Patent Grant
9913743
Field of the Invention
The invention lies in the field of endoluminal blood vessel repairs. The invention specifically relates to a delivery system, a kit, and method for endoluminally repairing aneurysm and/or dissections of the thoracic transverse aortic arch, thoracic posterior aortic arch, and the descending thoracic portion of the aorta with a self-aligning stent graft.
Description of the Related Art
A stent graft is an implantable device made of a tube-shaped surgical graft covering and an expanding or self-expanding frame. The stent graft is placed inside a blood vessel to bridge, for example, an aneurismal, dissected, or other diseased segment of the blood vessel, and, thereby, exclude the hemodynamic pressures of blood flow from the diseased segment of the blood vessel.
In selected patients, a stent graft advantageously eliminates the need to perform open thoracic or abdominal surgical procedures to treat diseases of the aorta and eliminates the need for total aortic reconstruction. Thus, the patient has less trauma and experiences a decrease in hospitalization and recovery times. The time needed to insert a stent graft is substantially less than the typical anesthesia time required for open aortic bypass surgical repair, for example.
Use of surgical and/or endovascular grafts have widespread use throughout the world in vascular surgery. There are many different kinds of vascular graft configurations. Some have supporting framework over their entirety, some have only two stents as a supporting framework, and others simply have the tube-shaped graft material with no additional supporting framework, 10 an example that is not relevant to the present invention.
One of the most commonly known supporting stent graft frameworks is that disclosed in U.S. Pat. Nos. 5,282,824 and 5,507,771 to Gianturco (hereinafter collectively referred to as “Gianturco”). Gianturco describes a zig-zag-shaped, self-expanding stent commonly referred to as a z-stent. The stents are, preferably, made of nitinol, but also have been made from stainless steel and other biocompatible materials.
There are various features characterizing a stent graft. The first significant feature is the tube of graft material. This tube is commonly referred to as the graft and forms the tubular shape that will, ultimately, take the place the diseased portion of the blood vessel. The graft is, preferably, made of a woven sheet (tube) of polyester or PTFE. The circumference of the graft tube is, typically, at least as large as the diameter and/or circumference of the vessel into which the graft will be inserted so that there is no possibility of blood flowing around the graft (also referred to as endoleak) to either displace the graft or to reapply hemodynamic pressure against the diseased portion of the blood vessel. Accordingly, to so hold the graft, self-expanding frameworks are attached typically to the graft material, whether on the interior or exterior thereof. Because blood flow within the lumen of the graft could be impaired if the framework was disposed on the interior wall of the graft, the framework is connected typically to the exterior wall of the graft. The ridges formed by such an exterior framework help to provide a better fit in the vessel by providing a sufficiently uneven outer surface that naturally grips the vessel where it contacts the vessel wall and also provides areas around which the vessel wall can endothelialize to further secure the stent graft in place.
One of the significant dangers in endovascular graft technology is the possibility of the graft migrating from the desired position in which it is installed. Therefore, various devices have been created to assist in anchoring the graft to the vessel wall.
One type of prior art prosthetic device is a stent graft made of a self-expanding metallic framework. For delivery, the stent graft is, first, radially compressed and loaded into an introducer system that will deliver the device to the target area. When the introducer system holding the stent graft positioned in an appropriate location in the vessel and allowed to open, the radial force imparted by the self-expanding framework is helpful, but, sometimes, not entirely sufficient, in endoluminally securing the stent graft within the vessel.
U.S. Pat. No. 5,824,041 to Lenker et al. (hereinafter “Lenker”) discloses an example of a stent graft delivery system. Lenker discloses various embodiments in which a sheath is retractable proximally over a prosthesis to be released. With regard to FIGS. 7 and 8, Lenker names components 72 and 76, respectively, as “sheath” and “prosthesis-containment sheath.” However, the latter is merely the catheter in which the prosthesis 74 and the sheath 72 are held. With regard to FIGS. 9 and 10, the sheath 82 has inner and outer layers 91, 92 fluid-tightly connected to one another to form a ballooning structure around the prosthesis P. This ballooning structure inflates when liquid is inflated with a non-compressible fluid medium and flares radially outward when inflated. With regard to FIGS. 13 to 15, Lenker discloses the “sheath” 120, which is merely the delivery catheter, and an eversible membrane 126 that “folds back over itself (everts) as the sheath 120 is retracted so that there are always two layers of the membrane between the distal end of the sheath [120] and the prosthesis P.” Lenker at col. 9, lines 63 to 66. The eversion (peeling back) is caused by direct connection of the distal end 130 to the sheath 120. The Lenker delivery system shown in FIGS. 19A to 19D holds the prosthesis P at both ends 256, 258 while an outer catheter 254 is retracted over the prosthesis P and the inner sheath 260. The inner sheath 260 remains inside the outer catheter 254 before, during, and after retraction. Another structure for holding the prosthesis P at both ends is illustrated in FIGS. 23A and 23B. Therein, the proximal holder having resilient axial members 342 is connected to a proximal ring structure 346. FIGS. 24A to 24C also show an embodiment for holding the prosthesis at both ends inside thin-walled tube 362.
To augment radial forces of stents, some prior art devices have added proximal and/or distal stents that are not entirely covered by the graft material. By not covering with graft material a portion of the proximal/distal ends of the stent, these stents have the ability to expand further radially than those stents that are entirely covered by the graft material. By expanding further, the proximal/distal stent ends better secure to the interior wall of the vessel and, in doing so, press the extreme cross-sectional surface of the graft ends into the vessel wall to create a fixated blood-tight seal.
One example of such a prior art exposed stent can be found in United States Patent Publication US 2002/0198587 to Greenberg et al. The modular stent graft assembly therein has a three-part stent graft: a two-part graft having an aortic section 12 and an iliac section 14 (with four sizes for each) and a contralateral iliac occluder 80. FIGS. 1, 2, and 4 to 6 show the attachment stent 32. As illustrated in FIGS. 1, 2, and 4, the attachment stent 32, while rounded, is relatively sharp and, therefore, increases the probability of puncturing the vessel.
A second example of a prior art exposed stent can be found in U.S. Patent Publication 2003/0074049 to Hoganson et al. (hereinafter “Hoganson”), which discloses a covered stent in which the elongated portions or sections 24 of the ends 20a and 20b extend beyond the marginal edges of the cover 22. See Hoganson at FIGS. 1, 3, 9, 11a, 11b, 12a, 12b, and 13. However, these extending exposed edges are triangular, with sharp apices pointing both upstream and downstream with regard to a graft placement location. Such a configuration of the exposed stent 20a, 20b increases the possibility of puncturing the vessel. In various embodiments shown in FIGS. 6a, 6b, 6c, 10, 14a, Hoganson teaches completely covering the extended stent and, therefore, the absence of a stent extending from the cover 22. It is noted that the Hoganson stent is implanted by inflation of a balloon catheter.
Another example of a prior art exposed stent can be found in U.S. Pat. No. 6,565,596 to White et al. (hereinafter “White I”), which uses a proximally extending stent to prevent twisting or kinking and to maintain graft against longitudinal movement. The extending stent is expanded by a balloon and has a sinusoidal amplitude greater than the next adjacent one or two sinusoidal wires. White I indicates that it is desirable to space wires adjacent upstream end of graft as close together as is possible. The stent wires of White I are actually woven into graft body by piercing the graft body at various locations. See White I at FIGS. 6 and 7. Thus, the rips in the graft body can lead to the possibility of the exposed stent moving with respect to the graft and of the graft body ripping further. Between the portions of the extending stent 17, the graft body has apertures.
The stent configuration of U.S. Pat. No. 5,716,393 to Lindenberg et al. is similar to White I in that the outermost portion of the one-piece stent—made from a sheet that is cut/punched and then rolled into cylinder—has a front end with a greater amplitude than the remaining body of the stent.
A further example of a prior art exposed stent can be found in U.S. Pat. No. 6,524,335 to Hartley et al. (hereinafter “Hartley”). FIGS. 1 and 2 of Hartley particularly disclose a proximal first stent 1 extending proximally from graft proximal end 4 with both the proximal and distal apices narrowing to pointed ends.
Yet another example of a prior art exposed stent can be found in U.S. Pat. No. 6,355,056 to Pinheiro (hereinafter “Pinheiro I”). Like the Hartley exposed stent, Pinheiro discloses exposed stents having triangular, sharp proximal apices.
Still a further example of a prior art exposed stent can be found in U.S. Pat. No. 6,099,558 to White et al. (hereinafter “White II”). The White II exposed stent is similar to the exposed stent of White I and also uses a balloon to expand the stent.
An added example of a prior art exposed stent can be found in U.S. Pat. No. 5,871,536 to Lazarus, which discloses two support members 68 longitudinally extending from proximal end to a rounded point. Such points, however, create a very significant possibility of piercing the vessel.
An additional example of a prior art exposed stent can be found in U.S. Pat. No. 5,851,228 to Pinheiro (hereinafter “Pinheiro II”). The Pinheiro II exposed stents are similar to the exposed stents of Pinheiro I and, as such, have triangular, sharp, proximal apices.
Still another example of a prior art exposed stent can be found in Lenker (U.S. Pat. No. 5,824,041), which shows a squared-off end of the proximal and distal exposed band members 14. A portion of the exposed members 14 that is attached to the graft material 18, 20 is longitudinally larger than a portion of the exposed members 14 that is exposed and extends away from the graft material 18, 20. Lenker et al. does not describe the members 14 in any detail.
Yet a further example of a prior art exposed stent can be found in U.S. Pat. No. 5,824,036 to Lauterjung, which, of all of the prior art embodiments described herein, shows the most pointed of exposed stents. Specifically, the proximal ends of the exposed stent are apices pointed like a minaret. The minaret points are so shaped intentionally to allow forks 300 (see Lauterjung at FIG. 5) external to the stent 154 to pull the stent 154 from the sheath 302, as opposed to being pushed.
A final example of a prior art exposed stent can be found in U.S. Pat. No. 5,755,778 to Kleshinski. The Kleshinski exposed stents each have two different shaped portions, a triangular base portion and a looped end portion. The totality of each exposed cycle resembles a castellation. Even though the end-most portion of the stent is curved, because it is relatively narrow, it still creates the possibility of piercing the vessel wall.
All of these prior art stents suffer from the disadvantageous characteristic that the relatively sharp proximal apices of the exposed stents have a shape that is likely to puncture the vessel wall.
Devices other than exposed stents have been used to inhibit graft migration. A second of such devices is the placement of a relatively stiff longitudinal support member longitudinally extending along the entirety of the graft.
The typical stent graft has a tubular body and a circumferential framework. This framework is not usually continuous. Rather, it typically takes the form of a series of rings along the tubular graft. Some stent grafts have only one or two of such rings at the proximal and/or distal ends and some have many stents tandemly placed along the entirety of the graft material. Thus, the overall stent graft has an “accordion” shape. During the systolic phase of each cardiac cycle, the hemodynamic pressure within the vessel is substantially parallel with the longitudinal plane of the stent graft. Therefore, a device having unsecured stents, could behave like an accordion or concertina with each systolic pulsation, and may have a tendency to migrate downstream. (A downstream migration, to achieve forward motion, has a repetitive longitudinal compression and extension of its cylindrical body.) Such movement is entirely undesirable. Connecting the stents with support along the longitudinal extent of the device thereof can prevent such movement. To provide such support, a second anti-migration device can be embodied as a relatively stiff longitudinal bar connected to the framework.
A clear example of a longitudinal support bar can be found in Pinheiro I (U.S. Pat. No. 6,355,056) and Pinheiro II (U.S. Pat. No. 5,851,228). Each of these references discloses a plurality of longitudinally extending struts 40 extending between and directly interconnecting the proximal and distal exposed stents 20a, 20b. These struts 40 are designed to extend generally parallel with the inner lumen 15 of the graft 10, in other words, they are straight.
Another example of a longitudinal support bar can be found in U.S. Pat. No. 6,464,719 to Jayaraman. The Jayaraman stent is formed from a graft tube 21 and a supporting sheet 1 made of nitinol. This sheet is best shown in FIG. 3. The end pieces 11, 13 of the sheet are directly connected to one another by wavy longitudinal connecting pieces 15 formed by cutting the sheet 1. To form the stent graft, the sheet 1 is coiled with or around the cylindrical tube 21. See FIGS. 1 and 4. Alternatively, a plurality of connecting pieces 53 with holes at each end thereof can be attached to a cylindrical fabric tube 51 by stitching or sutures 57, as shown in FIG. 8. Jayaraman requires more than one of these serpentine shaped connecting pieces 53 to provide longitudinal support.
United States Patent Publication 2002/0016627 and U.S. Pat. No. 6,312,458 to Golds each disclose a variation of a coiled securing member 20.
A different kind of supporting member is disclosed in FIG. 8 of U.S. Pat. No. 6,053,943 to Edwin et al.
Like Jayaraman, U.S. Pat. No. 5,871,536 to Lazarus discloses a plurality of straight, longitudinal support structures 38 attached to the circumferential support structures 36, see FIGS. 1, 6, 7, 8, 10, 11, 12, 14. FIG. 8 of Lazarus illustrates the longitudinal support structures 38 attached to a distal structure 36 and extending almost all of the way to the proximal structure 36. The longitudinal structures 38, 84, 94 can be directly connected to the body 22, 80 and can be telescopic 38, 64.
United States Patent Publication 2003/0088305 to Van Schie et al. (hereinafter “Van Schie”) does not disclose a support bar. Rather, it discloses a curved stent graft using an elastic materials connected to stents at a proximal end 2 and at a distal end 3 (see FIGS. 1, 2) thereof to create a curved stent graft. Because Van Schie needs to create a flexible curved graft, the elastic material 8 is made of silicone rubber or another similar material. Thus, the material 8 cannot provide support in the longitudinal extent of the stent graft. Accordingly, an alternative to the elastic support material 8 is a suture material 25 shown in FIGS. 3 to 6.
