure. The monitoring of pressures serves to reduce the risk of dissection, rupture or damage to the aneurysm from over pressurization and also can be used to determine an endpoint for filling. Monitoring can be done before, during or after filling and hardening of the filling structure with filling medium. Specific pressures which can be monitored include the pressure within the internal space of the filling structure as well as the pressure in the space between the external walls of the filling structure and the inner wall of the aneurysm. A composite measurement can also be made combining pressures such as those measured within the interior space of the filling structure, together with that in the space between the external walls of the structure and the aneurysm wall or other space at the aneurysm site and an external delivery pressure used by a fluid delivery device, such as a pump or syringe, to deliver the filling medium. Control decisions can be made using any one of these pressure measurements or a combination thereof Methods of pressure monitoring are discussed in detail in related commonly-owned applications: U.S. Pat. No. 7,666,220 and U.S. Patent Application No. US 20100036360 A1, the entire contents of which are incorporated herein by reference.
The pressure monitor as shown in
Pressure monitors 69, such as that shown in
Delivery System Coupling Mechanisms
Tether 51 may comprise a tether loop fixedly attached to inner shaft 17 distal of the filling structure 12, the tether loop extending through an opening in endoframe 19 and around release wire 46, as shown in detail in
Tether 53 may comprise a tether loop fixedly attached to filling tube 20, which then extends through a suture loop 45 on the proximal end of filling structure 12 and around the release wire 46. So long as release wire 46 remains within the suture loop 45, filling tube 20 remains coupled with the proximal end of filling structure 12. Tether 53 may inhibit movement of the proximal region of the filling structure 12 during delivery, and may help prevent release of the fill tube 20 from the filing structure 12. Thus, tether 53 provides a fail safe mechanism prior to filling and during filling or re-filling of the filling structure, until the procedure is over, at which time the release wire can be retracted releasing the coupling between filling tube 20 and the filling structure 12.
Once the filling structure 12 has been deployed and filled with hardenable fluid filling medium, the release wire 46 can be withdrawn by pulling the proximal end of the release wire 46 from the handle 60. After releasing the filing structure 12 and endoframe 19, the delivery system 10) can be withdrawn from the body as tether loops 51 and 53 no longer couple the filling structure 12 or endoframe 19 to the system. In an exemplary embodiment, the release wire 46 extends the length of and runs parallel to inner shaft 17. During delivery, the distal end of release wire 46 is releasably coupled to inner shaft 17 just proximal of the nosecone 33, as shown in detail in
As shown in
In an exemplary embodiment, suture 47 comprises a single thread having one end attached to endoframe 19 and the other end attached to endoframe 19, as shown in
The single operator manifold console has piping/tubing pressure and fluid supply lines leading to each to each corresponding fluid and pressure supply line function on the respective separate catheters. One half of quick release connection fittings at the ends of the tubing lines leading from the single operator manifold console are designated 83A for the endobag pressurization piping; 85A for the endoframe pressurization piping, and 87A for the guidewire lumen pressurization piping. The respective tubing leading from the single operator sequential manifold console 300 is designated 382A, 384A, and 386A. While on the second catheter 14B, the handle 60B houses similarly functioning fluid and pressure piping/tubing and quick connectors having a second set of pressurization lines leading from the single operator manifold console to the respective functioning pressurization lines of the catheter. The endobag pressurization piping 64B is connected to the manifold console tubing 382B through quick connector quick tubing connector halves 82B, 83B while the endoframe pressurization tubing 68B is connected to single operator manifold console tubing 384B through connector halves 84B, 85B and the guidewire lumen pressurization piping 62B is connected to single operator manifold console tubing 386B through quick connector halves 86B, 87B. On the catheter side of the manifold console there are six separate tubing lines leaving the console outlet opening 302. On the operator side of the manifold console 300 there are four tubing inlet lines: for endobag deflation (negative pressurization) 310, for endoframe pressurization (expansion of balloon) 320, for endobag polymer filling (positive pressurization) 330, and guidewire lumen pressurization (angiography (contrast) supply) 340.
