Methods and systems for providing or maintaining fluid flow through a body passageway

Abstract

A device for disabling a valve in a blood vessel is provided. The device (150) includes a proximal portion (102), a distal portion (104), and a longitudinal axis between the proximal and distal portions. The distal portion (104) has at least one blade having a retracted position in which the at least one blade is substantially parallel to the longitudinal axis and an extended position in which the at least one blade is not substantially parallel to the longitudinal axis. The at least one blade has a sharp surface facing distally and configured to at least partially resect a valve of a blood vessel as the device is advanced distally through the blood vessel, thereby facilitating the device to resect the valve as the device is advanced in a direction counter to the original flow of the blood vessel but in the direction of fluid flow through the blood vessel after fistula formation.

Description

[Technical Field]

[0001] This application relates to methods and systems for use in percutaneous interventional surgery. In particular, this application relates to methods and systems for providing or maintaining fluid flow through bodily passageways such as heart chambers and blood vessels.

[0002] [Incorporated by reference] U.S. Patent Application No. 13 / 791,185, filed March 8, 2013; U.S. Provisional Patent Application No. 61 / 901,753, filed November 8, 2013; U.S. Patent Application No. 11 / 662,128, filed January 3, 2008; U.S. Patent Application No. 14 / 141,913, filed December 27, 2013; and U.S. Patent Application No. 12 / 297,498, filed February 25, 2009, which is the international phase of PCT / GB2007 / 001430, filed April 20, 2007, and published May 14, 2013, as U.S. Patent Application No. 8,439,963, are incorporated herein by reference in their entireties. [Background technology]

[0003] Minimally invasive percutaneous surgery, or "keyhole" surgery, is a surgical procedure in which surgical devices are inserted into a patient's body cavities through small incisions made in the skin. This form of surgery is becoming increasingly popular because it allows patients to endure less surgical discomfort while retaining the benefits of traditional surgery. Patients treated with such procedures experience less discomfort, the need for general anesthesia, less trauma, and less risk of infection, and recovery times can be significantly reduced compared to traditional surgical procedures.

[0004] Keyhole surgery can be used, for example, in laparoscopic surgery, to treat cardiovascular disease. When treating cardiovascular disease, balloon angioplasty, in which a balloon catheter is inserted into an artery, usually near the patient's groin, and guided to the patient's heart, where a balloon at the distal portion of the catheter is inflated to open or widen the blocked vessel and help restore blood flow to the heart tissue, can be used to treat partially blocked coronary arteries as an alternative to open-heart surgery. A tubular support device (e.g., a stent) can be deployed at the site of the blockage to prevent subsequent closure (restenosis) or collapse of the vessel. The stent can be, for example, an expandable metal mesh tube carried by the balloon of a balloon catheter, or it can be self-expanding. A balloon-expandable stent expands when the balloon is inflated, thereby pressing the stent against the wall of the vessel. Once the stent reaches its expanded position, it is configured to retain its expanded shape, for example, by plastic deformation or a mechanical locking mechanism, to form a resilient scaffold or support within the vessel. Support structures (e.g., stents) support the walls of blood vessels and expand them to maintain a path for blood flow through the vessel. Self-expanding stents are also available, which are held in a collapsed state by a suitably adapted catheter for delivery through the artery and assume an expanded state upon deployment at the site of the blockage. The catheter, for example, can have a retention sleeve that holds the stent in a compressed or unexpanded state. When the sleeve is removed from the stent, the stent expands to support and expand the walls of the vessel.

[0005] For example, in acute cases and when the coronary artery is completely blocked, balloon angioplasty is not always an appropriate treatment. In these cases, the usual treatment is to use a coronary artery bypass. Coronary artery bypass surgery is an open-chest or open-heart procedure that typically involves grafting a section of healthy blood vessel onto the coronary artery to bypass the blocked section and return blood flow to the coronary tissue. The healthy blood vessel is typically a vein removed from the patient's leg or arm during the bypass surgery. To perform the procedure, the patient's heart must be exposed by opening the chest, separating the sternum, and cutting the pericardium surrounding the heart, resulting in significant surgical trauma.

[0006] Conventional coronary artery bypass surgery is not always optional. Some patients are poor candidates for conventional coronary artery bypass surgery due to poor chances of recovery or high risk of significant trauma from the surgery, high risk of infection, lack of healthy blood vessels to use as a bypass graft, significant comorbidities, and the expected long and tedious recovery time associated with open-heart surgery. For example, factors such as diabetes, old age, obesity, and smoking may exclude some candidate patients who truly need such treatment. Summary of the Invention

[0007] The present application provides methods and systems that overcome certain deficiencies and / or improve percutaneous methods and systems. For example, according to certain embodiments, the methods and systems described herein may improve the targeting and localization of therapy administration and may advantageously allow percutaneous procedures to be performed on patients who are ineligible for more invasive procedures. Some embodiments described herein may provide fluid flow within passageways, such as coronary and / or peripheral vessels, by creating a bypass using minimally invasive percutaneous surgical techniques.

[0008] In some embodiments, a method for diverting fluid flow from a first passageway to a second passageway includes deploying a device within a third passageway between the first passageway and the second passageway. The device includes a first end portion, a second end portion, an intermediate portion, and a graft material. The first end portion has a first end diameter. The second end portion has a second end diameter that is larger than the first end diameter. The intermediate portion is between the first end portion and the second end portion. The intermediate portion tapers between the first end portion and the second end portion. The graft material is bonded to at least the intermediate portion. The method further includes expanding the first end portion against a sidewall of the first passageway and expanding the second end portion against a sidewall of the second passageway.

[0009] The first passageway can be an artery, and the second passageway can be a vein. The first passageway can be a coronary artery, and the second passageway can be a coronary vein. The method can further include expanding a third passageway. The first passageway can be a peripheral artery, and the second passageway can be a peripheral vein. The method can further include expanding the third passageway. Expanding the third passageway can include expanding a middle portion. The first passageway can be substantially parallel to the second passageway. The middle portion can resemble an "S" shape. Expanding the first and second end portions can include allowing the first and second end portions to self-expand. Expanding the first and second end portions can include balloon-expanding at least one of the first and second end portions. Expanding one of the first and second end portions can include allowing one of the first and second end portions to self-expand, and expanding the other of the first and second end portions can include balloon-expanding the other of the first and second end portions. The method can further include expanding the intermediate portion.

[0010] In some embodiments, the device has a first end portion, a second end portion, an intermediate portion, and a graft material. The first end portion has a first end diameter. The second end portion has a second end diameter that is smaller than the first end diameter. The intermediate portion is between the first end portion and the second end portion. The intermediate portion tapers between the first end portion and the second end portion. The graft material is bonded to at least the intermediate portion.

[0011] At least one of the first end portion and the second end portion can be substantially cylindrical. The first end portion can be substantially cylindrical, and the second end portion can be substantially cylindrical. The first end portion can be tapered between a first end diameter and an intermediate portion, or the second end portion can be tapered between a second end diameter and an intermediate portion. The first end portion can be tapered between the first end diameter and an intermediate portion, and the second end portion can be tapered between the second end diameter and an intermediate portion. The first end portion can include a first type of material, the second end portion can include a second type of material, and the intermediate portion can include a third type of material. The first type of material can include a first cut material, the second type of material can include a second cut material, and the third type of material can include a filament. The first cut material can include a chromium-cobalt alloy, the second cut material can include nitinol, and the filament can include nitinol. The first type of material can include a cut material, the second type of material can include a cut material, and the third type of material can include a filament. The cut material can include Nitinol, and the filament can include Nitinol. At least one of the first end portion, the second end portion, the intermediate portion, and the graft material can include a bioabsorbable material. At least a portion of the graft material can be outside the intermediate portion. At least a portion of the graft material can be inside the intermediate portion. At least a portion of the graft material can be embedded within the intermediate portion. The device can be capable of or can be configured to maintain fluid flow between a first passageway in which the first end portion is located and a second passageway in which the second end portion is located. The first passageway can be substantially parallel to the second passageway. The intermediate portion can resemble an "S" shape.

[0012] In some embodiments, the device has a first end portion, a second end portion, an intermediate portion, and a graft material. The first end portion comprises a first material. The second end portion comprises a second material different from the first material. The intermediate portion is between the first and second end portions. The graft material is attached to at least the intermediate portion.

[0013] The first material can include nitinol, and the second material can include chromium cobalt. The first material can include nitinol, and the second material can include stainless steel. The first end portion can include cut struts, and the second end portion can include filaments. The first end portion can include cut struts, and the second end portion can include cut struts. The first material can include an alloy, and the first end portion can include struts or filaments having a first thickness, and the second material can include an alloy, and the second end portion can include struts or filaments having a second thickness different from the first thickness. The middle portion can include a third material. The third material can include nitinol. The middle portion can include filaments. The middle portion can include cut struts. At least one of the first end portion and the second end portion can be substantially cylindrical. At least one of the first end portion, the second end portion, the middle portion, and the graft material can include a bioabsorbable material. At least a portion of the graft material can be exterior to the middle portion. At least a portion of the graft material can be interior to the middle portion. At least a portion of the graft material can be embedded within the intermediate portion. The graft material can be coupled to at least one of the first end portion and the second end portion. The device can be capable of or can be configured to maintain fluid flow between a first passageway in which the first end portion is located and a second passageway in which the second end portion is located. The first passageway can be substantially parallel to the second passageway. The intermediate portion can resemble an "S" shape.

[0014] In some embodiments, the device includes a support structure and a graft material. The support structure has a first end portion, a second end portion, and an intermediate portion between the first end portion and the second end portion. At least one of the first end portion, the second end portion, and the intermediate portion includes cut struts, and at least one of the first end portion, the second end portion, and the intermediate portion includes filaments. The graft material is attached to at least the intermediate portion.

[0015] The first and second end portions may comprise cut struts, and the intermediate portion may comprise filaments. At least a portion of the graft material may be exterior to the intermediate portion. At least a portion of the graft material may be interior to the intermediate portion. At least a portion of the graft material may be embedded within the intermediate portion. The graft material may be coupled to at least one of the first and second end portions. The device may be capable of or may be configured to maintain fluid flow between a first passageway in which the first end portion is located and a second passageway in which the second end portion is located. The first passageway may be substantially parallel to the second passageway. The intermediate portion may resemble an "S" shape.

[0016] The device can have a diameter of about 1 mm to about 12 mm (e.g., 2 mm to 6 mm). The device can have a diameter of about 1 mm to about 10 mm (e.g., 4 mm to 8 mm). The device can have a diameter of about 6 mm to about 25 mm (e.g., about 12 mm to 15 mm). The device can have a diameter of about 20 mm to about 50 mm (e.g., 35 mm to 40 mm). The device can have a length of about 25 mm to about 150 mm (e.g., 70 mm to 110 mm). The device can have filaments with a diameter of about 0.001 inch to about 0.01 inch (e.g., 0.003 inch to 0.006 inch). The device can have struts with a diameter of about 0.001 inch to about 0.01 inch (e.g., 0.003 inch to 0.006 inch).

[0017] In some embodiments, a device for providing or maintaining fluid flow through at least one passageway in a human or animal body has two end portions that hold the device in place and an intermediate portion that allows the end portions to move relative to one another, together defining a pathway for fluid flow through the device.

[0018] The device can accommodate movement of the passageway(s) in which it is used by allowing the two end portions to move relative to one another. The mid-section can be flexible to allow relative movement of the end portions. In some embodiments, the device has varying, i.e., different, flexibility along the length of the device or along the length of portions of the device. The flexibility of the device can reduce the likelihood of device failure due to fatigue, for example, because the magnitude of stresses in the mid-section can be relatively small compared to stresses on a support structure (e.g., a stent) that has uniform flexibility along its entire length.

[0019] The device can be configured to provide or maintain fluid flow through a single passageway, e.g., an occluded blood vessel. The intermediate portion can be capable of or configured to maintain fluid flow between a proximal portion and a distal portion of the occluded blood vessel. The intermediate portion can pass through a further passageway, e.g., outside the blood vessel, extending between the proximal and distal portions of the blood vessel. The device can be configured for use as a bypass between the proximal and distal portions of a single blood vessel, e.g., an artery or a vein.

[0020] The device can be configured to provide fluid flow from an occluded blood passageway to another passageway. These two passageways can be interconnected by an intermediate portion passing through a further passageway extending between the two passageways. The device can be configured for use as a shunt between two passageways, for example, a shunt between an artery and a vein.

[0021] In embodiments in which the end portions are movable relative to one another by an intermediate portion, the device may be suitable for use in applications in which the end portions are placed in separate passageways that move relative to one another. A path for fluid communication is maintained by the device regardless of the relative movement of the end portions, and the device may be less susceptible to fatigue failure due to cyclic movement of the end portions compared to a support structure (e.g., a stent) without such an intermediate portion.

[0022] One or both of the end portions can be diametrically expandable to hold the device in place. The expanding end portion can be expandable, for example, to meet and press against the inner wall of the passageway to inhibit or prevent substantial sliding or rotation of the end portion within the passageway and / or to enlarge the passageway. The middle portion can be diametrically expandable, for example, to enlarge the fluid flow path.

[0023] The device can be in the form of a tube defining a lumen configured to act as a fluid flow path. In some embodiments, the tube can be fluid-tight to confine fluid flow within the lumen of the tube. The tube can include, but is not limited to, a polymeric material, such as a biocompatible polymer such as polytetrafluoroethylene (PTFE) or a polyurethane such as a polycarbonate-based aromatic biodurable thermoplastic polyurethane elastomer (e.g., ChronoFlex C® 80A and 55D medical grade, available from AdvanSource Biomaterials, Inc., Wilmington, Massachusetts).

[0024] The device can have a support structure that supports the end portions. The support structure can support the middle portion, in which case the support structure can be flexible within the middle portion to allow the end portions to move relative to one another.

[0025] Where a support structure is provided, the support structure, or portions thereof, may be embedded within the wall of the vessel. Alternatively or additionally, the structure, or portions thereof, may be located outside the vessel or within the lumen of the vessel.

[0026] The support structure can include at least one mesh. For example, a single mesh can extend along the entire length of the device. In another example, each end of the device has a mesh, in which case the mesh can extend into, but not reach, the mid-portion. If the mesh is in the mid-portion, it can be denser or have smaller window sizes (e.g., smaller spacing between filaments and / or struts of the mesh) at the end portions than in the mid-portion, such that the device is relatively more flexible at the mid-portion than at the end portions. The device can be relatively more flexible at the mid-portion than at the end portions by being free of mesh, or even if it includes a mesh with a substantially uniform density or window size (e.g., due to factors other than mesh density or window size), or by including a mesh with a non-uniform density.

[0027] At least one mesh can include a biocompatible metal wire. For example, the metal wire can be stainless steel. Alternatively or additionally, at least one mesh can include a shape memory material, such as nitinol and / or chromium cobalt. When a shape memory material is used, at least a portion of the device can be self-expanding.

[0028] One or both end portions may include a protrusion or barb disposed thereon that can and / or is configured to bite into or capture an inner wall of the passageway, e.g., to prevent or reduce slippage or other movement of each end portion relative to the passageway.

[0029] The two end portions can have different diameters, so that if the passageways have varying diameters, the device can fit tightly within the passageways of varying diameters, i.e., one end portion can fit tightly within a first passageway and the other end portion can fit tightly within a second passageway. The device can be configured for a particular application and / or for a particular patient.

[0030] In some embodiments, a method for diverting fluid flow from a first passageway to a second passageway (e.g., adjacent to the first passageway) includes forming a third passageway between the first passageway and the second passageway, providing a device having two end portions and a middle portion, deforming the middle portion of the device to allow insertion of the device into the passageway, and expanding the end portions against walls of the first and second passageways to retain the device within the passageway. The middle portion of the device can bend to allow insertion of the device into the passageway. The two end portions and the middle portion can be configured to maintain or provide fluid flow through the device.

[0031] One or more end portions of the device can be expanded by a balloon catheter. Alternatively or additionally, at least one end portion can be self-expanding, in which case the method can include delivering the device within a retaining sleeve and removing the retaining sleeve to allow the at least one end portion to expand.

[0032] The method can further include expanding the intermediate portion to enlarge the third passageway, thereby creating a larger path for fluid flow from the first passageway to the second passageway.

[0033] The methods described herein can be used in many surgical procedures and can be performed using minimally invasive (keyhole) techniques. The methods are particularly suitable for treating coronary heart disease, e.g., by providing a shunt or bypass to divert arterial blood from an occluded coronary artery to a coronary vein (e.g., adjacent to the coronary artery) and / or by crossing an occlusion within a coronary artery by exiting the artery proximate the occlusion, passing through the subintimal tissue, outer tissue, and / or a portion of an adjacent vessel, and re-entering the coronary artery distal to the occlusion; for treating peripheral vascular disease, e.g., critical limb ischemia, by providing a shunt or bypass to divert arterial blood from an occluded peripheral artery to a peripheral vein and / or by crossing an occlusion within a peripheral vessel by exiting the artery proximate the occlusion, passing through the subintimal tissue, outer tissue, and / or a portion of an adjacent vessel, and re-entering the vessel distal to the occlusion; and / or for treating non-occluded blood vessels, e.g., by creating a shunt between a healthy artery and a healthy vein that can be used for dialysis access.

[0034] In some embodiments, a method for treating coronary heart disease comprises diverting arterial blood from a coronary artery to a coronary vein by a method described herein. In some embodiments, a method for treating critical limb ischemia comprises diverting arterial blood from a peripheral artery to a peripheral vein by a method described herein.

[0035] In some embodiments, a method of accessing a target vein includes inserting a needle into the target vein and inserting a guidewire through the needle into the target vein.

[0036] The target vein can be a proximal tibial vein. The method can further include advancing a catheter over a second guidewire. The guidewire can include an ultrasound receiving transducer. The method can further include advancing the guidewire in the direction of blood flow in the target vein. The method can further include inserting an introducer sheath into a second vein upstream of the target vein. The method can further include inserting a second guidewire into the second vein. The second guidewire can include an ultrasound receiving transducer. The method can further include at least one of snaring the guidewire with the second guidewire or snare, snaring the second guidewire with the guidewire, and pulling the second guidewire in a direction counter to blood flow into the target vein. Snaring the guidewire can include injecting a contrast agent and visualizing using fluoroscopy. The method can further include advancing a catheter over the second guidewire. The catheter may include an ultrasound receiving transducer.

[0037] In some embodiments, a device for deactivating a valve in a blood vessel has a proximal portion, a distal portion, and a longitudinal axis between the proximal and distal portions. The distal portion can have at least one blade. The at least one blade can have a retracted position in which the at least one blade is substantially parallel to the longitudinal axis and an extended position in which the at least one blade is not substantially parallel to the longitudinal axis. The at least one blade can have a sharp surface facing distally and configured to at least partially ablate the valve upon distal advancement of the device.