The invention provides a two-part expanding stent graft delivery system and method for implanting a prosthesis with the delivery system that overcome the hereinafore-mentioned disadvantages of the heretofore-known devices and methods of this general type and that provides a vessel repair device that implants/conforms more efficiently within the natural or diseased course of the aorta by aligning with the natural curve of the aorta, decreases the likelihood of vessel puncture, increases the blood-tight vascular connection, retains the intraluminal wall of the vessel position, is more resistant to migration, and delivers the stent graft into a curved vessel while minimizing intraluminal forces imparted during delivery and while minimizing the forces needed for a user to deliver the stent graft into a curved vessel.
With the foregoing and other objects in view, there is provided, in accordance with the invention, a method of implanting a prosthesis in a patient at a treatment site, including the steps of providing a prosthesis delivery system with an inner sheath and an outer sheath, loading a prosthesis inside the inner sheath, loading the inner sheath containing the prosthesis within the outer sheath, advancing the outer sheath in a patient towards the treatment site up to a given position at a distance from the treatment site, while retaining the outer sheath in the given position: advancing the inner sheath out from the outer sheath to the treatment site to align the prosthesis with the treatment site, and retracting the inner sheath to at least partially implant the prosthesis at the treatment site, and upon completion of prosthesis implantation, retracting both of the inner and outer sheaths from the patient.
In accordance with another mode of the invention, the advancing step is carried out by advancing the inner sheath out from the outer sheath to the treatment site to axially align the prosthesis with the treatment site and rotating the inner sheath to circumferentially align the prosthesis with the treatment site.
In accordance with a further mode of the invention, the advancing step is carried out by advancing the outer sheath towards the treatment site only up to a point at a distance from the treatment site greater than a length of the prosthesis.
In accordance with an added mode of the invention, the advancing step is carried out by advancing the outer sheath in vasculature of a patient towards a vascular treatment site.
In accordance with an additional mode of the invention, the advancing step is carried out by advancing the outer sheath in aortic vasculature of the patient no closer to the heart than a celiac axis of the patient.
In accordance with yet another mode of the invention, the advancing step is carried out by advancing the outer sheath in aortic vasculature of the patient to a point in the aorta no closer to a heart of the patient than a celiac axis of the patient.
In accordance with yet a further mode of the invention, the outer sheath is provided with a length sufficient to reach only up to a celiac axis of a patient.
In accordance with yet an added mode of the invention, the outer sheath is provided with a length no greater than a distance from the patient's femoral arterial access site to the patient's celiac axis.
In accordance with yet an additional mode of the invention, the retracting step is carried out upon completion of prosthesis implantation by retracting the inner sheath into the outer sheath and, subsequently, the outer sheath containing the inner sheath is retracted from the patient.
In accordance with again another mode of the invention, the inner sheath is of a material relatively more flexible than a material of the outer sheath.
In accordance with again a further mode of the invention, the prosthesis delivery system has an inner sheath that relatively more flexible than the outer sheath.
In accordance with again an added mode of the invention, the inner sheath has a prosthesis holding inner diameter at least as great as an inner diameter of the outer sheath.
With the objects of the invention in view, there is also provided a method of implanting a prosthesis in a patient at a treatment site, including the steps of axially locking a set of inner catheters with respect to an outer catheter, at least a portion of one of the inner catheters constraining the prosthesis, threading the inner and outer catheters onto a guidewire and into a patient to place the outer catheter into an aorta of the patient only up to a point at a distance from the treatment site greater than a length of the prosthesis, unlocking the inner catheters with respect to the outer catheter, advancing the inner catheters distally out of the outer catheter in the aorta towards the patient's heart to transport the prosthesis further upstream into the aorta, unlocking the one inner catheter that is constraining the prosthesis from the remainder of the inner catheters, and retracting the one inner catheter in a proximal direction to at least partially implant the prosthesis in the vessel.
With the objects of the invention in view, there is also provided a method of implanting a prosthesis in a patient at a treatment site, including the steps of axially locking a set of inner catheters with respect to an outer catheter, at least a portion of one of the inner catheters constraining the prosthesis, threading the inner and outer catheters onto a guidewire and into a patient to place the outer catheter into an aorta of the patient no closer to the heart than approximately at the patient's celiac axis, unlocking the inner catheters with respect to the outer catheter, advancing the inner catheters distally out of the outer catheter in the aorta towards the patient's heart to transport the prosthesis further upstream into the aorta, unlocking the one inner catheter that is constraining the prosthesis from the remainder of the inner catheters, and retracting the one inner catheter in a proximal direction to at least partially implant the prosthesis in the vessel.
In accordance with again an additional mode of the invention, the threading step is carried out by threading the inner and outer catheters into the patient at a femoral access site.
In accordance with still another mode of the invention, before axially locking the inner catheters with respect to the outer catheter: the prosthesis is loaded within a sheath connected to the one inner catheter, the sheath being smaller in diameter than the prosthesis to radially compress the prosthesis therein, the inner catheters are loaded within the outer catheter to radially compress the sheath and to further radially compress the prosthesis, and the inner catheters are axially locked with respect to one another.
In accordance with still a further mode of the invention, the loading step is carried out by additionally releasably connecting a distal portion of the prosthesis with a portion of one of the inner catheters different from the one inner catheter and, after retracting the one inner catheter, the prosthesis is finally deployed in the vessel by releasing the distal portion of the prosthesis from the portion.
In accordance with still an added mode of the invention, the sheath is of a relatively flexible material and the outer catheter is of a relatively stiff material.
In accordance with still an additional mode of the invention, the advancing step is carried out by advancing the inner catheters distally out of the outer catheter and into the curved thoracic aorta.
In accordance with another mode of the invention, prior to unlocking the one inner catheter from the remainder of the inner catheters, the axially locked inner catheters are rotated to place the prosthesis in a desired rotational implanting position.
In accordance with a concomitant mode of the invention, the prosthesis is provided with a supporting rod, and the rotation step is carried out by rotating the prosthesis to approximately align the supporting rod along a superior longitudinal line of a curved portion of the thoracic aorta.
Other features that are considered as characteristic for the invention are set forth in the appended claims.
Although the invention is illustrated and described herein as embodied in a two-part expanding stent graft delivery system and method for implanting a prosthesis with the delivery system, it is, nevertheless, not intended to be limited to the details shown because various modifications and structural changes may be made therein without departing from the spirit of the invention and within the scope and range of equivalents of the claims.
The construction and method of operation of the invention, however, together with additional objects and advantages thereof, will be best understood from the following description of specific embodiments when read in connection with the accompanying drawings.
The features of the present invention, which are believed to be novel, are set forth with particularity in the appended claims. The invention, together with further objects and advantages thereof, may best be understood by reference to the following description, taken in conjunction with the accompanying drawings, in the several figures of which like reference numerals identify like elements, and in which:
While the specification concludes with claims defining the features of the invention that are regarded as novel, it is believed that the invention will be better understood from a consideration of the following description in conjunction with the drawing figures, in which like reference numerals are carried forward.
The present invention provides a stent graft, delivery system, and method for implanting a prosthesis with a two-part expanding delivery system that treats, in particular, thoracic aortic defects from the brachiocephalic level of the aortic arch distally to a level just superior to the celiac axis and provides an endovascular foundation for an anastomosis with the thoracic aorta, while providing an alternative method for partial/total thoracic aortic repair by excluding the vessel defect and making surgical repair of the aorta unnecessary. The stent graft of the present invention, however, is not limited to use in the aorta. It can be endoluminally inserted in any accessible artery that could accommodate the stent graft's dimensions.
Stent Graft
The stent graft according to the present invention provides various features that, heretofore, have not been applied in the art and, thereby, provide a vessel repair device that implants/conforms more efficiently within the natural or diseased course of the aorta, decreases the likelihood of vessel puncture, and increases the blood-tight vascular connection, and decreases the probability of graft mobility.
The stent graft is implanted endovascularly before or during or in place of an open repair of the vessel (i.e., an arch, in particular, the ascending and/or descending portion of the aorta) through a delivery system described in detail below. The typical defects treated by the stent graft are aortic aneurysms, aortic dissections, and other diseases such as penetrating aortic ulcer, coarctation, and patent ductus arteriosus, related to the aorta. When endovascularly placed in the aorta, the stent graft forms a seal in the vessel and automatically affixes itself to the vessel with resultant effacement of the pathological lesion.
Referring now to the figures of the drawings in detail and first, particularly to
The graft sleeve 10 is cylindrical in shape and is made of a woven graft material along its entire length. The graft material is, preferably, polyester, in particular, polyester referred to under the name DACRON® or other material types like Expanded Polytetrafluoroethylene (“EPTFE”), or other polymeric based coverings. The tubular graft sleeve 10 has a framework of individual lumen-supporting wires each referred to in the art as a stent 20. Connection of each stent 20 is, preferably, performed by sewing a polymeric (nylon, polyester) thread around an entirety of the stent 20 and through the graft sleeve 10. The stitch spacings are sufficiently close to prevent any edge of the stent 20 from extending substantially further from the outer circumference of the graft sleeve 10 than the diameter of the wire itself. Preferably, the stitches have a 0.5 mm to 5 mm spacing.
The stents 20 are sewn either to the exterior or interior surfaces of the graft sleeve 10.
A stent 20, when connected to the graft sleeve 10, radially forces the graft sleeve 10 open to a predetermined diameter D. The released radial force creates a seal with the vessel wall and affixes the graft to the vessel wall when the graft is implanted in the vessel and is allowed to expand.
Typically, the stents 20 are sized to fully expand to the diameter D of the fully expanded graft sleeve 10. However, a characteristic of the present invention is that each of the stents 20 and 30 has a diameter larger than the diameter D of the fully expanded graft sleeve 10. Thus, when the stent graft 1 is fully expanded and resting on the internal surface of the vessel where it has been placed, each stent 20 is imparting independently a radially directed force to the graft sleeve 10. Such pre-compression, as it is referred to herein, is applied (1) to ensure that the graft covering is fully extended, (2) to ensure sufficient stent radial force to make sure sealing occurs, (3) to affix the stent graft and prevent it from kinking, and (4) to affix the stent graft and prevent migration.
Preferably, each of the stents 20 is formed with a single nitinol wire. Of course other biocompatible materials can be used, for example, stainless steel, biopolymers, cobalt chrome, and titanium alloys.
The preferred shape of each stent 20 corresponds to what is referred in the art as a Z-stent, see, e.g., Gianturco (although the shape of the stents 20 can be in any form that satisfies the functions of a self-expanding stent). Thus, the wire forming the stent 20 is a ring having a wavy or sinusoidal shape. In particular, an elevational view orthogonal to the center axis 21 of the stent 20 reveals a shape somewhere between a triangular wave and a sinusoidal wave as shown in
Another advantageous feature of a stent lies in extending the longitudinal profile along which the stent contacts the inner wall of a vessel. This longitudinal profile can be explained with reference to
Prior art stents and stents according to the present invention are formed on mandrels 29, 29′ by winding the wire around the mandrel 29, 29′ and forming the apexes 22, 24, 32, 34 by wrapping the wire over non-illustrated pins that protrude perpendicular from the axis of the mandrel. Such pins, if illustrated, would be located in the holes illustrated in the mandrels 29, 29′ of
To remedy this problem and ensure co-columnar apposition of the stent and vessel, stents of the present invention are formed on a multiple-sided mandrel. In particular, the stents 20 are formed on a polygonal-shaped mandrel 29′. The mandrel 29′ does not have sharp edges. Instead, it has flat sections and rounded edge portions between the respective flat sections. Thus, a stent formed on the mandrel 29′ will have a cross-section that is somewhat round but polygonal, as shown in
To manufacture the stent 20, apexes of the stents 20 are formed by winding the wire over non-illustrated pins located on the rounded portions of the mandrel 29′. Thus, the struts 33 lying between the apexes 22, 24, 32, 34 of the stents 20 lie flat against the flat sides of the mandrel 29′. When so formed on the inventive mandrel 29′, the longitudinal profile is substantially less rounded than the profile of stent 20′ and, in practice, is substantially linear.
For stents 20 having six proximal 22 and six distal 24 apices, the stents 20 are formed on a dodecahedron-shaped mandrel 29′ (a mandrel having twelve sides), which mandrel 29′ is shown in
The fourteen-apex stent 20 shown in
Another way to improve the performance of the stent graft 1 is to provide the distal-most stent 25 on the graft 10 (i.e., downstream) with additional apices and to give it a longer longitudinal length (i.e., greater amplitude) and/or a longer circumferential length. When a stent having a longer circumferential length is sewn to a graft, the stent graft 1 will perform better clinically. The improvement, in part, is due to a need for the distal portion of the graft material 10 to be pressed firmly against the wall of the vessel. The additional apices result in additional points of contact between the stent graft 1 and vessel wall, thus ensuring better apposition to the wall of the vessel and better sealing of the graft material 10 to the vessel. The increased apposition and sealing substantially improves the axial alignment of the distal end 14 of the stent graft 1 to the vessel. As set forth above, each of the stents 20 and 30 has a diameter larger than the diameter D of the fully expanded graft sleeve 10. Thus, if the distal stent 25 also has a diameter larger than the diameter D, it will impart a greater radial bias on all 360 degrees of the corresponding section of the graft than stents not having such an oversized configuration.
