Patent Grant
11191630
In general, the present disclosure relates to medical devices for filtering blood. And, more particularly, in certain embodiments, to a method and a system of filters and deflectors for protecting the cerebral arteries from emboli, debris and the like dislodged during an endovascular or cardiac procedure.
There are four arteries that carry oxygenated blood to the brain, i.e., the right and left vertebral arteries, and the right and left common carotid arteries. Various procedures conducted on the human body, e.g., transcatheter aortic valve replacement (TAVR), aortic valve valvuloplasty, carotid artery stenting, closure of the left atrial appendage, mitral valve annuloplasty, repair or replacement, can cause and/or dislodge materials (whether native or foreign), these dislodged bodies can travel into one or more of the cerebral arteries resulting in, inter alia, stroke.
There exist devices for protecting one or more cerebral arteries by either collecting (filters) or deflecting (deflectors) debris. Single filters, such as those used during a carotid artery stenting are one such device.
Applicants have previously patented a dual filter embolic protection system that protects the right vertebral, and right and left common carotid arteries, see e.g., U.S. Pat. No. 9,492,264, the entirety of which is incorporated herein. Other attempts at deflecting debris from entering one or more cerebral arteries using a deflector placed in the aorta or aortic arch have also been disclosed. Of the known medical devices, delivery systems, and methods, each has certain advantages and disadvantages. There is an ongoing need to provide alternative medical devices and methods as well as alternative methods for manufacturing and using medical devices.
Certain aspects of the present disclosure address debris, tissue, etc., that can be dislodged during an endovascular procedure, this debris can travel toward, into and embolize within the cerebral vasculature leading to stroke or ischemia in an artery occluded, partially or totally, by the clot. For example, during a transcatheter aortic valve replacement (TAVR), stenotic material around the valve can be dislodged during implantation of the artificial valve. Moreover, atheroma along and within the aorta and aortic arch can be dislodged as the TAVR catheter is advanced toward the diseased aortic valve and subsequently withdrawn after implantation is completed. In addition, pieces of the catheter itself can be stripped away during delivery and implantation. These various forms of vascular debris, whether native or foreign, can then travel into one or more cerebral arteries, embolize and cause a stroke, strokes or neurocognitive deficits, for example.
Certain aspects of the present disclosure are intended to address these potentially devastating cerebral events by providing a delivery system comprised of filters and/or deflectors and/or combinations thereof, to intercept this debris before it can enter any of the cerebral arteries.
Certain aspects of the present disclosure, and its various embodiments, can provide a compound system of filters and/or deflectors for collecting (and/or deflecting) debris in a manner such that all four cerebral arteries are protected.
Vascular filters and deflectors and methods for filtering bodily fluids are disclosed herein. A blood filtering assembly can capture embolic material dislodged or generated during an endovascular procedure to inhibit or prevent the material from entering the cerebral vasculature. A blood deflecting assembly can deflect embolic material dislodged or generated during an endovascular procedure to inhibit or prevent the material from entering the cerebral vasculature.
In a first example a method of inhibiting embolic material from entering cerebral vasculature may comprise positioning a guidewire through a right subclavian artery and into a left subclavian artery and tracking a distal portion of a first protection device over the guidewire. The distal portion of the first protection device may comprise an outer sheath, a first self-expanding filter assembly radially within the outer sheath. The method may further comprise at least one of proximally retracting the outer sheath and distally advancing the self-expanding filter assembly to deploy the first self-expanding filter assembly from the outer sheath in the left subclavian artery upstream of the left vertebral artery. After deploying the self-expanding filter assembly, the method may further comprise withdrawing the outer sheath from the right subclavian artery and withdrawing the guidewire into an innominate artery and tracking a distal portion of a second protection device over the guidewire. The distal portion of the second protection device may comprise a proximal sheath, a proximal self-expanding filter assembly radially within the proximal sheath, a distal sheath, and a distal self-expanding filter assembly radially within the distal sheath The method may further comprise at least one of proximally retracting the proximal sheath and distally advancing the proximal self-expanding filter assembly to deploy the proximal self-expanding filter assembly from the proximal sheath in the innominate artery, steering the distal sheath into a left common carotid artery, at least one of proximally retracting the distal sheath and distally advancing the distal self-expanding filter assembly to deploy the distal self-expanding filter assembly from the distal sheath in the left common carotid artery, and after deploying the proximal and distal self-expanding filter assemblies, withdrawing the proximal and distal sheaths.
Alternatively or additionally to any of the examples above, in another example, the first protection device and the second protection device may be inserted into a right radial artery or a right brachial artery through a same incision.
Alternatively or additionally to any of the examples above, in another example, the method may further comprise performing an endovascular procedure, the deployed first, proximal, and distal filter assemblies inhibiting embolic material from entering cerebral vasculature through the left vertebral artery, a right common carotid artery, a right vertebral artery and the left common carotid artery during the endovascular procedure.
Alternatively or additionally to any of the examples above, in another example, the method may further comprise after performing the endovascular procedure, withdrawing the first, proximal, and distal filter assemblies.
Alternatively or additionally to any of the examples above, in another example, the first protection device may further comprise an inner member radially inward of the outer sheath.
Alternatively or additionally to any of the examples above, in another example, the method may further comprise measuring an arterial pressure using one of the first and second protection devices.
Alternatively or additionally to any of the examples above, in another example, the first protection device may further comprise a filter wire coupled to a proximal end of the first self-expanding filter and extending distally therefrom.
Alternatively or additionally to any of the examples above, in another example, an entirety of a length of the second protection device may be tracked over the filter wire.
Alternatively or additionally to any of the examples above, in another example, less than an entirety of a length of the second protection device may be tracked over the filter wire.
Alternatively or additionally to any of the examples above, in another example, the second protection device may further comprise a rapid exchange port.
In another example, a method of inhibiting embolic material from entering cerebral vasculature may comprise positioning a guidewire through a right subclavian artery and into a left subclavian artery and tracking a distal portion of a first protection device over the guidewire. The distal portion of the first protection device may comprise an outer sheath, an inner member radially inward of the outer sheath, the inner member comprising a guidewire lumen, and a first self-expanding filter assembly radially between the outer sheath and the inner member, the first self-expanding filter assembly having an opening facing a proximal end of the outer sheath. The method may further comprise at least one of proximally retracting the outer sheath and distally advancing the self-expanding filter assembly to deploy the first self-expanding filter assembly from the outer sheath in the left subclavian artery upstream of the left vertebral artery, after deploying the self-expanding filter assembly, withdrawing the outer sheath from the right subclavian artery and withdrawing the guidewire into an innominate artery, and tracking a distal portion of a second protection device over the guidewire. The distal portion of the second protection device may comprise a proximal sheath, a proximal self-expanding filter assembly radially within the proximal sheath, an articulatable distal sheath, and a distal self-expanding filter assembly radially within the distal sheath. The method may further comprise at least one of proximally retracting the proximal sheath and distally advancing the proximal self-expanding filter assembly to deploy the proximal self-expanding filter assembly from the proximal sheath in the innominate artery, steering the distal sheath into a left common carotid artery, at least one of proximally retracting the distal sheath and distally advancing the distal self-expanding filter assembly to deploy the distal self-expanding filter assembly from the distal sheath in the left common carotid artery, and after deploying the proximal and distal self-expanding filter assemblies, withdrawing the proximal and distal sheaths.
Alternatively or additionally to any of the examples above, in another example, the first protection device and the second protection device may be inserted into a right radial artery or a right brachial artery through a same incision.
Alternatively or additionally to any of the examples above, in another example, the method may further comprise performing an endovascular procedure, the deployed first, proximal, and distal filter assemblies inhibiting embolic material from entering cerebral vasculature through the left vertebral artery, a right common carotid artery, a right vertebral artery and the left common carotid artery during the endovascular procedure.
Alternatively or additionally to any of the examples above, in another example, the method may further comprise after performing the endovascular procedure, withdrawing the first, proximal, and distal filter assemblies.
