ES2532077T3 - Aparato para la neuromodulación renal - Google Patents
Aparato para la neuromodulación renal Download PDFInfo
- Publication number
- ES2532077T3 ES2532077T3 ES11192514.5T ES11192514T ES2532077T3 ES 2532077 T3 ES2532077 T3 ES 2532077T3 ES 11192514 T ES11192514 T ES 11192514T ES 2532077 T3 ES2532077 T3 ES 2532077T3
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- renal
- electrodes
- catheter
- stimulation
- balloon
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Abstract
Aparato de neuromodulación renal (250), comprendiendo el aparato (250): un catéter (252) configurado para su colocación intravascular dentro de una arteria renal, en el que el catéter (252) comprende una cesta expansible (254); y una pluralidad de electrodos (256) adaptados para expandirse hasta entrar en contacto con una pared de la arteria renal, en el que los electrodos (256) están configurados para suministrar un campo eléctrico para conseguir la neuromodulación renal, por ejemplo desnervación renal, en el que el aparato comprende además un sensor de temperatura.
Description
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E11192514
04-03-2015
La figura 5 es una vista lateral esquemática, parcialmente en sección, de un dispositivo intravascular que tiene un par de electrodos helicoidales de expansión dispuestos a una distancia deseada uno de otro según otra realización de la invención.
La figura 6 es una vista lateral esquemática, parcialmente en sección, de un dispositivo intravascular que tiene un primer electrodo sobre un balón expansible y un segundo electrodo sobre un cuerpo de catéter según otra realización de la invención.
La figura 7 es una vista lateral esquemática, parcialmente en sección, de un dispositivo intravascular que tiene un primer electrodo de expansión suministrado a través de la luz de un catéter y un segundo electrodo complementario llevado por el catéter según otra realización de la invención.
La figura 8 es una vista lateral esquemática, parcialmente en sección, de un dispositivo intravascular que tiene una cesta expansible y una pluralidad de electrodos en la cesta según otra realización de la invención.
La figura 9 es una vista de detalle esquemática del aparato de la figura 8 que ilustra una realización de los electrodos según otra realización de la invención.
La figura 10 es una vista lateral esquemática, parcialmente en sección, de un dispositivo intravascular que tiene electrodos de anillo expansibles para entrar en contacto con la pared del vaso y un elemento aislante opcional según otra realización de la invención.
La figuras 11A-11C son vistas de detalle esquemáticas de realizaciones de diferentes arrollamientos para los electrodos de anillo de la figura 10.
La figura 12 es una vista lateral esquemática, parcialmente en sección, de un dispositivo intravascular que tiene electrodos de anillo de la figura 10 con los arrollamientos mostrados en la figuras 11A-11C.
La figura 13 es una vista lateral esquemática, parcialmente en sección, de un dispositivo intravascular que tiene un electrodo de anillo y un electrodo suministrado luminalmente según otra realización de la invención.
La figura 14 es una vista lateral esquemática, parcialmente en sección, de un dispositivo intravascular que tiene un catéter de balón y electrodos de contacto de punta expansibles dispuestos de manera proximal y distal con respecto al balón según otra realización de la invención.
La figura 15 es una vista lateral esquemática de un dispositivo intravascular que tiene un catéter de balón y electrodos dispuestos de manera proximal y distal con respecto al balón según otra realización de la invención.
Las figuras 16A y 16B son vistas laterales esquemáticas, parcialmente en sección, que ilustran las fases de un método de uso del aparato de la figura 15 según una realización de la invención.
La figura 17 es una vista lateral esquemática de un dispositivo intravascular que tiene un catéter de balón y una pluralidad de electrodos que pueden accionarse dinámicamente según otra realización de la invención.
La figura 18 es una vista lateral esquemática de un dispositivo intravascular que tiene un electrodo distal desplegado a través de una luz del catéter de balón según otra realización de la invención.
La figuras 19A y 19B son vistas laterales, parcialmente en sección, que ilustran métodos de uso del dispositivo intravascular mostrado en la figura 18 para modular la actividad neural renal en pacientes con diversas vasculaturas renales.
La figura 20 es una vista lateral, parcialmente en sección, que ilustra un dispositivo intravascular que tiene una pluralidad de electrodos dispuestos a lo largo del cuerpo de, y en línea con, un elemento de centrado según otra realización de la invención.