[0038] The at least one blade can include a plurality of blades. The plurality of blades can include three blades. The three blades can be circumferentially spaced about 120 degrees apart. The proximal portion can include a handle configured to manipulate the at least one blade between a retracted position and an extended position. The at least one blade can include a shape memory material. The handle can be configured to allow the at least one blade to self-expand from the retracted position to the extended position. The handle can be configured to longitudinally compress the at least one blade and radially expand it from the retracted position to the extended position. A kit can include the device and a vasodilator. The vasodilator can include at least one of a tourniquet, a balloon, and a LeMaitre device.

[0039] In some embodiments, a method for disabling a valve of a blood vessel includes advancing a retrograde valvulotome in a direction opposite to the original fluid flow within the blood vessel, wherein at least one blade of the retrograde valvulotome at least partially excises the valve while advancing the retrograde valvulotome.

[0040] The retrograde valvulotome can include at least one blade. The at least one blade can have a retracted position in which the at least one blade is substantially parallel to the longitudinal axis and an extended position in which the at least one blade is not substantially parallel to the longitudinal axis. The at least one blade can have a sharp surface facing distally and configured to at least partially resect the valve upon distal advancement of the device. The at least one blade can include a plurality of blades. The plurality of blades can include three blades. The three blades can be circumferentially spaced about 120 degrees apart. The method can further include dilating the blood vessel and the intravascular valve. Dilating the blood vessel and the intravascular valve can include applying a tourniquet to the body site including the blood vessel. Dilating the blood vessel and the intravascular valve can include inflating an intravascular balloon. Dilating the blood vessel and the intravascular valve can include expanding a LeMaitre device within the blood vessel.

[0041] In some embodiments, a method of performing retrograde perfusion in a first blood vessel includes forming a fistula between the first blood vessel and a second blood vessel and disabling a valve in the first blood vessel.

[0042] The first blood vessel can include a vein, and the second blood vessel can include an artery. Disabling the valve in the first blood vessel can include inflating a balloon across the valve to a pressure greater than about 10 atmospheres (atm) (about 1013 kilopascals (kPa)). Disabling the valve in the first blood vessel can include deploying at least one stent across the valve. Disabling the valve in the first blood vessel can include inflating a cutting balloon. Disabling the valve in the first blood vessel can include atherectomy. Disabling the valve in the first blood vessel can include ultrasonically ablating the valve. Disabling the valve in the first blood vessel can include laser ablating the valve. Disabling the valve in the first blood vessel can include radiofrequency ablating the valve. Disabling the valve in the first blood vessel can include heating the valve. Disabling the valve in the first blood vessel can include at least one of advancing and retracting a catheter comprising a traumatic tip. Disabling the valve in the first blood vessel can include dilating the blood vessel and the valve in the blood vessel. Dilating the blood vessel and the valve in the blood vessel can include applying a tourniquet to a body site including the blood vessel. Dilating the blood vessel and the valve in the blood vessel can include dilating a balloon in the blood vessel. Dilating the blood vessel and the valve in the blood vessel can include dilating a LeMaitre device in the blood vessel. Disabling the valve in the first blood vessel can include dilating the first blood vessel and the valve in the first blood vessel, advancing a guidewire through the blood vessel, and tracking a device over the guidewire. Dilating the first blood vessel and the valve in the first blood vessel can include applying a tourniquet to a body site including the first blood vessel. Dilating the first blood vessel and the valve in the first blood vessel can include dilating a balloon in the first blood vessel. Dilating the first blood vessel and the valve in the first blood vessel can include dilating a LeMaitre device in the blood vessel.Forming a fistula between an artery and a vein can include accessing the vein. Accessing the vein can include inserting a needle into the vein and inserting a guidewire into the vein through the needle. The vein can be a proximal tibial vein. The method can further include advancing a catheter over a second guidewire. The guidewire can include an ultrasound receiving transducer. The method can further include advancing the guidewire in the direction of blood flow in the vein. The method can further include inserting an introducer sheath into a second blood vessel upstream of the vein. The method can further include inserting a second guidewire into the second vein. The second guidewire can include an ultrasound receiving transducer. The method can further include at least one of snaring the guidewire with a second guidewire or snare, snaring the second guidewire with the guidewire, and pulling the second guidewire in a direction counter to blood flow entering the vein. Snaring the guidewire can include injecting a contrast agent and visualizing using fluoroscopy. The method can further include advancing a catheter over a second guidewire. The catheter can include an ultrasound receiving transducer. Forming a fistula between the first blood vessel and the second blood vessel can include inserting a launch catheter into the second blood vessel, inserting a target catheter into the first blood vessel, transmitting an ultrasound signal from an ultrasound emitting transducer, at least one of rotating the launch catheter and longitudinally moving the launch catheter while transmitting the ultrasound signal until the ultrasound signal is received by the ultrasound receiving transducer, and extending a needle from the launch catheter after the ultrasound signal is received by the ultrasound receiving transducer. The launch catheter can include an ultrasound transmitting transducer and a needle configured to extend radially from the launch catheter.The target catheter can include an ultrasound receiving transducer. Extending the needle can include exiting the second blood vessel, traversing interstitial tissue between the second blood vessel and the first blood vessel, and entering the first blood vessel. The ultrasound transmitting transducer can include a directional transducer. The needle can be configured to extend radially from the launch catheter along a path aligned with the path of the directional transducer. The ultrasound receiving transducer can include an omnidirectional transducer. Forming a fistula between the first blood vessel and the second blood vessel can include identifying a signal matching peak on a display device. Identifying the signal matching peak on the display device can include identifying a color indicating that the signal matching peak is higher than a threshold. Forming a fistula between the first blood vessel and the second blood vessel can include identifying an audible signal indicating that the signal matching peak is greater than a threshold. Forming a fistula between the first blood vessel and the second blood vessel can include inserting the launch catheter into the second blood vessel. The launch catheter includes a needle configured to extend radially from the launch catheter. Forming a fistula between a first blood vessel and a second blood vessel can further include inserting a target catheter including a target device into the first blood vessel, expanding the target device, and extending a needle from the firing catheter. Extending the needle can include exiting the second blood vessel, crossing interstitial tissue between the second blood vessel and the first blood vessel, and entering the first blood vessel, where the needle pierces the target device upon entering the first blood vessel. The target device can include a balloon. The balloon can include a polymer and a mesh at least partially embedded within the polymer. Expanding the target device can include inflating the balloon. The target device can include a mesh. Expanding the target device can include advancing a proximal portion of the mesh distally. Expanding the target device can include contracting a distal portion of the mesh proximally. Expanding the target device can include allowing the mesh to self-expand.Forming a fistula between the first blood vessel and the second blood vessel can include inserting a crossing guidewire through the fistula. Forming a fistula between the first blood vessel and the second blood vessel can include enlarging the fistula. Enlarging the fistula can include inflating a balloon. Forming a fistula between the first blood vessel and the second blood vessel can include deploying a prosthesis. After deploying the prosthesis, at least a first portion of the prosthesis can be within the first blood vessel and at least a second portion of the prosthesis can be within the second blood vessel. Deploying the prosthesis can include actuating a trigger handle. The prosthesis can include a stent graft. The stent graft can have a longitudinal portion with a frustoconical longitudinal cross-section. Deploying the prosthesis can include allowing the prosthesis to self-expand. The method can further include expanding the prosthesis with a balloon. The method can further include applying a radiopaque clip to the skin from the exterior of the skin adjacent to the location of the fistula. The method may further include defining a distance between the first blood vessel and the second blood vessel.

[0043] In some embodiments, the fistula formation target catheter has a proximal portion and a distal portion, and the distal portion can have an expandable member and an ultrasound receiving transducer proximate to the expandable member.

[0044] The expandable member can include a balloon. The expandable member can include a mesh. The ultrasound receiving transducer can include an omnidirectional transducer. The ultrasound receiving transducer can be radially inward of the expandable member. The catheter can further include an inflation lumen in fluid communication with the expandable member and the proximal portion. The catheter can further include a pressure sensor configured to detect perforation of the expandable member.

[0045] In some embodiments, a kit for performing retrograde perfusion in a vein includes a valve disabler and at least one of the group consisting of a launch catheter, a target catheter, and a prosthesis delivery system.

[0046] The valve disablement device may include at least one of a retrograde valvulotome, a balloon, and a stent. The launch catheter may include a needle configured to extend radially from the launch catheter. The launch catheter may include an ultrasound transmitting transducer. The kit may further include a guidewire. The launch catheter may be configured to track over the guidewire. The kit may further include an arterial introducer sheath. The kit may further include a second guidewire. The target catheter may be configured to track over the second guidewire. The target catheter may include an ultrasound receiving transducer. The ultrasound transmitting transducer may include an omnidirectional transducer. The target catheter may include a balloon. The kit may further include a third guidewire. The second guidewire may be configured to snaring the third guidewire. The third guidewire may be configured to snaring the second guidewire. The kit may further include a venous transducer sheath. The kit may further include a venous access needle. The kit may further include an access guidewire. The kit may further include at least one balloon. The at least one balloon may be configured to pre-dilate the fistula. The at least one balloon may be configured to expand a blood vessel diameter. The at least one balloon may be configured to disable a valve. The at least one balloon may be configured to apply a pressure greater than about 10 atm (about 1013 kPa). The kit may further include a prosthesis delivery system. The kit may further include a device configured to stretch the blood vessel. The device configured to stretch the blood vessel may include at least one of a tourniquet, a balloon, and a LeMaitre device. The kit may further include a computing device configured to be communicatively connected to at least one of the launch catheter and the target catheter.The computing device can include a laptop computer. The computing device can include a tablet computer. The computing device can include a smartphone. The computing device can include a display device configured to display information regarding the relative position of the firing catheter and the target catheter. The computing device can include a speaker configured to broadcast information regarding the relative position of the firing catheter and the target catheter.

[0047] In some embodiments, a method of marking a fistula point comprises applying a marker to the skin adjacent to the location of the fistula, the marker being visible under fluoroscopy.

[0048] The marker can include a clip. The marker can include a radiopaque material. The fistula can be between a first blood vessel and a second blood vessel. The marker can be applied prior to deploying the prosthesis within the fistula.

[0049] In some embodiments, a method for disabling a valve in a blood vessel includes providing a retrograde valvulotome, wherein at least one blade of the retrograde valvulotome at least partially excises the valve upon advancing the retrograde valvulotome in a direction opposite to the original fluid flow within the blood vessel.

[0050] In some embodiments, a method of performing retrograde perfusion in a first blood vessel includes providing a first system configured to create a fistula between the first blood vessel and a second blood vessel, and providing a second device configured to disable a valve in the first blood vessel.

[0051] In some embodiments, a method for forming a fistula in a first blood vessel includes inserting a launch catheter into a second blood vessel. The launch catheter includes an ultrasound transmitting transducer and a needle configured to extend radially from the launch catheter. The method can further include inserting a target catheter including an ultrasound receiving transducer into the first blood vessel, transmitting an ultrasound signal from the ultrasound transmitting transducer, and at least one of rotating the launch catheter and longitudinally moving the launch catheter while transmitting the ultrasound signal and until the ultrasound signal can be received by the ultrasound receiving transducer. The method can further include extending a needle from the launch catheter after the ultrasound signal can be received by the ultrasound receiving transducer. Extending the needle can include exiting interstitial tissue between the second blood vessel and the first blood vessel that crosses the second blood vessel and entering the first blood vessel.

[0052] The ultrasound transmitting transducer can include a directional transducer. The needle can be configured to extend radially from the launch catheter along a path that aligns with the path of the directional transducer. The ultrasound receiving transducer can include an omnidirectional transducer.

[0053] In some embodiments, a kit for performing intravenous retrograde perfusion includes a launch catheter, a target catheter, and a prosthesis delivery system.

[0054] The launch catheter can include a needle configured to extend radially from the launch catheter. The launch catheter can include an ultrasound transmitting transducer. The targeting catheter can include an ultrasound receiving transducer. The ultrasound transmitting transducer can include an omnidirectional transducer.

[0055] It will be understood that the methods outlined above and described in more detail below describe some actions taken by a general practitioner, but may also include prescribing those actions to be taken by others. Thus, a measure such as "disabling a valve in a first blood vessel" includes "prescribing disabling a valve in a first blood vessel."

[0056] For purposes of outlining the invention and the advantages that may be achieved, certain objects and advantages are described herein. Not necessarily all such objects or advantages may be achieved in accordance with any particular embodiment. In some embodiments, the invention may be embodied or performed in a manner that may achieve or optimize one advantage or group of advantages without necessarily achieving other objects or advantages.

[0057] All of these embodiments are intended to be within the scope of the invention(s) disclosed herein. These and other embodiments will become apparent from the following detailed description, which refers to the accompanying drawings, without limiting the invention to any particular disclosed embodiment(s). Any features and / or preferred features described with reference to some embodiments may be combined with and incorporated into other embodiments. All documents mentioned herein, including patents and patent applications, are incorporated by reference in their entirety.

[0058] These and other features, aspects and advantages of the present disclosure will be described with reference to drawings of several embodiments, which are intended to illustrate several embodiments but not to limit the invention, and in which like reference numerals are used for like features. [Brief explanation of the drawings]

[0059] [Figure 1] 1A-1C are schematic diagrams illustrating an exemplary embodiment of a launch device for directing a signal from a first body cavity to a target device in a second body cavity. [Figure 2] FIG. 2 is a cross-sectional view taken along the dotted line BB in FIG. [Figure 3] 1A and 1B are schematic diagrams illustrating an exemplary embodiment of a launcher; [Figure 4] 1A and 1B are schematic diagrams illustrating an exemplary embodiment of a launcher; [Figure 5] FIG. 10 is a schematic diagram of another exemplary embodiment of a launcher. [Figure 6] 1A and 1B are schematic diagrams illustrating exemplary embodiments of a centering device for a launcher and / or targeting device. [Figure 7] 1A and 1B are schematic diagrams showing a prosthesis in place following a procedure such as arterial-venous arterialization. [Figure 8] 1 is a side perspective view of an exemplary embodiment of an apparatus for providing a fluid flow; [Figure 9] FIG. 9 shows the device of FIG. 8 used as a shunt between two blood vessels. [Figure 10] FIG. 10 is a side perspective view of another exemplary embodiment of an apparatus for providing a fluid flow. [Figure 11] FIG. 10 is a side perspective view of yet another exemplary embodiment of an apparatus for providing a fluid flow. [Figure 12] FIG. 10 is a side perspective view of yet another exemplary embodiment of an apparatus for providing a fluid flow. [Figure 13] 10 is a side perspective view of yet another exemplary embodiment of an apparatus for providing a fluid flow. FIG. [Figure 14A] 1 is a schematic side cross-sectional view of an exemplary embodiment of an ultrasound emitting catheter. [Figure 14B] 14B is an enlarged schematic side cross-sectional view of a distal portion of the ultrasound emitting catheter of FIG. 14A within circle 14B. [Figure 15A] 1 is a schematic side elevational view of an exemplary embodiment of an ultrasound targeting catheter. [Figure 15B] 15B is an enlarged schematic side cross-sectional view of the ultrasound targeted catheter of FIG. 15A within circle 15B. [Figure 15C]15C is an enlarged schematic side cross-sectional view of the ultrasound targeted catheter of FIG. 15A within circle 15C. [Figure 16] 10A-10C illustrate an exemplary embodiment of a graph for detecting catheter alignment. [Figure 17] 1 is a schematic side elevation view of an exemplary embodiment of a prosthesis delivery system. [Figure 18] 1 is a schematic side elevational view of an exemplary embodiment of a prosthesis. [Figure 19] FIG. 10 is a schematic side elevational view of another exemplary embodiment of a prosthesis. [Figure 20A] 1A-1C are diagrams illustrating an exemplary embodiment of a method for performing retrograde perfusion. [Figure 20B] 1A-1C are diagrams illustrating an exemplary embodiment of a method for performing retrograde perfusion. [Figure 20C] 1A-1C are diagrams illustrating an exemplary embodiment of a method for performing retrograde perfusion. [Figure 20D] 1A-1C are diagrams illustrating an exemplary embodiment of a method for performing retrograde perfusion. [Figure 20E] 1A-1C are diagrams illustrating an exemplary embodiment of a method for performing retrograde perfusion. [Figure 20F] 1A-1C are diagrams illustrating an exemplary embodiment of a method for performing retrograde perfusion. [Figure 20G] 1A-1C are diagrams illustrating an exemplary embodiment of a method for performing retrograde perfusion. [Figure 20H] 1A-1C are diagrams illustrating an exemplary embodiment of a method for performing retrograde perfusion. [Figure 21] 1 is a schematic perspective view of an exemplary embodiment of an ultrasonic receiving transducer. [Figure 22] 1 is a schematic cross-sectional view of another exemplary embodiment of an ultrasonic receiving transducer. [Figure 23A] 1 is a schematic perspective view of an exemplary embodiment of a valvulotome. [Figure 23B] 1 is a schematic perspective view of an exemplary embodiment of a retrograde valvulotome. [Figure 24] 1 is a schematic perspective view of an exemplary embodiment of a LeMaitre device; DETAILED DESCRIPTION OF THE INVENTION

[0060] Although several embodiments and examples are described below, the invention extends beyond the specifically disclosed embodiments and / or uses thereof and obvious modifications and equivalents thereof. The scope of the invention(s) disclosed herein is not intended to be limited by any particular embodiment(s) described below.

[0061] Minimally invasive procedures can provide access to a wider range of patient treatments, including those currently excluded from standard surgical procedures. One such procedure is percutaneous in situ coronary venous arterialization (PICVA), a catheter-based coronary artery bypass procedure in which a blockage in an affected artery is "bypassed" by creating a channel between the coronary artery and an adjacent coronary vein. In this way, arterial blood can be diverted into the venous system, perfusing cardiac tissue in a retrograde manner (retrograde perfusion), restoring blood supply to ischemic tissue. Some exemplary devices and methods for performing PICVA-like procedures are described in PCT Publication No. WO 99 / 049793 and U.S. Patent Application Publication No. 2004 / 0133225, both of which are incorporated herein by reference in their entireties.

[0062] To date, minimally invasive procedures for diverting blood flow from a coronary artery to an adjacent vein have had low success rates, often due to an inability to properly target the vein from the artery. Without appropriate systems and methods, such procedures (e.g., attempts to target veins using a combination of X-ray fluorescence and an imaging ultrasound probe positioned at the distal tip of a catheter, as described, for example, in U.S. Patent Application Publication No. 2004 / 0133225) often fail before they even begin. Indeed, such configurations can be difficult to navigate, and the limited location of the adjacent vein can require significant skill on the part of the clinician. Improvements in targeting systems and methods, such as the catheter-based systems and methods described herein, can enable procedures such as PICVA and transvascular procedures in general. Without such improvements, such percutaneous procedures will remain marginal to traditional open-heart surgical procedures and other types of bypass procedures.

