Patent Application
20170079814
The present invention generally relates to a stent system configured to deliver and place a stent to and at a target site in a living body lumen and to a method for manufacturing the stent system.
In recent years, for example, to treat acute myocardial infarction or angina pectoris, one procedure which has been used is target vessel revascularization, which is a procedure for improving blood flow by placing a stent at a lesion (stenosed site) of the coronary artery. An example is disclosed in Japanese Application Publication No. 2002-136601). Moreover, a stent can be placed for improving a lesion formed in another blood vessel, bile duct, trachea, esophagus, urethra, or other body lumens.
A stent system, which is used to place a stent, usually includes a catheter (deliver catheter) provided with an inflatable and deflatable balloon at the distal portion of a catheter shaft, and a hollow tubular expandable stent mounted on an outer peripheral portion of the balloon. When the balloon is inflated after being delivered to a target site (stenosed site) in the body via a narrow living body lumen, the stent expands while plastically deforming along with inflation of the balloon, so that the stenosed site is widened. After this, when the balloon is deflated, the stent is left in the expanded state, to thus keep the stenosed site in a widened state.
Therefore, the stent needs to be stably mounted on an outer peripheral portion of the deflated balloon until the stent reaches the target site in the living body lumen.
During insertion of the stent system into the living body lumen, if the stent comes into contact with, for example, a calcified lesion, the stent may come out of position with or come off the outer peripheral portion of the balloon. In the case where such a situation has occurred, the need for surgically removing the stent may arise, thus causing a decrease in treatment efficiency.
The stent delivery system disclosed here is able to prevent a stent from coming out of position on the outer peripheral portion of a balloon and a method for manufacturing the stent system.
The stent delivery system disclosed here comprises a catheter having an inflatable and deflatable balloon, and a stent mounted on an outer peripheral portion of the balloon and configured to expand along with inflation of the balloon. An outer surface of the balloon and an inner surface of the stent have respective modified surfaces, and adhesiveness between the outer surface and the inner surface is improved by the modified surfaces being in contact with each other.
Since both the outer surface of the balloon and the inner surface of the stent are modified and activated, and the modified surfaces are in contact with each other, the modified surfaces interact with each other, so that adhesiveness between the outer surface of the balloon and the inner surface of the stent can be improved. Accordingly, when the stent is delivered to a lesion in the living body lumen, the stent can be prevented from coming out of position with the balloon in the living body lumen, or the stent can be prevented from coming off there. Accordingly, the operator is enabled to efficiently perform treatment in the living body lumen.
The stent may be a drug eluting stent having a hollow tubular stent main body, and a coating layer provided at an outer surface of the stent main body and containing a drug. Among an outer surface and the inner surface of the stent, the outer surface of the stent can be configured not to be provided with the modified surface. With this configuration, modification by surface treatment is not applied to the coating layer containing a drug of the stent. Therefore, adhesiveness between the balloon and the stent can be improved without any effect on the function of the coating layer containing a drug.
According to another aspect, a stent system comprises a catheter possessing a distal end portion at which is fixed a folded balloon in a deflated state, wherein the folded balloon is expandable to an inflated state upon being inflated and the folded balloon possesses an outer surface. The stent system also comprises a stent mounted on an outer peripheral portion of the balloon and possessing an inner surface facing the outer surface of the folded balloon, with the stent being expandable as the balloon expands to the inflated state. The outer surface of the folded balloon is a surface-treated outer surface in which the outer surface of the folded balloon is modified to improve adhesiveness of the balloon with the stent, and the inner surface of the stent is a surface-treated inner surface in which the inner surface of the stent is modified to improve adhesiveness of the stent with the balloon. The surface-treated outer surface of the folded balloon is in contact with the surface-treated inner surface of the stent.
According to another aspect, a method for manufacturing a stent system comprises applying surface treatment to an outer surface of an inflatable and deflatable balloon so that the balloon possesses a surface-treated outer surface, and applying surface treatment to an inner surface of a stent so that the stent possesses a surface-treated inner surface. The surface treatment applied to the outer surface of the balloon and the surface treatment applied to the inner surface of the stent are selected to modify the outer surface of the balloon and to modify the inner surface of the stent to improve adhesiveness between the stent and the balloon. The method also comprises mounting the stent with the surface-treated inner surface on an outer peripheral portion of the balloon with the surface-treated outer surface.