La figura 21 es una vista lateral, parcialmente en sección, que ilustra un dispositivo intravascular que tiene electrodos configurados para recolocar radialmente de manera dinámica para facilitar el enfocado de un campo eléctrico pulsado según otra realización de la invención.
La figura 22 es una vista lateral, parcialmente en sección, de un dispositivo intravascular que tiene un catéter de infusión/aspiración según otra realización de la invención.
Las figuras 23A-23C son, respectivamente, una vista lateral, parcialmente en sección, y vistas en sección transversal a lo largo de la línea de corte A--A de la figura 23A, que ilustran un método de uso de un dispositivo intravascular según una realización de la invención configurado para hacer pasar electrodo(s) al menos parcialmente a través de la pared del vaso.
Las figuras 24A y 24B son vistas laterales, parcialmente en sección, que ilustran un dispositivo intravascular que tiene detectores para medir o monitorizar la eficacia del tratamiento según otra realización de la invención.
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Descripción detallada
A. Visión general
La presente invención se refiere a métodos y aparatos para la neuromodulación renal y/u otra neuromodulación. Más particularmente, la presente invención se refiere a métodos y aparatos para la neuromodulación renal usando un campo eléctrico pulsado para efectuar electroporación o electrofusión. Tal como se usa en el presente documento, la electroporación y la electropermeabilización son métodos de manipulación de la membrana celular o aparatos intracelulares. Por ejemplo, pulsos breves de alta energía hacen que se abran poros en las membranas celulares. La magnitud de la porosidad en la membrana celular (por ejemplo, tamaño y número de poros) y la duración de los poros (por ejemplo, temporal o permanente) dependen de la intensidad de campo, el ancho de pulso, el ciclo de trabajo, la orientación del campo, el tipo de célula y otros parámetros. En general, los poros generalmente se cerrarán de manera espontánea al interrumpir campos de intensidad menor o anchos de pulso más cortos (definido en el presente documento como “electroporación reversible”). Cada tipo de célula tiene un umbral crítico por encima del cual los poros no se cierran de manera que la formación de poros ya no es reversible; este resultado se define como “electroporación irreversible”, “rotura irreversible” o “daño irreversible”. En este punto, la membrana celular se rompe y/o se producen desequilibrios químicos irreversibles provocados por la alta porosidad. Esta alta porosidad puede ser el resultado de un único orificio grande y/o de una pluralidad de orificios más pequeños. Determinados tipos de parámetros de energía de electroporación apropiados también para su uso en neuromodulación renal son pulsos de alta tensión con una duración de orden inferior a los microsegundos (campos eléctricos pulsados en nanosegundos, o nsPEF) que pueden dejar la membrana celular intacta, pero alterar el aparato intracelular o la función de la célula de maneras que provocan la muerte o alteración celular. Se ha mostrado que determinadas aplicaciones de nsPEF provocan muerte celular al inducir apoptosis, o muerte celular programada, en lugar de muerte celular aguda. Asimismo, el término “que comprende” se usa a lo largo de todo el documento con el significado de que incluye al menos la característica mencionada de manera que no se descarta cualquier número mayor de la misma característica y/o características de tipos adicionales.
Diversas realizaciones de la presente invención proporcionan dispositivos intravasculares para inducir neuromodulación renal, tal como un cambio temporal en los nervios diana que se disipa con el tiempo, un control continuo sobre la función neural y/o desnervación. Los aparatos y métodos descritos en el presente documento pueden utilizar cualquier señal eléctrica o parámetros de campo adecuados, por ejemplo, cualquier campo eléctrico, que consiga la neuromodulación deseada (por ejemplo, efecto electroporativo). Para entender mejor las estructuras de los dispositivos intravasculares y los métodos de uso de estos dispositivos para la neuromodulación, es útil entender la anatomía renal en seres humanos.