[0063] This application describes, according to some embodiments, methods and systems useful in minimally invasive surgery that can reduce the workload of traditional surgery to treat conditions such as coronary heart disease and critical limb ischemia. For example, patients who would otherwise be unable to undergo surgery such as coronary artery bypass surgery or peripheral artery disease bypass surgery can be treated, and the degree of surgical trauma, risk of infection, and / or recovery time can be reduced or significantly reduced compared to traditional surgery.

[0064] FIG. 1 schematically illustrates an exemplary embodiment of a launching device 10 for directing a signal from a first body cavity 30 to a targeting device 20 in a second body cavity 35. The launching device 10 includes a signal transmitter 21. The launching device 10 may comprise, for example, a catheter having an elongated, flexible, rod-like portion and a tip portion, and may provide a conduit for delivering a treatment within a patient's body. The launching device 10 may be adapted for positioning and movement through a first body cavity or vessel 30 (e.g., a heart chamber, a coronary artery, a coronary vein, a peripheral artery, or a peripheral vein) within a patient's body. The elongated portion of the launching device 10 includes an outer sheath 11 enclosing a space that defines a lumen 13. The space within the lumen 13 may be appropriately segmented or subdivided as needed to define channels for delivering a treatment, controlling the positioning of the launching device 10, and the like. Such subdivision may be achieved, for example, axially, longitudinally, and concentrically.

[0065] The launcher 10 includes a signal transducer 12. The signal transducer 12 is configured to provide or emit a signal 40 that is directed outward from the launcher 10. In the embodiment shown in FIG. 1, the signal 40 is directed radially outward from the launcher 10 in a direction perpendicular to the longitudinal axis of the launcher 10. As will be described in more detail below, in some embodiments, the direction of the signal 40 need not be perpendicular to the longitudinal axis of the launcher 10, but can be directed at an angle relative to the longitudinal axis of the launcher 10. The signal transducer 12 can thereby form at least a portion of a signal generating means.

[0066] The signal transducer 12 is connected to a signal transmitter 50. The signal transmitter 50 may suitably be selected from an ultrasound or suitable electromagnetic source such as a laser, microwave radiation / illumination, radio waves, etc. In some embodiments, as described in further detail below, the signal transmitter 50 is configured to generate an ultrasound signal that is relayed to the signal transducer 12, which then directs the signal 40 from the first body cavity 30 into the surrounding tissue.

[0067] Targeting device 20 is positioned within an adjacent second body cavity or vessel 32 (e.g., a heart chamber, coronary artery, coronary vein, peripheral artery, peripheral vein) within the patient's body. First body cavity 30 and second body cavity 32 are separated by intervening tissue 34, sometimes referred to as interstitial tissue or a septum. First body cavity 30 and second body cavity 32 lie next to and parallel to one another along at least a portion of their respective lengths. For example, it is known that many of the veins and arteries in the body run parallel to one another along at least a portion of their entire lengths.

[0068] Targeting device 20 may be considered to be similar in configuration to launching device 10. For example, targeting device 20 may include a catheter having an elongated, flexible rod-like portion and a tip portion. In another example, fine movement and positioning of targeting device 20 within body cavity 32 may be achieved. In yet another example, targeting device 20 may include an outer sheath 21 surrounding a space that defines lumen 23. Lumen 23 may be suitably compartmentalized, for example, as in launching device 10.

[0069] The target device 20 includes a receiving transducer 22 configured to receive a signal 40 from the transducer 12 of the launcher 10. The receiving transducer 22 forms at least a part of a signal detection means. In use, upon receiving a signal 40 transmitted from the signal transducer 12, the receiving transducer 22 transmits the received signal to a signal detector 60. The signal detector 60 is configured to provide an output reading to a user of the system, for example, via an output display 61. The output display 61 may be a visual display, an audible display (e.g., beep or make some other sound upon receipt of a signal), etc.

[0070] In this manner, transmission and detection of directional signal 40 allows for manipulation and positioning of launcher 10 relative to target device 20. In use, launcher 10 and target device 20 can be manipulated by a user of the system until output display 61 indicates that signal 40 is being received by target device 40.

[0071] In some embodiments, the signal 40 includes or is an ultrasound signal. The signal 40 is directional and is emitted by the signal transducer 12 in the shape of a narrow cone or arc (e.g., the signal band widens with increasing distance from the signal transducer 12). Therefore, the accuracy of alignment between the launching device 10 and the target device 20 depends not only on signal detection but also on the distance between the two devices, since the signal beam width increases with increasing distance. This level of error is referred to as "position uncertainty." While there may be a certain tolerance level for position uncertainty, the degree of uncertainty should be reduced or minimized if treatment is to be accurately guided. For example, if the diameter d of the signal transducer 12 is 1 mm and the frequency of the ultrasound signal is 30 MHz, the position uncertainty x (e.g., the error limit on either side of the centerline) is 1 mm at a 5 mm vertical separation between the launching device 10 and the target device 20. For clinical applications, position uncertainty generally should not exceed about ±5 mm (for a total signal beamwidth of 10 mm at the point of reception). In some embodiments, position uncertainty is between about ±0.01 mm and about ±4.50 mm, or between about ±0.1 mm and about ±2 mm. In some embodiments, position uncertainty does not exceed about ±1 mm.

[0072] The strength of the signal 40 can be a factor in detection, with signal strength generally decreasing as the distance between the launching device 10 and the targeting device 20 increases. This distance is determined in part by the amount of intervening tissue 34 between the devices 10, 20. By way of example, if the signal 40 is an ultrasound signal, significant degradation of the signal can be expected if the launching device 10 and the targeting device 20 are separated by more than about 20 mm of solid tissue (e.g., intervening tissue 34). The density of the intervening tissue 34 can also affect the degradation of the signal 40 over distance (e.g., denser tissue degrades the signal more than less dense tissue).

[0073] The frequency of the ultrasonic signal can also affect the thickness of the signal transducer, which for a standard ultrasonic ceramic transducer (e.g., a piezoelectric transducer (PZT)) is 0.075 mm at 30 MHz.

[0074] FIG. 2 is a cross-sectional view taken along dotted line BB in FIG. 1. The correct orientation of the launcher relative to the target device can be a factor in detection, as the orientation line 41 can define where the treatment is to be administered. The clinical need for precise placement of treatment on the patient can be better served when the directional signal 40 is coupled to the treatment delivery means (e.g., parallel and longitudinally offset). For example, in this manner, a system user can administer treatment at the correct location by ensuring that the launcher 10 and target device 20 are properly positioned by transmitting and receiving the signal 40. The orientation line 41 in FIG. 2 indicates not only the direction of signal travel but also the path along which the treatment may be administered to the patient.

[0075] FIG. 3 schematically illustrates an exemplary embodiment of a launcher 10. The launcher 10 includes a signal transducer 120 oriented at an oblique angle relative to the longitudinal axis of the launcher 10. The signal 40 is transmitted at an angle relative to the direction of travel (e.g., forward travel, transverse travel) of the launcher 10 as it enters the body cavity 30 (FIGS. 1 and 2). In some embodiments, the beam angle is approximately perpendicular to the longitudinal axis of the launcher 10. In some embodiments, the beam angle is between about 20 degrees and about 60 degrees relative to normal, between about 30 degrees and about 50 degrees relative to normal, or about 45 degrees relative to normal, where 0 degrees corresponds to the longitudinal axis of the launcher 10 in the direction of travel.

[0076] Launching device 10 includes a hollow needle or cannula 17, which is an exemplary means for administering treatment. During advancement of launching device 10, hollow needle 17 is positioned in an undeployed or retracted state within lumen 13 of launching device 10. Hollow needle 17 can be deployed / expanded from launching device 10 via hole 16 in outer sheath 11 at a time deemed appropriate by the user (e.g., when signal 40 is detected by targeting device 20). Hole 16 can allow fluid communication between lumen 13 and body cavity 30 (FIG. 1). As shown by the exemplary embodiment of FIG. 3, hollow needle 17 can be advanced along a path that is parallel to the direction of signal 40. Hollow needle 17 can be used to puncture intervening tissue 34 (FIG. 1). In some embodiments, hollow needle 17 traverses the entire intervening tissue 34, allowing launching device 10 to access second body cavity 32 (FIG. 2). If desired, the pathway created by passage of hollow needle 17 through intervening tissue 34 can later be widened to allow fluid communication between first body cavity 30 and second body cavity 32 .

[0077] Therapeutic procedures suitable for use in some embodiments may include, for example, devices and / or instruments selected from the group consisting of cannulas, lasers, radiation emitting devices, probes, drills, blades, wires, needles, suitable combinations thereof, and the like.

[0078] In some embodiments, hollow needle 17 includes a sensor 19 that can help further determine positional information of the tip of hollow needle 17 relative to launch device 10. In some embodiments, sensor 19 is configured to detect changes in hydrostatic pressure. Other sensors suitable for use in the systems and methods described herein can include a temperature sensor, an oxygenation sensor, and / or a color vision sensor.

[0079] Optionally, hollow needle 17 can include an additional signal transducer 122. In the embodiment shown in FIG. 3, signal transducer 122 is positioned at one end of guidewire 14 near the tip of hollow needle 17. Signal transducer 122 can additionally or alternatively be positioned on hollow needle 17, if desired. In use, signal transducer 122 is driven by a short transmit pulse that generates a directional or non-directional signal pulse. The signal pulse can be detected by receiving transducer 22 attached to target device 20. The distance from guidewire 14 or hollow needle 17 to receiving transducer 22, and therefore target device 20, can be a time determined at least in part based on the delay between transmission of the signal pulse from signal transducer 122 and receipt of the signal pulse at receiving transducer 22.

[0080] FIG. 4 schematically illustrates an exemplary embodiment of a targeting device 20. In the embodiment illustrated in FIG. 4, the targeting device 20 is positioned within a body cavity 32. As described above, the targeting device 20 includes a receiving transducer 22 that receives a signal 40. The receiving transducer 22 can be unidirectional (e.g., capable of or configured to receive signals from only one direction) or omnidirectional (e.g., capable of or configured to receive signals from any direction). Arrow A indicates reverse blood flow after arterial-venous angiogenesis (also known as PICVA) has been performed. The targeting device 20 includes an omnidirectional ultrasound signal receiving transducer 60. An optional reflecting cone 601 can direct the signal 40 onto the disk-shaped receiving transducer 60. An acoustically transparent window 602 can separate the reflecting cone 601 from the receiving transducer 60. In some embodiments, an omnidirectional ultrasonic signal receiving transducer may be obtained by positioning a cylinder of flexible piezoelectric material, such as polyvinyl difluoride (PVDF), around the outer sheath of targeting device 20. In that way, the cylinder may act in a manner similar or equivalent to receiving transducer 60.

[0081] In the embodiment shown in FIG. 4, targeting device 20 includes an optional channel 25 for use in administering an agent, such as a therapeutic agent, to a patient. In some embodiments, channel 25 functions as a conduit to allow application of a blockage material 251 that acts to at least partially occlude or obstruct body cavity 32. Blockage material 251 may be suitably selected from gel-based materials. Blockage material 251 may additionally or alternatively include an embolic element (e.g., a balloon, a self-expanding stent, etc.). Placement of blockage material 251 may be guided by movement of targeting device 20. The presence of guide member 24 within lumen 23 of targeting device 20 may allow a user to precisely manipulate the position of targeting device 20 as desired.

[0082] Referring again to FIG. 2 , the launcher 10 includes a signal transducer 12 that can optionally be oriented so that the signal 40 is transmitted at an angle other than perpendicular to the signal transducer 12. FIG. 5 schematically illustrates another exemplary embodiment of the launcher 10. In some embodiments, for the exemplary launcher 10 shown in FIG. 5 , the signal transducer is in the form of a single-transducer array 123. The signal transducer array 123 includes a plurality of signal transducer elements 124 that can be oriented collectively to at least partially define a signal beamwidth and angle for the launcher 10. The smaller size of the elements 124 can allow the signal transducer array 123 to not occupy a significant portion of the lumen 13 of the launcher 10.

[0083] The embodiment shown in Figure 5 may be useful for ultrasound beamforming signal transmission. Figure 5 shows an array of signal transducer elements 124 separately connected to a transmitter 50 via delays 51, which allow the signals for each element 124 to be delayed relative to each other. The delays may provide or ensure that the ultrasound waveforms from each element 124 are aligned to generate an ultrasound beam 40 at a desired angle. In some embodiments, for example, where the signal 40 comprises visible light, an array of LEDs may additionally or alternatively be used.

[0084] 6 schematically illustrates an exemplary embodiment of a centering device for launching device 10 and / or targeting device 20. To aid in the process of aligning launching device 10 in first body cavity 30 and targeting device 20 in second body cavity 32, one or both of devices 10, 20 may include means for centering each device within its respective body cavity.

[0085] In some embodiments, the centering means comprises an inflatable bladder or balloon 111 that is positioned within the lumen 13, 23 when in an undeployed state and that can be inflated once the device 10, 20 reaches a desired location within the patient's body. The balloon 111 can be disposed on the exterior surface of the outer sheath 11, 21. The balloon 111 can be annular in shape so as to at least partially surround the device 10, 20 in a toroidal or donut-like fashion. The balloon 111 can be positioned to inflate on only one side of the device 10, 20 or on two opposing sides. As shown in FIG. 6, the balloon 111 is deployed on one side of the launch device 10.

[0086] In some embodiments, the centering means includes one or more loop structures 112 that, when in an undeployed or contracted state, are positioned within the lumen 13, 23 or within a recess formed in the outer sheath 11, 21. When the device 10, 20 reaches a desired location within the patient's body, the one or more loop structures 112 can expand radially outward from the device 10, 20, thereby centering the device 10, 20 within the body cavity 30, 32. Outward expansion of the loop structures 112 can be suitably achieved, for example, by compressing a length of wire so that it bows outward from the outer sheath 11, 21. A centering device employing this configuration can have multiple compressible lengths of wire or other suitable flexible material arranged in parallel, radially spaced apart positions around the circumference of the outer sheath 11, 21. Compression of the multiple wires can be facilitated by sliding members (not shown) positioned proximally and / or distally near both ends of the multiple wires. The sliding member is translatable along the longitudinal axis of the devices 10, 20. As shown in Figure 6, the targeting device 20 includes a fully deployed centering means 112 that allows the targeting device 20 to be centered within the body cavity 32.

[0087] Other possible means of centering the devices 10, 20 within the body lumens 30, 32 include, but are not limited to, expandable lantern devices, reversibly expandable stents, coils, helices, extendable probes or legs, combinations thereof, and the like.

[0088] In some embodiments, centering or other means (e.g., balloons, metal standoffs of various lengths, etc.) can be used to orient the device 10, 20 within the body cavity 30, 32 at or substantially off-center within the body cavity. For example, the device 10 can be oriented proximate the wall of the body cavity 30 where the needle 17 exits the body cavity 30, which can, for example, create a shorter ultrasound signal path and / or reduce errors due to the needle 17 traversing the intraluminal space. In another example, the device 10 can be oriented proximate the opposite wall of the body cavity 30 where the needle 17 exits the body cavity 30, which can, for example, create a firm surface for the needle 17 to press against. In yet another example, the device 20 can be oriented proximate the wall of the body cavity 32 where the needle 17 enters the body cavity 32, which can, for example, create a shorter ultrasound signal path. Other device orientations are also contemplated that are neither central nor proximal to the vessel wall (e.g., only a portion of the diameter away from the wall and / or center of the lumen, such as 1 / 2, 1 / 3, 1 / 4, etc.).

[0089] Example The methods and systems described herein, according to some embodiments, find particular utility in cardiovascular surgery. Some aspects are further illustrated by the following non-limiting example, in which the system is used by a clinician performing a connection of an artery to a vein (PICVA) to allow retrograde perfusion of cardiac tissue after occlusion of a coronary artery.

[0090] A launch catheter 10 is inserted into the blocked coronary artery using standard keyhole surgical techniques (e.g., tracking over a guidewire, tracking inside a guide catheter). A target catheter 20 is inserted into a coronary vein running parallel to the coronary artery using standard keyhole surgical techniques (e.g., tracking over a guidewire, tracking inside a guide catheter). The coronary vein is unobstructed, thus providing an alternative channel for blood flow to the myocardium, effectively bypassing the blockage in the coronary artery.

[0091] The launch catheter 10 includes a PZT ultrasound transducer 12 (available, for example, from CTS Piezoelectric Products of Albuquerque, New Mexico) oriented to transmit a directional ultrasound beam, in this example at a 45-degree angle (relative to the longitudinal axis of the launch device), preferably in the direction of blood flow within the artery 30, although other angles, including approximately 90 degrees, are contemplated. The ultrasound transducer 12 is activated, and in this example, a 30 MHz directional ultrasound signal 40 is transmitted from the launch catheter 10, although other frequencies are also contemplated. The target catheter 20 includes an omnidirectional ultrasound receiving transducer 60. To aid in determining the position of both the launch catheter 10 and the target catheter 20, both catheters 10, 20 include a centering or orienting means, in this example in the form of an annular inflatable balloon 111, although other centering or orienting means, or none at all, are contemplated. The centering means 111 on the launch catheter 10 is deployed by the clinician once the launch catheter 10 is deemed to be in the proper location near the site of the blockage within the coronary artery 30. This can be determined by standard fluoroscopic imaging and / or physical resistance. The target catheter 20 is then moved into the adjacent coronary vein 32 until a directional ultrasound signal 40 is detected by the signal-receiving transducer 60. To allow for more precise alignment of the launch catheter 10 and the target catheter 20, the centering means 111 on the target catheter 20 can be deployed before or after the signal 40 is detected.

[0092] Upon receiving the transmitted signal 40, the clinician can be confident that the launch catheter 10 and target catheter 20 are correctly positioned both rotationally and longitudinally within their respective blood vessels 30, 32 so that the arterial-venous connection procedure can begin. The target catheter 20 can be used to block blood flow within the coronary vein 32 by application of a gel blocking material 251 through a channel 25 in the target catheter 20. The blocking material 251 can be applied at a location within the coronary vein 32 that is downstream in terms of venous blood flow from the location of the signal-receiving transducer 60.

[0093] The clinician can then initiate the arterial-venous connection by deploying the hollow needle 17 from the launch catheter 10 substantially along a path parallel to and near the path taken by the ultrasound signal 40 through the intervening tissue 34 between the coronary artery 30 and the coronary vein 32, or the hollow needle 17 can traverse a path that interrupts the path of the ultrasound signal at a point within the coronary vein 32. The hollow needle 17 optionally includes a sensor 19 near its tip configured to detect changes in hydrostatic pressure or Doppler flow to allow a user to monitor the transition from arterial to venous pressure as the hollow needle 17 passes through the two blood vessels 30, 32. The hollow needle 17 optionally includes a guidewire 14 within its lumen or lumen upon deployment. Once the hollow needle 17 and guidewire 14 have traversed the intervening tissue 34, the hollow needle 17 can be retracted back into the lumen 13 of the launch catheter 10, leaving the guidewire 14 in place. In some embodiments, once hollow needle 17 has traversed intervening tissue 34 , the user can separately thread guidewire 14 through the lumen or lumen of hollow needle 17 and retract needle 17 into launch catheter 10 .

