Endovascular devices and methods for exploiting intramural space
Devices and methods for the treatment of chronic total occlusions are provided. One disclosed embodiment comprises a method of facilitating treatment via a vascular wall defining a vascular lumen containing an occlusion therein. The method includes inserting an intramural crossing device into the vascular lumen, positioning at least the distal tip of the crossing device in the vascular wall, advancing an orienting device over the crossing device such that an orienting element of the orienting device resides in the vascular wall, inserting a reentry device, and re-entering the true vascular lumen.
1. A system for facilitating treatment via a vascular wall defining a vascular lumen containing an occlusion therein, the system comprising:
an intramural orienting device defining a longitudinal axis and having an elongate shaft with a lumen extending therethrough to a distally facing opening transverse and intersecting the longitudinal axis, the elongate shaft being configured to be advanced over a guidewire positionable therein;
wherein the elongate shaft includes a distal orienting element comprising a plurality of extensions configured to extend laterally from the longitudinal axis in a planar fashion, the plurality of extensions formed as a part of the elongate shaft;
wherein the elongate shaft further includes a distal side opening in communication with the lumen, the distal side opening facing orthogonally relative to the plurality of extensions;
wherein the plurality of extensions each includes a collapsed delivery configuration and an expanded deployed configuration, and wherein a most proximal portion of each extension that is external the lumen of the elongate shaft in the deployed configuration is also external the lumen of the elongate shaft in the delivery configuration; and
a re-entry device configured to penetrate vascular tissue, the reentry device sized and configured to be inserted into the lumen of the elongate shaft;
wherein the re-entry device comprises:
an elongate drive shaft having a distal tapered section;
an abrasive tip connected to the distal tapered section of the drive shaft, the abrasive tip having an abrasive coating along an exterior surface of the tip; and
wherein the distal tapered section is configured to allow flexure of the tip such that after penetration of the re-entry device into the vascular lumen penetration of an opposite vascular wall is prevented.
2. A system of claim 1 , wherein the orienting device further comprises a flap disposed in the lumen of the elongate shaft to direct a front-loaded device toward the distal side opening and permitting a back-loaded device to pass proximally through the lumen of the elongate shaft.
3. The system of claim 2 , wherein the flap prevents the back-loaded device from exiting the distal side opening.
4. The system of claim 2 , wherein the flap is biased to form a ramp in the lumen of the elongate shaft that directs a front-loaded device toward the distal side opening.
5. The system of claim 2 , wherein the elongate shaft includes a slot to accommodate the flap.
6. The system of claim 1 , wherein the intramural orienting device is configured to direct the distal side opening toward the vascular lumen when the plurality of extensions are in the expanded deployed configuration.
7. The system of claim 1 , wherein the plurality of extensions includes two extensions extending in equal and opposite directions in the deployed configuration.
8. The system of claim 7 , wherein the extensions each have a distal end and a proximal end, a distal end of the elongate shaft is connected to the distal end of the extensions, and an outer tube slidably receives a proximal portion of the elongate shaft and has a distal end connected to the proximal end of the extensions, such that relative movement between the elongate shaft and the outer tube controls deployment of the extensions.
9. The system of claim 1 , wherein the plurality of extensions are integrally formed with a portion of the elongate shaft extending distally from the extensions to the distal facing opening.
10. The system of claim 1 , wherein the re-entry device comprises:
an elongate shaft having a distal portion defined by a spiral cut section having a sharpened tip configured to penetrate vascular tissue;
wherein spacing between respective turns of the spiral cut section increases in a distal direction such that a distal portion of the re-entry device is more flexible than a proximal portion; and
wherein the spiral cut section has sufficient flexibility such that after penetration of the re-entry device into the vascular lumen, penetration of an opposite vascular wall is prevented.
11. The system of claim 1 , wherein the re-entry device is configured for rotation by a rotary drive.
12. A system for facilitating treatment via a vascular wall defining a vascular lumen containing an occlusion therein, the system comprising:
an intramural orienting device including:
an elongate shaft with a lumen extending therethrough to a distal facing opening along a longitudinal axis of the elongate shaft;
a distal orienting element comprising first and second lateral extensions extending laterally from the elongate shaft; and
a side opening extending through a sidewall of the elongate shaft and in communication with the lumen, wherein the side opening exits the elongate shaft transverse to the longitudinal axis of the elongate shaft and faces orthogonally relative to the first and second lateral extensions;
wherein the first and second lateral extensions are integrally formed with a portion of the elongate shaft extending distally from the first and second lateral extensions to the distal facing opening;
wherein the elongate shaft includes a spiral cut portion proximal to the side opening; and
a re-entry device having a distal tip configured to penetrate vascular tissue, the re-entry device sized and configured to be inserted into the lumen of the orienting device.
13. The system of claim 12 , wherein the first and second lateral extensions are formed from a single tubular member.
14. The system of claim 12 , wherein the first and second lateral extensions are formed from a single tubular member and as unitary portions of the elongate shaft.
15. A system for facilitating treatment via a vascular wall defining a vascular lumen containing an occlusion therein, the system comprising:
an intramural orienting device including:
an elongate shaft with a lumen extending therethrough to a distal facing opening along a longitudinal axis of the elongate shaft;
a distal orienting element comprising first and second lateral extensions extending laterally from the elongate shaft; and
a side opening extending through a sidewall of the elongate shaft and in communication with the lumen, wherein the side opening exits the elongate shaft transverse to the longitudinal axis of the elongate shaft and faces orthogonally relative to the first and second lateral extensions; and
a re-entry device having a distal tip configured to penetrate vascular tissue, the re-entry device sized and configured to be inserted into the lumen of the orienting device;
wherein the first and second lateral extensions are formed from a single tubular member and as unitary portions of the elongate shaft;
wherein the single tubular member is a metal hypotube.
16. The system of claim 15 , wherein the intramural orienting device further comprises a flap disposed in the lumen to direct a front-loaded device outwardly through the side opening and permit a back-loaded device to pass proximally through the lumen past the side opening.
17. The system of claim 15 , wherein the first and second lateral extensions comprise first and second hinged wings configured for movement between a collapsed delivery configuration and an expanded substantially planar deployed configuration.
18. The system of claim 15 , wherein the first and second lateral extensions are movable from a collapsed delivery configuration to an expanded deployed configuration, and wherein a most proximal portion of each of the first and second extensions that is external the lumen of the elongate shaft in the deployed configuration is also external the lumen of the elongate shaft in the delivery configuration.
19. The system of claim 15 , wherein the side opening is located at a longitudinal position along the elongate shaft intermediate a proximal end and a distal end of the first and second lateral extensions.