Since the outer surface of the balloon and the inner surface of the stent are modified by surface treatment applied thereto, the outer surface of the balloon and the inner surface of the stent interact with each other, so that adhesiveness between the outer surface of the balloon and the inner surface of the stent can be improved. Accordingly, when the stent is delivered to a lesion in the living body lumen, the stent can be prevented from coming out of position with the balloon in the living body lumen, or the stent can be prevented from coming off there. Accordingly, the operator is enabled to efficiently perform treatment in the living body lumen.
The surface treatment of the inner surface of the stent includes applying plasma treatment to the inner surface of the stent under atmospheric pressure, and the surface treatment of the outer surface of the balloon includes applying plasma treatment to the outer surface of the balloon under atmospheric pressure. With this, the outer surface of the balloon and the inner surface of the stent can be easily treated by plasma treatment under atmospheric pressure. Moreover, since a process for reduction in pressure and exposure to atmospheric pressure in a treatment chamber is not required unlike a case where plasma treatment is performed under the reduced-pressure atmosphere, the balloon and the stent can be combined with each other rapidly following the surface treatment with the treatment effect kept still high. Accordingly, high adhesiveness between the balloon and the stent can be effectively attained.
The applying surface treatment to the outer surface of the balloon includes applying surface treatment to the outer surface of the balloon while the balloon is folded in a deflated state. This makes it possible to further reduce the time required to combine the balloon and the stent after plasma treatment.
The stent may be a drug eluting stent comprised of a hollow tubular stent main body and a coating layer provided at the outer surface of the stent main body and containing a drug. The applying surface treatment to the inner surface of the stent may include radiating energy in an axial direction of the stent from one axial end of the stent in a state in which the outer surface of the stent is covered. This enables performing surface treatment on the inner surface of the stent without affecting the coating layer containing a drug.
The applying surface treatment to the inner surface of the stent can alternatively include radiating energy in an axial direction of the stent from both axial ends of the stent in a state in which the outer surface of the stent is covered. This makes it possible to effectively perform surface treatment on the inner surface of the stent even in the case of the stent being long in the axial direction.
According to the stent system and the method for manufacturing the stent system disclosed here, when the stent is delivered to a lesion in the living body lumen, the stent can be prevented from coming out of position with the outer peripheral portion of the balloon.
Hereinafter, a stent system and a method for manufacturing the stent system according to several disclosed embodiments, representing examples of the inventive stent system and method disclosed here, will be described with reference to the accompanying drawings.
The stent system 10 includes a catheter 12 and stent 14, which is attached to the vicinity of the distal portion of the catheter 12. The catheter 12 has a thin and long shaft 16, a hub 18 provided at the proximal side or proximal end of the shaft 16, and a balloon 20 provided at the distal side or distal end of the shaft 16, and is a delivery catheter configured to deliver the stent 14 to a target site in the living body lumen.
The shaft 16 possesses a tubular shape and is made from, for example, a resin having high sliding property. The shaft 16 has adequate flexibility and adequate strength to enable the operator to smoothly insert the shaft 16 through into a biological organ, such as a blood vessel, while grasping and manipulating the proximal end of the shaft 16. The material used to make the shaft 16 can be selected from among materials described below as examples of the material used to make the balloon 20, or can be made of another material.
A guide wire lumen, into which a guide wire 17 used to guide the stent system 10 to a lesion of the coronary artery is inserted, and a balloon lumen, which is used to guide an inflation fluid into the balloon 20, are formed in the shaft 16. A detailed illustration of these aspects of the shaft is not provided as it such features are known.
In
The balloon 20 is able to inflate and deflate according to supply and drainage of an inflation fluid with respect to the balloon 20, and is bonded to the shaft 16 in a liquid-tight manner in the vicinity of the distal portion of the shaft 16. The balloon 20 is folded in a deflated state. The balloon 20 being folded in a deflated state, as mentioned herein, refers to the balloon 20 being deflated and one or more portions of the outer surface of the balloon 20 being folded in a circumferential direction of the balloon.