A typical implanted stent graft 1 typically does not experience a lifting off at straight portions of a vessel because the radial bias of the stents acting upon the graft sleeve give adequate pressure to align the stent and graft sleeve with the vessel wall. However, when a typical stent graft is implanted in a curved vessel (such as the aorta), the distal end of the stent graft 1 does experience a lift off from the vessel wall. The increased apposition and sealing of the stent graft 1 according to the present invention substantially decreases the probability of lift off because the added height and additional apices enhance the alignment of the stent graft perpendicular to the vessel wall as compared to prior art stent grafts (no lift off occurs).
The number of total apices of a stent is dependent upon the diameter of the vessel in which the stent graft 1 is to be implanted. Vessels having a smaller diameter have a smaller total number of apices than a stent to be implanted in a vessel having a larger diameter. Table 1 below indicates preferred stent embodiments for vessels having different diameters. For example, if a vessel has a 26 or 27 mm diameter, then a preferred diameter of the graft sleeve 10 is 30 mm. For a 30 mm diameter graft sleeve, the intermediate stents 20 will have 5 apices on each side (proximal and distal) for a total of 10 apices. In other words, the stent defines 5 periodic “waves.” The distal-most stent 25, in comparison, defines 6 periodic “waves” and, therefore, has 12 total apices. It is noted that the distal-most stent 25 in
To increase the security of the stent graft 1 in a vessel, an exposed or bare stent 30 is provided on the stent graft 1, preferably, only at the proximal end 12 of the graft sleeve 10—proximal meaning that it is attached to the portion of the graft sleeve 10 from which the blood flows into the sleeve, i.e., blood flows from the bare stent 30 and through the sleeve 10 to the left of
Significantly, the bare stent 30 is only partially attached to the graft sleeve 10. Specifically, the bare stent 30 is fixed to the graft sleeve 10 only at the distal apices 34 of the bare stent 30. Thus, the bare stent 30 is partially free to extend the proximal apices 32 away from the proximal end of the graft sleeve 10.
The bare stent 30 has various properties, the primary one being to improve the apposition of the graft material to the contour of the vessel wall and to align the proximal portion of the graft covering in the lumen of the arch and provide a blood-tight closure of the proximal end 12 of the graft sleeve 10 so that blood does not pass between the vascular inside wall and outer surface 16 of the sleeve 10 (endoleak).
The preferred configuration for the radius of curvature α of the distal apices 34 is substantially equal to the radius r of the proximal 22 and distal 24 apices of the stent 20, in particular, it is equal at least to the radius of curvature r of the proximal apices of the stent 20 directly adjacent the bare stent 30. Thus, as shown in
Inter-positioning the stents 23, 30 in phase with one another, creates an overlap, i.e., the apices 34 of the bare stent 30 are positioned within the troughs of the stent 23. A further advantage of such a configuration is that the overlap provides twice as many points of contact between the proximal opening of the graft 10 and the vessel in which the stent graft 1 is implanted. The additional apposition points keep the proximal opening of the graft sleeve 10 open against the vessel wall, which substantially reduces the potential for endoleaks. In addition, the overlap of the stents 23, 30 increases the radial load or resistance to compression, which functionally increases fixation and reduces the potential for device migration.
In contrast to the distal apices 34 of the bare stent 30, the radius of curvature β of the proximal apices 32 (those apices that are not sewn into the graft sleeve 10) is significantly larger than the radius of curvature a of the distal apices 34. A preferred configuration for the bare stent apices has a radius approximately equal to 1.5 mm for the proximal apices 32 and approximately equal to 0.5 mm for the distal apices 34. Such a configuration substantially prevents perforation of the blood vessel by the proximal apices 32, or, at a minimum, makes is much less likely for the bare stent 30 to perforate the vessel because of the less-sharp curvature of the proximal apices 32.
The bare stent 30 also has an amplitude greater than the other stents 20. Preferably, the peak-to-peak amplitude of the stents 20 is approximately 1.3 cm to 1.5 cm, whereas the peak-to-peak amplitude of the bare stent 30 is approximately 2.5 cm to 4.0 cm. Accordingly, the force exerted by the bare stent 30 on the inner wall of the aorta (due to the bare stent 30 expanding to its native position) is spread over a larger surface area. Thus, the bare stent 30 of the present invention presents a less traumatic radial stress to the interior of the vessel wall a characteristic that, while less per square mm than an individual one of the stents 20 would be, is sufficient, nonetheless, to retain the proximal end 12 in position. Simultaneously, the taller configuration of the bare stent 30 guides the proximal opening of the stent graft in a more “squared-off” manner. Thus, the proximal opening of the stent graft is more aligned with the natural curvature of the vessel in the area of the proximal opening.
As set forth above, because the vessel moves constantly, and due to the constantly changing pressure imparted by blood flow, any stent graft placed in the vessel has the natural tendency to migrate downstream. This is especially true when the stent graft 1 has graft sleeve segments 18 with lengths defined by the separation of the stents on either end of the segment 18, giving the stent graft 1 an accordion, concertina, or caterpillar-like shape. When such a shape is pulsating with the vessel and while hemodynamic pressure is imparted in a pulsating manner along the stent graft from the proximal end 12 to the downstream distal end 14, the stent graft 1 has a tendency to migrate downstream in the vessel. It is desired to have such motion be entirely prohibited.
Support along a longitudinal extent of the graft sleeve 10 assists in preventing such movement. Accordingly, as set forth above, prior art stent grafts have provided longitudinal rods extending in a straight line from one stent to another.
The present invention, however, provides a longitudinal, spiraling/helical support member 40 that, while extending relatively parallel to the longitudinal axis 11 of the graft sleeve 10, is not aligned substantially parallel to a longitudinal extent of the entirety of the stent graft 1 as done in the prior art. “Relatively parallel” is referred to herein as an extent that is more along the longitudinal axis 11 of the stent graft 1 than along an axis perpendicular thereto.
Specifically, the longitudinal support member 40 has a somewhat S-turn shape, in that, a proximal portion 42 is relatively parallel to the axis 11 of the graft sleeve 10 at a first degree 41 (being defined as a degree of the 360 degrees of the circumference of the graft sleeve 10), and a distal portion 44 is, also, relatively parallel to the axis 11 of the tube graft, but at a different second degree 43 on the circumference of the graft sleeve 10. The difference between the first and second degrees 41, 43 is dependent upon the length L of the graft sleeve 10. For an approximately 20 cm (approx. 8″) graft sleeve, for example, the second degree 43 is between 80 and 110 degrees away from the first degree 41, in particular, approximately 90 degrees away. In comparison, for an approximately 9 cm (approx. 3.5″) graft sleeve, the second degree 43 is between 30 and 60 degrees away from the first degree 41, in particular, approximately 45 degrees away. As set forth below, the distance between the first and second degrees 41, 43 is also dependent upon the curvature and the kind of curvature that the stent graft 1 will be exposed to when in vivo.
The longitudinal support member 40 has a curved intermediate portion 46 between the proximal and distal portions 42, 44. By using the word “portion” it is not intended to mean that the rod is in three separate parts (of course, in a particular configuration, a multi-part embodiment is possible). A preferred embodiment of the longitudinal support member 40 is a single, one-piece rod made of stainless steel, cobalt chrome, nitinol, or polymeric material that is shaped as a fully curved helix 42, 44, 46 without any straight portion. In an alternative stent graft embodiment, the proximal and distal portions 42, 44 can be substantially parallel to the axis 11 of the stent graft 1 and the central portion 46 can be helically curved.
One way to describe the preferred curvature embodiment of the longitudinal support member 40 can be using an analogy of asymptotes. If there are two asymptotes extending parallel to the longitudinal axis 11 of the graft sleeve 10 at the first and second degrees 41, 43 on the graft sleeve 10, then the proximal portion 42 can be on the first degree 41 or extend approximately asymptotically to the first degree 41 and the distal portion 44 can be on the second degree 43 or extend approximately asymptotically to the second degree 43. Because the longitudinal support member 40 is one piece in a preferred embodiment, the curved portion 46 follows the natural curve formed by placing the proximal and distal portions 42, 44 as set forth herein.
In such a position, the curved longitudinal support member 40 has a centerline 45 (parallel to the longitudinal axis 11 of the graft sleeve 10 halfway between the first and second degrees 41, 43 on the graft sleeve 10). In this embodiment, therefore, the curved portion intersects the centerline 45 at approximately 20 to 40 degrees in magnitude, preferably at approximately 30 to 35 degrees.
Another way to describe the curvature of the longitudinal support member can be with respect to the centerline 45. The portion of the longitudinal support member 40 between the first degree 41 and the centerline 45 is approximately a mirror image of the portion of the longitudinal support member 40 between the second degree 43 and the centerline 45, but rotated one-hundred eighty degrees (180°) around an axis orthogonal to the centerline 45. Such symmetry can be referred to herein as “reverse-mirror symmetrical.”
The longitudinal support member 40 is, preferably, sewn to the graft sleeve 10 in the same way as the stents 20. However, the longitudinal support member 40 is not sewn directly to any of the stents 20 in the proximal portions of the graft. In other words, the longitudinal support member 40 is independent of the proximal skeleton formed by the stents 20. Such a configuration is advantageous because an independent proximal end creates a gimbal that endows the stent graft with additional flexibility. Specifically, the gimbaled proximal end allows the proximal end to align better to the proximal point of apposition, thus reducing the chance for endoleak. The additional independence from the longitudinal support member allows the proximal fixation point to be independent from the distal section that is undergoing related motion due to the physiological motion of pulsutile flow of blood. Also in a preferred embodiment, the longitudinal support member 40 is pre-formed in the desired spiral/helical shape (counter-clockwise from proximal to distal), before being attached to the graft sleeve 10.
Because vessels receiving the stent graft 1 are not typically straight (especially the aortic arch), the final implanted position of the stent graft 1 will, most likely, be curved in some way. In prior art stent grafts (which only provide longitudinally parallel support rods), there exist, inherently, a force that urges the rod, and, thereby, the entire stent graft, to the straightened, natural shape of the rod. This force is disadvantageous for stent grafts that are to be installed in an at least partly curved manner.
The curved shape of the longitudinal support member 40 according to the present invention eliminates at least a majority, or substantially all, of this disadvantage because the longitudinal support member's 40 natural shape is curved. Therefore, the support member 40 imparts less of a force, or none at all, to straighten the longitudinal support member 40, and, thereby, move the implanted stent graft in an undesirable way. At the same time, the curved longitudinal support member 40 negates the effect of the latent kinetic force residing in the aortic wall that is generated by the propagation of the pulse wave and systolic blood pressure in the cardiac cycle, which is, then, released during diastole. As set forth in more detail below, the delivery system of the present invention automatically aligns the stent graft 1 to the most optimal position while traversing the curved vessel in which it is to be implanted, specifically, the longitudinal support member 40 is placed substantially at the superior longitudinal surface line of the curved aorta (with respect to anatomical position).
In a preferred embodiment, the longitudinal support member 40 can be curved in a patient-customized way to accommodate the anticipated curve of the actual vessel in which the graft will be implanted. Thus, the distance between the first and second degrees 41, 43 will be dependent upon the curvature and the kind of curvature that the stent graft 1 will be exposed to when in vivo. As such, when implanted, the curved longitudinal support member 40 will, actually, exhibit an opposite force against any environment that would alter its conformance to the shape of its resident vessel's existing course(es).
Preferably, the support member 40 is sewn, in a similar manner as the stents, on the outside surface 16 of the graft sleeve 10.
In prior art support rods, the ends thereof are merely a terminating end of a steel or nitinol rod and are, therefore, sharp. Even though these ends are sewn to the tube graft in the prior art, the possibility of tearing the vessel wall still exists. It is, therefore, desirable to not provide the support rod with sharp ends that could puncture the vessel in which the stent graft is placed.
The two ends of the longitudinal support member 40 of the present invention do not end abruptly. Instead, each end of the longitudinal support member loops 47 back upon itself such that the end of the longitudinal support member along the axis of the stent graft is not sharp and, instead, presents an exterior of a circular or oval shape when viewed from the ends 12, 14 of the graft sleeve 10. Such a configuration substantially prevents the possibility of tearing the vessel wall and also provides additional longitudinal support at the oval shape by having two longitudinally extending sides of the oval 47.
In addition, in another embodiment, the end of the longitudinal support member may be connected to the second proximal stent 28 and to the most distal stent. This configuration would allow the longitudinal support member to be affixed to stent 28 (see
A significant feature of the longitudinal support member 40 is that the ends of the longitudinal support member 40 may not extend all the way to the two ends 12, 14 of the graft sleeve 10. Instead, the longitudinal support member 40 terminates at or prior to the second-to-last stent 28 at the proximal end 12, and, if desired, prior to the second-to-last stent 28′ at the distal end 14 of the graft sleeve 10. Such an ending configuration (whether proximal only or both proximal and distal) is chosen for a particular reason—when the longitudinal support member 40 ends before either of the planes defined by cross-sectional lines 52, 52′, the sleeve 10 and the stents 20 connected thereto respectively form gimbaled portions 50, 50′. In other words, when a grasping force acting upon the gimbaled ends 50, 50′ moves or pivots the cross-sectional plane defining each end opening of the graft sleeve 10 about the longitudinal axis 11 starting from the planes defined by the cross-sectional lines 52, 52′, then the moving portions 50, 50′ can be oriented at any angle γ about the center of the circular opening in all directions (360 degrees), as shown in
Among other things, the gimbaled ends 50, 50′ allow each end opening to dynamically align naturally to the curve of the vessel in which it is implanted. A significant advantage of the gimbaled ends 50, 50′ is that they limit propagation of the forces acting upon the separate parts. Specifically, a force that, previously, would act upon the entirety of the stent graft 1, in other words, both the end portions 50, 50′ and the middle portion of the stent graft 1 (i.e., between planes 52, 52′), now principally acts upon the portion in which the force occurs. For example, a force that acts only upon one of the end portions 50, 50′ substantially does not propagate into the middle portion of the stent graft 1 (i.e., between planes 52, 52′). More significantly, however, when a force acts upon the middle portion of the stent graft 1 (whether moving longitudinally, axially (dilation), or in a torqued manner), the ends 50, 50′, because they are gimbaled, remain relatively completely aligned with the natural contours of the vessel surrounding the respective end 50, 50′ and have virtually none of the force transferred thereto, which force could potentially cause the ends to grate, rub, or shift from their desired fixed position in the vessel. Accordingly, the stent graft ends 50, 50′ remain fixed in the implanted position and extend the seating life of the stent graft 1.
