US 20080058886 A1
The present application describes a method and apparatus for implanting a medical device within a living body. The apparatus includes an elongate sleeve positionable with a living body, such as within a blood vessel, and a medical device insertable into the sleeve. During use, the sleeve is retained with the body, and the medical device is sealed within the sleeve. The sleeve substantially avoids biological growth onto the medical device, and thus permits removal of the medical device independently of the sleeve.
1. A method of implanting a medical device within a living body, the method comprising the steps of:
forming an incision in a living body;
introducing a sleeve having a length through the incision;
positioning the entire length of the sleeve within the body;
inserting an implantable medical device into the sleeve and sealing the medical device within the sleeve.
2. The method of
3. The method of
4. The method of
5. The method of
6. The method of
7. The method of
8. The method of
9. The method of
10. The method of
11. The method of
12. The method of
13. The method of
14. The method of
the introducing step introduces a sleeve having an exterior and at least one electrode on the exterior;
the sealing inserting step inserts a medical device having an interior and pulse generator sealed within the interior; and
the method further includes the step of electrically coupling the pulse generator to the electrode.
15. The method of
16. The method of
17. The method of
the introducing step introduces a sleeve having a fluid delivery port;
the inserting step inserts a medical device having an interior and a fluid reservoir in the interior; and
the method further includes the step of fluidly coupling the fluid delivery port and the fluid reservoir.
18. The method of
withdrawing a portion of the sleeve from the body; and
extracting the medical device from within the sheath.
19. The method of
after the extracting step, inserting a second medical device into the sleeve.
20. The method of
41. An implantable intravascular medical system kit, including:
a elongate sleeve proportioned for implantation within a blood vessel of a patient;
an implantable medical device positionable within the sleeve; and
instructions for use setting forth implantation methods for the sleeve and medical device, including the steps of:
forming an incision in a living body;
introducing the sleeve through the incision and into a blood vessel;
positioning an entire length of the sleeve within the body;
inserting the medical device into the sleeve and sealing the medical device within the sleeve.
This application claims priority from prior Provisional Application Ser. No. 60/529,051, filed Dec. 12, 2003, and which is incorporated herein by reference.
The present invention generally relates to devices or systems implanted within the body for therapeutic and/or diagnostic purposes. In particular, the invention provides methods and devices for facilitating implantation of such systems within the patient's vasculature.
Pacemakers, defibrillators and implanted cardioverter defibrillators (“ICDs”) have been successfully implanted for years for treatment of heart rhythm conditions.
Pacemakers are implanted in patients who have bradycardia (slow heart rate). The pacemakers detect periods of bradycardia and deliver electrical stimuli to increase the heartbeat to an appropriate rate.
ICDs are implanted in patients who may suffer from episodes of fast and irregular heart rhythms called tachyarrhythmias. An ICD can cardiovert the heart by delivering electrical current directly to the heart to terminate an atrial or ventricular tachyarrhythmia, other than ventricular fibrillation. An ICD may alternatively defibrillate the heart in a patient who may suffer ventricular fibrillation (VF), a fast and irregular heart rhythm in the ventricles. During a VF episode, the heart quivers and can pump little or no blood to the body, potentially causing sudden death. An ICD implanted for correction of ventricular fibrillation will detect a VF episode and deliver an electrical shock to the heart to restore the heart's electrical coordination.
Another type of implantable defibrillation device treats patients who may suffer from atrial fibrillation (AF), which is a loss of electrical coordination in the heart's upper chambers (atria). During AF, blood in the atria may pool and clot, placing the patient at risk for stroke. An electrophysiological device implanted for correction of atrial fibrillation will detect an AF episode and deliver an electrical shock to the atria to restore electrical coordination.
Pacemakers and ICDs are routinely implanted in the pectoral region either under the skin (subcutaneous) or under the pectoral muscle. The leads are placed at appropriate locations around, within or on the heart. Because of this complexity, a cardiologist identifying a heart rhythm condition may be required to refer his or her patient to sub-specialists or surgeons for implantation of a pacemaker or ICD—thus delaying implantation of the device in a patient who urgently needs it. It is thus desirable to simplify these devices and the procedures for implanting them so as to permit their implantation by a broader range of physicians.