In
Such a balloon 20 needs to have adequate flexibility, and also needs to have such a degree of strength as to be able to securely widen the stenosed site. More specifically, it is made from an organic polymeric material. Accordingly, for example, it can be formed of a polymer material, such as polyolefin (for example, polyethylene, polypropylene, polybutene, ethylene-propylene copolymer, ethylene-vinyl acetate copolymer, ionomer, or a mixture of two or more of these materials), polyvinyl chloride, polyamide, polyamide elastomer, polyurethane, polyurethane elastomer, polyimide, and fluorine resin, or a mixture of some of these materials, or a multi-layer tube or the like made from two or more of the above-mentioned polymer materials.
The stent 14 is what is called a balloon-expandable stent, which expands while plastically deforming due to a dilation force of the balloon 20, and is mounted on the tube portion 20a of the balloon 20. The inner surface of the stent 14 is in contact with the outer surface of the balloon 20.
The configuration of the stent 14 includes, for example, a configuration which has a mesh-like side peripheral wall provided with multiple side holes and is formed of a tube (cylinder) as an overall shape, and a configuration which is formed of a tube (cylinder) as an overall shape by connecting, in the axial direction, multiple circular bodies (annular bodies), each of which extends in a wavelike fashion in the circumferential direction. The distal end and proximal end of the stent 14 each can be provided with a radiopaque marker made from, for example, a radiopaque material.
The material used to make a framework (strut) of the stent 14 can include, for example, metal having biocompatibility, and a biodegradable polymer having bioabsorbability.
Examples of the metal having biocompatibility include an iron-base alloy, such as stainless steel, tantalum (a tantalum alloy), platinum (a platinum alloy), gold (a gold alloy), a cobalt-base alloy, a cobalt chrome alloy, a titanium alloy, and a niobium alloy.
The biodegradable polymer is a polymer which gradually biodegrades after the stent 14 is placed at the lesion and has no adverse influence on the living body of a human or animal. The biodegradable polymer is not specifically limited, but is desirably one having high biological stability, and, for example, is desirably at least one polymer selected from the group consisting of polylactic acid, polyglycolic acid, a copolymer of lactic acid and glycolic acid, polycaprolactone, polyhydroxybutyrate, polyhydroxybutyrate valeric acid, polymalic acid, poly-a-amino acid, polyorthoester, cellulose, collagen, laminin, heparan sulfate, fibronectin, vitronectin, chondroitin sulfate, hyaluronic acid, cinnamic acid, and a cinnamic acid derivative, a copolymer obtained by copolymerization of any of monomers constituting the polymers, or a mixture of the polymer and the copolymer.
The stent 14 can be comprised of a stent main body 14a (strut) constituting a framework, and a coating layer 14b (a drug-containing polymer layer) containing a drug provided on the outer surface of the stent main body 14a. The coating layer 14b can be formed on the entirety of the outer surface of the stent main body 14a, or can be formed on a part of the outer surface of the stent main body 14a.
The drug contained in the coating layer 14b is a biological physiological active substance, and, after placement of the stent 14 in the living body lumen, has the effect of preventing restenosis by gradually eluting at a region in which the stenosed site has been treated. Examples of such a drug include anticancer drug, immunosuppressive drug, antibiotic, antirheumatic, antithrombogenic drug, antihyperlipidemic drug, angiotensin-converting enzyme inhibitor, calcium antagonist agent, integrin inhibitor, anti-allergic drug, antioxidant agent, GpIIb/IIIa inhibitor, retinoid, flavonoid, carotenoid, lipid improving drug, DNA synthesis inhibitor, tyrosine kinase inhibitor, antiplatelet drug, vascular smooth muscle growth inhibitor, anti-inflammatory drug, a tissue-derived biomaterial, interferon, and NO production promoting substance.
In the catheter 12 according to the present embodiment, the outer surface of the balloon 20 has a surface modified by surface treatment in such a way as to have improved adhesiveness with the inner surface of the stent 14. Moreover, the inner surface of the stent 14 has a surface modified by surface treatment in such a way as to have improved adhesiveness with the outer surface of the balloon 20.
More specifically, surface treatment is applied to at least the outer surface of the tube portion 20a in the outer surface of the balloon 20. In this case, the range at which surface treatment is applied to the outer surface of the tube portion 20a can be the entirety of the outer surface of the tube portion 20a, can be a part of that outer surface as viewed in the axial direction, can be a part of that outer surface as viewed in the circumferential direction, or can be a part of that outer surface as viewed in both the axial direction and the circumferential direction. The range at which surface treatment is applied to the inner surface of the stent 14 can be the entirety of that inner surface, can be a part of that inner surface as viewed in the axial direction, can be a part of that inner surface as viewed in the circumferential direction, or can be a part of that inner surface as viewed in both the axial direction and the circumferential direction.