Another advantage of the longitudinal support member 40 is that it increases the columnar strength of the graft stent 1. Specifically, the material of the graft sleeve can be compressed easily along the longitudinal axis 11, a property that remains true even with the presence of the stents 20 so long as the stents 20 are attached to the graft sleeve 10 with a spacing between the distal apices 24 of one stent 20 and the proximal apices 22 of the next adjacent stent 20. This is especially true for the amount of force imparted by the flow of blood along the extent of the longitudinal axis 11. However, with the longitudinal support member 40 attached according to the present invention, longitudinal strength of the stent graft 1 increases to overcome the longitudinal forces imparted by blood flow.
Another benefit imparted by having such increased longitudinal strength is that the stent graft 1 is further prevented from migrating in the vessel because the tube graft is not compressing and expanding in an accordion-like manner—movement that would, inherently, cause graft migration.
A further measure for preventing migration of the stent graft 1 is to equip at least one of any of the individual stents 20, 30 or the longitudinal support member 40 with protuberances 60, such as barbs or hooks (
As shown in
It is not significant if the stent apices of the distal-most stent of the first stent graft 100 are not aligned with the stent apices of the proximal-most stent 220 of the second stent graft 200. What is important is the amount of junctional overlap between the two grafts 100, 200.
Delivery System
As set forth above, the prior art includes many different systems for endoluminally delivering a prosthesis, in particular, a stent graft, to a vessel. Many of the delivery systems have similar parts and most are guided along a guidewire that is inserted, typically, through an insertion into the femoral artery near a patient's groin prior to use of the delivery system. To prevent puncture of the arteries leading to and including the aorta, the delivery system is coaxially connected to the guidewire and tracks the course of the guidewire up to the aorta. The parts of the delivery system that will track over the wire are, therefore, sized to have an outside diameter smaller than the inside diameter of the femoral artery of the patient. The delivery system components that track over the guidewire include the stent graft and are made of a series of coaxial lumens referred to as catheters and sheaths. The stent graft is constrained, typically, by an outer catheter, requiring the stent graft to be compressed to fit inside the outer catheter. Doing so makes the portion of the delivery system that constrains the stent graft very stiff, which, therefore, reduces that portion's flexibility and makes it difficult for the delivery system to track over the guidewire, especially along curved vessels such as the aortic arch. In addition, because the stent graft exerts very high radial forces on the constraining catheter due to the amount that it must be compressed to fit inside the catheter, the process of deploying the stent graft by sliding the constraining catheter off of the stent graft requires a very high amount of force, typically referred to as a deployment force. Also, the catheter has to be strong enough to constrain the graft, requiring it to be made of a rigid material. If the rigid material is bent, such as when tracking into the aortic arch, the rigid material tends to kink, making it difficult if not impossible to deploy the stent graft.
Common features of vascular prosthesis delivery systems include a tapered nose cone fixedly connected to a guidewire lumen, which has an inner diameter substantially corresponding to an outer diameter of the guide wire such that the guidewire lumen slides easily over and along the guidewire. A removable, hollow catheter covers and holds a compressed prosthesis in its hollow and the catheter is fixedly connected to the guidewire lumen. Thus, when the prosthesis is in a correct position for implantation, the physician withdraws the hollow catheter to gradually expose the self-expanding prosthesis from its proximal end towards its distal end. When the catheter has withdrawn a sufficient distance from each portion of the expanding framework of the prosthesis, the framework can expand to its native position, preferably, a position that has a diameter at least as great as the inner diameter of the vessel wall to, thereby, tightly affix the prosthesis in the vessel. When the catheter is entirely withdrawn from the prosthesis and, thereby, allows the prosthesis to expand to the diameter of the vessel, the prosthesis is fully expanded and connected endoluminally to the vessel along the entire extent of the prosthesis, e.g., to treat a dissection. When treating an aneurysm, for example, the prosthesis is in contact with the vessel's proximal and distal landing zones when completely released from the catheter.
At such a point in the delivery, the delivery system can be withdrawn from the patient. The prosthesis, however, cannot be reloaded in the catheter if implantation is not optimal. G
The aorta usually has a relatively straight portion in the abdominal region and in a lower part of the thoracic region. However, in the upper part of the thoracic region, the aorta is curved substantially, traversing an upside-down U-shape from the back of the heart over to the front of the heart. As explained above, prior art delivery systems are relatively hard and inflexible (the guidewire/catheter portion of the prior art delivery systems). Therefore, if the guidewire/catheter must traverse the curved portion of the aorta, it will kink as it is curved or it will press against the top portion of the aortic curve, possibly puncturing the aorta if the diseased portion is located where the guidewire/catheter is exerting its force. Such a situation must be avoided at all costs because the likelihood of patient mortality is high. The prior art does not provide any way for substantially reducing the stress on the curved portion of the aorta or for making the guidewire/catheter sufficiently flexible to traverse the curved portion without causing damage to the vessel.
The present invention, however, provides significant features not found in the prior art that assist in placing a stent graft in a curved portion of the aorta in a way that substantially reduces the stress on the curved portion of the aorta and substantially reduces the insertion forces needed to have the compressed graft traverse the curved portion of the aorta. As set forth above, the longitudinal support member 40 is pre-formed in a desired spiral/helical shape before being attached to the graft sleeve 10 and, in a preferred embodiment, is curved in a patient-customized way to accommodate the anticipated curve of the actual vessel in which the graft will be implanted. As such, optimal positioning of the stent graft 1 occurs when the longitudinal support member 40 is placed substantially at the superior longitudinal surface line of the curved aorta (with respect to anatomical position). Such placement can be effected in two ways. First, the stent graft 1, the support member 40, or any portion of the delivery system that is near the target site can be provided with radiopaque markers that are monitored by the physician and used to manually align the support member 40 in what is perceived as an optimal position. The success of this alignment technique, however, is dependent upon the skill of the physician. Second, the delivery system can be made to automatically align the support member 40 at the optimal position. No such system existed in the prior art. However, the delivery system of the present invention provides such an alignment device, thereby, eliminating the need for physician guesswork as to the three-dimensional rotational position of the implanted stent graft 1. This alignment device is explained in further detail below with respect to
The delivery system of the present invention also has a very simple to use handle assembly. The handle assembly takes advantage of the fact that the inside diameter of the aorta is substantially larger that the inside diameter of the femoral arteries. The present invention, accordingly, uses a two-stage approach in which, after the device is inserted in through the femoral artery and tracks up into the abdominal area of the aorta (having a larger diameter (see
To describe the delivery system of the present invention, the method for operating the delivery assembly 600 will be described first in association with
Initially, the distal end 14 of the stent graft 1 is compressed and placed into a hollow, cup-shaped, or tubular-shaped graft holding device, in particular, the distal sleeve 644 (see, e.g.,
The distal sleeve 644 is fixedly connected to the distal end of the graft push lumen 642, which lumen 642 provides an end face for the distal end 14 of the stent graft 1. Alternatively, the distal sleeve 644 can be removed entirely. In such a configuration, as shown in
As set forth in more detail below, each apex 32 of the bare stent 30 is, then, loaded into the apex capture device 634 so that the stent graft 1 is held at both its proximal and distal ends. The loaded distal end 14, along with the distal sleeve 644 and the graft push lumen 642, are, in turn, loaded into the inner sheath 652, thus, further compressing the entirety of the stent graft 1. The captured bare stent 30, along with the nose cone assembly 630 (including the apex capture device 634), is loaded until the proximal end of the nose cone 632 rests on the distal end of the inner sheath 652. The entire nose cone assembly 630 and sheath assembly 650 is, then, loaded proximally into the rigid outer catheter 660, further compressing the stent graft 1 (resting inside the inner sheath 652) to its fully compressed position for later insertion into a patient. See
The stent graft 1 is, therefore, held both at its proximal and distal ends and, thereby, is both pushed and pulled when moving from a first position (shown in
The assembly 600 according to the present invention tracks along a guidewire 610 already inserted in the patient and extending through the aorta and up to, but not into, the left ventricle of the heart 720. Therefore, a guidewire 610 is inserted through the guidewire lumen 620 starting from the nose cone assembly 630, through the sheath assembly 650, through the handle assembly 670, and through the apex release assembly 690. The guidewire 610 extends out the proximal-most end of the assembly 600. The guidewire lumen 620 is coaxial with the nose cone assembly 630, the sheath assembly 650, the handle assembly 670, and the apex release assembly 690 and is the innermost lumen of the assembly 600 immediately surrounding the guidewire 610.
Before using the delivery system assembly 600, all air must be purged from inside the assembly 600. Therefore, a liquid, such as sterile U.S.P. saline, is injected through a nonillustrated tapered luer fitting to flush the guidewire lumen at a non-illustrated purge port located near a proximal end of the guidewire lumen. Second, saline is also injected through the luer fitting 612 of the lateral purge-port (see
After purging all air, the system can be threaded onto the guidewire and inserted into the patient. Because the outer catheter 660 has a predetermined length, the fixed front handle 672 can be disposed relatively close to the entry port of the femoral artery. It is noted, however, that the length of the outer catheter 660 is sized such that it will not have the fixed proximal handle 672 directly contact the entry port of the femoral artery in a patient who has the longest distance between the entry port and the thoracic/abdominal junction 742, 732 of the aorta expected in a patient (this distance is predetermined). Thus, the delivery assembly 600 of the present invention can be used with typical anatomy of the patient. Of course, the assembly 600 can be sized to any usable length.
The nose cone assembly 630 is inserted into a patient's femoral artery and follows the guidewire 610 until the nose cone 632 reaches the first position at least to a level of the celiac axis and possibly further but not into the intended stent graft deployment site, which would prevent deployment of at least the downstream end of the stent graft. The first position is shown in
After the nose cone assembly 630 is in the first position shown in
Before describing how various embodiments of the handle assembly 670 function, a summary of the multi-lumen connectivity relationships, throughout the neutral N, advancement A, and deployment D positions, is described.
When the locking ring is in the neutral position N shown in
When the locking ring 676 is moved into the advancement position A, shown in
At this point, the sheath lumen 654 needs to be withdrawn from the stent graft 1 to, thereby, expose the stent graft 1 from its proximal end 12 to its distal end 14 and, ultimately, entirely off of its distal end 14. Therefore, movement of the locking ring 676 into the deployment position D will engage the proximal spring 606 shown in
At this point, the delivery assembly 600 only holds the bare stent 30 of the stent graft 1. Therefore, final release of the stent graft 1 occurs by releasing the bare stent 30 from the nose cone assembly 630, which is accomplished using the apex release assembly 690 as set forth below.
In order to explain how the locking and releasing of the lumen occur as set forth above, reference is made to
An exploded view of these components is presented in
A setscrew 679 extends from the proximal handle 678 to contact a longitudinally helixed groove in the pusher clasp rotator 292 (shown in
An alternative embodiment of the locking ring 676 is shown in
In the alternative embodiment, a setscrew 584 is threaded into the clasp sleeve 614 through a slot 675 in the handle body 674 and through a slot 583 in the knob 582 to engage the locking knob 582. Because of the x-axis orientation of the slot 583 in the knob 582 and they axis orientation of the slot 675 in the handle body 674, when the knob 582 is slid over the end of the handle body 674 and the setscrew 584 is screwed into the clasp sleeve 614, the knob 582 is connected fixedly to the handle body 674. When the locking knob 582 is, thereafter, rotated between the neutral N, advancement A, and deployment D positions, the clasp sleeve 614 rotates to actuate the spring lock (see
A setscrew 586, shown in
The handle body 674 has a position pin 592 for engaging in position openings at the distal end of the locking knob 582. The position pin 592 can be a setscrew that only engages the handle body 674. When the locking knob 582 is pulled slightly proximally, therefore, the knob can be rotated clockwise or counter-clockwise to place the pin 592 into the position openings corresponding to the advancement A, neutral N, and deployment D positions.
As shown in
It is noted, at this point, that the inner sheath 652 contains a taper 653 at its proximal end, distal to the sheath's 652 connection to the sheath lumen 654 (at which connection the inner sheath 652 has a similar diameter to the distal sleeve 644 and works in conjunction with the distal sleeve 644 to capture the distal end 14 of the stent graft 1. The taper 653 provides a transition that substantially prevents any kinking of the outer catheter 660 when the stent graft 1 is loaded into the delivery assembly 600 (as in the position illustrated in
When the proximal handle 678 is moved towards its distal position, shown by the dashed lines in
It is noted that if the harder outer catheter 660 was to have been moved through the curved portion 710 of the aorta 700, there is a great risk of puncturing the aorta 700, and, particularly, a diseased portion 744 of the proximal descending aorta 710 because the outer catheter 660 is not as flexible as the inner sheath 652. But, because the inner sheath 652 is so flexible, the nose cone assembly 630 and the sheath assembly 650 can be extended easily into the curved portion 710 of the aorta 700 with much less force on the handle than previously needed with prior art systems while, at the same time, imparting harmless forces to the intraluminal surface of the curved aorta 710 due to the flexibility of the inner sheath 652.
