JP2001502588A - Medical implantation methods and devices - Google Patents

Abstract

(57) Abstract: A method and apparatus for delivering and installing a new length of tubing between two parts of an existing body organ tube of a patient and at least partially outside the existing structure. For example, this new length of tubing may be for the purpose of providing a patient with coronary artery bypass. The new tube can be an artificial graft, a natural graft (collected from somewhere in the patient's body), or both. The new tubing is primarily delivered and installed at its operating site by exerting the patient's existing tubing organ structure. This eliminates the need to perform any major surgery on the patient.

Description

DETAILED DESCRIPTION OF THE INVENTION Title of invention Medical implantation methods and devices Field of the invention The present invention relates to medical implantation methods and devices, and more particularly, to methods and devices for placing a tubular bypass graft in a lumen. Background of the Invention US Patent Application No. 08 / 745,618 to Goldsteen et al., Filed November 7, 1996, shows, among other things, a method and apparatus for placing a tubular bypass graft in a lumen. (The contents of the Goldsteen et al. References are incorporated herein by reference in their entirety). The Goldsteen et al. Reference discloses that each end of the implantation site is separately accessed and penetrated into the lumen, and then, between the ends of the implantation site, a vertical structure (e.g., the Goldsteen et al. FIG. 6 shows a method and apparatus for establishing the element 150) of FIG. The vertical structure may extend into the lumen from both ends of the implantation site all the way to the patient's body. The implant is fed along the vertical structure into a lumen in the patient's body until it is in a desired position extending from one end of the implantation site to the other. Each end of the implant is then secured to a respective end of the implantation site, respectively, and the vertical structure is withdrawn from the patient. In some cases, separate access to both ends of the implantation site is not necessary or desirable. Accordingly, it is an object of the present invention to provide an improved method and apparatus for intraluminal placement of a bypass graft. It is a more specific object of the present invention to provide a method and apparatus for placing a bypass graft in a lumen that does not require that both ends of the implantation site have separate access to the lumen. Summary of the Invention These and other objects of the present invention are achieved in accordance with the principles of the present invention by providing a method and apparatus by which a vertical structure can extend within a lumen to one end of an implantation site. At that end of the implantation site, the vertical structure extends extraluminally through the lumen of the anatomy and to the other end of the implantation site. At the other end of the implantation site, the vertical structure re-enters the body structure lumen. The implant is introduced intraluminally along the vertical structure until it extends through the anatomy lumen at the first end of the implantation site and to the second end of the implantation site. Is done. Both ends of the implant are then secured to opposing ends of the implantation site, and the vertical structure is withdrawn axially from the patient. Still other features of the invention, its nature and various advantages, will be apparent from the accompanying drawings and the following detailed description of the preferred embodiments. BRIEF DESCRIPTION OF THE FIGURES FIG. 1 is a schematic sectional view showing a schematic procedure of the present invention and a part of a related apparatus. FIG. 2 is a simplified longitudinal sectional view of a more detailed schematic embodiment of a portion of the apparatus of FIG. FIG. 3 is a simplified elevational view of a portion of the apparatus of FIG. 2, but the depicted elements are in different physical relationships from each other. FIG. 4 is a simplified longitudinal sectional view of another embodiment of one part of the device of FIG. FIG. 5 is a simplified longitudinal sectional view of another embodiment of another component of the device of FIG. FIG. 6 is a simplified elevation view of another alternative embodiment of the component shown in FIG. FIG. 7 is a simplified elevation view of another embodiment of yet another component shown in FIG. FIG. 8 is a simplified elevational view of another embodiment of the still other components shown in FIG. FIG. 9 is a simplified longitudinal sectional view similar to a part of FIG. 1, showing a stage after the schematic procedure partially