In another example, a method of inhibiting embolic material from entering cerebral vasculature may comprise positioning a guidewire in a first artery, tracking a distal portion of a first protection device over the guidewire. The distal portion of the first protection device may comprise a proximal sheath, a proximal self-expanding filter assembly radially within the proximal sheath, a distal sheath, a distal self-expanding filter assembly radially within the distal sheath, and an intermediate self-expanding filter assembly radially within the distal sheath. The method may further comprise at least one of proximally retracting the proximal sheath and distally advancing the proximal self-expanding filter assembly to deploy the proximal self-expanding filter assembly from the proximal sheath in the first artery, steering the distal sheath into a second artery, at least one of proximally retracting the distal sheath and distally advancing the distal self-expanding filter assembly to deploy the distal self-expanding filter assembly from the distal sheath in the second artery, steering the distal sheath into a third artery, at least one of proximally retracting the distal sheath and distally advancing the intermediate self-expanding filter assembly to deploy the distal self-expanding filter assembly from the distal sheath in the third artery, and after deploying the proximal, distal, and intermediate self-expanding filter assemblies, withdrawing the proximal and distal sheaths.
Alternatively or additionally to any of the examples above, in another example, the first protection device may be inserted into a right radial artery or a right brachial artery.
Alternatively or additionally to any of the examples above, in another example, the method may further comprise performing an endovascular procedure, the deployed proximal, intermediate, and distal self-expanding filter assemblies inhibiting embolic material from entering cerebral vasculature through the left vertebral artery, a right common carotid artery, a right vertebral artery and the left common carotid artery during the endovascular procedure.
Alternatively or additionally to any of the examples above, in another example, the method may further comprise after performing the endovascular procedure, withdrawing the proximal, intermediate, and distal filter assemblies.
Alternatively or additionally to any of the examples above, in another example, the first protection device may further comprise a tether extending between the distal self-expanding filter assembly and the intermediate self-expanding filter assembly.
Alternatively or additionally to any of the examples above, in another example, the tether may have a preformed shape configured to guide the intermediate filter assembly towards the third artery.
In another example, an embolic protection system for isolating the cerebral vasculature may comprise a first protection device having a proximal portion configured to remain outside the body and a distal portion and a second protection device having a proximal portion configured to remain outside the body and a distal portion. The distal portion of the first protection device may comprise an outer sheath and a first self-expanding filter assembly radially within the outer sheath. The distal portion of the second protection device may comprise a proximal sheath, a proximal self-expanding filter assembly radially within the proximal sheath, a distal sheath, and a distal self-expanding filter assembly radially within the distal sheath.
Alternatively or additionally to any of the examples above, in another example, the first self-expanding filter assembly may include a proximally facing opening.
Alternatively or additionally to any of the examples above, in another example, the proximal self-expanding filter assembly may include a distally facing opening.
Alternatively or additionally to any of the examples above, in another example, the distal self-expanding filter assembly may include a proximally facing opening.
Alternatively or additionally to any of the examples above, in another example, the first protection device may further comprise a filter wire coupled to a proximal end of the first self-expanding filter and extending distally therefrom.
Alternatively or additionally to any of the examples above, in another example, the second protection device may further comprise a lumen configured to receive the filter wire of the first protection device.
Alternatively or additionally to any of the examples above, in another example, the lumen may extend over less than an entire length of the second protection device.
Alternatively or additionally to any of the examples above, in another example, the lumen may be in communication with a rapid exchange port proximally spaced from a distal end of the distal sheath.
Alternatively or additionally to any of the examples above, in another example, the lumen may extend an entirety of a length of the second protection device.
Alternatively or additionally to any of the examples above, in another example, the first protection device may further comprise an inner member radially inward of the outer sheath.
Alternatively or additionally to any of the examples above, in another example, the inner member may comprise a guidewire lumen.
Alternatively or additionally to any of the examples above, in another example, at least one of the first or second protection devices may be connected to an arterial pressure monitoring device.
Alternatively or additionally to any of the examples above, in another example, the distal sheath may be articulatable.
Alternatively or additionally to any of the examples above, in another example, each of the first self-expanding filter, the proximal self-expanding filter, and the distal self-expanding filter may be configured to be individually deployed.
Alternatively or additionally to any of the examples above, in another example, the embolic protection system may further comprise a first handle assembly coupled to the proximal portion of the first embolic protection device and a second handle assembly coupled to the proximal portion of the second embolic protection device.
The above summary of exemplary embodiments is not intended to describe each disclosed embodiment or every implementation of the present disclosure.
The invention may be more completely understood in consideration of the following detailed description of various embodiments in connection with the accompanying drawings, in which:
While the invention is amenable to various modifications and alternative forms, specifics thereof have been shown by way of example in the drawings and will be described in detail. It should be understood, however, that the intention is not to limit aspects of the invention to the particular embodiments described. On the contrary, the intention is to cover all modifications, equivalents, and alternatives falling within the spirit and scope of the invention.
For the following defined terms, these definitions shall be applied, unless a different definition is given in the claims or elsewhere in this specification.
All numeric values are herein assumed to be modified by the term “about”, whether or not explicitly indicated. The term “about” generally refers to a range of numbers that one of skill in the art would consider equivalent to the recited value (i.e., having the same function or result). In many instances, the term “about” may be indicative as including numbers that are rounded to the nearest significant figure.
The recitation of numerical ranges by endpoints includes all numbers within that range (e.g., 1 to 5 includes 1, 1.5, 2, 2.75, 3, 3.80, 4, and 5).
Although some suitable dimensions ranges and/or values pertaining to various components, features and/or specifications are disclosed, one of skill in the art, incited by the present disclosure, would understand desired dimensions, ranges and/or values may deviate from those expressly disclosed.
As used in this specification and the appended claims, the singular forms “a”, “an”, and “the” include plural referents unless the content clearly dictates otherwise. As used in this specification and the appended claims, the term “or” is generally employed in its sense including “and/or” unless the content clearly dictates otherwise.
The following detailed description should be read with reference to the drawings in which similar elements in different drawings are numbered the same. The detailed description and the drawings, which are not necessarily to scale, depict illustrative embodiments and are not intended to limit the scope of the invention. The illustrative embodiments depicted are intended only as exemplary. Selected features of any illustrative embodiment may be incorporated into an additional embodiment unless clearly stated to the contrary.
The currently marketed Sentinel system made by Claret Medical and embodiments of which are described in U.S. Pat. No. 9,492,264 mentioned above has two filters, a first which protects the right brachiocephalic artery, from which the right vertebral and right common carotid arteries typically originate, and a second filter in the left common carotid artery. In a typical patient, the left vertebral which provides approximately seven percent of the perfusion to the brain is left unprotected.
One disclosed solution to protecting the left vertebral is the use of a second device intended to be placed in the left arm, e.g. through the left radial artery, with a filter placed in the left subclavian from which the left vertebral typically originates. Embodiments of such a solution can be found in U.S. Pat. No. 9,566,144, the entirety of which is hereby incorporated by reference herein and included as part of this Specification in an Appendix (labeled Appendix B) filed with this patent application.
While procedurally compatible, it may be preferred to achieve protection of all cerebral vessels from one access point. Deflector concepts which reside in the arch have been previously disclosed, and these devices can have a single access point of either the right arm, left arm or femoral artery. While deflector concepts which reside in the arch are technically feasible, they may result in substantial interference with the therapy (e.g. TAVR) or procedure, or may not be sufficiently compatible with the breadth of sizes and configurations of aortic arches to provide complete protection of the brain.
The present application discloses several single-access multi-vessel embodiments that can provide full cerebral protection with minimal arch interference.