B. Realizaciones seleccionadas de métodos para la neuromodulación
Haciendo referencia ahora a la figura 1, la anatomía renal humana incluye riñones K a los que se les suministra sangre oxigenada mediante las arterias renales RA, que están conectadas al corazón mediante la aorta abdominal AA. La sangre desoxigenada fluye desde los riñones hasta el corazón a través de las venas renales RV y la vena cava inferior IVC. La figura 2 ilustra una parte de la anatomía renal en mayor detalle. Más específicamente, la anatomía renal también incluye nervios renales RN que se extienden longitudinalmente a lo largo de la dimensión longitudinal L de la arteria renal RA generalmente dentro de la adventicia de la arteria. La arteria renal RA tiene células de músculo liso SMC que rodean la espiral de la circunferencia arterial alrededor del eje angular de la arteria, es decir, alrededor de la circunferencia de la arteria. Las células de músculo liso de la arteria renal tienen por consiguiente una dimensión longitudinal o más larga que se extiende de manera transversal (es decir, no paralela) a la dimensión longitudinal de la arteria renal. La desalineación de las dimensiones longitudinales de los nervios renales y las células de músculo liso se define como “desalineación celular”.
Haciendo referencia a la figura 3, la desalineación celular de los nervios renales y las células de músculo liso puede aprovecharse para afectar selectivamente a las células nerviosas renales con un efecto reducido sobre las células de músculo liso. Más específicamente, dado que células más grandes requieren menos energía para superar el umbral de irreversibilidad de la electroporación, diversas realizaciones de electrodos de la presente invención están configuradas para alinear al menos una parte de un campo eléctrico generado por los electrodos con o próximo a las dimensiones más largas de las células que van a verse afectadas. En realizaciones específicas, el dispositivo intravascular tiene electrodos configurados para crear un campo eléctrico alineado con o próximo a la dimensión longitudinal de la arteria renal RA para afectar a los nervios renales RN. Mediante la alineación de un campo eléctrico de modo que el campo afecta de manera preferencial al aspecto longitudinal de la célula en lugar de al aspecto diametral o radial de la célula, pueden usarse intensidades de campo más bajas para necrosar las células. Tal como se mencionó anteriormente, se espera que esto reduzca el consumo de energía y mitigue los efectos sobre células no diana en el campo eléctrico.
De manera similar, las dimensiones longitudinales o más largas de tejidos superpuestos o subyacentes al nervio diana son ortogonales o de otro modo están fuera del eje (por ejemplo, son transversales) con respecto a las dimensiones más largas de las células nerviosas. Por tanto, además de alinear el PEF con las dimensiones longitudinales o más largas de las células diana, el PEF puede propagarse a lo largo de las dimensiones laterales o más cortas de las células no diana (es decir de manera que el PEF se propaga al menos parcialmente de manera no
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configurados para la recolocación radial dinámica de uno o más de los electrodos con respecto a la pared de un vaso, facilitando así en enfoque de un campo eléctrico pulsado suministrado por los electrodos. El aparato 300 comprende un catéter 302 que tiene electrodos 304 dispuestos en línea con elementos expansibles encajados. Los elementos expansibles encajados comprenden un elemento expansible interno 306 y un elemento de centrado expansible externo 308. Los electrodos 304 se disponen a lo largo del elemento expansible interno, mientras que el elemento de centrado expansible externo está configurado para centrar y estabilizar el catéter 302 dentro del vaso. El elemento interno 306 puede expandirse en diversos grados, según lo que quiera el profesional médico, para alterar dinámicamente las posiciones radiales de los electrodos 304. Esta recolocación radial dinámica puede utilizarse para enfocar la energía suministrada por los electrodos 304 de manera que se suministra al tejido diana.
Los elementos encajados 306 y 308 pueden comprender una disposición de balón en balón, una disposición de cesta en cesta, alguna combinación de balón y cesta, o cualquier otra estructura expansible encajada. En la figura 21, el elemento expansible interno 306 comprende de manera ilustrativa una cesta expansible, mientras que el elemento de centrado expansible externo 308 comprende de manera ilustrativa un balón expansible. Los electrodos 302 se colocan a lo largo de la superficie del balón interno 306.