U.S. application Ser. Nos. 10/453,971 and 10/454,223 (“the '971 and '223 applications), filed Jun. 4, 2003, and 10/862,113, filed Jun. 4, 2004 (the '113 application) describe intravascular systems that may be used to deliver electrical energy to the heart such as for defibrillation, pacing, and/or cardioversion of the heart. Each of these applications is incorporated herein by reference for all purposes.
Generally speaking, the systems described in the '971, '113 and '223 applications include at least one housing containing the necessary circuitry and related components for delivering a charge to the heart for pacing, and/or defibrillation, etc. The systems may also include ‘at least one’ electrode lead through which the electrical energy is delivered to the body. Some or all of these components are positioned within the vasculature, such as in the superior vena cava (“SVC”), the inferior vena cava (“IVC”), or the left or right subclavian, coronary sinus, and/or other vessels of the venous or arterial systems. For example, the housing containing electronics, circuitry, batteries, capacitors, etc. may be positioned in the IVC or SVC, while leads extending from the housing may extend to the left subclavian vein (LSV), the IVC, the coronary sinus of the heart, and/or the right ventricle of the heart. Retention devices may be used to retain some of these components within the vasculature.
The present disclosure describes components that facilitate implantation and later removal of the housing containing electronics, circuitry, batteries, etc. in an intravascular system. In particular, the application describes a sleeve or “exoskeleton” that is implanted in the vasculature. The exoskeleton may be retained in place using a retention device. Following implantation of the exoskeleton, the housing is inserted into the exoskeleton. If at some date it becomes necessary to explant the housing, it may be withdrawn from the exoskeleton and removed from the body, leaving the exoskeleton in place.
Exoskeleton configurations will be described in the context of an intravascular system useful for electrophysiological (“EP”) applications (such as implantable defibrillation systems and associated components), it should be appreciated that the disclosed embodiments and methods or variations thereof may be used to implant other types of intravascular systems, including but not limited to pacing, defibrillation or cardioversion systems. The components may find further use in connection with intravascular systems for delivering other forms of therapy (e.g., pharmaceutical therapies) to the body. Such systems are described in U.S. application Ser. No. ______, INTRAVASCULAR DELIVERY SYSTEM FOR THERAPEUTIC AGENTS, filed Dec. 9, 2004, Attorney Docket No. NMX-110, the entirety of which is incorporated herein by reference. Other systems for which the exoskeleton components may be useful include intravascular diagnostic systems such as those that monitor blood glucose, blood oxygen, or other parameters. It should also be mentioned that although this application describes the systems for use in the vasculature, pre-implant exoskeletons may be implanted at other sites within the body where medical implants are to be placed. For example, exoskeletons may function as pre-implant devices in subcutaneous pockets or in organs or body cavities throughout the body.
The exoskeleton 13 a is proportioned to be passed into the vasculature and to be anchored within the patient's vasculature with minimal obstruction to blood flow. Suitable sites for the exoskeleton may include, but are not limited to the venous system using access through the right or left femoral vein or the subclavian or brachiocephalic veins, or the arterial system using access through one of the femoral arteries. Thus, the exoskeleton preferably has a streamlined maximum cross sectional diameter which may be in the range of 3-15 mm or less, with a most preferred maximum cross-sectional diameter of 3-8 mm or less. The cross-sectional area of the exoskeleton in the transverse direction (i.e., transecting the longitudinal axis) should be as small as possible while still accommodating the required components within the insert 13 b. This area is preferably in the range of approximately 79 mm2 or less, and more preferably in the range of approximately 40 mm2 or less, or most preferably between 12.5-40 mm2.
The exoskeleton preferably forms a fluid-tight barrier against migration of body fluids into its interior. Avoiding leakage of blood and body fluids avoids thrombus formation and endothelial or cellular growth within the exoskeleton and onto the insert, and thus allows the insert to be removed from the exoskeleton when necessary for replacement or servicing. Examples of materials useful for the exoskeleton include PTFE, ePTFE, PFPE, other fluropolymers, polyurethanes, silicone, polyolefin rubber, dacron polyester, PET, PMMA, EVA or polypropylene, ceramics, surface reactive glass ceramics (including bioglasses or bioceramics), or metals including titanium and its alloys and/or other biocompatible metals. Exoskeleton 13 a may be formed of a polymeric material having a reinforcing structure (e.g., a metallic or polymeric braid) over, under or integrated with the polymeric material. One example of this type of arrangement would be a braid lined with a Teflon polymer.