The disclosure generally relates to devices and methods for filtering fluids and/or deflecting debris contained within fluids, including body fluids such as blood. A filtering or deflecting device can be positioned in an artery before and/or during an endovascular procedure (e.g., transcatheter aortic valve implantation (TAVI) or replacement (TAVR), transcatheter mitral valve implantation (TAMI) or replacement (TAMR), surgical aortic valve replacement (SAVR), other surgical valve repair, implantation, or replacement, cardiac ablation (e.g., ablation of the pulmonary vein to treat atrial fibrillation) using a variety of energy modalities (e.g., radio frequency (RF), energy, cryo, microwave, ultrasound), cardiac bypass surgery (e.g., open-heart, percutaneous), transthoracic graft placement around the aortic arch, valvuloplasty, etc.) to inhibit or prevent embolic material such as debris, emboli, thrombi, etc. resulting from entering the cerebral vasculature.
The devices may be used to trap and/or deflect particles in other blood vessels within a subject, and they can also be used outside of the vasculature. The devices described herein are generally adapted to be delivered percutaneously to a target location within a subject, but can be delivered in any suitable way and need not be limited to minimally-invasive procedures.
It may be desirable to filter blood flow to all four arteries 14, 18, 20, 24 supplying blood to the brain and/or deflect particulates from entering the arteries 14, 18, 20, 24 supplying the brain. It may also be desirable to limit the number of incision sites or cuts required to deploy the system(s).
The protection device, or filter system, 30 comprises a proximal portion 34 and a distal portion 36. The proximal portion 34 is configured to be held and manipulated by a user such as a surgeon. The distal portion 36 is configured to be positioned at a target location such as the left subclavian artery 16 or the left vertebral artery 24. When the distal portion 36 is configured to be positioned at the left subclavian artery 16, the location may be upstream of the left vertebral artery 24 such that the blood is filtered prior to entering the left vertebral artery 24.
The proximal portion 34 may include a handle 38, a control 40 such as a slider, an outer sheath 42, a port 44, optionally an inner member translation control 46 such as a knob, and optionally a hemostasis valve control 48 such as a knob. The proximal portion 34 may also comprises an inner member 50 radially inward of the outer sheath 42. While not explicitly shown, the proximal portion 34 may also comprise a filter wire 52b radially inward of the outer sheath 42 (and sometimes radially outward of the inner member 50). Some illustrative filter wires are described in commonly assigned U.S. Pat. No. 9,566,144, the entirety of which is hereby incorporated by reference. The filter wire 52b may be coupled to the filter assembly 32 in the distal portion 36. The outer sheath 42 may have a diameter between about 4 French (Fr) (approximately 1.33 millimeters (mm)) and about 6 Fr (approximately 2 mm) (e.g., about 5 Fr (approximately 1.67 mm)).
The protection device 30 may further include a guidewire 56 disposed within a lumen of the inner member 50. The outer sheath 42 may comprise an atraumatic distal tip. Other features of the protection device 30 and other protection devices described herein may be flexible and/or atraumatic. The outer sheath 42 may comprise a curvature, for example based on an intended placement location (e.g., the left subclavian artery and/or the left vertebral artery).
The slider 40 can be used to translate the outer sheath 42 and/or a filter assembly 32 (e.g., coupled to a filter wire 52b). For example, the slider 40 may proximally retract the outer sheath 42, the slider 40 may distally advance the filter assembly 32 out of the outer sheath 42, or the slider 40 may proximally retract the outer sheath 42 and distally advance the filter assembly 32 (e.g., simultaneously or serially), which can allow the filter assembly 32 to radially expand. The slider 40 may also be configured to have an opposite translation effect, which can allow the filter assembly 32 to be radially collapsed (e.g., due to compression by the outer sheath 42) as the filter assembly 32 is drawn into the outer sheath 42. Other deployment systems are also possible, for example comprising gears or other features such as helical tracks (e.g., configured to compensate for any differential lengthening due to foreshortening of the filter assembly 32, configured to convert rotational motion into longitudinal motion), a mechanical element, a pneumatic element, a hydraulic element, etc. for opening and/or closing the filter assembly 32.
The port 44 is in fluid communication with the inner member 50 (e.g., via a Y-shaped connector in the handle 38). The port 44 can be used to flush the device (e.g., with saline) before, during, and/or after use, for example to remove air. The port 44 can additionally, or alternatively, be used to monitor blood pressure at the target location, for example by connecting an arterial pressure monitoring device in fluid communication with a lumen of the outer sheath 42. The port 44 can be also or alternatively be used to inject contrast agent, dye, thrombolytic agents such as tissue plasminogen activator (t-PA), etc. The slider 40 may be independent of the inner member 50 such that the inner member 50 is longitudinally movable independent of the filter assembly 32 and the outer sheath 42. The inner member translation control 46 can be used to longitudinally translate the inner member 50, for example before, after, and/or during deployment of the filter assembly 32. The inner member translation control 46 may comprise a slider in the housing 38 (e.g., separate from the slider 40).
The rotatable hemostasis valve control 48 can be used to reduce or minimize fluid loss through the protection device 30 during use. For example, a proximal portion and/or intermediate region of the protection device may be positioned in the right subclavian artery 22 and the direction of blood flow with respect to the device 30 will be distal to proximal, so blood may be otherwise inclined to follow the pressure drop out of the device 30. The hemostasis valve control 48 is illustrated as being rotatable, but other arrangements are also possible (e.g., longitudinally displaceable). The hemostasis valve control 48 may be configured to fix relative positions of the outer sheath 42 and the filter assembly 32, for example as described with respect to the hemostasis valve in U.S. Pat. No. 8,876,796. The hemostasis valve 48 may comprise, for example, an elastomeric seal and HV nut.
The distal portion 36 may include the outer sheath 42, a filter assembly 32 radially inward of the outer sheath 42 in a delivery configuration (not explicitly shown), and optionally the inner member 50. The filter assembly 32 may be radially between the outer sheath 42 and the inner member 50 (e.g., radially inward of the outer sheath 42 and the inner member 50 radially inward of the filter assembly 32) in a delivery state or shape or position.
The filter assembly 32 may include a support element or frame 31 and a filter element 33. The frame 31 may generally provide expansion support to the filter element 33 in the expanded state. In the expanded state, the filter element 33 is configured to filter fluid (e.g., blood) flowing through the filter element 33 and to inhibit or prevent particles (e.g., embolic material) from flowing through the filter element 33 by capturing the particles in the filter element 33.
The frame 31 is configured to engage or appose the inner walls of a lumen (e.g., blood vessel) in which the frame assembly 32 is expanded. The frame 31 may comprise or be constructed of, for example, nickel titanium (e.g., nitinol), nickel titanium niobium, chromium cobalt (e.g., MP35N, 35NLT), copper aluminum nickel, iron manganese silicon, silver cadmium, gold cadmium, copper tin, copper zinc, copper zinc silicon, copper zinc aluminum, copper zinc tin, iron platinum, manganese copper, platinum alloys, cobalt nickel aluminum, cobalt nickel gallium, nickel iron gallium, titanium palladium, nickel manganese gallium, stainless steel, combinations thereof, and the like. The frame 31 may comprise a wire (e.g., having a round (e.g., circular, elliptical) or polygonal (e.g., square, rectangular) cross-section). For example, in some embodiments, the frame 31 comprises a straight piece of nitinol wire shape set into a circular or oblong hoop or hoop with one or two straight legs running longitudinally along or at an angle to a longitudinal axis of the frame assembly 32. At least one of the straight legs may be coupled to a filter wire 52a or a strut 52a. The straight legs may be on a long side of the filter assembly 32 and/or on a short side of the filter assembly 32. The frame 31 may form a shape of an opening 35 of the filter assembly 32. The opening 35 may be circular, elliptical, or any shape that can appropriately appose sidewalls of a vessel such as the left subclavian artery or the left vertebral artery. The filter assembly 32 may have a generally proximally-facing opening 35. In other embodiments, the opening 35 may be distally facing. The orientation of the opening 35 may vary depending on where the access incision is located.
The frame 31 may include a radiopaque marker such as a small coil wrapped around or coupled to the hoop to aid in visualization under fluoroscopy. In some embodiments, the frame may not comprise a shape other than a hoop, for example a spiral. In some embodiments, the filter assembly 32 may not include or be substantially free of a frame.