[0094] The clinician withdraws the launch catheter 10 from the patient, leaving the guidewire 14 in place. An additional catheter device is then slid along the guidewire 14. FIG. 7 schematically illustrates a prosthesis 26, such as an expandable stent 26, in place, following a procedure such as arterial-venous revascularization. Further details regarding possible prostheses, including stents and stent-grafts, are provided below. The stent 26 can be deployed to open a perforation in the intervening tissue 34 between the coronary artery 30 and the coronary vein 32, where the intervening arrow A indicates the direction of blood flow through the stent 26 between the first and second body lumens 30 and 32 (e.g., allowing arterial blood to be diverted into the venous system for retrograde perfusion of myocardial tissue). The stent 26 blocks upstream flow within the body lumen 32, forcing blood flow within the body lumen 32 in the same direction as blood flow within the body lumen 30. The graft material of stent 26 can form a fluid-tight lumen between body lumen 30 and body lumen 32. Target catheter 20 is withdrawn from the patient, leaving block material 251 in place. Optionally, as described in further detail herein, additional blocks or sutures can be inserted into the coronary vein to block or prevent backflow of arterial blood.

[0095] While the specific examples discussed above relate to cardiovascular surgery, the methods and systems described herein may have broad application in other surgical procedures. For example, any procedure involving the need to direct a treatment from one body cavity to another adjacent body cavity (e.g., for the treatment of peripheral arterial disease) may be considered. As such, applications in the fields of neurosurgery, urological surgery, and general vascular surgery may also be considered. The type of treatment need not limit the creation of a channel between body cavities. For example, the methods and systems described herein may be used to guide techniques such as catheter ablation, non-contact mapping of cardiac chambers, and drug delivery to precise body regions.

[0096] Several techniques for effectively bypassing an arterial blockage via percutaneous surgery have been described above. These techniques involve creating a channel or passageway between a first passageway, such as an artery, vein, or heart chamber upstream of the blockage, and a second passageway, such as an artery, vein, or heart chamber adjacent to the first passageway, and interconnecting the first and second passageways through a third passageway. Fluid, such as blood, can be diverted from the first passageway to the second passageway through the interconnecting third passageway. In embodiments where the first passageway includes an artery and the second passageway includes a vein, arterial blood can be perfused retrogradely into the tissue (retrograde perfusion).

[0097] As described above, an interconnecting passage between a first and a second body cavity passage can be created, for example, by deploying a needle outward from a first catheter positioned within the first passage, whereby the needle traverses the interstitial tissue, i.e., septum, between the first and second passages. A second catheter can be positioned in the second passage, providing a targeting device that receives signals, e.g., ultrasound signals, transmitted from the first catheter. By monitoring the received signals, the position of the first catheter relative to the second catheter can be determined to ensure that the needle is deployed in the correct position and orientation to create a passage for fluid flow between the first and second passages.

[0098] To provide or maintain blood flow through interconnected passages or channels, a structure having a lumen can be inserted into the passage to support interstitial tissue and / or inhibit or prevent the passage from closing. The tube can include, for example, a stent that is expanded within the channel using a balloon catheter, or a self-expanding stent, as described herein. A catheter for delivering the structure, e.g., a balloon catheter or a self-expanding catheter, can be guided within the channel by a guidewire deployed within the passage by a first catheter.

[0099] Passageways, such as arteries, veins, and heart chambers, can pulsate as the heart beats due to, for example, heart wall movement, peripheral limb movement, and / or fluctuations in pressure within the passageways themselves. This pulsation can cause the passageways to move relative to one another, which can place stresses on structures within the interconnecting passageways between them. This stress can be greater than the stress experienced by structures within a single passageway. The stresses can lead to premature failure of the structures, for example, through fatigue failure of stent struts. Failure of the structures can result in damage to interstitial tissue and / or occlusion of interconnecting passageways, which can lead to significant complications or complete failure of the treatment.

[0100] 8 illustrates a device, i.e., implant, or prosthesis 100 for providing or maintaining fluid flow through at least one passageway. The device 100 has a first or proximal end portion 102, a second or distal end portion 104, and an intermediate portion 106 between the proximal and distal end portions 102, 104. The device has an internal lumen 110 through which fluid passes through the device 100. The device 100, for example, at least the intermediate portion 106 of the device 100, includes a flexible polymer tube 108. The flexible polymer tube can at least partially define the lumen 110.

[0101] Device 100 has a support structure (e.g., at least one stent) including mesh 112 and mesh 114. In some embodiments, at least a portion of mesh 112 is embedded within the outer wall of vessel 108 adjacent to proximal end portion 102 of device 100. In some embodiments, at least a portion of mesh 114, e.g., wires or struts, is embedded within the outer wall of vessel 108 adjacent to distal end portion 104 of device 100. Meshes 112, 114 can comprise a biocompatible metal, such as stainless steel, and / or a shape memory material, such as nitinol or cobalt chrome.

[0102] The wire meshes 112, 114 can stiffen the end portions 102, 104, respectively. In some embodiments where the intermediate portion 106 does not include a mesh, the intermediate portion 106 can be relatively flexible compared to the end portions 102, 104 and / or the end portions 102, 104 can have a relatively high radial stiffness.

[0103] In some embodiments, the end portions 102, 104 of the device 100 are diametrically expandable. For example, the wire mesh 112, 114, after formation or manufacture, may have a smaller diameter than the passageway, e.g., blood vessel, within which the device 100 is deployed. Once the device 100 is in place within the passageway, the end portions 102, 104 may be expanded, i.e., deformed outward, thereby increasing the diameter of each end portion 102, 104 and abutting, e.g., the interior sidewall of the passageway. The end portions 102, 104 are configured to be maintained at the expanded diameter indefinitely by plastic deformation of the material (e.g., wire, struts) of the mesh 112, 114 and / or by means of a locking mechanism arranged to mechanically lock the mesh 112, 114 in the expanded position. The intermediate portion 106 of the device 100 may be diametrically expandable, e.g., by plastic deformation of the tube 108.

[0104] Figure 9 shows the device 100 of Figure 8 deployed to provide a fluid flow path between a first passageway 116 and a second passageway 118. The passageways 116, 118 can include coronary blood vessels, such as a coronary artery 116 and a coronary vein 118, or vice versa. The passageways 116, 118 can include peripheral blood vessels (e.g., blood vessels in the limbs), such as a femoral artery or other peripheral artery 116 and a femoral vein or other peripheral vein 118, or vice versa. The end portions 102, 104 and the intermediate portion 106 of the device 100 expand to meet and press against the interior walls of the passageways 116, 118. The distal end portion 104 of the device 100 is positioned within the second passageway 118, and the proximal end portion 102 of the device 100 is positioned within the first passageway 116. The intermediate portion 106 extends through a surgically formed opening or interconnecting passageway 130 between the passageways 116 and 118.

[0105] The enlarged end portions 102, 104 of the device 100 are resilient and exert an outward radial force against the inner walls of the passageways 116, 118. The radial rigidity of the end portions 102, 104 of the device 100 holds or locks the end portions 102, 104 in place within their respective passageways 116, 118, thereby preventing or reducing migration of the device 100 within the passageways 116, 118. In this manner, the end portions 102, 104 of the device 100 can lock or secure the device 100 in place while providing or maintaining fluid flow through the lumen 110 of the tube 108 ( FIG. 8 ) during use. In this manner, the device 100 can act as a shunt between the first passageway 116 and the second passageway 118.

[0106] The middle portion 106 of the device 100 can be flexible, for example, allowing the middle portion 106 to form an "S" shape formed by combining the first passageway 116, the second passageway 118, and the interconnecting passageway 130 (FIG. 9). The flexible middle portion 106 can allow the end portions 102, 104 of the device 100 to move relative to one another in response to relative movement of the passageways 116, 118.

[0107] In embodiments in which the intermediate portion 106 does not include a wire mesh but does include the flexible polymer material of the tube 108, the intermediate portion 106 may be less susceptible to damage due to mesh fatigue due to, for example, cyclic or other stresses imparted by relative movement of the passages 116, 118.

[0108] The intermediate portion 106 of the device 100 has sufficient elasticity to maintain the expansion of the interconnecting passage 130 so that the interconnecting passage 130 remains open to provide or maintain a path for blood flow from the artery 116 to the vein 118 by way of the lumen 110 of the tube 108 (FIG. 8). Blood flow from the artery 116 to the vein 118 by way of the interconnecting passage 130 can thereby be provided or maintained through the lumen 110 of the tube 108. The device 100 at least partially supports the artery 116, the vein 118, and the interconnecting passage 130 to provide a path for fluid communication through the device 100.

[0109] The proximal end portion 102 and the distal end portion 104 of the device 100 are configured such that when the distal end portion 104 of the device 100 is deployed within a vein 118 and the proximal end portion 102 of the device 100 is deployed within an artery 116, for example, as shown in FIG. 9 , the diameter of the expanded distal end portion 104 is sufficient to retain the distal end portion 104 within the vein 118, and the diameter of the expanded proximal end portion 102 is sufficient to retain the proximal end portion 102 within the artery 116. Thus, the diameter of the proximal end portion 102 can be different from the diameter of the distal end portion 104. By selecting appropriate diameters for the end portions 102, 104 and intermediate portion 106, the device 100 can be tailored to fit a particular anatomy and / or the anatomy of an individual patient.

[0110] For example, as shown in FIG. 9, an exemplary procedure will now be described in which the device 100 of FIG. 8 is positioned to provide a shunt between an occluded artery 116 and vein 118 (e.g., between a coronary artery 116 and a coronary vein 118, or between a peripheral artery 116 and a peripheral vein 118) to achieve retrograde perfusion of arterial blood.

[0111] A catheter can be inserted into the patient's arterial system through a small incision, usually made in the patient's groin area. The catheter is fed into the artery 116 and guided to a location upstream of the blockage, for example, adjacent to, parallel to, or substantially parallel to, the vein 118. A hollow needle is deployed from the catheter, through the wall of the artery 116, through the interstitial tissue 132 separating the artery 116 and vein 118, and through the wall of the vein 118. This path of the needle creates an interconnecting passageway or opening 130, allowing blood to flow between the artery 116 and vein 118. Needle deployment can be guided, for example, by a transmitter (e.g., a directional ultrasound transmitter) connected to a catheter in artery 116 and a receiver (e.g., an omnidirectional ultrasound receiver) connected to a catheter in vein 118, as described herein, or vice versa, by a receiver connected to a catheter in vein 116 and a transmitter connected to a catheter in artery 118, as in U.S. Patent Application No. 11 / 662,128. Other methods of forming opening 130 are also contemplated (e.g., using other types of guides as described herein, from vein to artery, with or without directional ultrasound guidance, etc.).

[0112] Before withdrawing the hollow needle from the passageway 130, a guidewire (e.g., as described with respect to guidewire 14 in FIG. 3) is threaded through the needle and inserted into the vein 118. The needle is then retracted, leaving the guidewire in place within the artery 116, passageway 130, and vein 118. The catheter carrying the needle can then be withdrawn from the patient's body. The guidewire can be used to further guide the catheter into the interconnecting passageway 130 between the artery 116 and vein 118.

[0113] A catheter carrying device 100 in an unexpanded state is advanced toward interconnecting passage 130, guided by a guidewire, e.g., via a rapid exchange lumen or through lumen 110. The catheter may include, for example, a balloon catheter configured to expand at least a portion of device 100 and / or a catheter configured to self-expand at least a portion of device 100. Distal end portion 104 of device 100 passes through interconnecting passage 130 and into vein 118, while proximal end portion 102 remains in artery 116. An intermediate portion 106 of device 100 is at least partially within passage 130 and at least partially within artery 116 and vein 118. Intermediate portion 106 bends to assume a curved or "S"-shaped configuration depending on the local anatomy. Such curvature allows the shape of the intermediate portion 106, which extends through the interconnecting passage 130 and optionally into at least one of the passages 116, 118, to conform to the shape of at least the interconnecting passage 130.

[0114] The distal end portion 104 of the device 100 is expanded, for example, by balloon inflation or by self-expansion, to increase the diameter of the distal end portion 104 and position the distal end portion 104 against the inner wall of the vein 118. The catheter can be adapted to expand the intermediate portion 106 of the device 100, for example, by balloon inflation, thereby widening or enlarging the interconnecting passageway 130 to allow blood flow (e.g., sufficient blood flow) from the artery 116 to the vein 118. The proximal end portion 102 of the device 100 is expanded, for example, by balloon inflation or by self-expansion, to increase the diameter of the proximal end portion 102 and position the proximal end portion 102 against the inner wall of the artery 116.

[0115] After expanding the end portions 102, 104 of the device 100, for example by self-expansion and / or balloon expansion, with or without augmented post-deployment expansion, the catheter and guidewire are withdrawn from the patient's body. In this manner, the device 100 is left in place or secured within the vein 118, artery 116, and interconnecting passageway 130, as shown in FIGURE 9. In embodiments in which the device 100 comprises a stent graft, the graft can form a fluid-tight passage between the artery 116 and the vein 118, thereby blocking such passageway and thereby inhibiting or preventing antegrade flow of blood within the vein 118, and the graft can be in addition to or instead of a blocking material within the vein 118.

[0116] The catheter can be adapted to selectively expand the proximal end portion 102, distal end portion 104, and / or intermediate portion 106 of device 100, individually or in combination, by action of, for example, two or more separate inflatable balloons or balloon portions, a single balloon configured to expand all portions of device 100 simultaneously, or a single balloon configured to expand one or more selected portions of device 100. For example, end portions 102, 104 can be self-expanding, while intermediate portion 106 can be expanded by a balloon to enlarge passageway 130. In some embodiments involving balloon expansion, all or selected portions of device 100 can be expanded, for example, simultaneously by a balloon spanning the entire length of device 100, by multiple balloons spaced longitudinally to selectively expand selected portions of device 100, and / or sequentially by a single balloon or multiple balloons. In some embodiments involving at least partial self-expansion, all or selected portions of device 100 can be expanded, for example, by proximally retracting a sheath covering or surrounding device 100, thereby deploying device 100 from distal to proximal as the sheath is retracted proximally. Proximal-to-distal deployment of device 100 is also possible, as well as intermediate and then end-to-end deployment. In some embodiments, for example, in which device 100 is at least partially conical or tapered, device 100 can be at least partially expanded using a conical or tapered balloon. In some such embodiments, the portion of the balloon proximal to vein 118 can be larger in diameter than the portion of the balloon proximal to artery 116, so that, for example, device 100 can be adapted to change the diameter of the vein with any increase in pressure or blood flow within vein 118.

[0117] The procedure may also include other steps. For example, prior to deploying device 100, a balloon catheter may be guided into interconnecting passageway 130 and positioned so that the inflatable balloon portion of the catheter is within interconnecting passageway 130. When the balloon is inflated, it presses against the walls of interconnecting passageway 130, widening or expanding interconnecting passageway 130 to facilitate subsequent insertion of device 100.

[0118] 10 illustrates another device 134 for providing fluid flow through at least one passageway. The device 134 includes a mesh 136 and a polymer tube 108. While the mesh 136 is shown as being on the exterior of the polymer tube 108, it may additionally or alternatively be on the interior of the polymer tube and / or within the polymer tube 108, as described herein. As described with respect to the device 100, the device 134 includes a proximal end portion 102, a distal end portion 104, and an intermediate portion 106. In the embodiment illustrated in FIG. 10, the mesh 136 extends along the entire length of the device 134, including along the intermediate portion 106.

[0119] In some embodiments, the spacing of the filaments or struts of the mesh 136 varies along the length of the device 134. For example, the winding density of a woven or layered filament mesh can vary, and / or the window size pattern of a cut mesh can vary.

[0120] In some embodiments, the spacing can be relatively small at the proximal and distal end portions 102, 104 and relatively large at the intermediate portion 106. In other words, the density or fenestration size of the mesh 136 can be relatively small at the intermediate portion 106 and relatively large at the end portions 102, 104. In some such embodiments, the intermediate portion 106 can be more flexible than the end portions 102, 104. The relatively stiff end portions 102, 104 can engage and remain within a passageway. While the mesh 136 in the intermediate portion 106 may be subjected to stresses, such as cyclic stresses, during use, the relatively high flexibility of the intermediate portion 106 due to its lower density or fenestration size allows the intermediate portion 106 to flex in response to the stress and thus experience a smaller impact. Therefore, the risk of fatigue failure of the device 134, and particularly of the filaments or struts 138 of the mesh 136, can be reduced compared to a device having uniform flexibility along its entire length.

[0121] In some embodiments, the spacing can be relatively large at the proximal and distal end portions 102, 104 and relatively small at the intermediate portion 106. In other words, the density of the mesh 136 can be relatively high (or the window size of the mesh 136 can be relatively small) at the intermediate portion 106 and relatively small (or the window size of the mesh 136 can be relatively large) at the end portions 102, 104. In some such embodiments, the intermediate portion 106 can have sufficient radial stiffness to inhibit or prevent collapse of the passageway 130, yet still be flexible enough to flex in response to stress, such as cyclic stress. The end portions 102, 104 can engage and reside within the passageway.

[0122] 11 illustrates another device, i.e., implant or prosthesis 140, that provides for fluid flow through at least one passageway. As described with respect to device 100, device 140 has a proximal end portion 102, a distal end portion 104, and an intermediate portion 106. Device 140 comprises a polymer tube 108 and a support structure having a first mesh 142 and a second mesh 144. First mesh 142 extends from proximal end portion 102 toward (e.g., into) intermediate portion 106 and, optionally, into distal end portion 104. Second mesh 144 extends from distal end portion 104 toward (e.g., into) intermediate portion 106 and, optionally, into proximal end portion 102. Meshes 142, 144 thereby overlap one another at least at intermediate portion 106. The meshes 142, 144 can both be on the outside of the tube 108, on the inside of the tube 108, or embedded within the tube 108, or one mesh can be on the outside of the tube 108, on the inside of the tube 108, or embedded within the tube 108, while the other mesh is on a different side of the tube 108, on the inside of the tube 108, or embedded within the tube 108 (e.g., one mesh is on the inside of the tube 108 and the other mesh is on the outside of the tube 108). The meshes 142, 144 can be formed, for example, by braiding wire in a lattice configuration around or inside the polymer tube 108, by placing cut tubes around or inside the polymer tube 108, by being embedded within the polymer tube 108, combinations thereof, etc.