Examples of the surface treatment include plasma treatment, ultraviolet irradiation, and corona discharge. In particular, in terms of easiness of surface treatment, plasma treatment under atmospheric pressure is desirable. More desirably, it is plasma treatment in the presence of helium gas.
Applying such surface treatment to the outer surface of the balloon 20 causes all or at least one of the effects of (a) addition of, for example, a carboxyl group, a hydroxyl group, or an amino group to the surface of a polar group, (b) removal of fine organic dirt adhering to the surface (outer surface of the balloon 20), and (c) application of roughness to the surface (outer surface of the balloon 20).
In the case of the stent 14 being made from metal, applying surface treatment to the metal surface (metal-exposed surface) of the inner surface of the stent 14 causes all or at least one of the effects of (d) activation of water molecules hydrated with an oxide layer or removal of bound water, and (e) cleaning of fine organic dirt adhering to the surface (metal surface or metal-exposed surface).
In the case of the coating layer 14b made from a polymer being provided on the inner surface of the stent 14, applying surface treatment to the inner surface (a portion corresponding to the coating layer 14b) of the stent 14 causes all or at least one of the above-mentioned effects (a) to (c) on the inner surface of the stent 14.
In the plasma treatment, plasma can be generated in a vacuum, or plasma can be generated under atmospheric pressure.
The ultraviolet irradiation is desirably short-wavelength ultraviolet irradiation, which allows irradiation with high energy. The wavelength of short-wavelength ultraviolet is of the order of, for example, 180 nm to 310 nm.
The stent system 10 according to the present embodiment is basically configured as described above, and the function and effect thereof are described as follows.
According to the stent system 10, since both the outer surface of the balloon 20 and the inner surface of the stent 14 are modified to be activated and the modified surfaces are in contact with each other, the modified surfaces interact with each other, so that adhesiveness between the outer surface of the balloon 20 and the inner surface of the stent 14 can be effectively improved. In other words, the coefficient of friction between the outer surface of the balloon 20 and the inner surface of the stent 14 can be improved as compared with a case where the surfaces are not subjected to property modification. Accordingly, when the stent system 10 is used (when the stent 14 is delivered to a lesion in the living body lumen), the stent 14 can be prevented from coming out of position with the balloon 20 in the living body lumen, or the stent 14 can be prevented from coming off the balloon. Accordingly, the operator is able to efficiently perform treatment in the living body lumen.
Furthermore, in the case where the stent 14 is a drug eluting stent, among the outer surface and the inner surface of the stent 14, the outer surface is not provided with the modified surface. With this configuration, property modification by surface treatment is not applied to the coating layer 14b containing a drug of the stent 14. Therefore, adhesiveness between the balloon 20 and the stent 14 can be improved without any effect on the function of the coating layer 14b containing a drug.
Moreover, since adhesiveness between metal and an organic polymeric material is low, the surface treatment in the invention is effective for the case of attempting to increase adhesiveness between metal and an inelastic organic polymeric material. In other words, the surface treatment in the invention is particularly effective for the case where the stent 14 is made from metal and the balloon 20 is made from an organic polymeric material. Furthermore, the organic polymeric material subjected to surface treatment has an increased adhesiveness with organic metal since a polar group is introduced into a portion subjected to the surface treatment. Therefore, it is desirable that the inner side of the stent 14 be provided with an oxide layer formed thereon.
Next, a method for manufacturing the stent system 10 configured as described above is described.
The method for manufacturing the stent system 10 includes a provision step of providing the balloon 20 and the stent 14, a surface treatment step of applying surface treatment to each of the outer surface of the balloon 20 and the inner surface of the stent 14 to modify the outer surface and the inner surface in such a way as to improve adhesiveness between the outer surface of the balloon 20 and the inner surface of the stent 14, and a mount step of mounting the stent 14 with the surface-treated inner surface on an outer peripheral portion of the balloon 20 having the surface-treated outer surface.