Opcionalmente cualquiera de las variaciones de la presente invención descritas en el presente documento puede estar configurada para la infusión de agentes a la zona de tratamiento antes, durante o después de la aplicación de energía, por ejemplo, para mejorar o modificar el efecto neurodestructivo o neuromodulatorio de la energía, para proteger o desplazar temporalmente células no diana y/o para facilitar la visualización. Resultarán evidentes aplicaciones adicionales de agentes infundidos. Si se desea, puede mejorarse la captación de agentes infundidos por las células mediante la iniciación de electroporación reversible en las células en presencia de los agentes infundidos. La infusión puede ser especialmente deseable cuando se utiliza un elemento de centrado de balón. El infundido puede comprender, por ejemplo, solución salina o solución salina heparinizada, agentes protectores, tales como Poloxamer-188, o agentes antiproliferativos. Variaciones de la presente invención pueden estar configuradas adicional o alternativamente para la aspiración. Por ejemplo, pueden proporcionarse orificios o salidas de infusión en un cuerpo de catéter adyacente a un dispositivo de centrado, el dispositivo de centrado puede ser poroso (por ejemplo, un balón “permeable”), o los largueros de la cesta pueden estar formados por hipotubos huecos y ranurados o perforados para permitir la infusión o la aspiración.
Haciendo referencia a la figura 22 se describe una variación de la presente invención que comprende un catéter de PEF de infusión/aspiración. El aparato 310 comprende un catéter 312 que tiene balones inflables proximal y distal 314a y 314b, respectivamente. Un electrodo de cuerpo proximal 316a está dispuesto entre los balones a lo largo del cuerpo del catéter 312, mientras que un electrodo distal 316b está dispuesto de manera distal a los balones a lo largo del cuerpo del catéter. Uno o más orificios de infusión o aspiración 318 están dispuestos a lo largo del cuerpo del catéter 312 entre los balones en las proximidades del electrodo proximal 316a.
El aparato 310 puede usarse de una diversidad de maneras. En un primer método de uso, el catéter 312 se dispone dentro del vaso diana, tal como la arteria renal RA, en una ubicación deseada. Se inflan uno o ambos balones 314, y se infunde un agente protector u otro infundido a través del/de los orificio(s) 318 entre los balones en las proximidades del electrodo 316a. Se suministra un PEF adecuado para la iniciación de la electroporación reversible a través de los electrodos 316 para facilitar la captación del infundido por células no diana en la pared del vaso. El suministro del agente protector puede mejorarse inflando en primer lugar el balón distal 314b, después infundiendo el agente protector, que desplaza la sangre, y después inflando el balón proximal 314a.
El infundido restante puede aspirarse opcionalmente de manera que no esté disponible durante una posterior aplicación del PEF cuando se inicia la electroporación irreversible de células nerviosas. La aspiración puede conseguirse desinflando al menos parcialmente un balón durante la aspiración. Alternativamente, la aspiración puede conseguirse con ambos balones inflados, por ejemplo, infundiendo solución salina junto con la aspiración para lavar el segmento de vaso entre los balones inflados. Tal lavado de sangre puede reducir el riesgo de formación de coágulos a lo largo del electrodo proximal 316a durante la aplicación del PEF. Además, el lavado durante la aplicación de energía puede enfriar el electrodo y/o las células de la pared de la arteria. Tal enfriamiento de las células de la pared puede proteger las células frente a un daño electroporativo irreversible, reduciendo posiblemente la necesidad de infusión de un agente protector.
Tras la infusión y la aspiración opcional, puede suministrarse un PEF adecuado para la iniciación de electroporación irreversible en células nerviosas diana a través de los electrodos 316 para desnervar o modular la actividad neural. En un método alternativo, la infusión de un agente protector puede realizarse durante o después de iniciarse la electroporación irreversible con el fin de proteger células no diana. El agente protector puede taponar o rellenar, por ejemplo, los poros formados en las células no diana por la electroporación irreversible.
En otro método alternativo, puede infundirse y aspirarse simultáneamente una disolución de solución salina heparinizada fría (es decir, a una temperatura inferior a la del organismo) entre los balones inflados para lavar la región entre los balones y disminuir la sensibilidad de las células de la pared del vaso células a la electroporación. Se espera que esto proteja adicionalmente las células durante la aplicación del PEF adecuado para la iniciación de la electroporación irreversible. Opcionalmente tal lavado puede ser continuo durante toda la aplicación del campo eléctrico pulsado. Puede colocarse opcionalmente un termopar u otro sensor de temperatura entre los balones de
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manera que puede ajustarse la tasa de infusión de infundido frío para mantener una temperatura deseada. El infundido frío preferiblemente no enfría el tejido diana, por ejemplo, los nervios renales. Un agente protector, tal como el Poloxamer-188, puede infundirse opcionalmente tras el tratamiento como medida de seguridad adicional.