depicted in FIG. FIG. 10 is a simplified cross-sectional view of the device shown in FIG. 9 without the associated tissue structure. FIG. 11 is a simplified cross-sectional view of a schematic embodiment of yet another schematic device according to the present invention. FIG. 12 is a view similar to FIG. 1, but with associated equipment, showing a later stage of the schematic procedure partially depicted in FIG. 9, all in accordance with the present invention. FIG. 13 is a view similar to FIG. 12, showing a later stage of the schematic procedure partially depicted in FIG. FIG. 13a is a simplified elevational view of a schematic embodiment of structural details that may be included in a device of the type shown in FIGS. FIG. 14 is a view similar to FIG. 13, but showing a later stage of the schematic operation partially depicted in FIG. FIG. 15 is a simplified longitudinal sectional view of a part of a schematic embodiment of yet another schematic procedure according to the present invention. FIG. 15a is a simplified elevational view of a structure that can be used to provide a portion of the device shown in FIG. FIG. 15b is a view similar to FIG. 15a, where FIG. 15a shows a further part of the structure of which it is a part. FIG. 15c is a view similar to FIG. 15b, showing the structure of FIG. 15b under other operating conditions. FIG. 15d is a simplified elevational view of another structure that can be used to provide a portion of the device shown in FIG. FIG. 15e is a view similar to FIG. 15d, showing the structure of FIG. 15d under other operating conditions. FIG. 15f is a simplified longitudinal sectional view of another alternative structure that may be used to provide a portion of the device shown in FIG. FIG. 15g is a view similar to FIG. 15f, showing the structure of FIG. 15f under other operating conditions. FIG. 16 is a simplified elevational view of a schematic embodiment of one part of the apparatus of FIG. FIG. 17 is a simplified longitudinal sectional view of a schematic embodiment of another part of the device of FIG. FIG. 18 is a view similar to the part of FIG. 14 and shows a later stage of the schematic procedure partially depicted in FIG. FIG. 19 is similar to FIG. 18 and shows a stage after the procedure in FIG. FIG. 20 is a view similar to a part of FIG. 19, and shows a stage after the procedure in FIG. FIG. 21 is a view similar to the other parts of FIG. 14, and shows a stage after the procedure of FIG. FIG. 22 is a view similar to FIG. 21 and shows a stage after the procedure in FIG. FIG. 22a is a view similar to FIG. 22, but showing a later stage of the procedure of FIG. FIG. 22b is a view similar to FIG. 22a, but showing a later stage of the procedure of FIG. 22a. FIG. 23 is a view similar to FIG. 22b, but showing a further stage in the procedure of FIG. 22b. FIG. 24 is a view similar to FIG. 23, and shows a stage after the procedure of FIG. FIG. 25 is a simplified longitudinal sectional view of a schematic embodiment of a part of yet another device according to the present invention. FIG. 26 is a view similar to FIG. 20, but showing a stage after the procedure of FIG. FIG. 27 is a view similar to FIG. 26 and shows a stage after the procedure in FIG. FIG. 28 is a view similar to FIG. 24, and shows a stage after the procedure of FIG. 27. FIG. 29 is a view similar to FIG. 28, and shows a stage after the procedure of FIG. 28. FIG. 30 is a view similar to FIG. 29 and shows a stage after the procedure of FIG. 29. FIG. 31 is a view similar to FIG. 14, showing the end result of the procedure partially depicted in FIG. FIG. 32 is a simplified longitudinal sectional view similar to the end result of FIG. 31, but shown in a different situation. FIG. 33 is a simplified longitudinal sectional view showing another possible configuration of a part of the device shown in FIG. FIG. 34 is a simplified elevation (partial, cross-sectional) showing another possible alternative configuration of a portion of the apparatus of FIG. FIG. 35 is a simplified longitudinal sectional view of the device of FIG. 34 in another operating situation. FIG. 36 is a simplified elevational view of a device that may be used as a replacement for the specific device components shown in FIGS. FIG. 37 is a simplified elevational view (partially in cross section) showing the additional part of the device of FIG. FIG. 38 is a simplified longitudinal sectional view showing yet another possible alternative configuration of a part of the device of FIG. FIG. 39 is a simplified longitudinal sectional view detailing yet another possible configuration of a portion of the device of FIG. 38. FIG. 40 is a simplified elevational view of a schematic device that may be used as a substitute for the specific device shown in the other figures. Detailed