Referring now to
Although various configurations may be used, typically, a sequential configuration, such as first, second, and third ports for example, is arranged to match a recommended sequence of an operator's steps of operation such as pressure application to: endobag pressurization tubing, endoframe pressurization tubing, and guidewire lumen pressurization tubing. Functionally, there are only three separate (function) pressurization lines from each separate catheter connected to the sequential manifold console. Therefore a most simplified hypothetical manifold configuration would have only three lines matching the three separate system (functions) pressurization lines in the catheters. A console configuration for a catheter system utilizing three sequential steps of pressure application would be configured progressively (side by side by side) with three inlet ports to match the sequential steps of a deployment procedure requiring the operator to act (apply pressure) at a first inlet port, conclude activity at the first inlet port, act at a second inlet port, conclude activity at the second inlet port, act as a third inlet port, and conclude activity at the third inlet port in a sequential stepwise fashion. However, when two pressurization (positive or negative) activities need to be performed at one inlet port non-sequentially, (e.g., another step needs to be performed between the two (or more) steps to be performed at the one inlet port) the re-application or the attachment of a pressurization source and the re-application of pressure provide a non-ideal configuration in that the complexity of executing the recommended appointment steps shifts to the operator, and the operator must be knowledgeable and familiar with the deployment procedure to recognize and act on the three ports of the console while performing four or more steps of a deployment procedure. In this instance where only three steps are to be performed on the three inlet ports sequentially, a configuration of a manifold console as shown, would provide the benefit of simultaneous pressurization of the two separate catheters and their internal separate pressurization systems each from one pressure source as described herein for the configuration of
The first inlet port into the manifold console 300 on the left side as shown in
Arabic number “one” adjacent to port one on the console. In addition, the word ENDOBAG may be listed in alignment with the first port on the face of the console. Port one also has an on-off switch/shutoff valve 314 aligned with it which can be used as a shutoff valve to close the tubing and prevent any flow to or from port one. For example when vacuum is applied to port one, and there is no indication of blood in the endobag pressurization tubing, which would mean that there is a hole in the endobag and blood is being sucked into the tubing by the application of vacuum and that a vacuum pressure attained is maintained, the valve 314 can be closed to secure the system and release the vacuum source from the vacuum tubing connector 312.
A second port leading into the operator manifold console is associated endoframe pressurization tubing 320. The port associated sequence indicating symbol 321 is the Arabic number “two” on the console. The endoframe pressurization tubing 320 has a connection fitting 322 at its end.
The third port to the manifold console 300 adjacent to and to the right of the endoframe pressurization port in relation to the endoframes inlet tubing 320, endobag pressurization (polymer feed) tubing 330 has an end connection fitting 332 to which Tee and valve combination fitting 333 is connected. The side Tee fitting connection 334 is available for and is commonly used to monitor pressure by using a pressure monitoring device such as that shown and described in and for
The fourth inlet line to the manifold console 300 adjacent and to the right of the third port in sequence, the guidewire lumen pressurization port being having inlet tubing 340 aligned with an alphanumeric designator 341 which in this instance is the Arabic number “four,” 341. A guidewire lumen pressurization inlet port connector 342 is at the end of the tubing 340. A guidewire lumen pressurization port control on-off valve 344 is shown in line with the port. Such a valve prevent back leakage from blood being pressurized and finding its way through the guidewire lumen if left unchecked or may be used for angiography as described herein.
On the discharge side of the manifold console 300 the outlet opening 302 has six lines of tubing exiting. Two set of three lines of tubing are bundled by bracket connectors 380. The two bundles of lines each go to one catheter as previously discussed for
T valve combination fitting 333 through the supply tubing 330 to the T fitting 315, through the polymer cure indicator tubing 344, to the T fitting 316, from where the polymer is equally pressurized to be distributed into the aneurysmal sac filling structures of both treatment catheters through discharge tubing and 382A, 382B, and the quick connect halves 83A, 83B connected thereto and to corresponding fitting and tubing on the separates treatment catheters. The vacuum pressure which has been maintained in the piping system since the first pressurization step of the treatment process is aids in initial polymer flow until pressure is equalized in the system, then when pressurized, polymer flows freely at a rate according to the resistance that the flow encounters in passing through the feed tubes and into the endobags. Once the polymer has set the endobag pressurization the operator may turn the release wire access port 66 (such as shown in
While the above is a description of the embodiments, various alternatives, modifications, and equivalents may be used. For example, although the manifold console is described throughout as a single operator sequential manifold that allows a single user to operate the systems described herein, one of skill in the art would appreciate that various manifold consoles would be within the spirit and scope of the invention as described herein. The various features of the embodiments disclosed herein may be combined or substituted with one another. Therefore, the above description should not be taken as limiting in scope of the invention which is defined by the appended claims.
This application references and claims priority from U.S. provisional patent applications 61/472,209 and 61/473,051, filed on Apr. 6, 2011 and Apr. 7, 2011, respectively, which are incorporated herein by reference in their entirety.
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