La infusión puede conseguirse alternativamente mediante un catéter de balón permeable. Todavía adicionalmente, puede utilizarse un catéter de balón criogénico que tiene al menos un electrodo. El balón criogénico puede inflarse dentro de un segmento de vaso para reducir localmente la temperatura del segmento de vaso, por ejemplo, para proteger el segmento y/o para inducir apoptosis térmica de la pared del vaso durante el suministro de un campo eléctrico. El campo eléctrico puede comprender, por ejemplo, un PEF o un campo eléctrico término no pulsado, tal como un campo RF térmico.
Haciendo referencia ahora a la figura 23 se describe una variación de un catéter de PEF configurado para el paso de un(os) electrodo(s) al menos parcialmente a través de la pared del vaso. Por ejemplo, el/los electrodo(s) puede(n) colocarse dentro de la vena renal y después hacerse pasar a través de la pared de la vena renal de manera que se dispongan en la fascia de Gerota o renal y cerca o al menos parcialmente alrededor de la arteria renal. De esta manera, el/los electrodo(s) puede(n) colocarse en estrecha proximidad con las fibras del nervio renal diana antes del suministro de un campo eléctrico pulsado.
Como se observa en la figura 23A, el aparato 320 comprende un catéter 322 que tiene orificios de aguja 324 y un elemento de centrado 326, de manera ilustrativa un balón inflable. El catéter 322 también puede comprender opcionalmente marcadores radiopacos 328. Los orificios de aguja 324 están configurados para el paso de agujas 330 a través de los mismos, mientras que las agujas 330 están configuradas para el paso de electrodos 340.
La vena renal RV discurre en paralelo a la arteria renal RA. Puede usarse una modalidad de obtención de imágenes, tal como ecografía intravascular, para identificar la posición de la arteria renal con respecto a la vena renal. Por ejemplo, pueden integrarse opcionalmente elementos de ecografía intravascular en el catéter 322. El catéter 322 puede colocarse dentro de la vena renal RV usando técnicas percutáneas muy conocidas y el elemento de centrado 326 puede expandirse para estabilizar el catéter dentro de la vena. Entonces pueden hacerse pasar las agujas 330 a través del catéter 322 y salir por los orificios de aguja 324 de una manera según la cual las agujas penetran en la pared de la vena renal y entran en la fascia de Gerota o renal F. Pueden visualizarse los marcadores radiopacos 328 con fluoroscopía para orientar apropiadamente los orificios de aguja 324 antes de desplegar las agujas 330.
Los electrodos 340 se despliegan a través de las agujas 330 hasta rodear al menos parcialmente la arteria renal RA, como en las figuras 23A y 23B. Haciendo avanzar adicionalmente los electrodos, puede rodearse adicionalmente la arteria, como en la figura 23C. Con los electrodos desplegados, pueden aplicarse estimulación y/o formas de onda de electroporación por PEF para desnervar o modular los nervios renales. Opcionalmente las agujas 330 pueden retraerse parcial o completamente antes del tratamiento de manera que los electrodos 340 rodean una mayor parte de la arteria renal. Adicionalmente, puede proporcionarse y/o accionarse un único electrodo 340 para proporcionar un PEF monopolar.
El infundido puede infundirse opcionalmente desde las agujas 330 al interior de la fascia F para facilitar la colocación de los electrodos 340 creando un espacio para la colocación de los electrodos. El infundido puede comprender, por ejemplo, fluidos, fluidos calientes o fríos, aire, CO2, solución salina, agentes de contraste, geles, fluidos conductores
o cualquier otro material que ocupe espacio, ya sea gas, sólido o líquido. También puede inyectarse solución salina heparinizada. La solución salina o la solución salina hipertónica pueden mejorar la conductividad entre electrodos
340. Además o alternativamente, pueden infundirse o colocarse fármacos y/o elementos de administración de fármacos al interior de la fascia a través de las agujas.