More specifically, the above-mentioned provision step includes a balloon provision step of providing the balloon 20 (a balloon with the outer surface not yet subjected to surface treatment), and a stent provision step of providing the stent 14 (a stent with the inner surface not yet subjected to surface treatment).
The balloon provision step can include providing a catheter 12 that is composed of a combination of the shaft 16, the hub 18, and the balloon 20. Moreover, the catheter 12 as used herein can be one that is in a deflated state in which the balloon 20 is folded.
In the case where the stent 14 is a drug eluting stent, the stent provision step includes providing a stent 14 in which the coating layer 14b is formed on the outer surface of the stent main body 14a.
The above-mentioned surface treatment step includes applying surface treatment to, or performing surface treatment at, the outer surface of the balloon 20 and the inner surface of the stent 14 provided in the provision step. The following are some examples of a method for surface treatment, but the present invention is not limited to these examples.
A high-frequency power source is connected to the first electrode 34 and the second electrode 36, and, when a high-frequency voltage is applied to the first electrode 34 and the second electrode 36, the process gas G is converted into plasma by electric discharge. With this, a plasma region S is formed inside the plasma discharge tube 32. The process gas G is continuously discharged via an exhaust portion 38. Examples of the process gas G include a noble gas, such as helium and argon.
As illustrated in
Furthermore, as illustrated in
Moreover, radiating plasma from the plasma nozzle 40 toward the outer surface of the balloon 20 while displacing the plasma nozzle 40 and the balloon 20 relative to each other along the axial direction of the catheter 12 can be employed. This enables efficient irradiation of the entire length of the tube portion 20a of the balloon 20 with a plasma even in a case where the exit port diameter of the plasma nozzle 40 is less than the length of the tube portion 20a.
In this case, radiating ultraviolet light while rotating the balloon 20 and an output portion 46 of the ultraviolet irradiation device 44 relative to each other around the axial line (central axis) “a” of the catheter 12 enables irradiation of the entire circumference of the outer surface of the balloon 20 with ultraviolet light. The relative rotation of the balloon 20 and the output portion 46 can be performed by rotating the catheter 12 around the axial line (central axis) “a” or by rotating the output portion 46 around the axial line (central axis) “a” of the catheter 12.
Furthermore, although not illustrated, radiating ultraviolet light from a plurality of output portions 46, which are arranged around the balloon 20, toward the outer surface of the balloon 20 while rotating the plurality of output portions 46 and the balloon 20 relative to each other enables efficient irradiation of the entire circumference of the outer surface of the balloon 20 with ultraviolet light.
Moreover, radiating ultraviolet from the output portion 46 toward the outer surface of the balloon 20 while displacing the output portion 46 and the balloon 20 relative to each other along the axial direction of the catheter 12 can be employed. This enables efficient irradiation of the entire length of the tube portion 20a of the balloon 20 with ultraviolet irradiation even in a case where the output width of ultraviolet irradiation corresponding to the size of the output portion 46 is less than the length of the tube portion 20a.
Furthermore, although not illustrated, it is desirable that the surface treatment of the outer surface of the balloon 20 be performed in a state in which the balloon 20 is folded (in a deflated state). With this, in the state in which the balloon 20 is folded, adhesiveness between the balloon 20 and the stent 14 can be increased. Moreover, in a state in which the balloon 20 is inflated, adhesiveness between the balloon 20 and the stent 14 can be decreased. More specifically, performing surface treatment in the state in which the balloon 20 is folded makes it possible to form a surface-treated portion and a non-surface-treated portion on the outer surface of the balloon 20 in the inflated state. This is because, in the state in which the balloon 20 is folded, surface treatment of the balloon 20 is not applied to the folded portion of the balloon 20. Here, a non-surface-treated portion of the outer surface of the balloon 20 is weak in interaction with the stent 14 and is low in adhesiveness. Therefore, in the state in which the balloon 20 is inflated, adhesiveness between the balloon 20 and the stent 14 is decreased. Accordingly, during delivery in the living body lumen, the stent 14 can still be prevented from coming off the balloon 20. Furthermore, when the stent 14 is placed in the living body lumen, since the stent 14 is relatively easily detached from the balloon 20, placement of the stent 14 can be easily performed.