Description of the Preferred Embodiment A typical application of the present invention is to provide a bypass graft around a coronary artery constriction. Thus, FIG. 1 shows a patient's aorta 30, from which the coronary artery 20 branches. The constriction 22 of the coronary artery 20 blocks blood flow from the aorta 30 to the downstream portion of the coronary artery, thereby preventing the patient's heart from receiving whole blood needed for normal operation . To treat this condition, a bypass graft near the constriction 22 is needed, and one way to provide such a bypass is from the aorta 30 (eg, at location 34) to the downstream portion of the coronary artery 20. (E.g., location 24). To provide such an implanted conduit according to the present invention, the device 200 is preferably introduced into the patient's circulatory system from a location remote from the aorta 30. For example, device 200 may be introduced into the patient's circulatory system from the femoral artery, the brachial artery or any other suitable location. From that point of insertion, the device 200 passes through the lumen along the patient's circulatory system until the distal portion 204 of the device 200 is adjacent one end (eg, 34) of the desired implantation location. The undepicted proximity of the device should always be introduced to the physician (this term includes any technician or other assistant) so that the device can be controlled from outside the patient's body. Outside the patient adjacent to the point. In particular, the illustrated distal portion of instrument 200 is remotely controlled by a physician from outside the patient. Device 200 may be provided with a radioactive marker, such as 206, to assist a physician in properly positioning the device on a patient. It should be understood that the particular location 34 shown in FIG. 1 for one end of this bypass graft is merely exemplary, and that any other suitable location may be selected instead. The schematic configuration of the device 200 is shown in detail in FIG. This drawing shows the distal portions of the elements 220, 230, 240 and 250, which have been sequentially fitted from one another and from the distal end of the outer member 210 for further clarity. However, it can be seen that all of these elements are initially inside each other and the outer member 210. In fact, the member 210 may be initially placed on the patient without having any or all of the elements 220, 230, 240 and 250 inside, and these elements may then be inserted into the element 210. Further, the number of components, such as 220, 230, may be greater or less than the number shown in FIG. 2, depending on the particular procedural requirements. Outer member 210 can be a catheter-type member. The distal portion of catheter 210 may include two axially spaced annular balloons 212 and 214. Proximity balloon 212 is inflatable and deflateable via inflation lumen 216 in catheter 210. The distal balloon 214 can be inflated and deflated via an inflation lumen 218 in the catheter 210. Lumens 216 and 218 are separated from each other so that balloons 212 and 214 can be controlled separately. The balloons 212 and 214 are shown in FIG. 2 in a substantially deflated state. The distal end of the catheter 210 may be tapered, as shown at 211 in FIG. 4, to facilitate passage of the catheter 210 through the opening of the aorta 30, as described below. Inside the catheter 210 is coaxially a tubular sheath member 220. The sheath 220 is movable longitudinally with respect to the catheter 210. The distal portion of the sheath 220 may be tapered, as shown at 222 in FIG. 5, and / or may be threaded on its outer surface, as shown at 224 in FIG. Either or both of features 222 and 224 may be provided to facilitate passage of sheath 220 through the opening of aorta 30, as described below. If provided with a thread 224, the sheath 220 may be used (alone or otherwise) to allow the thread 224 to connect with the tissue of the aortic wall and to help withdraw the sheath 220 through the aortic wall. ), And can be rotated about the longitudinal axis of the instrument 200. Inside the sheath member 220 is coaxial with a power steering tube 230. Tube 230 is vertically movable with respect to sheath 220. Tube 230 may also be rotatable with respect to sheath 220 (around the central longitudinal axis of device 200), and the distal end of tube 230 may be threaded into sheath 220 for the same reason. , (As shown at 232 in FIG. 7) may be threaded outside. Tube 230 is preferably controllable from its proximal portion (outside the patient) to guide instrument 200 to the desired location on the patient and to deflect laterally in the desired amount to assist in pushing or twisting It is. Examples of schematic steering techniques are