At the second position shown in
Accordingly, the stent graft 1 can be pre-aligned by the physician to place the stent graft 1 in the optimal circumferential position.
In prior art stent grafts and stent graft delivery systems, the stent graft is, typically, provided with symmetrically-shaped radiopaque markers along one longitudinal line and at least one other symmetrically-shaped radiopaque marker disposed along another longitudinal line on the opposite side (one-hundred eighty degrees (180°)) of the stent graft. Thus, using two-dimensional fluoroscopic techniques, the only way to determine if the stent graft is in the correct rotational position is by having the user/physician rotate the stent graft in both directions until it is determined that the first longitudinal line is superior and the other longitudinal line is anterior. Such a procedure requires more work by the physician and is, therefore, undesirable.
According to a preferred embodiment of the invention illustrated in
Specifically, the stent graft 1 is provided with a pair of symmetrically shaped but diametrically opposed markers 232, 234 indicating to the user/physician which direction the stent graft 1 needs to be rotated to align the longitudinal support member 40 to the superior longitudinal line of the curved aorta (with respect to anatomical position). Preferably, the markers 232, 234 are placed at the proximate end 12 of the graft sleeve 10 on opposite sides (one-hundred eighty degrees (180°)) of the graft sleeve 10.
The angular position of the markers 232, 234 on the graft sleeve 10 is determined by the position of the longitudinal support member 40. In a preferred embodiment, the support member 40 is between the two markers 232, 234. To explain such a position, if the marker 232 is at a 0 degree position on the graft sleeve 10 and the marker 234 is at a one-hundred eighty degree (180°) position, then the centerline 45 of the support member 40 is at a ninety degree position. However, an alternative position of the markers can place the marker 234 ninety degrees away from the first degree 41 (see
Preferred ancillary equipment in endovascular placement of the stent graft 1 is a fluoroscope with a high-resolution image intensifier mounted on a freely angled C-arm. The C-arm can be portable, ceiling, or pedestal mounted. It is important that the C-arm have a complete range of motion to achieve AP to lateral projections without moving the patient or contaminating the sterile field. Capabilities of the C-arm should include: Digital Subtraction Angiography, High-resolution Angiography, and Roadmapping.
For introduction of the delivery system into the groin access arteries, the patient is, first, placed in a sterile field in a supine position. To determine the exact target area for placement of the stent graft 1, the C-arm is rotated to project the patient image into a left anterior oblique projection, which opens the radial curve of the thoracic aortic arch for optimal visualization without superimposition of structures. The degree of patient rotation will vary, but is usually 40 to 50 degrees. At this point, the C-arm is placed over the patient with the central ray of the fluoroscopic beam exactly perpendicular to the target area. Such placement allows for the markers 232, 234 to be positioned for correct placement of the stent graft 1. Failure to have the central ray of the fluoroscopic beam perpendicular to the target area can result in parallax, leading to visual distortion to the patient anatomy due to the divergence of the fluoroscopic x-ray beam, with a resultant misplacement of the stent graft 1. An angiogram is performed and the proposed stent graft landing zones are marked on the visual monitor. Once marked, neither the patient, the patient table, nor the fluoroscopic C-arm can be moved, otherwise, the reference markers become invalid. The stent graft 1 is, then, placed at the marked landing zones.
In a preferred embodiment, the markers 232, 234 are hemispherical, in other words, they have the approximate shape of a “D”. This shape is chosen because it provides special, easy-to-read indicators that instantly direct the user/physician to the correct placement position for the longitudinal support member 40.
Each of
A significant advantage provided by the diametrically opposed symmetric markers 232, 234 is that they can be used for migration diagnosis throughout the remaining life of a patient after the stent graft 1 has been placed inside the patient's body. If fluoroscopic or radiographic techniques are used any time after the stent graft 1 is inserted in the patient's body, and if the stent graft 1 is viewed from the same angle as it was viewed when placed therein, then the markers' 232, 234 relative positions observed should give the examining individual a very clear and instantaneous determination as to whether or not the stent graft 1 has migrated in a rotational manner.
The hemispherical shape of the markers 232, 234 are only provided as an example shape. The markers 232, 234 can be any shape that allows a user/physician to distinguish alignment and direction of rotation for alignment. For example, the markers 232, 234 can be triangular, in particular, an isosceles triangle having the single side be visibly longer or shorter than the two equal sides.
As set forth above, alignment to the optimal implantation position is dependent upon the skill of the physician(s) performing the implantation. The present invention improves upon the embodiments having longitudinal and rotational radiopaque markers 232, 234 and substantially eliminates the need for rotational markers. Specifically, it is noted that the guidewire 610 travels through a curve through the aortic arch towards the heart 720. It is, therefore, desirable to preshape the delivery system to match the aorta of the patient.
The guidewire lumen 620 is formed from a metal, preferably, stainless steel. Thus, the guidewire lumen 620 can be deformed plastically into any given shape. In contrast, the apex release lumen 640 is formed from a polymer, which tends to retain its original shape and cannot plastically deform without an external force, e.g., the use of heat. Therefore, to effect the preshaping of the delivery assembly 600, the guidewire lumen 620, as shown in
With the pre-curved guidewire lumen 620, when the nose cone 632 and inner sheath 652 exit the outer catheter 660 and begin to travel along the curved guide wire 610, the natural tendency of the pre-curved guidewire lumen 620 will be to move in a way that will best align the two curves to one another (see
Due to the configuration of the delivery system 600 of the present invention, when the guidewire lumen 620 is extended from the outer catheter 660 (along with the apex release lumen 640, the stent graft 1, the inner sheath 652 as shown in
The self-aligning feature of the invention begins with a strategic loading of the stent graft 1 in the inner sleeve 652. To describe the placement of the supporting member 40 of the stent graft 1 relative to the curve 622 of the guidewire lumen 620, an X-Y coordinate curve plane is defined and shown in
To insure optimal implantation, when loading the stent graft 1 into the inner sheath 652, a desired point on the supporting member 40 between the centerline 45 of the stent graft 1 and the proximal support member loop 47 is aligned to intersect the curve plane 624. The preferred, but not required, location of the desired point on the supporting member 40 is located forty-five (45) degrees around the circumference of the stent graft 1 shown in
It is noted that the guidewire lumen 620 need not be rotationally fixedly connected to the apex release lumen 640 when the apex release assembly 690 is in the locked position shown in
It is also noted that the pre-curved section 622 of the guidewire lumen need not be made at the manufacturer. As shown in
For tailoring the curve to the patient's curved vessel, the physician can, for example, fluoroscopically view the vessel (e.g., aortic arch) and determine therefrom the needed curve by, for example, holding up the curving device to the display. Any kind of curving device can be used to impart a bend to the guidewire lumen 620 when the guidewire lumen 620 is bent around the circumference.
Because of the predefined curvature of the support member 40, the support member 40 cannot align exactly and entirely along the superior longitudinal line of the curved aorta. Accordingly, an optimal superior surface position of the support member 40 places as much of the central portion of the support member 40 (between the two ends 47 thereof) as possible close to the superior longitudinal line 808 of the curved aorta. A particularly desirable implantation position has the superior longitudinal line 808 of the curved aorta intersecting the proximal half of the support member 40—the proximal half being defined as that portion of the support member 40 located between the centerline 45 and the proximal support member loop 47. However, for adequate implantation purposes, the centerline 45 of the support member 40 can be as much as seventy circumferential degrees away from either side of the superior longitudinal line of the curved aorta.
When the stent graft 1 is in place both longitudinally and circumferentially (
The nose cone assembly 630, along with the apex capture device 634, is securely attached to the guidewire lumen 620 (and the apex release lumen 640 at least until apex release occurs). The inner sheath 652 is securely attached to a sheath lumen 654, which is coaxially disposed around the guidewire lumen 620 and fixedly attached to the proximal handle 678. The stent graft 1 is also supported at its distal end by the graft push lumen 642 and the distal sleeve 644 or the taper 653 of the inner sheath 652. (The entire coaxial relationship of the various lumen 610, 620, 640, 642, 654, and 660 is illustrated for exemplary purposes only in
The stent graft 1 is, now, ready to be finally affixed to the aorta 700. To perform the implantation, the bare stent 30 must be released from the apex capture device 634. As will be described in more detail below, the apex capture device 634 shown in
To cause such relative movement, the apex release assembly 690 has, in a preferred embodiment, three parts, a distal release part 692, a proximal release part 694, and an intermediate part 696 (which is shown in the form of a clip in
To allow relative movement between the distal apex head 636 and the proximal apex body 638, the intermediate part 696 is removed easily with one hand and, as shown from the position in
Of course, the apex release assembly 690 can be formed with any kind of connector that moves the apex release lumen 640 and the guidewire lumen 620 relative to one another. In a preferred alternative embodiment, for example, the intermediate part 696 can be a selectable lever that is fixedly connected to either one of the distal release part 692 or the proximal release part 694 and has a length equal to the width of the clip 696 shown in
The apex capture device 634 is unique to the present invention in that it incorporates features that allow the longitudinal forces subjected on the stent graft 1 to be fully supported, through the bare stent 30, by both the guidewire lumen 620 and apex release lumen 640. Support occurs by providing the distal apex head 636 with a distal surface 639—which surface 639 supports the proximal apices 32 of the bare stent 30 (shown in the enlarged perspective view of the distal apex head 636 in
Having the distal surface 639 be the load-bearing surface of the proximal apices 32 ensures expansion of each and every one of the distal apices 32 from the apex release assembly 690. The proximal surface 641 of the distal apex head 636 (see
Simply put, the apex capture device 634 provides support for load placed on the stent graft 1 during advancement A of the inner sheath 652 and during withdrawal of the inner sheath 652 (i.e., during deployment D). Such a configuration benefits the apposition of the bare stent 30 by releasing the bare stent 30 after the entire graft sleeve 10 has been deployed, thus reducing the potential for vessel perforation at the point of initial deployment.
When the stent graft 1 is entirely free from the inner sheath 652 as shown in
The stent graft 1 is, now, securely placed within the vessel 700 and the entire portion 630, 650, 660 of the assembly 600 may be removed from the patient.
While the preferred embodiments of the invention have been illustrated and described, it will be clear that the invention is not so limited. Numerous modifications, changes, variations, substitutions, and equivalents will occur to those skilled in the art without departing from the spirit and scope of the present invention as defined by the appended claims.
This application is a continuation of U.S. patent application Ser. No. 14/157,194, filed Jan. 16, 2014, now U.S. Pat. No. 9,408,735, which is a continuation of U.S. application Ser. No. 11/449,337, filed Jun. 8, 2006, now U.S. Pat. No. 8,740,963, issued Jun. 3, 2014, which is a continuation-in-part of U.S. patent application Ser. No. 10/784,462, filed Feb. 23, 2004, now U.S. Pat. No. 8,292,943, issued on Oct. 23, 2012, which claims the benefit under 35 U.S.C. §119(e) of U.S. Provisional Application Nos. 60/499,652, filed Sep. 3, 2003, and 60/500,155, filed Sep. 4, 2003. U.S. application Ser. No. 11/449,337 is also a continuation-in-part of U.S. application Ser. No. 10/884,136, filed Jul. 2, 2004, now U.S. Pat. No. 7,763,063, issued on Jul. 27, 2010, which also claims the benefit under 35 U.S.C. §119(e) of U.S. Provisional Application Nos. 60/499,652, filed Sep. 3, 2003, and 60/500,155, filed Sep. 4, 2003. The complete disclosures of all prior applications are hereby incorporated by reference herein in their entirety.