Therefore, in the method illustrated in
In the case of a stent 14 having a length of 20 mm or more in the axial direction, plasmas (plasma jets PJ) can be radiated toward a hollow portion of the stent 14 from both sides in the axial direction of the stent 14, as illustrated in
In this case, radiating the plasma while rotating the stent 14 and the plasma nozzle 40 relative to each other around the axial line (central axis) “a” of the stent 14 enables irradiating the entire circumference of the inner surface of the stent 14 with the plasma. For example, as illustrated in
According to the method illustrated in
After the balloon 20 with the outer surface surface-treated (the catheter 12 provided with the balloon 20) and the stent 14 with the inner surface surface-treated are obtained as mentioned above, then, a mount step of combining the balloon 20 and the stent 14 is performed.
The mount step includes mounting the stent 14 on the outer peripheral portion of the balloon 20, which is folded into a deflated state. More specifically, in a state in which the balloon 20 in the deflated state and the stent 14 are arranged in a concentric fashion and the tube portion 20a of the balloon 20 and the stent 14 are superposed in the axial direction, the stent 14 is contracted in the radial direction, so that the stent 14 is mounted on the outer peripheral portion of the balloon 20. With this, the stent 14 decreases in diameter while plastically deforming, so that the outer surface of the balloon 20 and the inner surface of the stent 14 adhere tightly to each other.
After the completion of the mount step, predetermined packing and sterilization are performed, so that the stent system 10 is completed as a product.
According to the above-described method for manufacturing the stent system 10, since the outer surface of the balloon 20 and the inner surface of the stent 14 are modified by surface treatment applied thereto, the outer surface of the balloon 20 and the inner surface of the stent 14 interact with each other, so that adhesiveness between the outer surface of the balloon 20 and the inner surface of the stent 14 is improved. Accordingly, when the stent 14 is delivered to a lesion in the living body lumen, the stent 14 can be prevented from coming out of position with the balloon 20 in the living body lumen, or the stent 14 can be prevented from coming off the balloon. Accordingly, the operator is able to efficiently perform treatment in the living body lumen.
As described above, in the surface treatment step, if plasma treatment is applied to the outer surface of the balloon 20 and the inner surface of the stent 14 under atmospheric pressure, the outer surface of the balloon 20 and the inner surface of the stent 14 can be relatively easily treated.
Usually, the effect of surface treatment tends to decrease with time. Accordingly, it is desirable that the mount step be performed relatively rapidly following the surface treatment step. In other words, it is desirable that the mount step be performed when the effect of surface treatment obtained in the surface treatment step is still high.
In the case of the present embodiment, since a process for reduction in pressure and exposure to atmospheric pressure in a treatment chamber is not required unlike a case where plasma treatment is performed under the reduced-pressure atmosphere, the balloon 20 and the stent 14 can be combined with each other rapidly following the surface treatment with the treatment effect kept still high. Accordingly, high adhesiveness between the balloon 20 and the stent 14 can be effectively attained. In this case, it is desirable that the mount step be performed within, for example, 60 minutes, desirably 30 minutes, of the completion of the surface treatment on the outer surface of the balloon 20 and the inner surface of the stent 14 under atmospheric pressure.
Furthermore, in the surface treatment step, since surface treatment is applied to the outer surface of the balloon 20 in a deflated state in which the balloon 20 is folded, a time required to combine the balloon 20 and the stent 14 after plasma treatment can be further reduced.
Referring to
As understood from
Therefore, according to the invention, adhesiveness between the outer surface of the balloon 20 and the inner surface of the stent 14 can be effectively improved.
The detailed description above describes a stent delivery system and method according to embodiments disclosed by way of example. The invention here is not limited, however, to the precise embodiments and variations described above and illustrated in the drawing figures. Various changes, modifications and equivalents could be effected by one skilled in the art without departing from the spirit and scope of the invention as defined in the appended claims. It is expressly intended that all such changes, modifications and equivalents which fall within the scope of the claims are embraced by the claims.
| Number | Date | Country | Kind |
|---|---|---|---|
| 2014-135515 | Jul 2014 | JP | national |
This application is a continuation of International Application No. PCT/JP2015/067352 filed on Jun. 18, 2015, which claims priority to Japanese Application No. 2014-135515 filed on Jul. 1, 2014, the entire content of both of which is incorporated herein by reference.
| Number | Date | Country | |
|---|---|---|---|
| Parent | PCT/JP2015/067532 | Jun 2015 | US |
| Child | 15367878 | US |