[0123] In some embodiments, the density of the meshes 142, 144 is relatively high at their respective end portions 102, 104 (i.e., the window size of the meshes 142, 144 is relatively small) and decreases in density (i.e., the window size increases) toward the middle portion 106. The overall braid density (e.g., the braid density of both meshes 142, 144 joined together) can be lower in the middle portion 106 than in the end portions 102, 104, i.e., the overall window size (e.g., the window size of both meshes 142, 144 joined together) can be larger in the middle portion 106 than in the end portions 102, 104. In some such embodiments, the middle portion 106 is relatively flexible compared to the end portions 102, 104. In some embodiments, the meshes 142, 144 do not extend into the middle portion, and the absence of the mesh can make the middle portion 106 relatively flexible compared to the end portions 102, 104. In some embodiments, as the window size increases (e.g., longitudinally along the tapered portion of the device 140), the density decreases, the mesh coverage decreases, and / or the porosity increases because the width of the struts and / or filaments remains substantially constant or constant or does not increase at the same rate as the window size, which can result in changes in flexibility along the longitudinal length.

[0124] The first mesh 142 and the second mesh 144 can comprise different materials, which can allow the respective properties of each distal end portion 102 and proximal end portion 104 of the device 140 to be optimized for a particular application of the device 140. For example, the second mesh 144 at the distal end portion 104 of the device 140 can comprise a relatively flexible metal alloy to facilitate insertion into an interconnecting passage between two blood vessels, while the first mesh 142 at the proximal end portion 102 of the device 140 can comprise a relatively inelastic metal alloy to provide a high degree of resistance to the proximal end portion 104 to securely hold the device 140 in place. The first mesh 142 and the second mesh 144 can have the same material composition (e.g., both comprising Nitinol) but different wire diameters (gauges) or strut thicknesses.

[0125] FIG. 12 illustrates another device, i.e., implant or prosthesis 150, that provides fluid flow through at least one passageway. The device 150 includes a support structure (e.g., a stent) 152 and a graft 154. As described with respect to the device 100, the device 150 includes a proximal end portion 102, a distal end portion 104, and an intermediate portion 106. The proximal end portion 102 includes a cylindrical or substantially cylindrical portion, and the distal end portion 104 includes a cylindrical or substantially cylindrical portion. The diameter of the proximal end portion 102 is smaller than the diameter of the distal end portion 104. In some embodiments, the diameter of the proximal end portion 102 is larger than the diameter of the distal end portion 104. The intermediate portion 106 has a tapered or frustoconical shape between the proximal end portion 102 and the distal end portion 104. The stent 152 can include filaments (e.g., woven, layered), cut tubes, or cut sheets, and / or combinations thereof.

[0126] The parameters of the stent 152 may be uniform or substantially uniform across a portion and / or multiple portions, or may vary within a portion and / or between multiple portions. For example, the stent 152 may comprise a cut tube or cut sheet at the proximal end portion 102, the stent 152 may comprise a cut tube or cut sheet at the distal end portion 102, and the stent 152 may comprise filaments (e.g., woven or layered) at the intermediate portion 106. Some such embodiments may provide superior placement by the proximal end portion 102 and the distal end portion 104, and superior flexibility of the intermediate portion 106 (e.g., adaptability to third passageway sizes and dynamic stresses).

[0127] The stent 152 can include different materials in different portions. For example, the stent 152 can include cobalt chromium and / or tantalum in the proximal end portion 102, the stent 152 can include nitinol in the distal end portion 104, and the stent 152 can include nitinol in the intermediate portion 106. Some such embodiments can provide superior placement and / or wall apposition by the device 150 in each deployment region (e.g., the proximal end portion 102 engaging the sidewall of the artery, the distal end portion 104 engaging the sidewall of the vein, and the intermediate portion 106 engaging the sidewall of the passageway between the artery and the vein). In some embodiments in which the distal end portion 104 is self-expanding, the distal end portion 104 can adapt by changing the vessel diameter, for example, by further self-expanding (e.g., if the vein diameter increases due to increased pressure or blood flow).

[0128] Combinations of support structure materials and types are also contemplated. For example, the stent 152 may comprise a cut tube or sheet comprising cobalt chromium and / or tantalum in the proximal portion, the stent 152 may comprise a cut tube or sheet comprising nitinol in the distal end portion 104, and the stent 152 may comprise a filament comprising nitinol in the intermediate portion 106.

[0129] In embodiments, the stent 152 has at least a portion comprising a cut tube or sheet, and the cut pattern may be the same. For example, the cut pattern may be the same in the proximal end portion 102 and the distal end portion 104, but varies proportionally with the change in diameter. In some embodiments, the fenestration size or strut density is uniform or substantially uniform within the portions 102, 104, 106, within two or more of the portions 102, 104, 106, and / or from one end of the stent 152 to the other end of the stent 152. In embodiments in which the stent 152 has at least one portion comprising a filament, the number of turns may be the same. For example, the number of turns may be the same in the proximal end portion 102 and the distal end portion 104, but varies with the change in diameter. In some embodiments, the winding density or porosity is uniform or substantially uniform within sections 102, 104, 106, within two or more of sections 102, 104, 106, and / or from one end of stent 152 to the other end of stent 152. In embodiments in which stent 152 has at least one section comprising cut tube or sheet and at least one section comprising filament, the cut pattern and windings may be configured to achieve a uniform or substantially uniform density. Non-uniformities are also possible, for example, as described herein.

[0130] The graft 154 may include materials such as those described for the tube 108 and attachment to the stent 152. The graft 154 generally forms a fluid-tight passageway through at least a portion of the device 150. Although the graft 154 is shown as being only around the mid-section 106, it may extend the entire length of the device 150 or may overlap partially within at least one of the cylindrical end sections 102, 104.

[0131] FIG. 13 illustrates another device 160 for providing fluid flow through at least one passageway. The device 160 includes a support structure (e.g., a stent) and a graft 164. As described with respect to the device 100, the device 160 includes a proximal end portion 102, a distal end portion 104, and an intermediate portion 106. The proximal end portion 102 includes a tapered or frustoconical portion, and the distal end portion 104 includes a tapered or frustoconical portion. The diameter of the proximal end of the proximal end portion 102 is smaller than the diameter of the distal end of the distal end portion 104. In some embodiments, the diameter of the proximal end of the proximal end portion 102 is larger than the diameter of the distal end of the distal end portion 104. The intermediate portion 106 includes a tapered or frustoconical shape between the proximal end portion 102 and the distal end portion 104. In some embodiments, the bevel angles of portions 102, 104, 106 are the same or substantially the same (e.g., as shown in FIG. 13 ). In some embodiments, the bevel angle of at least one portion is sharper, i.e., narrower, than at least one other portion. The frustoconical proximal and distal end portions 102, 104 can enable better placement within a body passageway because, for example, arteries taper away from the heart and veins taper toward the heart, and end portions 102, 104 can be configured to at least partially correspond to such anatomical tapers.

[0132] Figure 12 shows a device 150 having a first cylindrical or straight portion, a conical or tapered portion, and a second cylindrical or straight portion. Figure 13 shows a device 160 having one or more conical or tapered sections (e.g., the entire device 160 is conical or tapered or has multiple conical or tapered sections). In some embodiments, combinations of devices 150, 160 are possible. For example, a device may have a cylindrical or straight portion and the remainder of the device may have a conical or tapered portion. In some such embodiments, the device can have a length of about 1 cm to about 10 cm (e.g., about 5 cm) and have a cylindrical or straight portion having a diameter of about 1 mm to about 5 mm (e.g., about 3 mm) and a length of about 0.5 cm to about 4 cm (e.g., about 2 cm), and a conical or tapered portion having a diameter that gradually increases from the diameter of the cylindrical or straight portion to a diameter of about 3 mm to about 10 mm (e.g., about 5 mm) and a length of about 1 cm to about 6 cm (e.g., about 3 cm). Such devices may not have a separate cylindrical or conical portion following them.

[0133] As described above with respect to support structure 152, support structure 162 can include filaments (eg, woven, layered), cut tubes or sheets, the same material, different materials, and combinations thereof.

[0134] The graft 164 may include materials such as those described for the tube 108 and attachment to the stent 162. The graft 164 generally forms a fluid-tight passageway through at least a portion of the device 160. Although the graft 164 is shown as being only around the mid-section 106, it may extend the entire length of the device 160 or may overlap partially within at least one of the frusto-conical end sections 102, 104.

[0135] In some embodiments, a combination of device 150 and device 160 may be contemplated. For example, proximal end portion 102 may be cylindrical or substantially cylindrical (e.g., as in device 150), and distal end portion 104 may be tapered or frustoconical (e.g., as in device 160), with proximal end portion 102 having a larger diameter than the distal end of distal end portion 104. In another example, proximal end portion 102 may be tapered or frustoconical (e.g., as in device 160), and distal end portion 104 may be cylindrical or substantially cylindrical (e.g., as in device 150), with the proximal end of proximal end portion 102 having a larger diameter than the distal end portion 104. In each example, intermediate portion 106 may have a tapered or frustoconical shape between proximal end portion 102 and distal end portion 104.

[0136] Exemplary deployment devices for the implantable devices described herein are described in U.S. Patent Application No. 12 / 545,982, filed August 24, 2009, and U.S. Patent Application No. 13 / 486,249, filed June 1, 2012, the entire contents of each of which are incorporated herein by reference. The device generally has a handle with a user-actuable trigger at its proximal end and a combination of tubular members at its distal end configured to be pushed and / or pulled upon actuation of the trigger to release the device. Other delivery devices are also contemplated. The delivery device may have a portion slidable over a guidewire (e.g., manipulated between an artery and a vein by a tissue-crossing needle) and / or may be trackable through a lumen of a catheter.

[0137] While several embodiments and examples have been shown or described in detail herein, various combinations, subcombinations, modifications, variations, substitutions and omissions of specific features and aspects of those embodiments are possible, some of which are described herein by way of example only.

[0138] The device, e.g., the stent of the device, the mesh of the device, the support structure of the device, etc., can be self-expanding. For example, the mesh can include a shape-memory material, such as Nitinol, that is capable of or configured to return to a preset shape after undergoing deformation. In some embodiments, the stent can be fabricated into a desired shape in its expanded configuration and can be compressed to fit inside a sleeve for delivery to a vascular site via a catheter. To deploy and expand the stent, the sleeve is retracted from the stent, allowing the shape-memory material to return to the preset shape, thereby depositing the stent within the passageway and, if the stent has sufficient radial strength, enlarging the passageway. The use of a balloon catheter is not required to expand a fully self-expanding stent, but can be used, for example, to enhance or optimize deployment.

[0139] The device can have one or more self-expanding portions and one or more portions that are expandable by deformation, for example, with a balloon catheter. For example, in the embodiment shown in Figure 11, the first mesh 142 can comprise stainless steel that is expandable with a balloon catheter, and the second mesh 144 can comprise nitinol to self-expand upon expansion.

[0140] For any of the embodiments described herein, the polymer tube 108 carrying the graft 154, 164 can comprise any suitable compliant or flexible polymer, such as PTFE, silicone, polyethylene terephthalate (PET), polyurethanes such as polycarbonate-based aromatic biodurable thermoplastic polyurethane elastomers (e.g., ChronoFlex C® 80A and 55D Medical Grade, available from AdvanSource Biomaterials, Inc., Wilmington, Massachusetts), combinations thereof, etc. The polymer tube 108 can comprise a biodegradable, bioabsorbable, or biocompatible polymer (e.g., polylactic acid (PLA), polyglycolic acid (PGA), polyglycollactic acid (PLGA), polycaprolactone (PCL), polyorthoesters, polyanhydrides, combinations thereof, etc.). The polymer can be in tubular form prior to interacting with a support structure (e.g., a stent), or can be formed on, within, and / or around the support structure (e.g., a stent). For example, the polymer can comprise spun fibers, dip coatings, combinations thereof, etc. In some embodiments, the device may omit the tube, for example, if the device is to be deployed within a single blood vessel. In some such embodiments, the middle portion of the stent may have a mesh with a lower winding density or a larger fenestration size, while the end portions of the stent have a mesh with a higher winding density or a smaller fenestration size, and the mesh is generally tubular to define a path for fluid flow through the center of the mesh. In some embodiments, the polymer tube 108 has a lip (e.g., comprising the same or a different material), which can help form a fluid-tight seal between the polymer tube 108 and the body passageway. The seal may be angled, for example, for angled positioning of the polymer tube 108 between the body passageways. In some embodiments, the polymer tube 108 may extend longitudinally beyond the support structure in at least one direction, with the extending portion being supported by the support structure.

[0141] The mesh can comprise any suitable material, such as nickel, titanium, chromium, cobalt, tantalum, platinum, tungsten, iron, manganese, molybdenum, combinations thereof (e.g., nitinol, cobalt chromium, stainless steel), etc. The mesh can comprise a biodegradable, bioabsorbable, or biocompatible polymer (e.g., polylactic acid (PLA), polyglycolic acid (PGA), polyglycollactic acid (PLGA), polycaprolactone (PCL), polyorthoesters, polyanhydrides, combinations thereof, etc.) and / or glass, and can be metal-free. As discussed above with reference to FIG. 11 , for example, different materials can be used in several portions of the mesh or within the same mesh. For example, mesh 114 at distal end portion 104 and mesh 112 at proximal end portion 102 of device 100 can comprise different materials. For another example, mesh 112 and / or mesh 114 may comprise various types of metal alloys (e.g., a shape memory alloy combined with a non-shape memory alloy, a first shape memory alloy combined with a second shape memory alloy different from the first shape memory alloy, a metal alloy (e.g., including cobalt, chromium, nickel, titanium, combinations thereof, etc.) combined with a cladding material (e.g., including a core comprising a radiopaque material such as titanium, tantalum, rhenium, bismuth, silver, gold, platinum, iridium, tungsten, etc.)), and / or a non-metallic material such as a polymer (e.g., polyester fiber), carbon, and / or bioabsorbable glass fiber. In some embodiments, at least one mesh 112, 114 comprises nitinol and stainless steel. Nitinol may allow for some self-expansion (e.g., partial and / or complete self-expansion), in which case the mesh may be further expanded, for example, using a balloon.

[0142] While generally shown in Figures 8, 10, and 11 as a woven filament mesh, any other structure capable of providing the desired degree of elasticity can be used. For example, layers of counter-wound filaments can be fused at both ends of the filaments to provide an expandable structure. In another example, a metal sheet can be cut (e.g., laser cut, chemically etched, plasma cut, etc.) to form perforations and then heat-set into a tubular former, or a metal tube (e.g., hypotube) can be cut (e.g., laser cut, chemically etched, plasma cut, etc.) to form perforations. Cut tubes (including cut sheets rolled into tubes) can be heat-set to provide an expanded configuration.

[0143] The filaments, wires, or ribbons, which can be woven, braided, layered, or otherwise configured, are generally elongated and have a cross-section that is circular, oval, square, rectangular, etc. Exemplary nonwoven filaments can have a first layer of filaments wound in a first direction and a second layer of filaments wound in a second direction, with at least some of the filament ends joined together (e.g., by bonding to an expandable ring). Exemplary braid patterns include one over one, two over one, two over two, and / or combinations thereof, although other braid patterns are also contemplated. At filament intersections, the filaments can be helically wound, can cross in a sliding relationship, and / or combinations thereof. The filaments can be loose (e.g., held together by braiding), and / or can be joined by a weld, sleeve, or other joining element, and / or combinations thereof. The ends of the filaments can be recurved, crimped into rings (e.g., end crimped with a radiopaque material such as titanium, tantalum, rhenium, bismuth, silver, gold, platinum, iridium, tungsten, etc., which can also act as radiopaque markers), twisted, ball welded, combinations thereof, etc. The woven ends can include filament ends and / or recurved filaments and can have open cells, secured or unsecured filaments, welds, adhesives or other fusing means, radiopaque markers, combinations thereof, etc. The filament parameters can be uniform or substantially uniform across a portion and / or multiple portions, or can vary within a portion and / or between multiple portions. For example, the proximal end portion 102 can have first parameters and the distal end portion 104 can have second parameters that differ from the first braid pattern. As another example, the proximal end portion 102 and the distal end portion 104 may each have a first parameter, and the intermediate portion 106 may have a second parameter that is different from the first parameter. As yet another example, at least one of the proximal end portion 102, the distal end portion 104, and the intermediate portion 106 may have both a first parameter and a second parameter that is different from the first parameter.Filament parameters can include, for example, filament type, filament thickness, filament material, amount of filaments, weave pattern, layering, winding direction, pitch, angle, cross type, filament bonding or lack thereof, filament end treatment, weave end treatment, layered end treatment, amount of layers, presence or absence of welds, radiopacity, braid pattern, density, porosity, filament angle, braid diameter, winding diameter, and shape setting.

[0144] The tube or sheet can be cut to form a strut or cell pattern, with the struts being the portions of the tube or sheet that remain after cutting and the cells, perforations, or windows being the cut-out portions. The tube (e.g., hypotube) can be cut directly, or the sheet can be cut and then rolled into a tube. The tube or sheet can be in a set shape before cutting or after cutting. The tube or sheet can be welded or otherwise bonded to itself, another tube or sheet, a filament, a graft material, etc. Cutting can be done with a laser, a chemical etchant, a plasma, combinations thereof, etc. Exemplary cut patterns include helical spirals, woven braids, coils, individual rings, continuous rings, open-celled cells, closed-celled cells, combinations thereof, etc. In embodiments involving continuous rings, the rings can be connected using flexible connectors, non-flexible connectors, and / or combinations thereof. In embodiments including continuous rings, the connectors of the rings (e.g., flexible, inflexible, and / or combinations thereof) intersect the peaks of the rings, the valleys of the rings, the intermediate portions of the struts, and / or combinations thereof (e.g., peak to peak, valley to valley, intermediate to intermediate, peak to valley, peak to intermediate, valley to intermediate, valley to peak, intermediate to peak, intermediate to valley). The tubes, sheets, or sections may be ground and / or polished before or after cutting. Internal ridges may be formed, for example, to aid in fluid flow. The parameters of the cut tubes or sheets may be uniform or substantially uniform across a portion and / or multiple portions, or may vary within a portion and / or between multiple portions. For example, the proximal end portion 102 may have a first parameter and the distal end portion 104 may have a second parameter that is different from the first parameter. As another example, the proximal end portion 102 and the distal end portion 104 may each have a first parameter, and the intermediate portion 106 may have a second parameter that is different from the first parameter. As yet another example, at least one of the proximal end portion 102, the distal end portion 104, and the intermediate portion 106 may have both a first parameter and a second parameter that is different from the first parameter.Cut tube or sheet parameters may include, for example, radial strut thickness, circumferential strut width, strut shape, cell shape, cut pattern, cut type, material, density, porosity, tube diameter, and shape settings.

[0145] In some embodiments, the perforations may result in a mesh having a relatively flexible middle portion and relatively stiff end portions. Alternatively, the support structure may be an open-cell foam disposed within the tube.

[0146] The filaments, stent-grafts, or portions thereof of a stent, and / or struts, stent-grafts, or portions thereof of a cut stent may be surface modified to carry a drug such as, for example, a thrombosis modifier, a fluid flow modifier, an antibiotic, etc. The filaments, stent-grafts, or portions thereof of a stent, and / or struts, stent-grafts, or portions thereof of a cut stent may be at least partially covered by a coating including a drug such as a thrombosis modifier, a fluid flow modifier, an antibiotic, etc. embedded in, for example, a polymer layer or a series of polymer layers that may be the same as or different from the polymer tube 108.