described in further detail below in connection with FIGS. Inside the tube 230, coaxial there is a tube 240. Tube 240 is vertically movable with respect to tube 230 and may be, for example, a metal (eg, stainless steel) hypotube. At the distal end of tube 240 is attached a screw head 242, the distal conical surface of which is threaded (as shown at 244). The tube 240 is used to rotate the head 242 and use the thread 244 in connection with the tissue of the aortic wall, as described more fully below, to help pull the head 242 through the wall. It is rotatable (around the central longitudinal axis of the instrument 200, alone or with other elements). Because the tube 240 is hollow, it can be used to pass liquid or pressure into or out of the patient. Inside the tube 240 is coaxial with a vertical structure 250. The vertical structure 250 is vertically movable with respect to the tube 240. Structure 250 may also be rotatable (about its longitudinal axis) with respect to tube 240 and / or other elements. Structure 250 may be a wire having a distal end portion 252 that is resiliently bent and laterally bowed to one side. The wire section 252 remains relatively straight when it is inside the tube 240 as shown in FIG. However, when the wire portion 252 is pushed axially out of the distal end of the tube 240, it bends laterally, as shown in FIG. Instead of, or in addition to, the resilient lateral deflection, the distal portion of the structure 250 may be threaded as shown at 254 in FIG. 8 to help it penetrate the wall of the aorta 30. . All of the parts 210, 220, 230, 240 and 250 are controlled from outside the patient's body, as described generally above. When the distal portion of the catheter 210 is at the desired location 34, the proximity balloon 212 is inflated. Even when inflated, the proximity balloon 212 is not large enough to occlude the aorta 30. After inflating the proximal balloon 212, the wire 250 is urged distally so that its distal portion emerges from the distal end of the tube 240 and penetrates the wall of the aorta 30 at location. This anchors the distal portion of the instrument 200 at the desired location to the aortic wall. Due to the operation of anchoring the instrument 200 in this manner, the wire 250 is sometimes referred to as an anchoring wire. The rotational ability of the wire 250, as well as its resilient lateral deflection (FIG. 3) and / or thread 254 (FIG. 8), may be used to achieve the desired anchoring of the instrument 200 at the distal end of the wire. Has reached the desired location 34 and can be used there to help ensure penetration into the aortic wall. When the instrument 200 is fully anchored by the wire 250, the tubes 230 and 240 are moved distally relative to the wire 250 such that the screw head 242 begins following the aortic wall following the wire 250. . During this movement, at least the tube 240 rotates about its longitudinal axis to help the thread 244 pull the head 242 into and through the aortic wall. The distal portion of tube 230 follows head 242 and proceeds into the aortic wall. The rotation of thread 232 (if attached) and tube 230 may facilitate movement of the aortic wall tissue from head 242 to tube 230 relative to the tissue. As tube 230 passes through the aortic wall, sheath 220 moves distally with respect to tube 230 such that the distal portion of sheath 220 follows tube 230 and continues through the aortic wall. Rotation of the distal taper 222 and / or the thread 224 (if present) and the sheath 220 helps the distal portion of the sheath 220 pass through this aortic wall. The catheter 210 is then advanced distally to the sheath 220 such that the distal portion of the catheter 210 follows the sheath 220 and follows this aortic wall. As above, the distal taper 211 (if any) of the catheter 210 helps the distal portion of the catheter pass through the aortic wall. The inflated proximal balloon 212 prevents portions of the catheter 210 other than the portion distal to the balloon 212 from passing through the aortic wall. At each point in time, the other larger portion of the elements 240, 230, 220 and 210 is pressed against this aortic wall, and the previously elongated elements are held fixed or they are fixed outside the aorta. It should be noted that it can be, or is preferably, pushed back proximally so as not to damage body tissue. Also, threading such as 254, 244, 232 and 224 is entirely optional, and if the element to which it is attached is formed sufficiently sharp, and without the aid of threading or rotation, this aortic wall It should also be noted that this can be omitted if it can be pushed distally strong enough to penetrate the. As the distal portion of the catheter 210 passes through the aortic wall, the distal balloon 214, which is now outside