| Number | Name | Date | Kind |
|---|---|---|---|
| 3416531 | Edwards | Dec 1968 | A |
| 3485234 | Stevens | Dec 1969 | A |
| 3502069 | Silverman | Mar 1970 | A |
| 3868956 | Alfidi | Mar 1975 | A |
| 4351333 | Lazarus | Sep 1982 | A |
| 4425919 | Alston | Jan 1984 | A |
| 4487808 | Lambert | Dec 1984 | A |
| 4515593 | Norton | May 1985 | A |
| 4516972 | Samson | May 1985 | A |
| 4534363 | Gold | Aug 1985 | A |
| 4572186 | Gould | Feb 1986 | A |
| 4580568 | Gianturco | Apr 1986 | A |
| 4634432 | Kocak | Jan 1987 | A |
| 4655771 | Wallsten | Apr 1987 | A |
| 4665906 | Jervis | May 1987 | A |
| 4665918 | Garza et al. | May 1987 | A |
| 4705511 | Kocak | Nov 1987 | A |
| 4787899 | Lazarus | Nov 1988 | A |
| 4817613 | Jaraczewski | Apr 1989 | A |
| 4990151 | Wallsten et al. | Feb 1991 | A |
| 5019057 | Truckai | May 1991 | A |
| 5041126 | Gianturco | Aug 1991 | A |
| 5057092 | Webster | Oct 1991 | A |
| 5067957 | Jervis | Nov 1991 | A |
| 5104399 | Lazarus | Apr 1992 | A |
| 5154701 | Cheer et al. | Oct 1992 | A |
| 5158543 | Lazarus | Oct 1992 | A |
| 5176652 | Littrell | Jan 1993 | A |
| 5176660 | Truckai | Jan 1993 | A |
| 5201757 | Heyn et al. | Apr 1993 | A |
| 5254105 | Haaga | Oct 1993 | A |
| 5282824 | Gianturco | Feb 1994 | A |
| 5290295 | Querals et al. | Mar 1994 | A |
| 5292331 | Boneau | Mar 1994 | A |
| 5306263 | Voda | Apr 1994 | A |
| 5324306 | Makower et al. | Jun 1994 | A |
| 5334164 | Guy et al. | Aug 1994 | A |
| 5334168 | Hemmer | Aug 1994 | A |
| 5338295 | Cornelius | Aug 1994 | A |
| 5342384 | Sugarbaker | Aug 1994 | A |
| 5358493 | Schweich | Oct 1994 | A |
| 5380304 | Parker | Jan 1995 | A |
| 5387235 | Chuter | Feb 1995 | A |
| 5397345 | Lazarus | Mar 1995 | A |
| 5405377 | Cragg | Apr 1995 | A |
| 5415664 | Pinchuk | May 1995 | A |
| 5433723 | Lindenberg et al. | Jul 1995 | A |
| 5456713 | Chuter | Oct 1995 | A |
| 5458615 | Klemm et al. | Oct 1995 | A |
| 5464449 | Ryan et al. | Nov 1995 | A |
| 5474563 | Myler et al. | Dec 1995 | A |
| 5480423 | Ravenscroft et al. | Jan 1996 | A |
| 5489295 | Piplani et al. | Feb 1996 | A |
| 5507771 | Gianturco | Apr 1996 | A |
| 5522881 | Lentz | Jun 1996 | A |
| 5522882 | Gaterud et al. | Jun 1996 | A |
| 5531715 | Engelson | Jul 1996 | A |
| 5533987 | Pray | Jul 1996 | A |
| 5534007 | Germain | Jul 1996 | A |
| 5540712 | Kleshinski et al. | Jul 1996 | A |
| 5545210 | Hess et al. | Aug 1996 | A |
| 5549565 | Ryan et al. | Aug 1996 | A |
| 5562726 | Chuter | Oct 1996 | A |
| 5562728 | Lazarus et al. | Oct 1996 | A |
| 5569218 | Berg | Oct 1996 | A |
| 5571135 | Fraser et al. | Nov 1996 | A |
| 5575816 | Rudnick et al. | Nov 1996 | A |
| 5575817 | Martin | Nov 1996 | A |
| 5582614 | Feingold | Dec 1996 | A |
| 5591194 | Berthiaume | Jan 1997 | A |
| 5591195 | Taheri et al. | Jan 1997 | A |
| 5597378 | Jervis | Jan 1997 | A |
| 5601568 | Chevillon et al. | Feb 1997 | A |
| 5607442 | Fischell et al. | Mar 1997 | A |
| 5609625 | Piplani et al. | Mar 1997 | A |
| 5609627 | Goicoechea et al. | Mar 1997 | A |
| 5613974 | Andreas et al. | Mar 1997 | A |
| 5618270 | Orejola | Apr 1997 | A |
| 5628754 | Shevlin | May 1997 | A |
| 5628783 | Quiachon et al. | May 1997 | A |
| 5632763 | Glastra | May 1997 | A |
| 5639278 | Dereume et al. | Jun 1997 | A |
| 5658263 | Dang | Aug 1997 | A |
| 5662675 | Polanskyj Stockert et al. | Sep 1997 | A |
| 5662700 | Lazarus | Sep 1997 | A |
| 5674208 | Berg | Oct 1997 | A |
| 5676696 | Marcade | Oct 1997 | A |
| 5683449 | Marcade | Nov 1997 | A |
| 5693086 | Goicoechea et al. | Dec 1997 | A |
| 5700269 | Pinchuk et al. | Dec 1997 | A |
| 5707376 | Kavteladze et al. | Jan 1998 | A |
| 5709703 | Lukic et al. | Jan 1998 | A |
| 5713917 | Leonhardt et al. | Feb 1998 | A |
| 5716365 | Goicoechea et al. | Feb 1998 | A |
| 5716393 | Lindenberg et al. | Feb 1998 | A |
| 5720776 | Chuter et al. | Feb 1998 | A |
| 5723003 | Winston et al. | Mar 1998 | A |
| 5730733 | Mortier | Mar 1998 | A |
| 5733267 | Del Toro | Mar 1998 | A |
| 5735859 | Fischell et al. | Apr 1998 | A |
| 5749921 | Lenker et al. | May 1998 | A |
| 5755778 | Kleshinski | May 1998 | A |
| 5776142 | Gunderson | Jul 1998 | A |
| 5782811 | Samson | Jul 1998 | A |
| 5782904 | White et al. | Jul 1998 | A |
| 5782909 | Quiachon et al. | Jul 1998 | A |
| 5788707 | Del Toro et al. | Aug 1998 | A |
| 5792144 | Fischell et al. | Aug 1998 | A |
| 5800515 | Nadal et al. | Sep 1998 | A |
| 5800517 | Anderson et al. | Sep 1998 | A |
| 5800520 | Fogarty et al. | Sep 1998 | A |
| 5824036 | Lauterjung | Oct 1998 | A |
| 5824037 | Fogarty et al. | Oct 1998 | A |
| 5824039 | Piplani et al. | Oct 1998 | A |
| 5824040 | Cox et al. | Oct 1998 | A |
| 5824041 | Lenker et al. | Oct 1998 | A |
| 5824042 | Lombardi et al. | Oct 1998 | A |
| 5824044 | Quiachon et al. | Oct 1998 | A |
| 5843158 | Lenker et al. | Dec 1998 | A |
| 5843160 | Rhodes | Dec 1998 | A |
| 5843164 | Frantzen et al. | Dec 1998 | A |
| 5843167 | Dwyer et al. | Dec 1998 | A |
| 5851228 | Pinheiro | Dec 1998 | A |
| 5860998 | Robinson et al. | Jan 1999 | A |
| 5871536 | Lazarus | Feb 1999 | A |
| 5891110 | Larson | Apr 1999 | A |
| 5891114 | Chien | Apr 1999 | A |
| 5893868 | Hanson et al. | Apr 1999 | A |
| 5899892 | Mortier | May 1999 | A |
| 5902334 | Dwyer et al. | May 1999 | A |
| 5904713 | Leschinsky | May 1999 | A |
| 5906619 | Olson et al. | May 1999 | A |
| 5910101 | Andrews et al. | Jun 1999 | A |
| 5911715 | Berg | Jun 1999 | A |
| 5916263 | Goicoechea et al. | Jun 1999 | A |
| 5938696 | Goicoechea et al. | Aug 1999 | A |
| 5944726 | Blaeser et al. | Aug 1999 | A |
| 5947939 | Mortier | Sep 1999 | A |
| 5951495 | Berg | Sep 1999 | A |
| 5954651 | Berg | Sep 1999 | A |
| 5957949 | Leonhardt et al. | Sep 1999 | A |
| 5961511 | Mortier | Oct 1999 | A |
| 5968069 | Dusbabek et al. | Oct 1999 | A |
| 5984955 | Wisselink | Nov 1999 | A |
| 5993481 | Marcade et al. | Nov 1999 | A |
| 6004310 | Bardsley | Dec 1999 | A |
| 6004328 | Solar | Dec 1999 | A |
| 6004347 | McNamara et al. | Dec 1999 | A |
| 6019778 | Wilson et al. | Feb 2000 | A |
| 6024763 | Lenker et al. | Feb 2000 | A |
| 6039749 | Marin et al. | Mar 2000 | A |
| 6039758 | Quiachon et al. | Mar 2000 | A |
| 6039759 | Carpentier et al. | Mar 2000 | A |
| 6045557 | White et al. | Apr 2000 | A |
| 6051020 | Goicoechea et al. | Apr 2000 | A |
| 6053943 | Edwin et al. | Apr 2000 | A |
| 6063112 | Sgro | May 2000 | A |
| 6071307 | Rhee | Jun 2000 | A |
| 6077297 | Robinson et al. | Jun 2000 | A |
| 6099548 | Taheri | Aug 2000 | A |
| 6099558 | White et al. | Aug 2000 | A |
| 6099559 | Nolting | Aug 2000 | A |
| 6110191 | Dehdashtian et al. | Aug 2000 | A |
| 6110198 | Fogarty et al. | Aug 2000 | A |
| 6117167 | Giocoechea et al. | Sep 2000 | A |
| 6120480 | Zhang et al. | Sep 2000 | A |
| 6123723 | Konya et al. | Sep 2000 | A |
| 6126685 | Lenker et al. | Oct 2000 | A |
| 6152944 | Holman et al. | Nov 2000 | A |
| 6165163 | Chien | Dec 2000 | A |
| 6165213 | Goicoechea et al. | Dec 2000 | A |
| 6168616 | Brown, III | Jan 2001 | B1 |
| 6168623 | Fogarty et al. | Jan 2001 | B1 |
| 6183481 | Lee et al. | Feb 2001 | B1 |
| 6183505 | Mohn | Feb 2001 | B1 |
| 6183506 | Penn et al. | Feb 2001 | B1 |
| 6193705 | Mortier | Feb 2001 | B1 |
| 6200336 | Pavcnik et al. | Mar 2001 | B1 |
| 6200339 | Leschinsky et al. | Mar 2001 | B1 |
| 6203550 | Olson | Mar 2001 | B1 |
| 6203568 | Lombardi et al. | Mar 2001 | B1 |
| 6210435 | Piplani et al. | Apr 2001 | B1 |
| 6212422 | Berg | Apr 2001 | B1 |
| 6213976 | Trerotola | Apr 2001 | B1 |
| 6214038 | Piplani et al. | Apr 2001 | B1 |
| 6221079 | Magovern et al. | Apr 2001 | B1 |
| 6221102 | Baker et al. | Apr 2001 | B1 |
| 6224609 | Ressemann et al. | May 2001 | B1 |
| 6228063 | Aboul-Hosn | May 2001 | B1 |
| 6231601 | Myers et al. | May 2001 | B1 |
| 6238430 | Klumb et al. | May 2001 | B1 |
| 6245052 | Orth et al. | Jun 2001 | B1 |
| 6248112 | Gambale et al. | Jun 2001 | B1 |
| 6248116 | Chevillon | Jun 2001 | B1 |
| 6251132 | Ravenscroft et al. | Jun 2001 | B1 |
| 6254609 | Vrba et al. | Jul 2001 | B1 |
| 6267775 | Clerc et al. | Jul 2001 | B1 |
| 6270521 | Fischell et al. | Aug 2001 | B1 |
| 6273909 | Kugler et al. | Aug 2001 | B1 |
| 6280466 | Kugler et al. | Aug 2001 | B1 |
| 6280467 | Leonhardt | Aug 2001 | B1 |
| 6285903 | Rosenthal et al. | Sep 2001 | B1 |
| 6287315 | Wijeratne et al. | Sep 2001 | B1 |
| 6302906 | Goicoechea et al. | Oct 2001 | B1 |
| 6302907 | Hijlkema | Oct 2001 | B1 |
| 6306141 | Jervis | Oct 2001 | B1 |
| 6312458 | Golds | Nov 2001 | B1 |
| 6319275 | Lashinski et al. | Nov 2001 | B1 |
| 6319278 | Quinn | Nov 2001 | B1 |
| 6322585 | Khosravi et al. | Nov 2001 | B1 |
| 6334869 | Leonhardt et al. | Jan 2002 | B1 |
| 6338709 | Geoffrion et al. | Jan 2002 | B1 |
| 6342066 | Toro et al. | Jan 2002 | B1 |
| 6344044 | Fulkerson | Feb 2002 | B1 |
| 6344052 | Greenan et al. | Feb 2002 | B1 |
| 6346118 | Baker et al. | Feb 2002 | B1 |
| 6350278 | Lenker et al. | Feb 2002 | B1 |
| 6355056 | Pinheiro | Mar 2002 | B1 |
| 6355060 | Lenker et al. | Mar 2002 | B1 |
| 6368345 | Dehdashtian et al. | Apr 2002 | B1 |
| 6375675 | Dehdashtian et al. | Apr 2002 | B2 |
| 6375676 | Cox | Apr 2002 | B1 |
| 6379372 | Dehdashtian et al. | Apr 2002 | B1 |
| 6389946 | Frid et al. | May 2002 | B1 |
| 6395017 | Dwyer et al. | May 2002 | B1 |
| 6395022 | Piplani et al. | May 2002 | B1 |
| 6402781 | Langberg et al. | Jun 2002 | B1 |
| 6416490 | Ellis et al. | Jul 2002 | B1 |
| 6416542 | Marcade et al. | Jul 2002 | B1 |
| 6419686 | McLeod et al. | Jul 2002 | B1 |
| 6425898 | Wilson | Jul 2002 | B1 |