In some embodiments, the frame 31 and the filter element 33 form an oblique truncated cone having a non-uniform or unequal length around and along the length of the filter assembly 32. In such a configuration, along the lines of a windsock, the filter assembly 32 has a larger opening 35 (upstream) diameter and a reduced ending (downstream) diameter.
The filter element 33 may include pores configured to allow blood to flow through the filter element 33, but that are small enough to inhibit prevent particles such as embolic material from passing through the filter element 33. The filter element 33 may comprise a filter membrane such as a polymer (e.g., polyurethane, polytetrafluoroethylene (PTFE)) film mounted to the frame 32. The filter element may have a thickness between about 0.0001 inches and about 0.03 inches (e.g., no more than about 0.0001 inches, about 0.001 inches, about 0.005 inches, about 0.01 inches, about 0.015 inches, about 0.02 inches, about 0.025 inches, about 0.03 inches, ranges between such values, etc.).
The film may comprise a plurality of pores or holes or apertures extending through the film. The film may be formed by weaving or braiding filaments or membranes and the pores may be spaces between the filaments or membranes. The filaments or membranes may comprise the same material or may include other materials (e.g., polymers, non-polymer materials such as metal, alloys such as nitinol, stainless steel, etc.). The pores of the filter element 33 are configured to allow fluid (e.g., blood) to pass through the filter element 33 and to resist the passage of embolic material that is carried by the fluid. The pores can be circular, elliptical, square, triangular, or other geometric shapes. Certain shapes such as an equilateral triangular, squares, and slots may provide geometric advantage, for example restricting a part larger than an inscribed circle but providing an area for fluid flow nearly twice as large, making the shape more efficient in filtration verses fluid volume. The pores may be laser drilled into or through the filter element 33, although other methods are also possible (e.g., piercing with microneedles, loose braiding or weaving). The pores may have a lateral dimension (e.g., diameter) between about 10 micron (μm) and about 1 mm (e.g., no more than about 10 μm, about 50 μm, about 100 μm, about 150 μm, about 200 μm, about 250 μm, about 300 μm, about 400 μm, about 500 μm, about 750 μm, about 1 mm, ranges between such values, etc.). Other pore sizes are also possible, for example depending on the desired minimum size of material to be captured.
The material of the filter element 33 may comprise a smooth and/or textured surface that is folded or contracted into the delivery state by tension or compression into a lumen. A reinforcement fabric may be added to or embedded in the filter element 33 to accommodate stresses placed on the filter element 33 during compression. A reinforcement fabric may reduce the stretching that may occur during deployment and/or retraction of the filter assembly 32. The embedded fabric may promote a folding of the filter to facilitate capture of embolic debris and enable recapture of an elastomeric membrane. The reinforcement material could comprise, for example, a polymer and/or metal weave to add localized strength. The reinforcement material could be imbedded into the filter element 33 to reduce thickness. For example, imbedded reinforcement material could comprise a polyester weave mounted to a portion of the filter element 33 near the longitudinal elements of the frame 31 where tensile forces act upon the frame 31 and filter element 33 during deployment and retraction of the filter assembly 32 from the outer sheath 42.
In some cases, the filter assembly 32 may include a self-expanding filter assembly (e.g., comprising a superelastic material with stress-induced martensite due to confinement in the outer sheath 42). The filter assembly 32 may comprise a shape-memory material configured to self-expand upon a temperature change (e.g., heating to body temperature). The filter assembly 32 may comprise a shape-memory or superelastic frame (e.g., comprising a distal end hoop comprising nitinol) and a microporous material (e.g., comprising a polymer including laser-drilled holes) coupled to the frame, for example similar to the filter assemblies described in U.S. Pat. No. 8,876,796.
The filter assembly 32 may be coupled (e.g., crimped, welded, soldered, etc.) to a distal end of a deployment wire or filter wire 52b via a strut or wire 52a. When both or all of the filter wire 52a and the strut 52a are provided, the filter wire 52b and the strut 52a may be coupled within the outer sheath 42 proximal to the filter assembly 30 using a crimp mechanism. In other embodiments, the filter wire 52b and the strut 52a may be a single unitary structure. The filter wire 52b and/or strut 52a can comprise a rectangular ribbon, a round (e.g., circular, elliptical) filament, a portion of a hypotube, a braided structure (e.g., as described herein), combinations thereof, and the like. The filter wire 52b can be coupled to the handle 38 and/or the slider 40 to provide differential longitudinal movement versus the outer sheath 42, as shown by the arrows 54, which can sheathe and unsheathe the filter assembly 32 from the outer sheath 42.
The filter assembly 32 in an expanded, unconstrained state has a maximum diameter or effective diameter (e.g., if the mouth is in the shape of an ellipse) d. The diameter d can be between about 1 mm and about 15 mm (e.g., at least about 1 mm, about 2 mm, about 3 mm, about 4 mm, about 5 mm, about 6 mm, about 7 mm, about 8 mm, about 9 mm, about 10 mm, about 11 mm, about 12 mm, about 13 mm, about 14 mm, about 15 mm, ranges between such values, etc.). In some embodiments (e.g., when the filter assembly is configured to be positioned in the left subclavian artery), the diameter d is between about 7 mm and about 12 mm (e.g., about 7 mm, about 8 mm, about 9 mm, about 10 mm, about 11 mm, about 12 mm, ranges between such values, etc.). In some embodiments (e.g., when the filter assembly is configured to be positioned in the left vertebral artery), the diameter d is between about 2 mm and about 4.5 mm (e.g., about 2 mm, about 2.5 mm, about 3 mm, about 3.5 mm, about 4 mm, about 4.5 mm, ranges between such values, etc.). Other diameters d or other types of lateral dimensions are also possible. Different diameters d can allow treatment of a selection of subjects having different vessel sizes.
The filter assembly 32 has a maximum length 1. The length 1 can be between about 7 mm and about 50 mm (e.g., at least about 7 mm, about 8 mm, about 9 mm, about 10 mm, about 11 mm, about 12 mm, about 13 mm, about 14 mm, about 15 mm, about 16 mm, about 17 mm, about 18 mm, about 19 mm, about 20 mm, about 21 mm, about 22 mm, about 23 mm, about 24 mm, about 25 mm, about 30 mm, about 35 mm, about 40 mm, about 45 mm, about 50 mm, ranges between such values, etc.). Other lengths 1 are also possible, for example based on the diameter or effective diameter d. For example, the length 1 of the filter assembly 32 may increase as the diameter d increases, and the length 1 of the filter assembly 32 may decrease as the diameter d decreases. A distance from an apex of the mouth of the filter assembly 32 to an elbow in the frame may be about 35 mm. Different lengths 1 can allow treatment of a selection of subjects having different vessel sizes.
The inner member 50 may be optional, but can provide additional uses and/or advantages in combination with the filter assembly 32. For example, the inner member 50 may comprise a guidewire lumen (not explicitly shown), allowing the device 30 to be tracked over a guidewire 56 without contacting the filter assembly 32. For another example, a lumen of the inner member 50 may be fluidly coupled to the flush port 44, which can allow flushing of fluid through the inner member 50, for example to remove air. For yet another example, a lumen of the inner member 50 may be connected to an arterial pressure monitoring device, allowing measurement of pressure proximate to the location of the filter assembly 32.
The distal portion 36 may include fluoroscopic markers one or more 58a, 58b to aid a user in positioning the device 30, deploying the filter assembly 32, utilizing the inner member 50, etc. A fluoroscopic marker 58b may be positioned is proximate to a distal end of the outer sheath 42. Another fluoroscopic marker (not explicitly shown) may be positioned proximate to a proximal end of the filter assembly 32. In some cases, another fluoroscopic marker 58b maybe proximate to a distal end of the filter assembly 32. Another fluoroscopic marker (not explicitly shown) may be proximate to a distal end of the inner member 50. The fluoroscopic markers may comprise a radiopaque material (e.g., iridium, platinum, tantalum, gold, palladium, tungsten, tin, silver, titanium, nickel, zirconium, rhenium, bismuth, molybdenum, combinations thereof, and the like). More or fewer fluoroscopic markers are also possible.