the aorta, is also inflated. The axial spacing between balloons 212 and 214 is preferably small enough that the aortic wall is clamped between the two balloons, as shown in FIG. For example, if balloons 212 and 214 were inflated without the presence of this aortic wall, their appearance could be as shown in FIG. The close spacing of the balloons 212 and 214, as well as their resilient bends toward each other, helps the catheter 210 to be anchored to the aortic wall and also allows the Help to seal to. Balloons 212 and 214 can be inflated with a liquid or gas, which may be specially coated to help improve the seal between catheter 210 and the aortic wall. After reaching the condition of the catheter 210 shown in FIG. 9, all of the components 220, 230, 240 and 250 can be withdrawn from the patient by pulling them from the catheter 210 in the proximal direction. The next step in the described schematic procedure is to vertically insert the elongated steerable endoscopic device 300 into the catheter 210. A simplified cross-sectional view of a schematic steerable endoscopic instrument 300 is shown in FIG. As shown in the drawing, the device 300 includes one or more sheath structures (e.g., 310a and 310b), which can be curved laterally in a desired variable amount by It can be operated by a doctor operating this device. Instead of or in addition to the steering sheaths 310a and 310b, any other convenient steering element may be provided and used. Other examples of suitable steering structures are shown in U.S. Patent Application No. 08 / 842,391 to Bachinski et al., Filed April 23, 1997, the contents of which are incorporated herein by reference. Have been. Inside the sheath 310, (1) a fiber optic bundle 320 for carrying light from outside the patient to the distal end of the device 300 to illuminate the distal end of the device, (2) the device For transporting images from the far end of the device to an optical and / or video device outside the patient (this can be used by a physician to know what is beyond the far end of the device) There are other components, such as a fiber optic bundle 330, and (3) a lumen 340 with a vertical structure 150 (ie, wire) inside it. (1) introducing a liquid that can help clarify the distal ends of the fiber optic bundles 320 and 330; (2) introducing a liquid to irrigate and / or dispense the patient; (3) liquid from the patient. A lumen such as 360 may be further provided for purposes such as aspirating the blood. As shown in FIG. 12, the distal portion of the steerable endoscopic instrument 300 is extended distally beyond the distal end of the catheter 210 until it is adjacent the exterior of the coronary artery portion 24. Steered by. The endoscopic features of the instrument 300 are used to assist a physician in manipulating the distal end of the instrument to a desired location. The device 300 may also include a radioactive marker (similar to the marker 206 on the device 200 of FIG. 1) to further assist the physician in reaching the desired position of the distal end of the device 300. The next step in the schematic procedure described is to extend the vertical structure 150 from the distal end of the instrument 300 as shown in FIG. Is to enter the lumen. To facilitate this penetration of the coronary artery wall, the distal end of the vertical structure 150 may be sharpened. The distal end of the vertical structure 150 may also be threaded (similar to the thread 254 shown at the distal portion of the vertical structure 250 in FIG. 8), and the vertical structure 150 These threads may rotate about their longitudinal axis so as to engage the tissue of the coronary artery wall and draw the vertical structure 150 through and through the coronary artery wall. The distal portion of the vertical structure 150 is preferably pushed down far enough into the lumen of the coronary artery 20 so that it does not accidentally exit this coronary artery. FIG. 13a shows another device that may be used to introduce the distal portion of the vertical structure 150 at position 24 into the coronary artery 20. FIG. The device includes a hypotube 370 extending distally from the distal end of the instrument 300. The hypotube 370 may be extendable from the device 300 in a fixed amount, or may be selectively extendable from the device 300. The hypotube 370 has a sharpened distal tip portion 372, the purpose of which is described below. The typical size of the hypotube is about 0 in diameter. 