Tras el tratamiento, los electrodos 340 pueden retraerse dentro de las agujas 330, y las agujas 330 pueden retraerse dentro del catéter 322 a través de los orificios de aguja 324. Las agujas 330 preferiblemente son lo suficientemente pequeñas como para producir un sangrado mínimo y conseguir hemostasia bastante rápido. Opcionalmente el elemento de centrado de balón 326 puede permanecer inflado durante algún tiempo tras la retirada de las agujas 330 con el fin de bloquear el flujo sanguíneo y facilitar el proceso de coagulación. Alternativamente, puede hacerse avanzar un catéter de balón al interior de la vena renal e inflarse tras la retirada del aparato 320.
Haciendo referencia a la figura 24 se describen variaciones de la invención que comprenden detectores u otros elementos para medir o monitorizar la eficacia del tratamiento. Variaciones de la invención pueden estar configuradas para suministrar campos eléctricos de estimulación, además de los PEF de desnervación o modulación. Estos campos de estimulación pueden utilizarse para colocar apropiadamente el aparato para el tratamiento y/o para monitorizar la eficacia del tratamiento al modular la actividad neural. Esto puede conseguirse monitorizando las respuestas de parámetros fisiológicos que se sabe que se ven afectados por la estimulación de los nervios renales. Tales parámetros comprenden, por ejemplo, niveles de renina, niveles de sodio, flujo sanguíneo renal y tensión arterial. También puede usarse estimulación para comprobar la desnervación para monitorizar la eficacia del tratamiento: tras la desnervación de los nervios renales, las respuestas fisiológicas conocidas a la estimulación ya no deben producirse en respuesta a tal estimulación.
Las formas de onda de estimulación de los nervios eferentes pueden comprender, por ejemplo, frecuencias de
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aproximadamente 1-10 Hz, mientras que las formas de onda de estimulación de los nervios aferentes pueden comprender, por ejemplo, frecuencias de hasta aproximadamente 50 Hz. Las amplitudes de forma de onda pueden oscilar, por ejemplo, hasta aproximadamente 50 V, mientras que las duraciones de pulso pueden oscilar, por ejemplo, hasta aproximadamente 20 milisegundos. Cuando las formas de onda de estimulación de los nervios se suministran por vía intravascular, como en varias realizaciones de la presente invención, parámetros de campo tales como frecuencia, amplitud y duración de pulso pueden modularse para facilitar el paso de las formas de onda por la pared del vaso para el suministro a los nervios diana. Además, aunque se han descrito parámetros a modo de ejemplo de formas de onda de estimulación, debe entenderse que puede utilizarse cualquier parámetro alternativo según se desee.
Los electrodos usados para suministrar PEF en cualquiera de las variaciones de la presente invención descritas anteriormente también pueden usarse para suministrar formas de onda de estimulación a la vasculatura renal. Alternativamente, las variaciones pueden comprender electrodos independientes configurados para la estimulación. Como otra alternativa, puede proporcionarse un aparato de estimulación independiente.
Una forma de usar la estimulación para identificar nervios renales es estimular los nervios de manera que el flujo sanguíneo renal se vea afectado, o se hubiese visto afecto si no se hubieran desnervado modulado los nervios renales. La estimulación actúa reduciendo el flujo sanguíneo renal, y esta respuesta puede atenuarse o anularse con la desnervación. Por tanto, se espera que la estimulación antes de la modulación neural reduzca el flujo sanguíneo, mientras que no se espera que la estimulación después de la modulación neural reduzca el flujo sanguíneo en la misma medida utilizando parámetros y ubicación/ubicaciones de estimulación similares a los de antes de la modulación neural. Este fenómeno puede utilizarse para cuantificar la magnitud de la neuromodulación renal. Variaciones de la presente invención pueden comprender elementos para monitorizar el flujo sanguíneo renal o para monitorizar cualquiera de los demás parámetros fisiológicos que se sabe que se ven afectados por la estimulación renal.