The protection device 30 is illustrated as comprising a guidewire 56 therethrough, although the guidewire 56 may be characterized as being separate from the protection device 30, for example independently sold, packaged, and/or directed. The guidewire 56 may extend through a lumen of the outer sheath 42 or the inner member 50. The lumen of the outer sheath 42 or the inner member 50 (if so provided) may be configured to receive a guidewire 56 having a diameter between about 0.014 inches (0.356 mm) and about 0.025 inches (0.635 mm). The guidewire 56 may extend through a lumen of the filter assembly 32. For example, the protection device 30 may be tracked over the guidewire 56 to position the protection device 30 at a desired location.
The filter assembly 32 may be positioned, for example, in the left subclavian artery 16, to protect the cerebral vasculature (e.g., the left vertebral artery 24) from embolic debris during an endovascular procedure such as TAVI. While the procedure described positioning the first filter assembly 32 in the left subclavian artery, the method is not limited to positioning the first filter assembly 32 within the left subclavian artery, the first filter assembly 32 may be positioned within other arteriers (or other lumens), as desired. The filter assembly 32 may be positioned in the left subclavian artery 16 upstream of the left vertebral artery 24. The user may choose a protection device 30 comprising a proximal-facing filter assembly 32 having a diameter appropriate for the artery (or other lumen) in which it is to be deployed, for example, but not limited to, between about 7 mm and about 12 mm for the left subclavian artery 16. The protection device 30 may be packaged in a sterile coiled packaging. The protection device 30 may comprise an outer sheath 42 having a diameter of about 5 Fr (approximately 1.67 mm). The outer sheath 42 may include a curvature, for example complementing the size and orientation of the filter assembly 32. The outer sheath 42 may be steerable (e.g., a pull wire-controlled sheath).
Lumens of the protection device 30, for example a lumen of the outer sheath 42 and a lumen of the inner member 50, may be flushed (e.g., using saline) once or several times before, during, and/or after the procedure. The filter assembly 32 of the protection device 30 may be flushed and/or submerged (e.g., in a bowl of saline). Flushing and/or submerging of the filter assembly 32 may be with the filter assembly 32 in the outer sheath 42 (e.g., in the compressed state) and/or with the filter assembly 32 out of the outer sheath 42 (e.g., in the deployed state). If the filter assembly 32 is flushed and/or submerged in the deployed state, the filter assembly 32 may be compressed into the outer sheath 42 before use.
An artery in the right arm is accessed, for example using a 5 Fr introducer. The guidewire 56 (e.g., having a diameter between about 0.014 inches and about 0.25 inches) is steered, into or towards the right subclavian artery 22, then into the innominate artery 12, then into the aortic arch 10, and finally into the left subclavian artery 16. In some cases, a distal end of the guidewire 56 may be curved (e.g., a pigtail curve) to facilitate navigation from the right subclavian artery 22 to the left subclavian artery 16. A proximal end of the guidewire may be inserted into a distal end of the protection device 30, for example into a distal end of an inner member 50. During navigation through the vasculature, the filter assembly 32 may be disposed within a lumen of the outer sheath and held in a collapsed position therein until the filter assembly 32 advanced distally from the outer sheath 42 and/or the outer sheath 42 is proximally retracted relative to the filter assembly 32. The protection device 30 may be tracked over the guidewire until the distal end of the protection device 30 extends beyond a distal end of the introducer. In some implementations, the guidewire and the protection device 30 may be tracked together, with the guidewire leading the device 30 (e.g., advance the guidewire a distance, then advance the device 30 over the guidewire approximately the same distance). In some cases, where the guidewire and the inner member 50 may both be floppy or lack rigidity, they may be introduced inside the outer sheath 42 and then advanced ahead of the device 30 in the vasculature. The guidewire may be advanced at least about 6 centimeters (cm) distal to the distal end of the protection device 30.
The protection device 30 may be tracked or distally advanced over the guidewire until the proximal end of the protection device 30 (e.g., the opening 35) is at a desired location such as proximate to the left subclavian artery ostium 17, just above the aortic arch 10. Tracking of the protection device 30 may be performed under fluoroscopy, for example using radiopaque markers (e.g., at a distal end of the outer sheath 42 and/or the inner member 50) and/or radiopaque fluid or contrast media. Radiopaque fluid may be provided through the inner member 50 and/or the outer sheath 42. The protection device 30 may be positioned so that the filter assembly 32 is upstream of the left vertebral artery 24 or proximate to the ostium 17 so that the filter assembly 32 can inhibit or prevent embolic material from entering the cerebral vasculature through the left vertebral artery 24. Using terminology of the procedure rather than blood flow, the protection device 30 is preferably positioned so that the filter assembly 32 is proximal to the point in the left subclavian artery 16 where the left vertebral artery 24 branches off. However, it is contemplated that positioning may be based on available anatomy.
Once the protection device 30 is in position, the filter assembly 32 may be deployed from the outer sheath 42. For example, the outer sheath 42 may be proximally retracted and/or the filter assembly 32 may be distally advanced. Radiopaque markers, for example on the filter assembly 32 can help determine when the filter assembly 32 achieves a deployed state. Differential longitudinal movement of the filter assembly 32 and the outer sheath 42 can cease upon full or appropriate deployment of the filter assembly 32. Apposition of the filter assembly 32 with sidewalls of the left subclavian artery 16 can be verified, for example using radiopaque fluid or contrast media. Radiopaque fluid may be provided through the inner member 50. If the radiopaque fluid is able to flow between the frame of the filter assembly 32 and the sidewalls of the left subclavian artery 16, then the filter assembly 32 may be improperly positioned (e.g., indicative of inadequate deployment, inadequate sizing, calcium, etc.). The filter assembly 32 may be retracted back into the outer sheath 42 and redeployed, or a different protection device may be used.
After positioning of the protection device 30, the outer sheath 42 and the inner member 50 may be withdrawn while the filter wire 52b and/or strut 52a are left in place. It is contemplated that the filter wire 52b and/or strut 52a may function as a guidewire to direct the outer sheath 42 back to the filter assembly 32 when removal of the filter assembly 32 is desired. Alternatively, or additionally, the guidewire 56 may be left in place during the endovascular procedure (e.g., TAVI, TAVR, TAMI, TAMR, SAVR, other surgical valve repair, implantation, or replacement, cardiac ablation, cardiac bypass surgery, etc.). In some embodiments, the inner member 50 may be retracted to a position suitable for monitoring or sensing blood pressure. For example, a blood pressure monitoring device can be connected in fluid communication to the inner member 50 (e.g., using a luer fitting). In embodiments in which the protection device lacks an inner member, blood pressure may be monitored or sensed by connecting a blood pressure monitoring device to the outer sheath 42.
The protection devices described herein may be used alone or in combination with other protection devices. For example, a second protection device as described herein may be advanced via the right subclavian artery and positioned in both the innominate artery 12 and the left common carotid artery 14, providing protection to the right carotid artery, the right vertebral artery, and the left carotid artery 14. For another example, an aortic arch filter or deflector such as the Embrella Embolic Deflector System, the TriGuard embolic protection system, or the like may be placed across the great branch artery ostia and/or apposing sidewalls of the aortic arch upstream of at least one of the great branch artery ostia. For another example, the filter systems and methods described in U.S. Pat. No. 8,876,796 can be used in combination with the protection devices described herein to further protect the cerebral vasculature during an endovascular procedure.
For example, after the first filter assembly 32 has been positioned, a second protection device, or filter system, 60 may be deployed in the innominate artery 12 and the left common carotid artery 14, as shown in
The second protection device 60 may include a distal end region 66 including at least the filter assembles 62, 64 and a proximal end region (not explicitly shown) coupled to a handle (not explicitly shown) configured to remain outside the body. In some cases, the handle of the second protection device 60 may be similar in form and function to the handle 38 described herein. The distal end region 66 may include a proximal sheath 68, a proximal shaft 70 coupled to an expandable proximal filter assembly 64, a distal shaft 72 coupled to a distal articulatable sheath 74, a distal filter 62, and guiding member 76.