| 6443979 | Stalker et al. | Sep 2002 | B1 |
| 6443980 | Wang | Sep 2002 | B1 |
| 6450988 | Bradshaw | Sep 2002 | B1 |
| 6451053 | Dehdashtian et al. | Sep 2002 | B1 |
| 6454796 | Barkman et al. | Sep 2002 | B1 |
| 6458867 | Wang | Oct 2002 | B1 |
| 6464684 | Galdonik | Oct 2002 | B1 |
| 6464719 | Jayaraman | Oct 2002 | B2 |
| 6464721 | Marcade et al. | Oct 2002 | B1 |
| 6478818 | Taheri | Nov 2002 | B1 |
| 6488700 | Klumb et al. | Dec 2002 | B2 |
| 6503274 | Howanec, Jr. et al. | Jan 2003 | B1 |
| 6505066 | Berg | Jan 2003 | B2 |
| 6514282 | Inoue | Feb 2003 | B1 |
| 6517571 | Brauker et al. | Feb 2003 | B1 |
| 6517572 | Kugler et al. | Feb 2003 | B2 |
| 6517573 | Pollock et al. | Feb 2003 | B1 |
| 6520951 | Carrillo, Jr. et al. | Feb 2003 | B1 |
| 6520986 | Martin et al. | Feb 2003 | B2 |
| 6524335 | Hartley et al. | Feb 2003 | B1 |
| 6524336 | Papazolgou et al. | Feb 2003 | B1 |
| 6533753 | Haaarstad et al. | Mar 2003 | B1 |
| 6540698 | Ishii | Apr 2003 | B1 |
| 6540778 | Quiachon et al. | Apr 2003 | B1 |
| 6551350 | Thornton et al. | Apr 2003 | B1 |
| 6562022 | Hoste | May 2003 | B2 |
| 6565596 | White et al. | May 2003 | B1 |
| 6565597 | Fearnot et al. | May 2003 | B1 |
| 6575994 | Marin et al. | Jun 2003 | B1 |
| 6576007 | Dehdashtian et al. | Jun 2003 | B2 |
| 6582458 | White et al. | Jun 2003 | B1 |
| 6582460 | Cryer | Jun 2003 | B1 |
| 6592526 | Lenker | Jul 2003 | B1 |
| 6613073 | White et al. | Sep 2003 | B1 |
| 6616626 | Crank et al. | Sep 2003 | B2 |
| 6620126 | Unsworth et al. | Sep 2003 | B2 |
| 6641606 | Ouriel et al. | Nov 2003 | B2 |
| 6645242 | Quinn | Nov 2003 | B1 |
| 6652571 | White et al. | Nov 2003 | B1 |
| 6652572 | Kugler et al. | Nov 2003 | B2 |
| 6660033 | Marcade et al. | Dec 2003 | B1 |
| 6676666 | Vrba et al. | Jan 2004 | B2 |
| 6682536 | Vardi et al. | Jan 2004 | B2 |
| 6682537 | Ouriel et al. | Jan 2004 | B2 |
| 6682557 | Quiachon et al. | Jan 2004 | B1 |
| 6685736 | White et al. | Feb 2004 | B1 |
| 6689152 | Balceta et al. | Feb 2004 | B2 |
| 6689158 | White et al. | Feb 2004 | B1 |
| 6692458 | Forman et al. | Feb 2004 | B2 |
| 6692483 | Vardi et al. | Feb 2004 | B2 |
| 6692512 | Jang | Feb 2004 | B2 |
| 6695875 | Stelter et al. | Feb 2004 | B2 |
| 6706033 | Martinez et al. | Mar 2004 | B1 |
| 6726712 | Raeder-Devens | Apr 2004 | B1 |
| 6733519 | Lashinski et al. | May 2004 | B2 |
| 6733523 | Shaolian et al. | May 2004 | B2 |
| 6755856 | Fierens et al. | Jun 2004 | B2 |
| 6761731 | Majercak | Jul 2004 | B2 |
| 6790222 | Kugler et al. | Sep 2004 | B2 |
| 6802860 | Cosgrove et al. | Oct 2004 | B2 |
| 6808529 | Fulkerson | Oct 2004 | B2 |
| 6811559 | Thornton | Nov 2004 | B2 |
| 6814748 | Baker et al. | Nov 2004 | B1 |
| 6821291 | Bolea et al. | Nov 2004 | B2 |
| 6827710 | Mooney et al. | Dec 2004 | B1 |
| 6827711 | Sunseri | Dec 2004 | B2 |
| 6830575 | Stenzel et al. | Dec 2004 | B2 |
| 6843803 | Ryan et al. | Jan 2005 | B2 |
| 6849084 | Rabkin et al. | Feb 2005 | B2 |
| 6849088 | Dehdashtian et al. | Feb 2005 | B2 |
| 6858034 | Hijlkema et al. | Feb 2005 | B1 |
| 6859986 | Jackson | Mar 2005 | B2 |
| 6860901 | Baker et al. | Mar 2005 | B1 |
| 6863668 | Gillespie et al. | Mar 2005 | B2 |
| 6866660 | Garabedian | Mar 2005 | B2 |
| 6871085 | Sommer | Mar 2005 | B2 |
| 6884260 | Kugler et al. | Apr 2005 | B2 |
| 6890348 | Sydney et al. | May 2005 | B2 |
| 6911039 | Shiu et al. | Jun 2005 | B2 |
| 6916335 | Kanji | Jul 2005 | B2 |
| 6918925 | Tehrani | Jul 2005 | B2 |
| 6932829 | Majercak | Aug 2005 | B2 |
| 6938646 | Litton | Sep 2005 | B2 |
| 6939371 | Kugler et al. | Sep 2005 | B2 |
| 6945989 | Betelia et al. | Sep 2005 | B1 |
| 6945990 | Greenan | Sep 2005 | B2 |
| 6964679 | Marcade et al. | Nov 2005 | B1 |
| 6989024 | Hebert et al. | Jan 2006 | B2 |
| 6994722 | DiCarlo | Feb 2006 | B2 |
| 7001420 | Speck et al. | Feb 2006 | B2 |
| 7011647 | Purdy et al. | Mar 2006 | B2 |
| 7014653 | Ouriel | Mar 2006 | B2 |
| 7025773 | Gittings et al. | Apr 2006 | B2 |
| 7052511 | Weldon et al. | May 2006 | B2 |
| 7070582 | Freyman et al. | Jul 2006 | B2 |
| 7105016 | Shiu et al. | Sep 2006 | B2 |
| 7112217 | Kugler et al. | Sep 2006 | B1 |
| 7115134 | Chambers | Oct 2006 | B2 |
| 7125419 | Sequin et al. | Oct 2006 | B2 |
| 7147657 | Chiang et al. | Dec 2006 | B2 |
| 7147660 | Chobotov et al. | Dec 2006 | B2 |
| 7160318 | Greenberg et al. | Jan 2007 | B2 |
| 7163552 | Diaz | Jan 2007 | B2 |
| 7166125 | Baker et al. | Jan 2007 | B1 |
| 7169170 | Widenhouse | Jan 2007 | B2 |
| 7195639 | Quiachon et al. | Mar 2007 | B2 |
| 7225518 | Eidenschink et al. | Jun 2007 | B2 |
| 7238197 | Sequin et al. | Jul 2007 | B2 |
| 7264632 | Wright et al. | Sep 2007 | B2 |
| 7294147 | Hartley | Nov 2007 | B2 |
| 7351256 | Hojeibane et al. | Apr 2008 | B2 |
| 7708771 | Chuter et al. | May 2010 | B2 |
| 7717950 | Greenan | May 2010 | B2 |
| 7722663 | Austin | May 2010 | B1 |
| 7763063 | Arbefeuille et al. | Jul 2010 | B2 |
| 7766962 | Quinn | Aug 2010 | B1 |
| 7815671 | Wright et al. | Oct 2010 | B2 |
| 7837724 | Keeble et al. | Nov 2010 | B2 |
| 8043354 | Greenberg et al. | Oct 2011 | B2 |
| 8062345 | Ouellette et al. | Nov 2011 | B2 |
| 8062349 | Moore et al. | Nov 2011 | B2 |
| 8070790 | Berra et al. | Dec 2011 | B2 |
| 8292943 | Berra et al. | Oct 2012 | B2 |
| 8308790 | Arbefeuille et al. | Nov 2012 | B2 |
| 8449595 | Ouellette et al. | May 2013 | B2 |
| 8500792 | Berra | Aug 2013 | B2 |
| 8579963 | Tabor | Nov 2013 | B2 |
| 8636788 | Arbefeuille et al. | Jan 2014 | B2 |
| 8672992 | Orr | Mar 2014 | B2 |
| 8702787 | Arbefeuille | Apr 2014 | B2 |
| 8734501 | Hartley et al. | May 2014 | B2 |
| 8740963 | Arbefeuille et al. | Jun 2014 | B2 |
| 8998970 | Arbefeuille et al. | Apr 2015 | B2 |
| 9101506 | Arbefeuille et al. | Aug 2015 | B2 |
| 9173755 | Berra et al. | Nov 2015 | B2 |
| 9198786 | Moore et al. | Dec 2015 | B2 |
| 9220617 | Berra et al. | Dec 2015 | B2 |
| 9320631 | Moore et al. | Apr 2016 | B2 |
| 9333104 | Ouellette et al. | May 2016 | B2 |
| 9364314 | Berra et al. | Jun 2016 | B2 |
| 9408734 | Arbefeuille et al. | Aug 2016 | B2 |
| 9408735 | Arbefeuille et al. | Aug 2016 | B2 |
| 9439751 | White et al. | Sep 2016 | B2 |
| 9554929 | Arbefeuille et al. | Jan 2017 | B2 |
| 9561124 | Arbefeuille et al. | Feb 2017 | B2 |
| 9592112 | Arbefeuille et al. | Mar 2017 | B2 |
| 9655712 | Berra et al. | May 2017 | B2 |
| 20010000801 | Miller et al. | May 2001 | A1 |
| 20010001833 | Ravenscroft et al. | May 2001 | A1 |
| 20010034549 | Bartholf et al. | Oct 2001 | A1 |
| 20010049547 | Moore | Dec 2001 | A1 |
| 20020007193 | Tanner et al. | Jan 2002 | A1 |
| 20020013617 | Matsutani et al. | Jan 2002 | A1 |
| 20020016597 | Dwyer et al. | Feb 2002 | A1 |
| 20020016627 | Golds | Feb 2002 | A1 |
| 20020035394 | Fierens | Mar 2002 | A1 |
| 20020045929 | Diaz | Apr 2002 | A1 |
| 20020052643 | Wholey et al. | May 2002 | A1 |
| 20020052660 | Geenhalgh | May 2002 | A1 |
| 20020072755 | Bigus et al. | Jun 2002 | A1 |
| 20020082523 | Kinsella et al. | Jun 2002 | A1 |
| 20020082674 | Anson et al. | Jun 2002 | A1 |
| 20020091439 | Baker et al. | Jul 2002 | A1 |
| 20020095140 | Lootz et al. | Jul 2002 | A1 |
| 20020107561 | Pinheiro | Aug 2002 | A1 |
| 20020108621 | Berg et al. | Aug 2002 | A1 |
| 20020138133 | Lenz et al. | Sep 2002 | A1 |
| 20020156518 | Tehrani | Oct 2002 | A1 |
| 20020156522 | Ivancev et al. | Oct 2002 | A1 |
| 20020161424 | Rapacki et al. | Oct 2002 | A1 |
| 20020165554 | Dworschak et al. | Nov 2002 | A1 |
| 20020177890 | Lenker | Nov 2002 | A1 |
| 20020188344 | Bolea et al. | Dec 2002 | A1 |
| 20020198587 | Greenberg et al. | Dec 2002 | A1 |
| 20030028237 | Sullivan et al. | Feb 2003 | A1 |
| 20030074049 | Hoganson et al. | Apr 2003 | A1 |
| 20030083734 | Friedrich et al. | May 2003 | A1 |
| 20030088305 | Van Schie et al. | May 2003 | A1 |
| 20030114910 | Juhani Laakso et al. | Jun 2003 | A1 |
| 20030120263 | Ouriel et al. | Jun 2003 | A1 |
| 20030120333 | Ouriel et al. | Jun 2003 | A1 |
| 20030135259 | Simso | Jul 2003 | A1 |
| 20030135269 | Swanstrom | Jul 2003 | A1 |
| 20030139803 | Sequin et al. | Jul 2003 | A1 |
| 20030163156 | Hebert et al. | Aug 2003 | A1 |
| 20030163193 | Widenhouse | Aug 2003 | A1 |
| 20030176911 | Iancea et al. | Sep 2003 | A1 |
| 20030176912 | Chuter et al. | Sep 2003 | A1 |
| 20030191516 | Weldon et al. | Oct 2003 | A1 |
| 20030195614 | Ryan et al. | Oct 2003 | A1 |
| 20030199966 | Shiu et al. | Oct 2003 | A1 |
| 20030199967 | Hartley et al. | Oct 2003 | A1 |
| 20030212431 | Brady et al. | Nov 2003 | A1 |
| 20030220682 | Kujawski | Nov 2003 | A1 |
| 20030233140 | Hartley et al. | Dec 2003 | A1 |
| 20030236564 | Majercak | Dec 2003 | A1 |
| 20030236565 | DiMatteo et al. | Dec 2003 | A1 |
| 20040073284 | Bates et al. | Apr 2004 | A1 |
| 20040073289 | Hartley | Apr 2004 | A1 |
| 20040093063 | Wright et al. | May 2004 | A1 |
| 20040098084 | Hartley et al. | May 2004 | A1 |
| 20040106974 | Greenberg et al. | Jun 2004 | A1 |
| 20040117003 | Ouriel et al. | Jun 2004 | A1 |
| 20040148007 | Jackson et al. | Jul 2004 | A1 |
| 20040148009 | Buzzard et al. | Jul 2004 | A1 |
| 20040193141 | Leopold et al. | Sep 2004 | A1 |
| 20040193244 | Hartley et al. | Sep 2004 | A1 |
| 20040193245 | Deem et al. | Sep 2004 | A1 |
| 20040193252 | Perez | Sep 2004 | A1 |
| 20040199240 | Dorn | Oct 2004 | A1 |
| 20040230284 | Headley et al. | Nov 2004 | A1 |
| 20040230286 | Moore et al. | Nov 2004 | A1 |
| 20040236403 | Leonhardt et al. | Nov 2004 | A1 |
| 20040236407 | Fierens et al. | Nov 2004 | A1 |
| 20040267281 | Harari et al. | Dec 2004 | A1 |
| 20050021125 | Stack et al. | Jan 2005 | A1 |