En la figura 24A se describe una variación del aparato 280 de la figura 16 que tiene un elemento para monitorizar el flujo sanguíneo renal. Se ha hecho avanzar un hilo guía 350 que tiene un sensor de ecografía Doppler 352 por la luz del catéter 282 para monitorizar el flujo sanguíneo dentro de la arteria renal RA. El sensor de ecografía Doppler 352 está configurado para medir la velocidad de flujo a través de la arteria. Entonces puede calcularse un caudal según la fórmula:
Q = VA (1)
en la que Q es igual al caudal, V es igual a la velocidad de flujo y A es igual al área de sección transversal. Puede determinarse un valor de referencia del flujo sanguíneo renal mediante mediciones del sensor 352 antes de suministrar una forma de onda de estimulación, después puede suministrarse la estimulación entre electrodos 286, preferiblemente con el balón 284 desinflado. La alteración, o no, del flujo sanguíneo renal con respecto al valor de referencia puede monitorizarse con el sensor 352 para identificar ubicaciones óptimas para la neuromodulación y/o desnervación de los nervios renales.
La figura 24B ilustra una variación del aparato de la figura 24A, en la que el sensor de ecografía Doppler 352 está acoplado al cuerpo del catéter 282. El sensor 352 está dispuesto de manera ilustrativa de manera proximal al balón 284, pero debe entenderse que el sensor puede disponerse alternativamente de manera distal al balón.
Además o como alternativa a la monitorización intravascular del flujo sanguíneo renal mediante ecografía Doppler, tal monitorización puede realizarse opcionalmente desde fuera del paciente, según lo cual el flujo sanguíneo renal se visualiza a través de la piel (por ejemplo, usando un transductor de ecografía). En otra variación, pueden usarse uno
o más transductores de presión intravascular para detectar cambios locales en la presión que pueden ser indicativos del flujo sanguíneo renal. Como aún otra alternativa, puede determinarse la velocidad de la sangre, por ejemplo, mediante termodilución midiendo el lapso de tiempo que tarda una entrada de temperatura intravascular en viajar entre puntos con una distancia de separación conocida.
Por ejemplo, puede incorporarse un termopar en, o preverse en las proximidades de, cada electrodo 286, y puede infundirse solución salina o fluido frío (es decir, a una temperatura inferior a la del organismo) de manera proximal al/a los termopar(es). Puede usarse el lapso de tiempo que tarda en registrarse el descenso de temperatura entre el/los termopar(es) para cuantificar característica(s) de flujo. Puede determinarse una estimación de valor de referencia de la(s) característica(s) de flujo de interés antes de la estimulación de los nervios renales y puede compararse con una segunda estimación de la(s) característica(s) determinada(s) tras la estimulación.
Pueden utilizarse opcionalmente dispositivos comercialmente disponibles para monitorizar el tratamiento. Tales dispositivos incluyen, por ejemplo, los dispositivos SmartWire™, FloWire™ y WaveWire™ disponibles de Volcano™ Therapeutics Inc., de Rancho Cordova, CA, así como el dispositivo PressureWire® disponible de RADI Medical Systems AB de Uppsala, Suecia. Resultarán evidentes dispositivos comercialmente disponibles adicionales. Adicional o alternativamente puede monitorizarse la magnitud de la electroporación usando directamente tomografía de impedancia eléctrica (“EIT”) u otras mediciones de impedancia eléctrica, tales como un índice de impedancia eléctrica.