[0147] The thickness (e.g., diameter) of the filaments of the stent, stent graft, or portion thereof, and / or struts of the cut stent, stent graft, or portion thereof, may be from about 0.0005 inches to about 0.02 inches, from about 0.0005 inches to about 0.015 inches, from about 0.0005 inches to about 0.01 inches, from about 0.0005 inches to about 0.008 inches, from about 0.0005 inches to about 0.007 inches, from about 0.0005 inches to about 0.006 inches, from about 0.0005 inches to about 0.005 inches, or from about 0.0005 inches to about 0.004 inches. about 0.0005 inches to about 0.003 inches, about 0.0005 inches to about 0.002 inches, about 0.0005 inches to about 0.001 inches, about 0.001 inches to about 0.02 inches, about 0.001 inches to about 0.015 inches, about 0.001 inches to about 0.01 inches, about 0.001 inches to about 0.008 inches, about 0.001 inches to about 0.007 inches, about 0.001 inches to about 0.006 inches, about 0.001 inches to about 0.005 inches, about 0.001 inches to about 0.004 inches, about 0.001 inches to about 0.003 inches, about 0.001 inches inches to about 0.002 inches, about 0.002 inches to about 0.02 inches, about 0.002 inches to about 0.015 inches, about 0.002 inches to about 0.01 inches, about 0.002 inches to about 0.008 inches, about 0.002 inches to about 0.007 inches, about 0.002 inches to about 0.006 inches, about 0.002 inches to about 0.005 inches, about 0.002 inches to about 0.004 inches, about 0.002 inches to about 0.003 inches, about 0.003 inches to about 0.02 inches, about 0.003 inches to about 0.015 inches, about 0.003 inches to about 0.01 inches, 0.003 inches to about 0.008 inches, about 0.003 inches to about 0.007 inches, about 0.003 inches to about 0.006 inches, about 0.003 inches to about 0.005 inches, about 0.003 inches to about 0.004 inches, about 0.004 inches to about 0.02 inches, about 0.004 inches to about 0.015 inches, about 0.004 inches to about 0.01 inches, about 0.004 inches to about 0.008 inches, about 0.004 inches to about 0.007 inches, about 0.004 inches to about 0.006 inches, about 0.004 inches to about 0.005 inches, about 0.005 inches to about 0.0.02 inches, about 0.005 inches to about 0.015 inches, about 0.005 inches to about 0.01 inches, about 0.005 inches to about 0.008 inches, about 0.005 inches to about 0.007 inches, about 0.005 inches to about 0.006 inches, about 0.006 inches to about 0.02 inches, about 0.006 inches to about 0.015 inches, about 0.006 inches to about 0.01 inches, about 0.006 inches to about 0.008 inches, about 0.006 inches to about 0.007 inches The thickness may be about 0.007 inches to about 0.02 inches, about 0.007 inches to about 0.015 inches, about 0.007 inches to about 0.01 inches, about 0.007 inches to about 0.008 inches, about 0.008 inches to about 0.02 inches, about 0.008 inches to about 0.015 inches, about 0.008 inches to about 0.01 inches, about 0.01 inches to about 0.02 inches, about 0.01 inches to about 0.015 inches, or about 0.015 inches to about 0.02 inches. Other thicknesses are contemplated, including thicknesses greater or less than those specified. Filaments and / or struts comprising some materials (e.g., biodegradable materials, low resilience materials, etc.) may be thicker than those specified.

[0148] The thickness of the filaments and / or struts can be based on, for example, at least one of the device or device portion size (e.g., diameter and / or length), porosity, radial strength, material, amount of filaments and / or struts, cut pattern, weave pattern, layering pattern, etc. For example, larger filament and / or strut thicknesses (e.g., greater than about 0.006 inches) may be useful for larger devices or device portions used to treat larger vessels such as coronary vessels, intermediate filament and / or strut thicknesses (e.g., from about 0.003 inches to about 0.006 inches) may be useful for medium-sized devices or device portions used to treat medium-sized vessels such as peripheral vessels, and small filament and / or strut thicknesses (e.g., less than about 0.003 inches) may be useful for smaller devices or device portions used to treat smaller vessels such as veins and neurovasculature.

[0149] The inner or outer diameter of a stent, stent graft, or first end portion, second end portion, intermediate portion, or sub-portion of a stent, taking into account, for example, the thickness of the filaments or struts, can be about 1 mm to about 12 mm, about 1 mm to about 10 mm, about 1 mm to about 8 mm, about 1 mm to about 6 mm, about 1 mm to about 4 mm, about 1 mm to about 2 mm, about 2 mm to about 12 mm, about 2 mm to about 10 mm, about 2 mm to about 8 mm, about 2 mm to about 6 mm, about 2 mm to about 4 mm, about 4 mm to about 12 mm, about 4 mm to about 10 mm, about 4 mm to about 8 mm, about 4 mm to about 6 mm, about 6 mm to about 12 mm, about 6 mm to about 10 mm, about 6 mm to about 8 mm, about 8 mm to about 12 mm, about 8 mm to about 10 mm, or about 10 mm to about 12 mm. Some such diameters may be suitable, for example, for treating coronary vessels. The inner or outer diameter of a stent, stent graft, or portion of a stent, taking into account, for example, the thickness of the filaments or struts, can be about 1 mm to about 10 mm, about 1 mm to about 8 mm, about 1 mm to about 6 mm, about 1 mm to about 4 mm, about 1 mm to about 2 mm, about 2 mm to about 10 mm, about 2 mm to about 8 mm, about 2 mm to about 6 mm, about 2 mm to about 4 mm, about 4 mm to about 10 mm, about 4 mm to about 8 mm, about 4 mm to about 6 mm, about 6 mm to about 10 mm, about 6 mm to about 8 mm, or about 8 mm to about 10 mm. Some such diameters may be suitable, for example, for treating a vein. The inner or outer diameter of a stent, stent graft, or portion of a stent, taking into account, for example, the thickness of the filaments or struts, can be about 6 mm to about 25 mm, about 6 mm to about 20 mm, about 6 mm to about 15 mm, about 6 mm to about 12 mm, about 6 mm to about 9 mm, about 9 mm to about 25 mm, about 9 mm to about 20 mm, about 9 mm to about 15 mm, about 9 mm to about 12 mm, about 12 mm to about 25 mm, about 12 mm to about 20 mm, about 12 mm to about 15 mm, about 15 mm to about 25 mm, about 15 mm to about 20 mm, or about 20 mm to about 25 mm. Some such diameters may be suitable, for example, for treating peripheral blood vessels.The inner or outer diameter of a stent, stent-graft, or portion of a stent, taking into account, for example, the thickness of the filaments or struts, can be about 20 mm to about 50 mm, about 20 mm to about 40 mm, about 20 mm to about 35 mm, about 20 mm to about 30 mm, about 30 mm to about 50 mm, about 30 mm to about 40 mm, about 30 mm to about 35 mm, about 35 mm to about 50 mm, about 35 mm to about 40 mm, or about 40 mm to about 50 mm. Some such diameters may be suitable for treating, for example, the aorta. Other diameters, including diameters larger or smaller than the specified diameters, are also contemplated. The diameter of the device may refer to the diameter of the first end portion, the second end portion, or the intermediate portion, each of which may be in the expanded or unexpanded configuration. The diameter of the device may refer to the average diameter of the device when all portions of the device are in the expanded or unexpanded configuration.

[0150] The length of the stent, stent graft, or first end portion, second end portion, intermediate portion, or sub-portion of the stent may be from about 5 mm to about 150 mm, from about 5 mm to about 110 mm, from about 5 mm to about 70 mm, from about 5 mm to about 50 mm, from about 5 mm to about 25 mm, from about 5 mm to about 20 mm, from about 5 mm to about 10 mm, from about 10 mm to about 150 mm, from about 10 mm to about 110 mm, from about 10 mm to about 70 mm, from about 10 mm to about 50 mm, from about 10 mm to about 25 mm, from about 10 mm to about 2 The length may be about 0 mm, about 20 mm to about 150 mm, about 20 mm to about 110 mm, about 20 mm to about 70 mm, about 20 mm to about 50 mm, about 20 mm to about 25 mm, about 25 mm to about 150 mm, about 25 mm to about 110 mm, about 25 mm to about 70 mm, about 25 mm to about 50 mm, about 50 mm to about 150 mm, about 50 mm to about 110 mm, about 50 mm to about 70 mm, about 70 mm to about 150 mm, about 70 mm to about 110 mm, or about 110 mm to about 150 mm. Other lengths, including lengths longer or shorter than those specified, are also contemplated.

[0151] The porosity of a stent, stent graft, or first end portion, second end portion, intermediate portion, or sub-portion of a stent can be about 5% to about 95%, about 5% to about 50%, about 5% to about 25%, about 5% to about 10%, about 10% to about 50%, about 10% to about 25%, about 25% to about 50%, about 50% to about 95%, about 50% to about 75%, about 50% to about 60%, about 60% to about 95%, about 75% to about 90%, about 60% to about 75%, and combinations thereof. The density of the stent can be inversely proportional to the porosity of the stent. The porosity of a portion of the stent covered by a graft can be about 0%. The porosity can be varied depending on the purpose of certain portions of the stent. For example, the middle section may have a low porosity to increase fluid flow through the device, while the end sections may have a lower porosity to increase flexibility and wall apposition.

[0152] The radial strength or compressive resistance of a stent, stent graft, or a first end portion, second end portion, intermediate portion, or sub-portion of a stent can be about 0.1 N / mm to about 0.5 N / mm, about 0.2 N / mm to about 0.5 N / mm, about 0.3 N / mm to about 0.5 N / mm, about 0.1 N / mm to about 0.3 N / mm, about 0.1 N / mm to about 0.2 N / mm, about 0.2 N / mm to about 0.5 N / mm, about 0.2 N / mm to about 0.3 N / mm, or about 0.3 N / mm to about 0.5 N / mm.

[0153] The values ​​of some parameters of a stent, stent-graft, or first end portion, second end portion, intermediate portion, or sub-portion of a stent can be related (e.g., proportional). For example, the ratio of strut or filament thickness to the diameter of the device portion containing the struts or filaments can be about 1:10 to about 1:250, about 1:25 to about 1:175, or about 1:50 to about 1:100. In other examples, the ratio of device or device portion length to device or device portion diameter can be about 1:1 to about 50:1, about 5:1 to about 25:1, or about 10:1 to about 20:1.

[0154] Portions of a device can include a radiopaque material. For example, the filaments and / or struts of a stent, stent-graft, or first end portion, second end portion, intermediate portion, or sub-portion of a stent can include (e.g., be at least partially made of) titanium, tantalum, rhenium, bismuth, silver, gold, platinum, iridium, tungsten, combinations thereof, or the like. As another example, the filaments and / or struts of a stent, stent-graft, or portion of a stent can include (e.g., be at least partially made of) a material having a density greater than about 9 grams per cubic centimeter. Separate radiopaque markers can be attached to portions of a device. For example, radiopaque markers can be applied to the proximal end of a device or device portion (e.g., proximal portion of an intermediate portion, proximal portion of a distal portion), the distal end of a device or device portion (e.g., distal portion of an intermediate portion, distal portion of a proximal portion), and / or other portions of a device or device portion. Radiopaque markers between the ends of the device can be useful, for example, to distinguish transitions between materials, sections, etc. Radiopacity can vary along the length of the device. For example, the proximal section can have a first radiopacity (e.g., due to the distal section material and / or a separate marker) and the distal section can have a second radiopacity (e.g., due to the distal section material and / or a separate marker) that is different from the first radiopacity.

[0155] In some embodiments, the device comprises a polymer tube and no support structure is provided, and the middle portion of such a device can be made relatively more flexible than the end portions, for example, by reducing the wall thickness of the polymer tube within the middle portion.

[0156] When a mesh or other support structure is provided in combination with a polymeric tube, the support structure can be positioned around the outside of the tube, positioned within the lumen of the tube, or embedded within the wall of the tube. Two or more support structures can be provided, where each support structure may be in a different position relative to the tube.

[0157] One or both of the end portions of the device can have retention elements, such as hooks, protrusions, or barbs, configured to capture or grasp the inner wall of a blood vessel. The radial force of the end portions after expansion can be sufficient to capture or grasp the inner wall of a blood vessel without the use of retention elements.

[0158] There need not be a well-defined transition between the middle and end portions: for example, the mesh type, material, wall thickness, flexibility, etc. may vary gradually from the end portion to the middle portion, or from the middle portion to the end portion.

[0159] The flexibility of the device may gradually increase moving from the end portions toward the middle portion, as described for devices 134, 140, for example. The change in flexibility may be due to changes in mesh density (e.g., winding density, fenestration size), tube thickness, or other factors. The flexibility of the device may be uniform or substantially uniform throughout the entire length of the support structure (e.g., a stent), or over several portions of the support structure (e.g., over the entire end portion, over the entire middle portion, over one end portion and the middle portion but not the other end portion, etc.).

[0160] The devices described herein may be particularly suited for use as transvascular shunts in percutaneous procedures and may be used in many other medical applications. For example, the devices may be used in angioplasty procedures to treat blocked blood vessels with tortuous or twisted paths, or when the blood vessel may bend or deform at or near the location of the stent. Stents may also be used to repair damaged blood vessels, for example, in aortic graft procedures or after perforation during percutaneous procedures. In some such cases, a midsection of the device may allow the device to conform to the shape of the blood vessel and deform in response to the vessel's movements, while remaining fixed or anchored in place by the end sections, reducing the risk of fatigue failure. In another example, the device may be used to form a shunt between a healthy artery and a healthy vein for dialysis access and / or access for drug administration (e.g., intermittent injections of cancer treatments, which may damage blood vessels).

[0161] 4 and 7, blocking material 251 can be used to help block or prevent backflow of arterial blood. As described in more detail herein, additional or other methods and systems can be used to block or prevent backflow of arterial blood, or, stated differently, to block or prevent arterial blood flow entering a vein from flowing in the normal pre-treatment direction of blood flow in the vein, thereby bypassing oxygenated blood to downstream tissue, such as the leg.

[0162] Without treatment, peripheral vascular disease (PVD) can progress to critical limb ischemia (CLI), which is characterized by severe chronic pain and extensive tissue loss that limits revascularization options and often leads to amputation. CLI has an estimated incidence of approximately 50-100 cases per 100,000 per year and is associated with a mortality rate of as much as 20% within 6 months of onset.

[0163] Interventional radiologists have actively attempted to treat CLI by attempting to completely open a chronic total occlusion (CTO) or by bypassing the CTO into the subintimal space using products such as the Medtronic Pioneer catheter, which attempts to thread a wire into the subintimal space proximal to the CTO and then re-enter the vessel distal to the occlusion. Once the wire is in place, the user can optionally place a stent to create a wider channel and then provide a bypass conduit through the occlusion. Traditional approaches such as percutaneous transluminal angioplasty (PTA), stenting, and drug-eluting balloons (DEBs) for treating PAD can additionally or alternatively be used to treat CLI if a wire can cross the occlusion.

[0164] According to the amputee-coalition.org website, some statistics on the issue of CLT are as follows: There are nearly 2 million limb amputees in the United States. Among those with limb loss, the main causes are: vascular disease (54%) (diabetes and peripheral arterial disease (PAD)); trauma (45%), and Cancer (less than 2%). Approximately 185,000 amputations are performed in the United States each year. Hospital costs associated with amputations totaled more than $6.5 billion in 2007. Survival rates after amputation vary based on a variety of factors. Those undergoing amputation due to vascular disease (including PAD and diabetes) have a reported 30-day mortality rate of 9%-15%, with long-term survival rates of 60% at 1 year, 42% at 3 years, and 35%-45% at 5 years. Nearly half of those who lose a limb to dysvascular disease die within five years, a higher five-year mortality rate than those who suffer from colorectal, breast, and prostate cancer. Up to 55% of people with diabetes who have had a lower limb amputation will need another leg amputated within two to three years.

[0165] CLI has been treated surgically by open venous arterialization since the early 1900s. A small series of clinical trials using open surgical approaches, such as those outlined in a 2006 meta-analysis by Lu et al. entitled "Meta-analysis of the clinical effectiveness of venous arterialization for salvage of critically ischemic limbs" (European Journal of Vascular and Endovascular Surgery, vol. 31, pp. 493-499), have been published over the years. The paper reached the following results and conclusions: result: A total of 56 studies were selected for comprehensive review. No randomized controlled trials (RCTs) were identified. Seven patient groups, including 228 patients, met the inclusion criteria. Overall limb salvage at 1 year was 71% (95% CI: 64% to 77%), and the 1-year secondary patency rate was 46% (95% CI: 39% to 53%). The majority of patients who avoided major amputation had successful wound healing, did not experience rest pain, and were free of serious complications. Conclusion: Based on limited evidence, venous arterialization can be considered a viable alternative before major amputation in patients with “inoperable” chronic critical limb ischemia.

[0166] Among other conditions described herein, the methods and systems described herein can create an arterial-venous (AV) fistula within the below-the-knee (BKT) vasculature using an endovascular, minimally invasive approach. Such methods may be appropriate for patients who (i) have a clinical diagnosis of symptomatic critical limb ischemia as defined by Rutherford 5 or 6 (critical ischemic ulcer or frank gangrene), (ii) are evaluated by a vascular surgeon and interventionist and determined not to be amenable to surgical or endovascular treatment, and / or (iii) have a clear preference for major amputation.

[0167] In some embodiments, the system or kit optionally includes one or more of the following components: a first ultrasound catheter (e.g., an arterial catheter, a launching catheter with a needle, etc.), a second ultrasound catheter (e.g., a venous catheter, a targeting catheter, etc.), and a prosthesis (e.g., a covered nitinol stent graft in a delivery system (e.g., a 7 Fr (approximately 2.3 mm) delivery system)). The system or kit optionally further includes an ultrasound system, a control system (e.g., a computer). Some users may already have a suitable ultrasound system that can be connected to the ultrasound catheter(s). The catheters and prostheses described above can be used in the system or kit, and other, additional, and / or modified possible components are described in detail below.

[0168] FIG. 14A is a schematic side cross-sectional view of an exemplary embodiment of an ultrasound-emitting catheter 170 (e.g., a first ultrasound catheter, an arterial catheter (e.g., for extending the needle from an artery into a vein), or a venous catheter (e.g., for extending the needle from a vein into an artery)) having a needle 172. The catheter 170 is placed in an artery with the needle 172 in a retracted position within the lumen of the catheter 170. The catheter 170 can be tracked over a guidewire (e.g., a 0.014 inch (approximately 0.36 mm) guidewire) and / or placed through a sheath within the artery (e.g., the femoral artery) and advanced to the point of total occlusion in the artery (e.g., in the tibial artery). The catheter 170 has a handle 174 with a pusher ring 176. Longitudinal or distal advancement of the pusher ring 176 can advance the needle 172 from the lumen of the catheter 170 out of the artery and into the vein, as described herein. Other mechanisms for advancing needle 172 are contemplated (e.g., rotary, motorized, etc.). A guidewire (e.g., a 0.014 inch (approximately 0.36 mm) guidewire) can be placed through needle 172 (e.g., as described with respect to guidewire 14 of FIG. 3) before, after, and / or during needle advancement; this guidewire can be referred to as a crossover wire.