The proximal shaft 70 is co-axial with proximal sheath 68, and a proximal region 78 of proximal filter assembly 64 is secured to proximal shaft 70. In its collapsed configuration (not explicitly shown), the proximal filter assembly 64 may be disposed within proximal sheath 68 and is disposed distally relative to proximal shaft 70. The proximal sheath 68 may be axially (distally and proximally) movable relative to proximal shaft 70 and the proximal filter assembly 64. The system 60 may also include a distal sheath 74 secured to a distal region of distal shaft. The distal shaft 72 may be co-axial with the proximal shaft 70 and the proximal sheath 68. The distal sheath 74 and distal shaft 72 may be secured to one another axially movable relative to proximal sheath 68, the proximal shaft 70 and the proximal filter assembly 64. The system 60 may also include a distal filter assembly 62 carried by the guiding member 76. While not explicitly shown, the distal filter assembly 62 may be maintained in a collapsed configuration within the distal sheath 74. The guiding member 76 may be coaxial with distal sheath 74 and distal shaft 72 as well as proximal sheath 68 and proximal shaft 70. The guiding member 76 may be axially movable relative to distal sheath 74 and distal shaft 72 as well as proximal sheath 68 and proximal shaft 70. The proximal sheath 68, the distal sheath 74, and the guiding member 76 may each be adapted to be independently moved axially relative to one other. That is, the proximal sheath 68, the distal sheath 74, and the guiding member 76 are adapted for independent axial translation relative to each of the other two components. It is contemplated that the handle may include control elements (such as, but not limited to, slides, switches, buttons, dials, etc.) configured to individually actuate the proximal sheath 68, the distal sheath 74, and the guiding member 76.
The proximal filter assembly 64 may include a support element or frame 65 and filter element 67. Similarly, the distal filter assembly 62 includes support element 61 and filter element 63. The frames 61, 65 may be similar in form and function to the frame 31 described herein. Similarly, the filter elements 63, 67 may be similar in form and function to the filter element 33 described herein. The support elements 61, 65 generally provide expansion support to the filter elements 63, 67 in their respective expanded configurations, while the filter elements 63, 67 are adapted to filter fluid, such as blood, and trap particles flowing therethrough. The expansion supports 61, 65 are adapted to engage the wall of the lumen in which they are expanded. The filter elements 63, 67 have pores therein that are sized to allow the blood to flow therethrough, but are small enough to prevent unwanted foreign particles from passing therethrough. The foreign particles are therefore trapped by and within the filter elements 63, 67.
As shown in
The filters 62, 64 may be secured to separate system components. For example, the proximal filter assembly 64 is secured to the proximal shaft 70, while the distal filter assembly 62 is secured to guiding member 76. In
In some embodiments, the distal sheath 74 and the proximal sheath 68 have substantially the same outer diameter. When the filter assemblies 62, 64 are collapsed within the sheaths, the sheath portion of the system 60 therefore has a substantially constant outer diameter, which can ease the delivery of the system 60 through the patient's body and increase the safety of the delivery. The distal and proximal sheaths 74 and 68 may have substantially the same outer diameter, both of which have larger outer diameters than the proximal shaft 70. The proximal shaft 70 may have a larger outer diameter than the distal shaft 72, wherein the distal shaft 72 is disposed within the proximal shaft 70. The guiding member 76 may have a smaller diameter than the distal shaft 72. In some embodiments the proximal and distal sheaths 68, 74 have an outer diameter between 3 French (F) and 70 F. In certain embodiments, the outer diameter is between 4 F and 8 F. In still other embodiments, the outer diameter is between 4 F and 6 F. In some embodiments, the sheaths 68, 74 have different outer diameters. For example, the proximal sheath 68 can have a size of 6 F, while the distal sheath 74 has a size of 5 F. In an alternate embodiment the proximal sheath 68 is 5 F and the distal sheath 74 is 4 F. These are just examples and are not intended to limit the sheaths 68, 74 to a particular size. A distal sheath 74 with a smaller outer diameter than the proximal sheath 68 reduces the delivery profile of the system 60 and can ease delivery. In some methods of use, the filter system 60 is advanced into the subject through an incision made in the subject's right radial artery, or alternatively the right brachial artery. In a variety of medical procedures a medical instrument is advanced through a subject's femoral artery, which is larger than the right radial artery. A delivery catheter used in femoral artery access procedures has a larger outer diameter than would be allowed in a filter system advanced through a radial artery. Additionally, in some uses the filter system is advanced from the right radial artery into the aorta via the brachiocephalic trunk. The radial artery has the smallest diameter of the vessels through which the system is advanced. The radial artery therefore limits the size of the system that can be advanced into the subject when the radial artery is the access point. The outer diameters of the systems described herein, when advanced into the subject via a radial artery, are therefore smaller than the outer diameters of the guiding catheters (or sheaths) typically used when access is gained via a femoral artery.
The system 60 may be delivered to the left carotid artery 14 and the innominate artery 12 in a delivery configuration. The system's delivery configuration generally refers to the configuration when both filter assemblies 62, 64 are in collapsed configurations within the system. The distal articulating sheath 74 may be independently movable with 3 degrees of freedom relative to the proximal sheath 68 and proximal filter 64. In some embodiments, the proximal sheath 68 and the distal sheath 74 may be releasably coupled together. For example, the proximal sheath 68 can be coupled to the distal sheath 74 using an interference fit, a friction fit, a spline fitting, end to end butt fit or any other type of suitable coupling between the two sheaths 68, 74. When coupled together, the components move as a unit. For example, the proximal sheath 68, the proximal shaft 70, the proximal filter 64, the distal shaft 72, and the distal filter 62 will rotate and translate axially (in the proximal or distal direction) as a unit. When proximal sheath 68 is retracted to allow proximal filter 64 to expand, the distal sheath 74 can be independently rotated, steered, or translated axially (either in the proximal direction or distal direction). The distal sheath 74 therefore has 3 independent degrees of freedom: axial translation, rotation, and steering. The adaptation to have 3 independent degrees of freedom is advantageous when positioning the distal sheath 74 in a target location, details of which are described below.
The system 60 is advanced into the subject's right radial artery through an incision in the right arm, or alternately through the right brachial artery. For example, the system 60 may be advanced through the same incision as the first system 30. The system is advanced through the right subclavian artery 22 and into the brachiocephalic or innominate artery 12, and a portion of the system is positioned within aortic arch 10. The proximal sheath 68 is retracted proximally to allow proximal filter support element 65 to expand to an expanded configuration against the wall of the innominate artery 12, as is shown in
The distal sheath 74 is then steered, or bent, and the distal end 84 of the distal sheath 74 is advanced into the left common carotid artery 14. The guiding member 76 is thereafter advanced distally relative to distal sheath 74, allowing the distal support element 61 to expand from a collapsed configuration to a deployed configuration against the wall of the left common carotid artery 14, as shown in
The filter system(s) 30, 60 can thereafter be removed from the subject (or at any point in the procedure). In an exemplary embodiment, distal filter assembly 62 is first retrieved back within distal sheath 74 to the collapsed configuration. To do this, the guiding member 76 is retracted proximally relative to the distal sheath 74. This relative axial movement causes the distal sheath 74 to engage a strut or wire 86 and begin to move strut 86 towards guiding member 76. The support element 61, which is coupled to the strut 86, begins to collapse upon the collapse of the strut 86. The filter element 63 therefore begins to collapse as well. Continued relative axial movement between the guiding member 76 and the distal sheath 74 continues to collapse the strut 86, the support element 61, and the filter element 63 until the distal filter assembly 62 is retrieved and re-collapsed back within distal sheath 74 (not explicitly shown). Any foreign particles trapped within the distal filter element 63 are contained therein as the distal filter assembly 62 is re-sheathed. The distal sheath 74 is then steered into a configuration where the distal sheath 74 is generally parallel with the distal shaft 72. Said differently, the distal sheath 74 is steered such that it has generally linear orientation. The proximal sheath 70 is then advanced distally relative to proximal filter assembly 64. This causes proximal filter assembly 64 to collapse around distal shaft 72, trapping any particles within the collapsed proximal filter 67. The proximal sheath 68 continues to be moved distally towards the distal sheath 74 until the proximal sheath 68 is coupled with or nearly coupled with the distal sheath 74. The entire system 60 can then be removed from the subject.