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| US11/129,765 US7653438B2 (en) | 2002-04-08 | 2005-05-13 | Methods and apparatus for renal neuromodulation |
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| ES16183801T Expired - Lifetime ES2743974T3 (es) | 2004-10-05 | 2005-10-05 | Aparato para neuromodulación renal |
| ES16184488T Expired - Lifetime ES2740836T3 (es) | 2004-10-05 | 2005-10-05 | Aparato para neuromodulación renal |
| ES16160715.5T Expired - Lifetime ES2691040T3 (es) | 2004-10-05 | 2005-10-05 | Aparato para neuromodulación renal |
| ES12180432.2T Expired - Lifetime ES2534535T3 (es) | 2004-10-05 | 2005-10-05 | Aparato para neuromodulación renal |
| ES12180428.0T Expired - Lifetime ES2684499T3 (es) | 2004-10-05 | 2005-10-05 | Uso de un catéter para la neuromodulación renal |
| ES11192514.5T Expired - Lifetime ES2532077T3 (es) | 2004-10-05 | 2005-10-05 | Aparato para la neuromodulación renal |
| ES12180426.4T Expired - Lifetime ES2531888T3 (es) | 2004-10-05 | 2005-10-05 | Aparato para neuromodulación renal |
| ES12180427.2T Expired - Lifetime ES2538708T3 (es) | 2004-10-05 | 2005-10-05 | Aparato para neuromodulación renal |
| ES12180430T Expired - Lifetime ES2570927T3 (es) | 2004-10-05 | 2005-10-05 | Aparato para neuromodulación renal |
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| ES12180431.4T Expired - Lifetime ES2494119T3 (es) | 2004-10-05 | 2005-10-05 | Aparato para neuromodulación renal |
| ES16183801T Expired - Lifetime ES2743974T3 (es) | 2004-10-05 | 2005-10-05 | Aparato para neuromodulación renal |
| ES16184488T Expired - Lifetime ES2740836T3 (es) | 2004-10-05 | 2005-10-05 | Aparato para neuromodulación renal |
| ES16160715.5T Expired - Lifetime ES2691040T3 (es) | 2004-10-05 | 2005-10-05 | Aparato para neuromodulación renal |
| ES12180432.2T Expired - Lifetime ES2534535T3 (es) | 2004-10-05 | 2005-10-05 | Aparato para neuromodulación renal |
| ES12180428.0T Expired - Lifetime ES2684499T3 (es) | 2004-10-05 | 2005-10-05 | Uso de un catéter para la neuromodulación renal |
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| Application Number | Title | Priority Date | Filing Date |
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| ES12180426.4T Expired - Lifetime ES2531888T3 (es) | 2004-10-05 | 2005-10-05 | Aparato para neuromodulación renal |
| ES12180427.2T Expired - Lifetime ES2538708T3 (es) | 2004-10-05 | 2005-10-05 | Aparato para neuromodulación renal |
| ES12180430T Expired - Lifetime ES2570927T3 (es) | 2004-10-05 | 2005-10-05 | Aparato para neuromodulación renal |
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| EP (18) | EP2457614B1 (es) |
| JP (7) | JP5646135B2 (es) |
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| DE (9) | DE202005022059U1 (es) |
| ES (10) | ES2494119T3 (es) |
| MX (1) | MX2007004238A (es) |
| PL (1) | PL2561905T3 (es) |
| WO (1) | WO2006041881A2 (es) |
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2012
- 2012-02-01 JP JP2012020266A patent/JP2012110738A/ja not_active Withdrawn
- 2012-03-02 JP JP2012047200A patent/JP2012135630A/ja not_active Withdrawn
- 2012-03-02 JP JP2012047201A patent/JP2012143573A/ja not_active Withdrawn
- 2012-03-02 JP JP2012047199A patent/JP2012106081A/ja not_active Withdrawn
- 2012-03-02 JP JP2012047198A patent/JP2012110748A/ja not_active Withdrawn
- 2012-09-14 US US13/619,950 patent/US20130116685A1/en not_active Abandoned
- 2012-09-14 US US13/619,851 patent/US8548600B2/en not_active Expired - Fee Related
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2013
- 2013-06-28 US US13/930,863 patent/US8852163B2/en not_active Expired - Lifetime
- 2013-10-17 US US14/056,888 patent/US9125661B2/en not_active Expired - Lifetime
- 2013-10-17 US US14/056,885 patent/US20140058377A1/en not_active Abandoned
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2014
- 2014-04-22 US US14/258,802 patent/US8934978B2/en not_active Expired - Lifetime
- 2014-08-22 JP JP2014169723A patent/JP5952356B2/ja not_active Expired - Lifetime
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2015
- 2015-03-03 US US14/636,317 patent/US9289255B2/en not_active Expired - Fee Related
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2016
- 2016-02-09 US US15/019,793 patent/US9675413B2/en not_active Expired - Fee Related
- 2016-04-28 US US15/141,764 patent/US20160296279A1/en not_active Abandoned
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2017
- 2017-08-03 US US15/667,781 patent/US20170326363A1/en not_active Abandoned
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2018
- 2018-04-06 US US15/946,919 patent/US10245429B2/en not_active Expired - Lifetime
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2019
- 2019-02-08 US US16/271,728 patent/US11033328B2/en not_active Expired - Fee Related
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2021
- 2021-06-14 US US17/347,179 patent/US11963714B2/en not_active Expired - Lifetime
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