Because the ekoskeleton might remain permanently in the vasculature, it may be desirable to promote tissue growth (e.g., cellular encapsulation, in-growth, endothelialization) onto and/or into the exoskeleton 13 a. Tissue growth onto/into the exoskeleton can improve the stability of the exoskeleton within the vessel, and may improve the biocompatibility of the system within the vessel by improving blood-surface compatibility. Cellular growth may be encouraged by giving the exoskeleton an in-growth promoting surface using structural features. For example, all or a portion of the exterior surface of the exoskeleton may have pores (e.g., from a porous material), interstices (e.g., in a mesh material), or other surface modifications into or onto which cellular growth can occur. In one embodiment, the exoskeleton may have an exterior surface formed or covered by Dacron or by a form of ePTFE having a node to fibril length of approximately 15-25 microns. Cellular growth into or onto the exoskeleton may also be promoted using a substance that promotes in-growth. For example, the exoskeleton may be coated or impregnated with a substance such as albumen, growth factors, synthetic or natural therapeutic molecules, or any other substance that will promote cellular growth.
On the other hand, if the option to explant the exoskeleton is desired, it may be formed of a material or covered by a layer or coating having anti-proliferative properties so as to minimize endothelialization or cellular ingrowth, since minimizing growth into or onto the device will help minimize vascular trauma when the device is explanted. A form of ePTFE having a note-to-fibril length of approximately 1-10 microns, and preferably less than approximately 10 microns, may be used for this purpose.
In another embodiment, the exoskeleton may be constructed such that it will degrade over a period of time calculated such that degradation will occur after the intended useful life of the insert. Materials suitable for this purpose include LPLA, polyglycolic acid, polydioxanone, polyanhydrides or other erodable materials. According to this embodiment, degradation of the exoskeleton would preferably be timed to occur following removal of the implant.
The exoskeleton surface may also be anti-thrombogenic (e.g., using materials or coating such as perfluorocarbon coatings applied using supercritical carbon dioxide), although if cellular ingrowth is desired some thrombosis may be allowed as a substrate for endothelial growth. The exoskeleton may also include a surface or coating, which elutes compositions, such as anti-thrombogenic compositions (e.g., heparin sulfate) and/or anti-proliferative compositions and/or immunosuppressive agents.
In another embodiment, the insert 13 b may fit snugly into the exoskeleton 13 a, in which case the exoskeleton may function as a coating on the insert 13 b.
One or more electrode leads 14 may extend as branches from the exoskeleton 13 a. Leads include electrodes 16 for delivering electrical energy to the surrounding body tissue. In the
It should be noted that the term “exoskeleton” is not intended to mean that the exoskeleton 13 a is necessarily hard or rigid. As discussed, the exoskeleton preferably forms a barrier against migration of body fluids into contact with the insert, but it need not be a rigid barrier. In a preferred embodiment the exoskeleton is sufficiently flexible to be passed through the vasculature. However, certain sections of the exoskeleton 13 a may include additional features that supplement the strength and stability of those sections after they have been positioned at their final location within the vasculature. This may be desirable during removal of the insert 13 b from the exoskeleton 13 a to assist the exoskeleton 13 a in resisting axial forces applied against it during withdrawal of the insert.
For example, in the
Referring again to
One or more electrical contacts 22 a, 22 b, 22 c are positioned on the exterior surface of the insert 13 b. The contacts 22 a, 22 b, 22 c may take the form of conductive elements attached to the housing of the device insert. Alternatively, if the insert 13 b includes a conductive housing to which an insulating material is to be applied, the contacts may be formed by selectively applying the coating or removing portions of the coating to leave one or more exposed contact regions on the surface of the insert.
Contacts 22 a, 22 b, 22 c are positioned to electrically couple to the corresponding contacts 20 a, 20 b, 20 c (
Returning again to
Another arrangement of contacts is shown in
The system may include alternative features that engage the insert 13 b within the exoskeleton 13 a. The retention forces between the exoskeleton and insert are preferably sufficient to retain the insert, but also such that they may be overcome by manually withdrawing the insert 13 b. As one example, the interior surface of the exoskeleton and/or the exterior surface of the insert may include raised elements (e.g., rib features, broadened sections etc.) that cause the two components to engage due to friction forces between adjacent surfaces.