Once the second filter system 60 has been removed from the body, the outer sheath 42 of the first filter system 30 can be advanced (e.g., over a guidewire 56 or the filter wire 52b) such that the filter assembly 32 may be retracted back into the outer sheath 42 (e.g., by distally advancing the outer sheath 42 and/or by proximally retracting the filter assembly 32). The action to re-sheathe the filter assembly 32 may by opposite to the action to unsheathe the filter assembly 32 (e.g., retraction of a slider and advancement of the slider, respectively) or may be a completely different action. The inner member 50 may be distally advanced before, during, or after re-sheathing of the filter assembly 32. Radiopaque markers, for example on the filter assembly 32 can help determine when the filter assembly 32 achieves a compressed state. Differential longitudinal movement of the filter assembly 32 and the outer sheath 42 can cease upon full or appropriate capture of the filter assembly 32. Radiopaque fluid may be provided through the inner member 50. Embolic material trapped in the filter assembly 32 may also be captured by the re-sheathing process. Once the protection device 30 is in a compressed state, the protection device 30 may be proximally retracted out of the right subclavian artery 22.
In any of the embodiments mentioned herein, the filter or filter assemblies 32, 62, 64 may alternatively be detached from the delivery catheter, and the delivery catheter removed leaving the filter 32, 62, 64 behind. The filter or filter assemblies 32, 62, 64 can be left in place permanently, or retrieved by snaring it with a retrieval catheter following a post procedure treatment period of time. Alternatively, the filter assemblies 32, 62, 64 may remain attached to the catheter, and the catheter may be left in place post procedure for the treatment period of time. That treatment period may be at least one day, one week, three weeks, five weeks or more, depending upon the clinical circumstances. Patients with an indwelling filter or filter assemblies may be administered any of a variety of thrombolytic or anticoagulant therapies, including tissue plasminogen activator, streptokinase, coumadin, heparin and others known in the art.
The system 100 is advanced into the subject's right radial artery through an incision in the right arm, or alternatively through the right brachial artery. While not explicitly shown, the system 100 may be advanced over or in conjunction with one or more guidewires. The system is advanced through the right subclavian artery 22 and into the innominate artery 12, and a portion of the system is positioned within aortic arch 10. The proximal sheath 110 is retracted proximally to allow proximal filter support element 118 to expand to an expanded configuration against the wall of the innominate artery 12, as is shown in
The distal sheath 112 is then steered, or bent, and the distal end of the distal sheath 112 is advanced into the left subclavian artery 16. The guiding member (not explicitly shown) is thereafter advanced distally relative to distal sheath 112, allowing the distal support element 114 to expand from a collapsed configuration to a deployed configuration against the wall of the left subclavian artery 16, as shown in
Once the distal filter assembly 104 has been positioned in the left subclavian artery, the tether 126 may be distally advanced to provide additional length or “slack” to allow the distal sheath 112 to be repositioned. The distal sheath 112 may be manipulated to then cannulate the left common carotid artery 14. The guiding member (not explicitly shown) is thereafter advanced distally relative to distal sheath 112, allowing the intermediate support element 116 to expand from a collapsed configuration to a deployed configuration against the wall of the left common carotid artery 14, as shown in
The system 100 is advanced into the subject's right radial artery through an incision in the right arm. The system is advanced through the right subclavian artery 22 and into the innominate artery 12, and a portion of the system is positioned within aortic arch 10. The proximal sheath 110 is retracted proximally to allow proximal filter support element 118 to expand to an expanded configuration against the wall of the innominate artery 12, as is shown in
The distal sheath 112 is then steered, or bent, and the distal end of the distal sheath 112 is advanced into the left subclavian artery 16. The guiding member (not explicitly shown) is thereafter advanced distally relative to distal sheath 112, allowing the distal support element 114 to expand from a collapsed configuration to a deployed configuration against the wall of the left subclavian artery 16, as shown in
Once the distal filter assembly 104 has been positioned in the left subclavian artery, the distal sheath 112 may be manipulated to then cannulate the left common carotid artery 14. The guiding member (not explicitly shown) is thereafter advanced distally relative to distal sheath 112, allowing the intermediate support element 116 to expand from a collapsed configuration to a deployed configuration against the wall of the left common carotid artery 14, as shown in
The system 200 is advanced into the subject's right radial artery through an incision in the right arm, or alternatively through the right brachial artery. While not explicitly shown, the system 200 may be advanced over or in conjunction with one or more guidewires. The system is advanced through the right subclavian artery 22 and into the innominate artery 12, and both the distal sheath 212 and a distal portion of the of proximal sheath 210 positioned within the ascending portion of the aorta 10.
The proximal sheath 210 is retracted proximally to allow intermediate filter support element 216 to expand to an expanded configuration within the aorta 10. The system 200 may then be retracted (e.g., proximally displaced) to move the intermediate filter assembly 206 into the left common carotid artery 14, as shown at arrow 230. The predetermined hook shape of the flexible link 228 may help guide the intermediate filter assembly 206 into place. The intermediate support element 216 is moved against the wall of the left common carotid artery 14, as shown in
The proximal sheath 210 then be further proximally retracted, as shown at arrow 232, to deploy the proximal filter assembly 208. The position of distal sheath 212 can be substantially maintained while proximal sheath 210 is retracted proximally. The proximal sheath 210 is retracted proximally to allow proximal filter support element 218 to expand to an expanded configuration against the wall of the innominate artery 12, as is shown in
The distal sheath 212 is then steered, or bent, and the distal end of the distal sheath 212 is advanced into the left subclavian artery 16. The guiding member (not explicitly shown) is thereafter advanced distally relative to distal sheath 212, allowing the distal support element 214 to expand from a collapsed configuration to a deployed configuration against the wall of the left subclavian artery 16, as shown in
The steerable sheath 310 is advanced into the subject's right radial artery through an incision in the right arm, or alternatively through the right brachial artery. While not explicitly shown, the system 300 may be advanced over or in conjunction with one or more guidewires. The sheath 310 is advanced through the right subclavian artery 22 and into the innominate artery 12, the arch of aorta 10 to a site proximate the ostium of the left subclavian artery 16 (if not actually cannulating left subclavian artery 16). The first filter assembly 304 may then be advanced through a lumen of the sheath 310. Alternately, the first filter assembly 304 may be pre-loaded within the sheath 310 and advanced therewith. The filter assembly 304 may be distally advanced from the sheath 310 (or the sheath 310 proximally retracted) to allow the distal filter support element 314 to expand from a collapsed configuration to a deployed configuration against the wall of the left subclavian artery 16, as shown in
After placement of the first filter assembly 304, the sheath 310 completely withdrawn from the patient such that the filter wire 330 (similar in form and function to filter wire 52b described herein) is free from the sheath 310. The steerable sheath 310 is then advanced into the subject's right radial artery through the incision in the right arm. The sheath 310 is advanced through the right subclavian artery 22 and into the innominate artery 12, the arch of aorta 10 to a site proximate the ostium of the left common carotid artery 14 (if not actually cannulating left common carotid artery 30). The second filter assembly 306 may then be advanced through a lumen of the sheath 310. Alternately, the second filter assembly 306 may be pre-loaded within the sheath 310 and advanced therewith. The filter assembly 306 may be distally advanced from the sheath 310 (or the sheath 310 proximally retracted) to allow the intermediate filter support element 316 to expand from a collapsed configuration to a deployed configuration against the wall of the left common carotid artery 14, as shown in
After placement of the second filter assembly 306, the sheath 310 is again completely withdrawn from the patient such that a second filter wire 332 (similar in form and function to filter wire 52b described herein) is free from the sheath 310. The steerable sheath 310 is then advanced into the subject's right radial artery through the incision in the right arm. The sheath 310 is advanced through the right subclavian artery 22 and into the innominate artery 12. The third filter assembly 308 may then be advanced through a lumen of the sheath 310. Alternately, the third filter assembly 308 may be pre-loaded within the sheath 310 and advanced therewith. The filter assembly 308 may be distally advanced from the sheath 310 (or the sheath 310 proximally retracted) to allow the proximal filter support element 318 to expand from a collapsed configuration to a deployed configuration against the wall of the innominate artery 12, as shown in
The filter system 400 may be advanced into the subject's right radial (or alternatively, the right brachial) artery through an incision in the right arm. While not explicitly shown, the system 400 may be advanced over or in conjunction with one or more guidewires. The system 400 is advanced through the right subclavian artery 22 and into the innominate artery 12 until the distal end 418 of the outer sheath 404 is adjacent to the ostium 420 of the innominate artery 12. The outer sheath 404 may then be proximally retracted to deploy the proximal filter assembly 408 over the ostia 420, 422 of the innominate and left common carotid arteries 12, 14. As can be seen, the support member 412 and the filter element 416 of the proximal filter assembly 408 may be sized and shaped to extend over both the ostia 420, 422 of the innominate and left common carotid arteries 12, 14. The inner sheath 402 may then be distally advanced toward and, sometimes through, the ostium 424 of the left subclavian artery 16. The inner sheath 402 may be proximally retracted to deploy the distal filter assembly 406 within the left subclavian artery 16. Alternatively, the order in which the filter assemblies 406, 408 are deployed may be reversed. It is contemplated that when the procedure is completed, the insertion steps may be performed in reverse to remove the system 500.