[0169] Figure 14B is an enlarged, schematic, side cross-sectional view of the distal portion of ultrasound-emitting catheter 170 within circle 14B in Figure 14A. As needle 172 is advanced or launched, it extends radially outward from lumen 173 of catheter 170. In some embodiments, lumen 173 terminates proximate ultrasound transmitting device 178. Needle 172 can extend along a path that aligns with (e.g., parallel to) the path of the directional ultrasound signal transmitted by ultrasound transmitting device 178. Figure 14B also shows lumen 175, which can be used to house a guidewire that tracks catheter 170 to a desired location.

[0170] FIG. 15A is a schematic side view of an exemplary embodiment of an ultrasound targeted catheter 180 (e.g., a second ultrasound catheter, an arterial catheter (e.g., for extending a needle from a vein into an artery), or a venous catheter (e.g., for extending a needle from an artery into a vein)). FIG. 15B is an enlarged, schematic, side cross-sectional view of the ultrasound targeted catheter 180 within circle 15B of FIG. 15A. FIG. 15C is an enlarged, schematic, side cross-sectional view of the ultrasound targeted catheter 180 within circle 15C of FIG. 15A. The catheter 180 can be tracked over a guidewire (e.g., a 0.014 inch (approximately 0.36 mm) guidewire) and / or placed through a sheath in a vein (e.g., the femoral vein) and advanced to a point proximal to and / or parallel to the distal end of the catheter 170 (e.g., in the tibial artery) and / or to an occlusion in the artery. The catheter 180 has an ultrasound receiving transducer 182 (e.g., an omnidirectional ultrasound receiving transducer) that can act as a target in the vein to align the needle 172 of the catheter 170. The catheter 180 can be left in place, or can remain stationary or substantially stationary while the catheter 170 is rotated and moved longitudinally to obtain a good or optimal ultrasound signal that indicates that the needle 172 is aligned with the catheter 180.

[0171] The catheters 170, 180 may be connected to ultrasound transmitters and receivers that are connected to and controlled by computer-implemented transmitter and receiver software. As described in further detail herein, the catheter 170 has a flat or directional ultrasound transmitter 178 configured to transmit ultrasound signals having a small angular spread or tight beam (e.g., small beam width) in the direction of the path of the needle 172 upon advancement from the lumen 173 of the catheter 170. The catheter 180 has an omnidirectional (360-degree) ultrasound receiver 182 configured to act as a target for the ultrasound signals transmitted by the directional transmitter 178 of the catheter 170. Upon extending the needle 172 (e.g., by advancing the ring 176 of the handle 174 longitudinally), the catheter 170 is rotated until a peak ultrasound signal is displayed indicating that the needle 172 is aligned with the catheter 180 so that the needle 172 can advance out of the artery in which the catheter 170 resides, through the interstitial tissue, and into the vein in which the catheter 180 resides.

[0172] FIG. 16 is an exemplary embodiment of a graph for detecting catheter alignment as may be displayed on an ultrasound system display device (e.g., a laptop, tablet computer, smartphone, combinations thereof, etc.). The graph in FIG. 16 shows a signal emanating from a transmitting catheter in a vein being received by a receiving catheter in a vein. The second frequency envelope on the right is the received signal. The distance from the left side of the illustrated screen to the leading edge of the second frequency envelope may indicate the distance between the catheters. The operator may, for example, move the catheter within the artery both rotationally and longitudinally until the second envelope is maximized, indicating that the catheter is correctly oriented.

[0173] FIG. 17 is a schematic side elevation view of an exemplary embodiment of a prosthesis (e.g., stent, stent-graft) delivery system 190. In some embodiments, delivery system 190 is a 7 Fr (approximately 2.3 mm) delivery system. FIG. 18 is a schematic side elevation view of an exemplary embodiment of a prosthesis (e.g., stent, stent-graft) 200. In FIG. 17, a prosthesis (e.g., prosthesis 200, other prostheses described herein, etc.) is in a compressed or crimped state adjacent a distal end 192 of delivery system 190. In some embodiments, prosthesis 200 comprises a shape-memory stent covered by a graft material, e.g., as described above. Once the cross wires extend from the artery into the vein, delivery system 190 can be advanced over the cross wires, e.g., as a result of being advanced through needle 172, as described herein. The prosthesis 200 can be deployed from the delivery system 190 by, for example, squeezing a trigger handle 194 of the delivery system 190 to retract the prosthesis 200 proximally and / or advance it distally through an outer covering sheath. The prosthesis 200 can create a flow path between an artery and a vein through interstitial tissue. Other types of delivery systems and prostheses are also contemplated.

[0174] Referring again to FIG. 17 , some non-limiting exemplary dimensions of the delivery system 190 are provided. The travel distance 196 of the trigger handle 194 can be, for example, from about 0.4 inches (approximately 1 cm) to about 12 inches (approximately 30 cm), from about 1 inch (approximately 2.5 cm) to about 8 inches (approximately 20 mm), or from about 2 inches (approximately 5 cm) to about 6 inches (approximately 15 mm) (e.g., about 2 inches (approximately 5 cm)). In some embodiments, the travel distance 196 of the trigger handle 194 is at least as long as the length of the prosthesis 200 to be deployed (e.g., in a radially expanded state). In some embodiments, a gearing or other mechanism can be used to shorten the travel distance 196 of the trigger handle 194 to less than the length of the prosthesis 200 to be deployed (e.g., in a radially expanded state). Distance 196 can be adjusted based on, for example, at least one of the length of deployed prosthesis 200, the degree to which deployed prosthesis 200 is retracted, the deployment mechanism (e.g., whether the outer sheath is retracted proximally, the prosthesis 200 is pushed distally forward, or both, whether delivery system 190 includes a transmission, etc.), combinations thereof, etc. The length 197 of the outer sheath or catheter portion can be, for example, about 40 inches (approximately 1020 mm) to about 50 inches (approximately 1270 mm), about 46 inches (approximately 1170 mm) to about 47 inches (approximately 1190 mm), or about 46.48 inches (approximately 1180 mm) to about 46.7 inches (approximately 1186 mm). The overall length 198 of delivery system 190 from the proximal tip to the distal tip can be, for example, about 40 inches (approximately 1000 mm) to about 60 inches (approximately 1500 mm). Lengths 197, 198 can be adjusted based on, for example, at least one of the length of deployed prosthesis 200, the degree to which deployed prosthesis 200 is to be retracted, the height of the patient, the location of the occlusion being treated, combinations thereof, etc. In some embodiments, it may be advantageous to space trigger handle 194 from the vascular access point, for example, by about 10 cm to about 30 cm (e.g., at least about 20 cm), to allow for easier handling or management by a user.In some such embodiments, length 197 may be about 120 cm to about 130 cm (eg, for an antegrade approach) or about 150 cm to about 180 cm (eg, for a contralateral approach).

[0175] Referring again to FIG. 18, some non-limiting exemplary dimensions of the prosthesis 200 are provided, depending on the circumstances, at least in the compressed state. The thickness 201 of the structural struts can be, for example, about 0.05 mm to about 0.5 mm, or about 0.1 mm to about 0.2 mm (e.g., about 0.143 mm). The inter-strut spacing 202 of the structural struts can be, for example, about 0.005 mm to about 0.05 mm, or about 0.01 mm to about 0.03 mm (e.g., about 0.025 mm). The thickness 203 of the connecting struts can be, for example, about 0.05 mm to about 0.5 mm, or about 0.1 mm to about 0.2 mm (e.g., about 0.133 mm). The longitudinal length 204 of the structural components can be, for example, about 1 mm to about 5 mm, or about 2.5 mm to about 3 mm (e.g., about 2.8 mm). The longitudinal length 205 between structural components can be, for example, about 0.25 mm to about 1 mm, or about 0.5 mm to about 0.6 mm (e.g., about 0.565 mm). The length 206 of the strut within the structural component, including all portions that wrap around and around, can be, for example, about 25 mm to about 100 mm, or about 65 mm to about 70 mm (e.g., about 67.62 mm). The overall longitudinal length of the prosthesis 200 can be, for example, about 25 mm to about 150 mm, or about 50 mm to about 70 mm (e.g., about 62 mm). As described herein, a wide variety of laser-cut stents, woven stents, and combinations thereof, including various sizes, are contemplated. The struts described herein can include wire or filament, or portions not cut from hypotubes or sheets.

[0176] The proximal and / or distal ends of the prosthesis 200 may optionally include a ring 210. The ring 210 can, for example, aid in placement of the prosthesis 200 within an artery and / or vein. The circumferential width 211 of the ring 210 can be, for example, about 0.25 mm to about 1 mm, or about 0.5 mm to about 0.75 mm (e.g., 0.63 mm). The longitudinal length 212 of the ring 210 can be, for example, about 0.25 mm to about 2 mm, or about 0.5 mm to about 1 mm (e.g., 0.785 mm). In some embodiments, the ratio of the overall length of the prosthesis 200 to the longitudinal length 212 of the ring 210 can be about 50:1 to about 100:1 (e.g., about 79:1). The dimensions 211, 212 of the ring 210 can be adjusted based on, for example, at least one of strut thickness, diameter of the prosthesis (eg, relative to the vessel), overall length of the prosthesis, material, shape-setting characteristics, combinations thereof, and the like.

[0177] FIG. 19 is a schematic side elevation view of another exemplary embodiment of a prosthesis 220. The prosthesis 200 can have the shape of the prosthesis 220, for example, in a radially expanded state (e.g., upon deployment from a delivery system 190). FIG. 19 illustrates an exemplary shape of the prosthesis 220 having a first portion 221 and a second portion 225. The first portion 221 has a substantially cylindrical or frustoconical shape with a length 222 of about 15 mm to about 25 mm (e.g., about 21 mm) and a diameter 223 of about 2.5 mm to about 5 mm (e.g., about 3.5 mm). The second portion 225 has a substantially frustoconical or frustoconical shape with a length 226 of about 30 mm to about 50 mm (e.g., about 41 mm) and a widest diameter 227 of about 4 mm to about 10 mm, about 4 mm to about 7 mm (e.g., about 5.5 mm), etc. The taper angle of the second portion 225 away from the first portion 221 can be about 0.02 degrees to about 0.03 degrees (eg, about 0.024 degrees).

[0178] Further details regarding prostheses that can be used in accordance with the methods and systems described herein are provided in U.S. patent application Ser. No. 13 / 791,185, filed March 8, 2013, the entire contents of which are incorporated herein by reference.

[0179] 20A-20H generally illustrate an exemplary embodiment of a method for performing retrograde perfusion. The method is described with respect to the peripheral vasculature, such as the lower extremities, but can be adapted as needed for other body cavities (e.g., the heart, other peripheries, etc.). Some steps, such as anesthesia, incision of specific sites, suturing, etc., can be omitted for clarity. In some embodiments, the method can be performed from a vein to an artery (e.g., via an intravenous catheter, as described below).

[0180] Access to the femoral artery and femoral vein is gained. For example, using the Seldinger technique, an introducer sheath (e.g., a 7 French (approximately 2.3 mm)) is inserted into the femoral artery, and an introducer sheath (e.g., a 6 French (approximately 2 mm)) is inserted into the femoral vein. A guidewire (e.g., a 0.014 inch (approximately 0.36 mm), 0.035 inch (approximately 0.89 mm), or 0.038 inch (approximately 0.97 mm)) is inserted through the introducer sheath in the femoral artery and guided into the distal portion of the affected posterior or anterior tibial artery 300. A second guidewire (e.g., a 0.014 inch (approximately 0.36 mm), 0.035 inch (approximately 0.89 mm), or 0.038 inch (approximately 0.97 mm)) or snare is inserted through the introducer sheath in the femoral artery. In embodiments in which a snare is used, the third guidewire, fourth guidewire, etc. described herein are accurate even if the numbering is not sequential.

[0181] A venous access needle is inserted percutaneously into a target vein, for example, a tibial vein (e.g., the proximal tibial vein (PTV)). In some embodiments, the venous access needle may be ultrasound-guided. In some embodiments, contrast is injected (retrograde) into the saphenous vein on the side of the leg and then flows into the PTV. This flow path can be visualized using fluoroscopy, allowing the venous access needle to be guided by fluoroscopy rather than or in addition to ultrasound.

[0182] The target vein can be accessed proximally and distally (e.g., several inches or centimeters) below where the launch catheter 310 is to be placed. In some embodiments, the target vein can be in the ankle. Once the venous access needle is in the vein, a third guidewire (or a "second" guidewire, if a snare is used instead of a second guidewire) is inserted into the venous access needle and advanced antegrade through the target vein to the femoral vein. This access method can advantageously reduce problems caused by advancing a wire retrograde across a venous valve, as described in more detail below. The third guidewire is snared, for example, using fluoroscopic guidance, and pulled through the femoral venous sheath. The target catheter 320 is inserted into the femoral venous sheath over the snared third guidewire. As shown in FIG. 20A, the target catheter 320 is advanced over the third guidewire into the venous system until the target catheter 320 is adjacent to and / or parallel to the guidewire and / or adjacent to the occlusion 304 in the distal portion of the affected posterior or anterior tibial artery.

[0183] In some embodiments, the third guidewire may have an ultrasound receiving transducer (e.g., omnidirectional) attached to provide a target for the signal transmitted by the launch catheter 310, or the target catheter 320 may be tracked over the third guidewire, either of which may allow for the omission of several techniques (e.g., femoral vein access, introduction of a venous introducer sheath, insertion of a second guidewire, antegrade advancement of the third guidewire into the femoral vein, snaring of the third guidewire, and advancement of the target catheter 320 over the third guidewire).

[0184] In some embodiments, the PTV may be accessed directly using, for example, ultrasound, which may allow the target catheter 320 to be placed directly into the PTV using, for example, a small sheath, which may allow omission of several techniques (e.g., femoral vein access, introduction of a venous introducer sheath, insertion of a second guidewire, and antegrade advancement of a third guidewire up to the femoral vein).

[0185] In some embodiments, catheter 320 is not an over-the-wire catheter, but rather includes a guidewire and an ultrasound receiving transducer (e.g., omnidirectional). Catheter 320 can be inserted as a third guidewire, as a second guidewire, or as a guidewire through a small sheath when directly accessing the PTV.

[0186] An ultrasound transducer generally has two electrodes capable of vibrating, with surfaces separated by a ceramic. Incoming or received ultrasound signal waveforms combine into a length-extension mode, as shown in FIG. 21. FIG. 21 is a schematic perspective view of an exemplary embodiment of an ultrasound receiving transducer 350. When the proximal or upper end 352 of the transducer 350 and the distal or lower end 354 of the transducer are conductive and electrically connect to a wire, the transducer can receive ultrasound signals. In some embodiments, the transducer 350 has a length 356 of about 0.1 mm to about 0.4 mm (e.g., about 0.25 mm). In some embodiments, the transducer 350 has an overlap length 358 of about 0.1 mm to about 0.3 mm (e.g., about 0.2 mm). In some embodiments, the transducer 350 has a diameter similar to, substantially similar to, or the same as the guidewire to which the transducer 350 is attached. In some embodiments, an array or series of laminates may enhance the signal reception capabilities of the transducer 350 .

[0187] In some embodiments, a guidewire having an ultrasound receiving transducer can include a piezoelectric film (e.g., including plastic), which can enhance the transducer's signal reception capabilities. FIG. 22 is a schematic cross-sectional view of another exemplary embodiment of an ultrasound receiving transducer 360. The ultrasound receiving transducer 360 shown in FIG. 22 includes an optional lumen 368. The ultrasound receiving transducer 360 includes a series of layers 362, 364, and 366. Layer 362 can include a polymer (e.g., polyvinylidene fluoride (PVDF)) layer. Layer 364 can include an inorganic (e.g., tungsten carbide) layer. Layer 366 can include a polymer (e.g., polyimide) layer. Layer 366 can have a thickness of about 25 micrometers (μm or microns) to about 250 μm (e.g., at least about 50 μm).

[0188] Launching catheter 310 is tracked over a guidewire within the femoral and tibial arteries proximal to and adjacent to occlusion 304, as shown in FIG. 20B. Catheter 310 may be more proximal to occlusion 304, depending on the suitability of the retroperfusion process in that portion of the anatomy. In some embodiments, catheter 310 may be positioned in the distal portion of the posterior or anterior tibial artery, for example, adjacent to catheter 320. In some embodiments, catheter 310 may be positioned within a few inches or centimeters of the ankle.

[0189] The launch catheter 310 transmits a directional ultrasound signal. As indicated by arrows 311, 312 in FIG. 20C, the launch catheter 310 is rotated and moved longitudinally until the signal is received by the target catheter 320. When the signal is received, alignment is indicated, whereby the vein is successfully accessed by extending a needle from the launch catheter 310, and a crossover needle 314 advances from the catheter 310 into the tibial artery 300 and into the tibial vein 302, as shown in FIG. 20D. The accuracy of the placement of the crossover needle 314 to form a fistula between the artery 300 and the vein 302 can be confirmed using, for example, contrast and fluoroscopy.

[0190] In some embodiments, the ultrasound signal can be used to determine the distance between the artery 300 and the vein 302. Referring again to Figure 16, the distance from the left side of the illustrated screen to the leading edge of the second frequency envelope can be used as an indication of the distance between the catheters.

[0191] 16, a display device can graphically show the signal alignment peaks to allow the user to determine the alignment position. In some embodiments, the signal alignment can change color, for example, from red to green, when it exceeds or falls below a threshold. In some embodiments, for example, an audible signal can be sent when the alignment signal exceeds a threshold, thereby allowing the user to maintain focus on the patient rather than nearly continuously monitoring the screen.

[0192] In some embodiments, a horizontal line on the screen can be moved to indicate the maximum signal, or peak, achieved to that point during the procedure. This line can be referred to as a "peak hold." If a greater signal value is achieved, the horizontal line moves to match the higher value. If manipulation cannot raise the peak above the horizontal line, this can indicate maximum alignment. If the signal peak drops below the horizontal line by a certain amount, the catheter has moved and can no longer be properly aligned. Because the alignment level indicated by the horizontal line was previously achieved during the procedure, the user knows that such alignment level can be achieved with further rotational and / or longitudinal manipulation.