As another example, one or more of the contacts within the exoskeleton 13 a may take the form of a metallic leaf spring radially biased towards the central axis of the exoskeleton. This is illustrated in
Some alternative electrode and contact designs similar to the
In one embodiment shown in
In a similar embodiments shown in
Referring again to
During implantation, a retractable sheath 26 may be slidably positioned over the anchor 24 and the exoskeleton 13 a so as to retain the anchor in its compressed position. (The sheath 26 may also be used to hold the lead branch 14 streamlined against the exoskeleton 13 a during implantation.) Retraction of the sheath once the exoskeleton is properly positioned allows the anchor 24 to expand into contact with the surrounding walls of the vessel, thereby holding the exoskeleton in the desired location. Once deployed, the anchor 24 is preferably intimate to the vessel wall, which is distended slightly, allowing the vessel lumen to remain approximately continuous despite the presence of the anchor and thus minimizing turbulence or flow obstruction. Although self-expansion of the anchor is preferable, mechanical expansion means (e.g., balloon expanders etc) may be used for active expansion of the anchor.
The anchor may also have drug delivery capability via a coating matrix impregnated with one or more pharmaceutical agents.
The anchor 24 may be configured such that the exoskeleton 13 a and anchor 24 share a longitudinal axis, or such that the axes of the exoskeleton 13 a and anchor 24 are longitudinally offset.
An implantation mandrel 28 is attachable to the proximal end of exoskeleton 13 a (e.g., at transition region 17 a) for advancing the exoskeleton into position within the body. The mandrel 28 may also be used to push the insert into the exoskeleton or a separate tool can be used for this purpose. The system may additionally be provided with other components useful for implanting the system, including guidewires 30 a, 30 b and an introducer 32. If guidewires are to be used for implantation of the exoskeleton, the exoskeleton will preferably include guidewire lumens that permit tracking of the exoskeleton over the guidewires, or openings formed at the distal end of the exoskeleton and/or lead 14 for receiving the guidewires. The distal openings would preferably include seals to prevent migration of blood or other body fluids into the exoskeleton. The openings might instead include one-way valves that allow any body fluids that pass into the exoskeleton to be purged from the exoskeleton using a fluid (e.g., saline or carbon dioxide gas) injected into the proximal opening 15.
A small incision is first formed in the femoral vein and the introducer sheath 32 is inserted through the incision into the vein to keep the incision open during the procedure. Next, guidewires 30 a, 30 b are passed through the sheath 32 and into the inferior vena cava 3 b. Guidewire 30 a is steered under fluoroscopy into the left subclavian vein 2 b and guidewire 30 b is guided into the right ventricle 7 a of the heart. In an alternative embodiment of the implantation, only guidewire 30 b is used and is advanced into the right ventricle 7 a.
Next, the lead 14 (
The guidewires 30 a, 30 b are withdrawn. If necessary, a fluid such as saline or CO2 is directed through exoskeleton as described above to purge any body fluids from the exoskeleton.
Next, implantation mandrel 28 is attached to the proximal portion of the exoskeleton 13 a (e.g., at transition region 17 a) and is used to push the exoskeleton further into the vasculature. Advancement of the mandrel 28 is continued until the distal portion of the exoskeleton reaches the desired position within the LSV 2 b, and the lead 14 had tracked the guidewire 30 b into the right ventricle 7 a as shown in
The exoskeleton is next anchored in place by releasing the anchor 24 to its expanded position as shown in
Next, the insert 13 b is inserted into the exoskeleton as shown in
Future access to the insert 13 b may be needed for a variety of reasons. For example, if the battery within the insert 13 b should become depleted, the insert may be removed and replaced with a new device, or a charging device may be coupled to the insert 13 b.
If the insert is to be replaced, a femoral incision is formed to gain access to the tail section 17 b. A sufficient length of the tail 17 b is removed from the body to permit access to the opening 15 a in the tail 17 b. The opening 15 a is unsealed such as by removing its cap, plug 15 b or seal. Alternatively, the exoskeleton may be re-opened by snipping off the proximal portion of the tail within which the cap, plug or seal is positioned. An extraction tool such as mandrel 28 may be passed into the exoskeleton and used to engage the insert. To facilitate this process, an alternative mandrel may be used that includes a distal coupling comprising a mouth that is significantly broader than the proximal end of the device. When the mandrel is advanced through the exoskeleton towards the insert 13 b, the mouth will pass over the proximal end of the device 10 and will then be actuated to clamp over the proximal end of the insert, allowing the insert to be withdrawn by retracting the mandrel from within the tail section 17 b. Once the insert is extracted, a fresh insert may be advanced into the exoskeleton using techniques described above, and the tail may be re-sealed and returned to its pocket within the body.