The distal end region 502 may include a proximal sheath 510, a proximal shaft (not explicitly shown) coupled to an expandable proximal filter assembly 508, a distal shaft (not explicitly shown) coupled to a distal articulatable sheath 512, a proximal filter assembly 506, a deflector 504, and guiding member (not explicitly shown). As can be seen, the filter system 500 may be structurally similar to the second filter system 60 and/or the filter system 100 described herein and may be similarly arranged. However, in the filter system 500 illustrated in
The system 500 is advanced into the subject's right radial artery through an incision in the right arm, or alternatively through the right brachial artery. While not explicitly shown, the system 500 may be advanced over or in conjunction with one or more guidewires. The system is advanced through the right subclavian artery 22 and into the innominate artery 12, and a portion of the system is positioned within aortic arch 10. The proximal sheath 510 is retracted proximally to allow proximal filter support element 518 to expand to an expanded configuration against the wall of the innominate artery 12, as is shown in
The distal sheath 512 is then steered, or bent, and the distal end of the distal sheath 512 is advanced into the left common carotid artery 14. The guiding member (not explicitly shown) is thereafter advanced distally relative to distal sheath 512, allowing the deflector 504 and the distal filter assembly 506 to be discharged from the distal end of the distal sheath 512. The pre-formed tether 526 may position the deflector proximate the ostium of the left subclavian artery 16 while the distal filter assembly 506 is positioned in the left common carotid artery 14. As the distal filter assembly is deployed, the distal support element 516 expands from a collapsed configuration to a deployed configuration against the wall of the left common carotid artery 14, as shown in
It is contemplated that the deflector 504 may not be coupled or linked to the distal filter assembly 506 via the tether 526 (e.g., the tether 526 is not present in the system 500). In such an instance, the deflector 504 may include a deflector wire 528a, 528b. It is contemplated that the deflector is provided with only a single wire 528a or 528b. However, the deflector wire 528a may be positioned outside of the distal sheath 512 (and in some cases, also outside of the proximal sheath 510). In other embodiments, the deflector wire 528b may be disposed within a lumen of the distal sheath 512 and/or the proximal sheath 510.
In some embodiments, the deflector 504 and the distal filter assembly 506 may be deployed prior to the deployment of the proximal filter assembly 508. It is contemplated that when the procedure is completed, the insertion steps may be performed in reverse to remove the system 500. As can be seen in
In the embodiment of
The system 600 is advanced into the subject's right radial artery through an incision in the right arm, or alternatively through the right brachial artery. While not explicitly shown, the system 600 may be advanced over or in conjunction with one or more guidewires. The system is advanced through the right subclavian artery 22 and into the innominate artery 12, and a portion of the system may positioned within aortic arch 10. The filter assembly 604 may be distally advanced from the distal end of the guide sheath 602 and partially into the aorta 10. The deployment wires 610, 612 and/or the pull wires 614, 616 may then be manipulated to position the filter assembly 604 in the desired orientation, such that the filter assembly 604 covers the ostia of the left subclavian, left common carotid and innominate arteries 16, 14, 12. The guide sheath 602 may then be retracted or left within the vasculature during the remainder of the procedure. As can be seen in
The system 700 is advanced into the subject's right radial artery through an incision in the right arm, or alternatively through the right brachial artery. While not explicitly shown, the system 700 may be advanced over or in conjunction with one or more guidewires. The system is advanced through the right subclavian artery 22 and into the innominate artery 12, and a portion of the system may positioned within aortic arch 10. The filter assembly 704 may be distally advanced from the distal end of the guide sheath 702 and partially into the aorta 10. The filter assembly 704 may be manipulated such that it covers the ostia of the left subclavian, left common carotid and innominate arteries 16, 14, 12. In some cases, the filter assembly 704 may include deployment wires and/or pull wires similar to those described with respect to
While the methods and devices described herein may be susceptible to various modifications and alternative forms, specific examples thereof have been shown in the drawings and are described in detail herein. It should be understood, however, that the inventive subject matter is not to be limited to the particular forms or methods disclosed, but, to the contrary, covers all modifications, equivalents, and alternatives falling within the spirit and scope of the various implementations described and the appended claims. Further, the disclosure herein of any particular feature, aspect, method, property, characteristic, quality, attribute, element, or the like in connection with an implementation or embodiment can be used in all other implementations or embodiments set forth herein. In any methods disclosed herein, the acts or operations can be performed in any suitable sequence and are not necessarily limited to any particular disclosed sequence and not be performed in the order recited. Various operations can be described as multiple discrete operations in turn, in a manner that can be helpful in understanding certain embodiments; however, the order of description should not be construed to imply that these operations are order dependent. Additionally, the structures described herein can be embodied as integrated components or as separate components. For purposes of comparing various embodiments, certain aspects and advantages of these embodiments are described. Not necessarily all such aspects or advantages are achieved by any particular embodiment. Thus, for example, embodiments can be carried out in a manner that achieves or optimizes one advantage or group of advantages without necessarily achieving other advantages or groups of advantages. The methods disclosed herein may include certain actions taken by a practitioner; however, the methods can also include any third-party instruction of those actions, either expressly or by implication. For example, actions such as “deploying a self-expanding filter” include “instructing deployment of a self-expanding filter.” The ranges disclosed herein also encompass any and all overlap, sub-ranges, and combinations thereof. Language such as “up to,” “at least,” “greater than,” “less than,” “between,” and the like includes the number recited. Numbers preceded by a term such as “about” or “approximately” include the recited numbers and should be interpreted based on the circumstances (e.g., as accurate as reasonably possible under the circumstances, for example ±5%, ±10%, ±15%, etc.). For example, “about 7 mm” includes “7 mm.” Phrases preceded by a term such as “substantially” include the recited phrase and should be interpreted based on the circumstances (e.g., as much as reasonably possible under the circumstances). For example, “substantially straight” includes “straight.”
Those skilled in the art will recognize that the present invention may be manifested in a variety of forms other than the specific embodiments described and contemplated herein. Accordingly, departure in form and detail may be made without departing from the scope and spirit of the present invention as described in the appended claims.
This application claims the benefit of priority under 35 U.S.C. § 119 to U.S. Provisional Application Ser. No. 62/577,870, filed Oct. 27, 2017, the entirety of which is incorporated herein by reference.
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