[0193] A fourth guidewire 316 (e.g., 0.014 inches (approximately 0.36 mm)) (or a "third" guidewire if a snare is used instead of the second guidewire) is placed through the lumen of the crossing needle 314 of the catheter 310 in a retrograde (of the vein 302) direction on the leg side into the tibial vein 302, as shown in FIG. 20E. Outer cuff pressure can be applied over the needle intersection to reduce flow in the artery 300 to inhibit or prevent hematoma formation and / or to flood the vein to facilitate valve crossing. Leaving the guidewire 316 in place, the catheters 310, 320 can be advanced and extended out of the introducer sheath in the femoral artery, through the arterial tree, and into the tibial vein 302.

[0194] Several techniques for crossing the guidewire 316 from the artery 300 into the vein 302 may be used instead of or in addition to the directional ultrasound techniques described herein.

[0195] In some embodiments, a tourniquet can be applied to the leg, thereby increasing the diameter of the vein. In some embodiments, a blocking material (e.g., a blocking balloon, as described with respect to FIGS. 4 and 7) can be used to increase the diameter of the vein. For example, the vein can be enlarged by restricting venous flow. A larger vein diameter provides a larger target for the crossover needle 314, making the vein 300 more easily accessible by the crossover needle 314.

[0196] In some embodiments, a PTA balloon can be used in the target vein, and a needle catheter (e.g., Outback, available from Cordis) can be targeted to the PTA balloon under fluoroscopy. The crossing needle 314 can puncture the PTA balloon, and a drop in pressure in the PTA balloon can confirm proper alignment of the crossing needle 314. The PTA balloon can increase the diameter of the vein, making the crossing needle 314 a larger target, making the vein 300 more easily accessible by the crossing needle 314. A guidewire 316 can be advanced through the crossing needle 314 to the PTA balloon.

[0197] In some embodiments, the PTA balloon may have a mesh (e.g., a woven mesh) embedded within the balloon's polymer. If a balloon without such a mesh were punctured, the balloon material could break and cause embolism (e.g., fragments of the balloon could be washed downstream). The mesh can help limit tearing of the balloon material, thereby inhibiting or preventing the balloon material from causing embolism.

[0198] In some embodiments, two PTA balloons spaced longitudinally along the catheter axis can be used within the target vein, and a needle catheter can target one of the PTA balloons. When one of the PTA balloons is punctured by the cross needle 314, the punctured PTA balloon no longer acts as a dam for the contrast agent, allowing the contrast agent in the well between the balloons to be released. The release of contrast agent can be monitored using fluoroscopy. The PTA balloons can be on the same catheter side or on different catheter sides.

[0199] In some embodiments, two PTA balloons spaced longitudinally along the catheter axis can be used within the target vein, and a needle catheter can target the space or well between the PTA balloons. Puncture of the well by the cross needle 314 can disturb the contrast agent within the well. The contrast agent disturbance can be monitored using fluoroscopy. The PTA balloons can be on the same catheter side or on different catheter sides.

[0200] In some embodiments where a PTA balloon may be used in combination with an ultrasound target within a target vein, the PTA balloon catheter includes a PTA balloon and an ultrasound receiving transducer (e.g., omnidirectional). In some such embodiments, the launch catheter 310 can target the PTA balloon under fluoroscopy and / or target the ultrasound receiving transducer, as described herein. The crossing needle 314 can puncture the PTA balloon, and a drop in pressure in the PTA balloon can confirm proper alignment of the crossing needle 314. The PTA balloon can increase the diameter of the vein, thereby creating a larger target for the crossing needle 314 and making the vein 300 more accessible by the crossing needle 314. A guidewire 316 can be advanced through the crossing needle 314 to the PTA balloon.

[0201] In some embodiments, a LeMaitre device (e.g., the UnBalloon™ Non-Occlusive Modeling Catheter, available from LeMaitre Vascular, Inc., Burlington, Massachusetts) can be used within the target vein. In some embodiments, the LeMaitre device can increase the diameter of the vein. A larger diameter vein can provide a larger target for the crossing needle 314, making the vein 300 easier to access by the crossing needle 314. In some embodiments, the needle 314 can penetrate the LeMaitre device. In some such embodiments, the LeMaitre device can serve as a mesh target (e.g., comprising a radiopaque material visible under fluoroscopy) for the crossing needle 314. The mesh of the LeMaitre device can be radially expanded by distally advancing a proximal portion of the mesh and / or proximally retracting a distal portion of the mesh (e.g., by squeezing the ends together like an umbrella) and / or by allowing the mesh to self-expand (e.g., in embodiments in which at least a portion of the mesh comprises a shape-memory material). In some embodiments, the LeMaitre device can grip the crossover wire as it closes to hold the crossover wire within the target vein.

[0202] In some embodiments, the launch catheter 310 can include a first magnet having a first polarity, and the target catheter 320 can include a second magnet having a second polarity. When the magnets are close enough to cause a magnetic force to move one or both of the catheters 310, 320, the crossing catheter 314 can be advanced to create a fistula between the artery 300 and the vein 302. In some embodiments, the first magnet can be circumferentially aligned with the crossing needle 314, and / or the launch catheter 310 can be magnetically shielded to provide rotational alignment. In some embodiments, the second magnet can be relatively thin longitudinally to provide longitudinal alignment. In some embodiments, the crossing needle 314 and / or guidewire 316 can be magnetically pulled from the artery 300 to the vein 302, or vice versa. Some systems can have both ultrasound and magnetic guidance. For example, ultrasound guidance can be used for initial alignment, and magnetic guidance can be used for fine alignment.

[0203] 20A-20H, as shown in FIG. 20F, prosthesis delivery system 330 carrying prosthesis 349 is tracked over guidewire 316 through the interstitial space between artery 300 and vein 302. In some embodiments, a separate PTA balloon catheter (e.g., about 2 mm) can be tracked over guidewire 316 to pre-dilate the fistula between artery 300 and vein 302 prior to introducing prosthesis delivery system 330. The use of a PTA balloon catheter can depend, for example, on the radial force of prosthesis 340.

[0204] The prosthesis 340 is deployed from the prosthesis delivery system 330, for example, by manipulating the trigger handle 194 (FIG. 17). In some embodiments, for example, if the prosthesis 340 is unable to expand and / or advance, the prosthesis delivery system 330 can be removed and a PTA catheter (e.g., about 2 mm) can be advanced over the guidewire 316 to attempt to enlarge or further enlarge the fistula between the artery 300 and the vein 302. Deployment of the prosthesis 340 can then be attempted again (e.g., by self-expansion, balloon expansion, etc.). In some embodiments, deployment of the prosthesis 340 can remodel the vessel, expanding the vessel diameter by at least about 10%, at least about 20%, at least about 30% or more, between about 0% and about 10%, between about 0% and about 20%, between about 0% and about 30% or more. In embodiments in which prosthesis 340 is self-expanding, the degree of remodeling may vary over time, eg, prosthesis 340 expands when the blood vessel expands and contracts when the blood vessel contracts.

[0205] As shown in FIG. 20G, once the prosthesis 340 is deployed, the fistula can be dilated with a PTA catheter. The diameter of the PTA catheter (e.g., about 3 mm to about 6 mm) can be selected based at least in part on the diameter of the artery 300, the diameter of the vein 302, the composition of the interstitial tissue, the characteristics of the prosthesis 340, a combination thereof, etc. In some embodiments, the prosthesis delivery system 330 can comprise a PTA balloon catheter (e.g., proximal or distal to the prosthesis 340) useful for one, more than one, or all of the optional PTA balloon catheterization techniques described herein. In embodiments in which the prosthesis has a conical portion, the PTA balloon can have a conical portion. Once the prosthesis 340 is in place, the prosthesis delivery system 330 can be removed, as shown in FIG. 20H. This creates an AV fistula between the artery 300 and the vein 302. Verification of placement of the venous catheters 310, 320, 330 and prosthesis 340 may be confirmed throughout part or all of the procedure under fluoroscopy using contrast injection.

[0206] In some embodiments, a marker (e.g., a clip, lancet, scissors, pencil, etc.) can be applied to the skin (e.g., glued, placed on, etc.) to generally mark the location of the fistula formed between the artery 300 and the vein 302 by the crossing needle 314 prior to deployment of the prosthesis 340. In embodiments using a blood pressure monitor that the user inflates over the fistula to avoid bleeding, the lack of blood flow can make visualizing or even assessing the fistula site difficult, and the marker can provide such identification. In embodiments in which the transmitting / receiving catheters are removed after fistula formation, the intersection point can be difficult for the user to feel or determine, and the marker can provide such identification. If the fistula is enlarged (e.g., to increase or maximize interstitial space penetration), it may be preferable to be able to align the midpoint of the dilation balloon with the midpoint of the fistula. In some embodiments, the marker can be visible under fluoroscopy (e.g., comprising a radiopaque material) to allow the user to locate and remember the location of the fistula under fluoroscopy before deploying the prosthesis 340.

[0207] Once the prosthesis 340 is in place, the only obstacle to blood flowing through the vein 302 to the foot is the valve within the vein. Maneuvering a guidewire across the venous valve can be difficult because, for example, pressure from the artery may be insufficient to dilate the vein and disable the valve. As described in more detail below, it has been discovered that the venous valve distal to the AV fistula can be disabled or rendered nonfunctional using one or more of a variety of techniques, such as a PTA catheter, a stent, and a valvulotome. Disabling the venous valve can allow blood to flow distal to the venous circulation of the leg via retrograde perfusion from the femoral artery, retrograde flow within the vein 302, and retrograde flow within the venules and capillaries to supply oxygenated blood to the foot in CLI patients.

[0208] In some embodiments, a high pressure PTA balloon catheter can be used (eg, when inflated to greater than about 10 atm (approximately 1013 kPa)) to render the venous valves non-functional.

[0209] In some embodiments, one or more stents can be placed across one or more venous valves to disable those valves, e.g., such stents should have sufficient radial force to hold the valves open.

[0210] In some in situ bypass procedures, the saphenous vein is attached to an artery in the upper limb and another artery in the lower limb, bypassing any blockages in the artery. In some such procedures, the vein is peeled from the patient, longitudinally inverted, and left in place so that blood flow is retrograde (across the vein's valves) rather than used as a prosthesis. A standard valvulotome can be placed into the saphenous vein from below, advanced to the apex in a collapsed state, opened, and then pulled back in an open state, cutting the venous valves in the process. The cutting surface of such a valvulotome faces backward to cut when retracted during these procedures. FIG. 23A is a schematic perspective view of an exemplary embodiment of a valvulotome 400 having a proximally facing blade 402 that can be used in conjunction with such procedures.

[0211] In some embodiments of the methods described herein, distal access to the venous valve is unavailable, making it impossible to pull the valvulotome backward, but rather to push the retrograde valvulotome forward as described herein. FIG. 23B is a schematic perspective view of an exemplary embodiment of a valvulotome 410 that can be used with such a procedure. The retrograde valvulotome 410 has one or more blades 412 (e.g., two to five blades, e.g., three blades) that face forward or distally so as to be able to cut the valve as the retrograde valvulotome 410 advances distally. At least because retrograde access to an attenuated vein has not previously been recognized as a problem, there has previously been no motivation to reverse the direction of the valvulotome blades to create a retrograde valvulotome 410 as described herein. The retrograde valvulotome 410 can be tracked over the guidewire 414 and advanced into the vein to disable the venous valve. After creating a fistula between the artery and the vein as described herein, fluid flow within the vein is in the opposite direction to the original or normal or pre-procedure direction of fluid flow within the vein, and therefore pushing the retrograde valvulotome 410 is in the opposite direction to the original fluid flow, but in the direction of fluid flow after the fistula is created.

[0212] Other systems and methods for disabling valves in veins (e.g., cutting balloons, atherectomy, laser ablation, ultrasonic ablation, heating, radiofrequency (RF) ablation, catheters with traumatic or non-traumatic tips (e.g., introducer sheaths) advanced and / or retracted, combinations thereof, etc.) may also be contemplated.

[0213] It can also be difficult to cross a valve in a vein retrogradely before disabling it. Figure 24 is a schematic perspective view of an exemplary embodiment of a LeMaitre device 420 that can be used to radially expand a vein and, therefore, its valve. The LeMaitre device 420 has expandable elliptical or oblong lobes 422, e.g., a self-expanding nitinol mesh. In some embodiments, a PTA balloon catheter can be used to radially expand the vein and, therefore, its valve. In some embodiments, a tourniquet can be applied to the leg to radially expand the vein and, therefore, its valve. During radial expansion, a guidewire can be advanced (e.g., through an expansion device such as a LeMaitre device) through the expansion valve(s), and a catheter (e.g., for PTA, stent delivery, atherectomy, etc.) or other over-the-wire device can be advanced over the guidewire.

[0214] Although several exemplary embodiments have been disclosed in detail herein, this is done by way of example and for purposes of illustration only. The above-described embodiments are not intended to be limiting with respect to the scope of the following appended claims. It is contemplated by the inventors that various substitutions, alterations, and modifications can be made to the present invention without departing from the spirit and scope of the invention as defined by the claims.

[0215] The devices described herein can be used in applications where the fluid flowing through the device is a liquid such as blood, but can additionally or alternatively be used in applications such as tracheal or bronchial surgery where the fluid is a gas such as air. In some embodiments, the fluid may contain solid matter, such as emboli, or in gastric surgery, the fluid may include food particles.

[0216] While the present invention is susceptible to various modifications and alternative forms, specific examples have been shown in the drawings and described in detail herein. However, the present invention is not intended to be limited to the particular forms or methods disclosed; on the contrary, it encompasses all modifications, equivalents, and alternatives falling within the spirit and scope of the various described embodiments and the appended claims. Any methods disclosed herein need not be performed in the order described. Methods disclosed herein include steps taken by a practitioner, but may also include any explicit or implicit third-party instructions of those steps. For example, a step such as "disabling a valve in a first blood vessel" includes "instructing to disable a valve in a first blood vessel." Ranges disclosed herein also encompass all inclusions, subranges, and combinations thereof. Words such as "up to," "at least," "greater than," "less than," "between," and the like, include the stated numerals. Numbers preceded by terms such as "about" or "approximately" include the stated numerals. For example, "about 10 mm" includes "10 mm." Terms or phrases preceded by words such as "substantially" include the stated term or phrase. For example, "substantially parallel" includes "parallel."

[0217] The following claims describe several embodiments of the invention(s). These non-limiting claims set forth certain permutations of the combinations of features disclosed herein, but other permutations of the combinations of features are also encompassed within the scope of the invention(s).

Claims

1. 1. A device for altering blood flow, comprising: A support structure comprising: a first end configured to coaxially oppose a sidewall of a first blood vessel, the first end having a first diameter; a second end configured to coaxially oppose a sidewall of a second blood vessel, the second end having a second diameter greater than the first diameter; an intermediate portion longitudinally disposed between the first end and the second end and configured to be disposed in a passage between the first blood vessel and the second blood vessel, the intermediate portion having a frustoconical shape; and the support structure, a tube coupled to the support structure, the tube comprising a polymer, the tube forming a lumen configured to at least partially divert blood flow from the first blood vessel through the passage to the second blood vessel; and Equipped with Device.

2. the second end is frustoconical; 10. The apparatus of claim 1.

3. the first end is cylindrical; 3. The apparatus of claim 2.

4. the first end is frustoconical; 3. The apparatus of claim 2.

5. the first end is frustoconical; 10. The apparatus of claim 1.

6. the support structure is self-expanding; 10. The apparatus of claim 1.

7. the support structure is balloon expandable; 10. The apparatus of claim 1.

8. the support structure includes a wire; 10. The apparatus of claim 1.

9. at least one of the first end and the second end is frustoconical, the support structure comprises a laser-drilled nitinol tube, and the tube comprises PTFE; 10. The apparatus of claim 1.

10. The intermediate portion is trapezoidal along the entire length of the intermediate portion between the first end and the second end.

10. The apparatus of claim 1.

11. the first end, the second end, and the intermediate portion self-expand from a compressed state inside the delivery catheter to an expanded state outside the delivery catheter, wherein in the expanded state, the first end has the first diameter and the second end has the second diameter.

10. The apparatus of claim 1.

12. 1. A device for altering blood flow, comprising: A support structure comprising: a first end configured to oppose a sidewall of a first blood vessel and having a first diameter; a second end configured to face a sidewall of a second vessel different from the first vessel, the second end having a second diameter different from the first diameter; an intermediate portion longitudinally disposed between the first end and the second end and configured to be disposed in a passage between the first blood vessel and the second blood vessel, wherein at least one of the first end, the second end, and the intermediate portion is frustoconical; and the support structure, a tube coupled to the support structure, the tube defining a lumen configured to at least partially divert blood flow from the first blood vessel through the passage to the second blood vessel; and Equipped with Device.

13. The second end is frusto-conical and the first end is cylindrical.

13. The apparatus of claim 12.

14. the second end is frusto-conical and the first end is frusto-conical; 13. The apparatus of claim 12.

15. the support structure is self-expanding; 13. The apparatus of claim 12.

16. at least one of the first end and the second end is frustoconical, the first blood vessel is an artery, the second blood vessel is a vein, the support structure comprises a laser-drilled shape memory material tube, and the tube comprises a polymer.

13. The apparatus of claim 12.

17. 1. A device for altering blood flow, comprising: A support structure comprising: a first end configured to be secured to the first passageway and having a first diameter; a second end configured to be secured in a second passageway different from the first passageway, the second end having a second diameter different from the first diameter; an intermediate portion longitudinally disposed between the first end and the second end and configured to be disposed in a third passage between the first passage and the second passage, the intermediate portion having a third diameter tapering from the first diameter to the second diameter along an entire length of the intermediate portion; the support structure, a tube coupled to the support structure, the tube defining a lumen configured to at least partially divert blood flow from the first passageway through the third passageway to the second passageway; and Equipped with Device.

18. At least one of the first end and the second end is frustoconical.

18. The apparatus of claim 17.

19. The intermediate portion is frustoconical.

18. The apparatus of claim 17.

20. A device for disabling a vascular valve, comprising: a blade having a longitudinally compressed contracted configuration and a radially expanded configuration, the blade including a distally facing sharp surface configured to at least partially ablate the valve within the blood vessel while advancing the device through the blood vessel in a direction opposite to the natural flow of the blood vessel in the expanded configuration; Device.

21. the blade is configured to be pushed into the blood vessel through a fistula between the blood vessel and an artery and at least partially excise the valve within the blood vessel without retrograde access.

21. The apparatus of claim 20.

22. the blade is configured to, after forming a fistula between the blood vessel and the artery, be pushed through the blood vessel in the direction of fluid flow of the blood vessel to at least partially ablate the valve within the blood vessel without retrograde access.

21. The apparatus of claim 20.

23. the blade is one of three blades, each of the three blades including a sharp surface facing distally and configured to at least partially ablate a valve within a blood vessel during distal advancement of the device through the blood vessel, the three blades being circumferentially spaced apart at approximately 120 degrees, and the three blades including a shape memory material; 21. The apparatus of claim 20.

24. the blades are parallel to the longitudinal axis of the device in the contracted configuration and non-parallel to the longitudinal axis of the device in the expanded configuration; 21. The apparatus of claim 20.

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