An alternative extraction method is illustrated in
The exoskeleton and the insert 113 a, 113 b are preferably provided with means for securely engaging one another. For example, as shown in
As yet another alternative, as shown in
As discussed, one or more o-ring seals 50 (
In another alternative embodiment shown in
During implantation of the system 212, leads 214 are fed through the sleeves 52 and are positioned within the heart and/or vessels in a manner similar to that described above. Fluid such as saline or gas such as carbon dioxide may be directed into the open proximal end of the exoskeleton to prevent inflow of blood or to displace blood that may have already have entered the exoskeleton during implantation. Holes or one-way valves (not shown) may also be formed in the distal region of the exoskeleton to allow any blood that may have accumulated within the exoskeleton to be displaced and evacuated as the insert is passed into the exoskeleton to facilitate retention in the body.
Drug Delivery System
The exoskeleton configuration may be adapted for use with an intravascular drug delivery system of the type describe in U.S. application Ser. No. ______, INTRAVASCULAR DELIVERY SYSTEM FOR THERAPEUTIC AGENTS, filed Dec. 9, 2004, Attorney Docket No. NMX-110, which is incorporated herein by reference. Such a system includes an implantable drug reservoir, together with components that function to transfer drug from the reservoir into the bloodstream or into certain organs or tissues. Components used for this purpose may include pumps, motors and batteries, and/or other components such as those listed in the NMX-110 application.
Exoskeleton includes a port 322 that allows fluid released through the exit orifice 320 to pass into the bloodstream. A seal 324 may be positioned within the exoskeleton to prevent backflow of drug from exit orifice 320 into the exoskeleton 313 a.
The exoskeleton may include a flexible tail portion 317 that, as described in connection with the
A subcutaneous portal 326 is fluidly coupled to the refill line 318 of reservoir, and may also function to seal the tail 317 of the exoskeleton. Portal 326 may include a one-way valve (not shown) that prevents fluid from entering the exoskeleton, or it may include a seal formed of a material that will reseal itself following puncture.
Implantation of the system 310 and replacement of the insert 313 b may be performed using techniques described above. The reservoir 314 may be refilled by using a refill vessel such as a recharge syringe 328 filled with the desired drug. The needle tip of the recharge syringe may be inserted through the skin and into the subcutaneous portal 326. In this embodiment, drug reservoir within the insert 313 b may be maintained at a negative pressure so as to draw the agent from the syringe once fluid communication is established. Thus provides feedback to the user that the syringe needle has been inserted at the proper location and can thus help to avoid injection of the agent directly into the patient in the event the portal 326 is missed by the needle.
In an alternative refill method, the tail 317 may be withdrawn from the body through a small incision, and the recharge syringe 328 or other refill device may be coupled to the portal 326 outside the body. In either case, the drug is then injected from the syringe into the reservoir via the portal 326 and refill line 318. If the system 310 is provided without a refill line and portal, the insert may instead be replaced with a new component containing a fresh supply of drug using methods described above.
In another embodiment, the insert 313 b may be provided with a refill port in the insert body 313 b rather than a fill line 318 extending from the insert. Such an embodiment might be refilled using a mandrel having a distal coupling including a mouth that is significantly broader than the proximal end of the device. To refill a device according to this embodiment, the mandrel would be introduced into the exoskeleton and advanced towards the insert until it passes over the proximal end of the insert. The mandrel is then clamped over the proximal end of the insert to sealingly engage the insert and to create a fluid coupling between the mandrel's fluid lumen and a refill lumen into the insert. Drug is then introduced into the mandrel for delivery into the reservoir within the insert.
Various embodiments of systems, devices and methods have been described herein. These embodiments are given only by way of example and are not intended to limit the scope of the present invention. The examples and alternatives set forth for the described components are merely examples and should not be considered to be all-inclusive lists. It should be appreciated, moreover, that the various features of the embodiments that have been described might be combined in various ways to produce numerous additional embodiments. Moreover, while various materials, dimensions, shapes, implantation locations, etc. have been described for use with disclosed embodiments, others besides those disclosed may be utilized without exceeding the scope of the invention.