| 20050027305 | Shiu et al. | Feb 2005 | A1 |
| 20050033406 | Barnhart et al. | Feb 2005 | A1 |
| 20050038495 | Greenan | Feb 2005 | A1 |
| 20050049667 | Arbefeuille et al. | Mar 2005 | A1 |
| 20050049674 | Berra et al. | Mar 2005 | A1 |
| 20050060016 | Wu et al. | Mar 2005 | A1 |
| 20050080476 | Gunderson et al. | Apr 2005 | A1 |
| 20050080477 | Sydney et al. | Apr 2005 | A1 |
| 20050096726 | Sequin et al. | May 2005 | A1 |
| 20050107862 | Ohlenschlaeger | May 2005 | A1 |
| 20050149166 | Schaeffer et al. | Jul 2005 | A1 |
| 20050159803 | Lad et al. | Jul 2005 | A1 |
| 20050159804 | Lad et al. | Jul 2005 | A1 |
| 20050171597 | Boatman et al. | Aug 2005 | A1 |
| 20050171598 | Schaeffer | Aug 2005 | A1 |
| 20050177222 | Mead | Aug 2005 | A1 |
| 20050183259 | Eidenschink et al. | Aug 2005 | A1 |
| 20050192659 | Dahl et al. | Sep 2005 | A1 |
| 20050222668 | Schaeffer et al. | Oct 2005 | A1 |
| 20050283223 | Greenan | Dec 2005 | A1 |
| 20050288764 | Snow et al. | Dec 2005 | A1 |
| 20060004433 | Greenberg et al. | Jan 2006 | A1 |
| 20060020319 | Kim et al. | Jan 2006 | A1 |
| 20060020320 | Shaolian et al. | Jan 2006 | A1 |
| 20060058864 | Schaeffer et al. | Mar 2006 | A1 |
| 20060127439 | Mattes et al. | Jun 2006 | A1 |
| 20060129169 | Fogarty et al. | Jun 2006 | A1 |
| 20060129224 | Arbefeuille et al. | Jun 2006 | A1 |
| 20060135961 | Rosenman et al. | Jun 2006 | A1 |
| 20060178726 | Douglas | Aug 2006 | A1 |
| 20060178733 | Pinchuk et al. | Aug 2006 | A1 |
| 20060188408 | Arbefeuille et al. | Aug 2006 | A1 |
| 20060195172 | Luo et al. | Aug 2006 | A1 |
| 20060200110 | Lentz et al. | Sep 2006 | A1 |
| 20060212105 | Dorn et al. | Sep 2006 | A1 |
| 20060265047 | Dorn | Nov 2006 | A1 |
| 20060276872 | Arbefeuille et al. | Dec 2006 | A1 |
| 20060282150 | Olson et al. | Dec 2006 | A1 |
| 20070021822 | Boatman | Jan 2007 | A1 |
| 20070048348 | Atanasoska et al. | Mar 2007 | A1 |
| 20070053952 | Chen et al. | Mar 2007 | A1 |
| 20070055338 | Dorn | Mar 2007 | A1 |
| 20070055340 | Pryor | Mar 2007 | A1 |
| 20070055341 | Edoga et al. | Mar 2007 | A1 |
| 20070055345 | Arbefeuille | Mar 2007 | A1 |
| 20070055347 | Arbefeuille | Mar 2007 | A1 |
| 20070083252 | McDonald | Apr 2007 | A1 |
| 20070100422 | Shumer et al. | May 2007 | A1 |
| 20070100425 | Sequin et al. | May 2007 | A1 |
| 20070123972 | Greenberg et al. | May 2007 | A1 |
| 20070135818 | Moore et al. | Jun 2007 | A1 |
| 20070135889 | Moore et al. | Jun 2007 | A1 |
| 20070142894 | Moore et al. | Jun 2007 | A1 |
| 20070156228 | Majercak et al. | Jul 2007 | A1 |
| 20070162109 | Davila et al. | Jul 2007 | A1 |
| 20070163668 | Arbefeuille et al. | Jul 2007 | A1 |
| 20070168014 | Jimenez et al. | Jul 2007 | A1 |
| 20070173929 | Boucher et al. | Jul 2007 | A1 |
| 20070179592 | Schaeffer | Aug 2007 | A1 |
| 20070179593 | Fierens et al. | Aug 2007 | A1 |
| 20070179601 | Fierens et al. | Aug 2007 | A1 |
| 20070198078 | Berra et al. | Aug 2007 | A1 |
| 20070203566 | Arbefeuille et al. | Aug 2007 | A1 |
| 20070207186 | Scanlon et al. | Sep 2007 | A1 |
| 20070213800 | Fierens et al. | Sep 2007 | A1 |
| 20070219620 | Eells et al. | Sep 2007 | A1 |
| 20070244545 | Birdsall et al. | Oct 2007 | A1 |
| 20080021538 | Wright et al. | Jan 2008 | A1 |
| 20080027528 | Jagger et al. | Jan 2008 | A1 |
| 20080046065 | Hartley et al. | Feb 2008 | A1 |
| 20080065011 | Marchand et al. | Mar 2008 | A1 |
| 20080071343 | Mayberry et al. | Mar 2008 | A1 |
| 20080077226 | Ouellette et al. | Mar 2008 | A1 |
| 20080077227 | Ouellette et al. | Mar 2008 | A1 |
| 20080082158 | Tseng et al. | Apr 2008 | A1 |
| 20080114441 | Rust et al. | May 2008 | A1 |
| 20080132996 | Drasler et al. | Jun 2008 | A1 |
| 20080172122 | Mayberry et al. | Jul 2008 | A1 |
| 20080195191 | Luo et al. | Aug 2008 | A1 |
| 20080208175 | Beckman et al. | Aug 2008 | A1 |
| 20080262590 | Murray | Oct 2008 | A1 |
| 20080264102 | Berra | Oct 2008 | A1 |
| 20080269865 | Snow et al. | Oct 2008 | A1 |
| 20090163951 | Simmons et al. | Jun 2009 | A1 |
| 20090254165 | Tabor et al. | Oct 2009 | A1 |
| 20100030255 | Berra et al. | Feb 2010 | A1 |
| 20100030318 | Berra | Feb 2010 | A1 |
| 20100049313 | Alon et al. | Feb 2010 | A1 |
| 20100234932 | Arbefeuille et al. | Sep 2010 | A1 |
| 20100274340 | Hartley et al. | Oct 2010 | A1 |
| 20110087318 | Daugherty et al. | Apr 2011 | A1 |
| 20110208288 | Arbefeuille et al. | Aug 2011 | A1 |
| 20110218607 | Arbefeuille et al. | Sep 2011 | A1 |
| 20110251664 | Acosta de Acevedo | Oct 2011 | A1 |
| 20110307049 | Kao | Dec 2011 | A1 |
| 20110313503 | Berra et al. | Dec 2011 | A1 |
| 20120123517 | Ouellette et al. | May 2012 | A1 |
| 20120143305 | Berra et al. | Jun 2012 | A1 |
| 20120296413 | Arbefeuille et al. | Nov 2012 | A1 |
| 20130274856 | Arbefeuille et al. | Oct 2013 | A1 |
| 20130325099 | Berra | Dec 2013 | A1 |
| 20130331924 | Ouellette et al. | Dec 2013 | A1 |
| 20140135890 | Berra | May 2014 | A9 |
| 20140135892 | Arbefeuille et al. | May 2014 | A1 |
| 20140135896 | Arbefeuille et al. | May 2014 | A1 |
| 20140148890 | Ouellette et al. | May 2014 | A9 |
| 20140243952 | Parodi | Aug 2014 | A1 |
| 20140277340 | White et al. | Sep 2014 | A1 |
| 20140288627 | Ouellette et al. | Sep 2014 | A1 |
| 20140316510 | Berra | Oct 2014 | A1 |
| 20150173922 | Arbefeuille et al. | Jun 2015 | A1 |
| 20150202066 | Berra | Jul 2015 | A1 |
| 20150202068 | Arbefeuille | Jul 2015 | A1 |
| 20150272755 | Arbefeuille et al. | Oct 2015 | A1 |
| 20160045350 | Berra | Feb 2016 | A1 |
| 20160081787 | Parodi | Mar 2016 | A1 |
| 20160270901 | Berra et al. | Sep 2016 | A1 |
| 20160270936 | Berra et al. | Sep 2016 | A1 |
| 20160310301 | Moore et al. | Oct 2016 | A1 |
| 20160338867 | White et al. | Nov 2016 | A1 |
| 20170000600 | Berra et al. | Jan 2017 | A1 |
| 20170100232 | Arbefeuille et al. | Apr 2017 | A1 |
| 20170100271 | Arbefeuille et al. | Apr 2017 | A1 |
| 20170135807 | Arbefeuille et al. | May 2017 | A1 |
| 20170151076 | Arbefeuille et al. | Jun 2017 | A9 |
| 20170165090 | Arbefeuille et al. | Jun 2017 | A1 |
| 20170281332 | Lostetter et al. | Oct 2017 | A1 |
| 20170281382 | Lostetter et al. | Oct 2017 | A1 |
| Number | Date | Country |
|---|---|---|
| 2451136 | Oct 2001 | CN |
| 197 53 123 | Aug 1999 | DE |
| 10 2006 053748 | Apr 2008 | DE |
| 0 510 851 | Oct 1992 | EP |
| 0 873 733 | Oct 1998 | EP |
| 0 960 607 | Dec 1999 | EP |
| 0 696 447 | Jan 2000 | EP |
| 0 990 426 | Apr 2000 | EP |
| 1 177 779 | Feb 2002 | EP |
| 1 302 178 | Apr 2003 | EP |
| 1 358 903 | Nov 2003 | EP |
| 1 369 098 | Dec 2003 | EP |
| 1522277 | Apr 2005 | EP |
| 1 772 120 | Apr 2007 | EP |
| 1 923 024 | May 2008 | EP |
| 1 929 979 | Jun 2008 | EP |
| 1 440 673 | Sep 2008 | EP |
| 1 982 677 | Oct 2008 | EP |
| 1 508 313 | Dec 2008 | EP |
| 2 714 816 | Jul 1995 | FR |
| 2 722 678 | Jan 1996 | FR |
| 2 779 939 | Dec 1999 | FR |
| WO 9523008 | Aug 1995 | WO |
| WO 9609013 | Mar 1996 | WO |
| WO 9623455 | Aug 1996 | WO |
| WO 9631174 | Oct 1996 | WO |
| WO 9638101 | Dec 1996 | WO |
| WO 9710778 | Mar 1997 | WO |
| WO 9733532 | Sep 1997 | WO |
| WO 9820811 | May 1998 | WO |
| WO 9823242 | Jun 1998 | WO |
| WO 9842276 | Oct 1998 | WO |
| WO 9853761 | Dec 1998 | WO |
| WO 9925273 | May 1999 | WO |
| WO 9937242 | Jul 1999 | WO |
| WO 9965420 | Dec 1999 | WO |
| WO 0002615 | Jan 2000 | WO |
| WO 0030562 | Jun 2000 | WO |
| WO 0078248 | Dec 2000 | WO |
| WO 0117602 | Mar 2001 | WO |
| WO 0121102 | Mar 2001 | WO |
| WO 0228316 | Apr 2002 | WO |
| WO 03015662 | Feb 2003 | WO |
| WO 2004000169 | Dec 2003 | WO |
| WO 2004002370 | Jan 2004 | WO |
| WO 2004071352 | Aug 2004 | WO |
| WO 2005023149 | Mar 2005 | WO |
| WO 2005034808 | Apr 2005 | WO |
| WO 2005058409 | Jun 2005 | WO |
| WO 2005067819 | Jul 2005 | WO |
| WO 2005081936 | Sep 2005 | WO |
| WO 2005112821 | Dec 2005 | WO |
| WO 2006019551 | Feb 2006 | WO |
| WO 2006088638 | Aug 2006 | WO |
| WO 2006125382 | Nov 2006 | WO |
| WO 2007008533 | Jan 2007 | WO |
| WO 2007028086 | Mar 2007 | WO |
| WO 2007092276 | Aug 2007 | WO |
| WO 2007123956 | Nov 2007 | WO |
| WO 2008031103 | Mar 2008 | WO |
| WO 2008098252 | Aug 2008 | WO |
| WO 2009023221 | Feb 2009 | WO |
| WO 2009124124 | Oct 2009 | WO |
| WO 2010005524 | Jan 2010 | WO |
| WO 2010042950 | Apr 2010 | WO |
| WO 2010105195 | Sep 2010 | WO |
| WO 2013154749 | Oct 2013 | WO |
| Entry |
|---|
| Notification of Transmittal of the International Search Report and the Written Opinion or the International Searching Authority, or the Declaration for International Application No. PCT/US04/28530, dated Sep. 15, 2005. |
| Notification of Transmittal of the International Preliminary Report on Patentability for International Application No. PCT/US04/28530, dated Jul. 26, 2006. |
| Office Action, U.S. Appl. No. 14/157,194, dated Jul. 3, 2014 (11 pages). |
| Office Action, U.S. Appl. No. 14/157,194, dated Jan. 13, 2015 (41 pages). |
| Office Action, U.S. Appl. No. 14/157,194, dated Aug. 12, 2015 (13 pages). |
| Notice of Allowance, U.S. Appl. No. 14/157,194, dated Apr. 25, 2016 (17 pages). |
| Number | Date | Country | |
|---|---|---|---|
| 20170165091 A1 | Jun 2017 | US |
| Number | Date | Country | |
|---|---|---|---|
| 60499652 | Sep 2003 | US | |
| 60500155 | Sep 2003 | US |
| Number | Date | Country | |
|---|---|---|---|
| Parent | 14157194 | Jan 2014 | US |
| Child | 15217486 | US | |
| Parent | 11449337 | Jun 2006 | US |
| Child | 14157194 | US |
| Number | Date | Country | |
|---|---|---|---|
| Parent | 10784462 | Feb 2004 | US |
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| Parent | 10884136 | Jul 2004 | US |
| Child | 11449337 | US |