015 inches. The vertical structure 150 is disposed coaxially inside the hypotube 370 and is movable with respect to the hypotube 370 so as to be axially rotatable. The proximity portion 150a of the structure 150 is approximately 0. It may be a wire having a diameter of 009 inches. The distal portion 150b of the wire 150a To create a safety ribbon inside the wire coil 150c, It may be polished. The schematic size of the coil 150c wire is About 2 mils. The proximal end of the coil wire 150c is It is fixed to the wire 150a. The distal end of the coil wire 150c is Fixed to the distal tip 150d, This is also Secured to the distal end of safety ribbon 150b. Element 150b, 150c and 150d are Working together, For the vertical structure 150, Provides a very flexible distal portion. Before using the sharpened cutter tip 372 described below, The distal portion of the vertical structure 150 The hypotube 370 may extend distally from a distal portion. This allows The cutter tip 372 is protected, Also, Adjacent tissue is protected from the cutter tip. The appliance 300 To place the cutter tip 372 adjacent to the coronary artery portion 24, It is controlled as described above with reference to FIG. Then The vertical structure 150 is retracted close, The cutter tip 372 is exposed. next, The cutter tip 372 Like making a slit in the coronary artery part 24, Be advanced. While still placing the cutter tip 372 in this slit, The vertical structure 150 So that the distal portion of the structure 150 enters the lumen of the coronary artery 20 through the slit Moved distally with respect to hypotube 370. Once Once inside the coronary lumen, The distal portion of the vertical structure 150 Along its lumen, It can be pushed further down. Wire coil 150c To help releasably anchor the distal portion of structure 150 to this coronary artery, If this coronary artery narrows further along its length, It can be used to screw into the interior of the coronary artery. This screw connection As one begins to encounter resistance to pushing the vertical structure further distally along the coronary artery, By rotating the vertical structure 150 around its vertical axis, Can be provided. of course, This screw connection Vertical structure 150, By rotating in the direction opposite to the direction in which this screw connection occurred, You can go back. The distal portion of the vertical structure 150, As described above in connection with FIG. 13 and / or FIG. 13a, After successful placement in the appropriate location of the lumen of the coronary artery 20, The next stage is By retracting the device 300 from the catheter 210, Appliance 300 (if any, (Including hypotube 370) from the patient. As shown in FIG. For patients, Only the vertical structure 150 from the instrument 300 remains. If desired, In the vertical structure 150, To help the physician measure the exact length between position 24 and position 34 by radiography, Radioactive markers 154 may be provided that are evenly spaced along the length of the distal portion. This allows The doctor The exact length of graft tubing required to connect locations 24 and 34 can be measured. The next step in the schematic procedure described is The installation of a new length of tubing between region 24 and region 34. This new length of tubing, Artificial grafts, Natural body organ tubing, collected from the patient's body, Or a combination of artificial and natural tubing (e.g., (Natural tubing coaxially present inside the artificial tubing). In the following discussion, The new tubing is Natural tubing inside an artificial conduit (e.g., It is assumed that the patient is a certain length of saphenous vein collected for this purpose. When using such a combination of natural and artificial conduits, Both conduits Can be supplied and installed at the same time, Or an external artificial conduit, First, Can be supplied and installed, Then An internal natural conduit can be supplied and installed. In the following discussion, At first, It is assumed that the latter method is used. According to the assumptions mentioned above, The next step in the above procedure is Catheter 210 and vertical structure 150 (hereinafter, referred to as For convenience and simplicity of terminology, (Called wire 150) That is to send it to extend between regions 24 and 34. The distal portion of the exemplary assembly 400 to do this is As shown in FIG. (Some other configurations of this part of this device are Shown in subsequent drawings, Described below). As shown in FIG. Assembly 400 Including a threaded conical distal tip 412, this is, A tubular member 410 through which the wire 150 can freely pass (e.g., Metal hypotube). A more detailed description of the various possible configurations of tip 412 can be found at: As will be mentioned later in connection with FIGS. 15a to 15g, here, In this embodiment, Tip 412 is To facilitate withdrawing it from the patient after serving its purpose, It should be noted that it can be selectively collapsed. Around the tubular member 410, Another tubular member 420 is coaxially arranged. The inflatable balloon 422 Attached to the distal end of tubular member 420. The tubular member 420 Includes an axially extending lumen (not shown in FIG. 15) for use in selectively inflating and deflating balloon 422. Balloon 422 In FIG. It is shown in an expanded state. Around the tubular member 420, Coaxial with it, There is an artificial implantation conduit 430. A schematic embodiment of a suitable conduit 430 is As shown in FIG. A first highly elastic material (e.g., (Nitinol) frame 432 this is, A second highly elastic material that substantially fills the opening in the frame (e.g., (A rubber-like material such as silicone). Additional information regarding this possible embodiment of the conduit 430 and other suitable prosthetic graft structures may be found at: Goldsteen et al.'S reference, first mentioned above (also Bachinski et al., U.S. Patent Application No. 08/839, filed April 23, 1997, No. 080 (The contents are also (Also incorporated herein by reference). here, This structure Extremely elastic, Flexible, It is sufficient to state that it is plastic and elastic. For example, that is, Can be stretched until its original diameter becomes a small part, afterwards, By itself, Without any kind of damage or permanent deformation, Return to original size and shape. further, This structure is So that it can beat very similar to the natural circulatory system tubes in response to the pressure waves of the bloodstream, It is inflatable. This means In particular, By itself, If used as a final graft conduit, Helps keep this conduit open. At its distal end, Extension of the frame 432 occurs to form a resilient hook or barb 436, The purpose is It will become apparent as this description proceeds. Near the proximal end of conduit 430, Two axially spaced elastic flaps 438a and 438b Provided with hooks or barbs 439. The purpose and operation of elements 438 and 439 are also It will become apparent as this description proceeds. Assembly 400 (see FIG. 15 again, Also, (See also Figure 17) Hook 436 and flap 438 Conduit delivery tube 440 (this is Radially inward against (concentrically surrounding conduit 430), It is confined in the conduit delivery pipe 440. In fact, Conduit 430 By tube 440, To some extent, It may be pressed from the outer periphery. The portion of the assembly 440 where the proximal end of the conduit 430 is located This is shown in FIG. In this drawing, Flap 438, It can be seen how it is trapped in the conduit delivery tube 440. FIG. 17 also shows To allow a physician to remotely control the distal portion of assembly 400 from outside the patient, Tube 410, 420 and 440 18 shows how it extends proximally from the proximal end of conduit 430 (to the right as viewed in FIG. 17). To place an artificial graft conduit 430 in a patient between regions 24 and 34, Assembly 400 Through catheter 210, Along wire 150, Supplied to the patient. When tip 412 reaches coronary artery segment 24, Tip 412 is Rotate tube 412, Thereby, by rotating the tip 412, The coronary artery is penetrated. As the tip 412 passes through this coronary artery wall, The opening previously formed by the wire 150 is opened in the wall. After the tip 412 has passed through this artery wall, The wall is As shown in FIG. To the outside of the distal portion of the conduit delivery tube 440, Naturally sealed. The next stage is Delivery tube 440 (this is (It is fixed) Pushing tube 410 and tip 412 distally. Conduit 430 Along with parts 410 and 412, First, it is moved distally. this is, Inflate the balloon 422 to engage the conduit 430, Then By moving tube 420 distally with parts 410 and 412, Can be done. Due to the distal movement of the conduit 430, Hook 436 moves beyond the distal end of delivery tube 440, Thereby, As shown in FIG. These hooks It is possible to bend inside the coronary artery 20. this is, The distal end of the conduit 430 is prevented from being pulled near this coronary artery. Balloon 422, If inflated during this stage of the procedure, that is, Before the next stage begins, It may shrink. The next stage is As the delivery tube 440 is withdrawn from the coronary artery 20, Pull it back slightly. Then Tube 420 As the balloon 422 exists radially inside the ring of the hook 436, Moved distally. Balloon 442 Then To ensure that hook 4 36 is firmly placed within coronary artery 20, Inflated. The current state, As shown in FIG. The cross section of the balloon 422 is When inflated, It may be L-shaped (one leg of this L is Extends parallel to the longitudinal axis of conduit 430, Also, The other leg Extending radially outward from the longitudinal axis just distal to hook 436). This means further, Hooks 436 may help ensure that the hooks 436 mesh well with the wall of the coronary artery 20. The next stage is The purpose is to deflate the balloon 422. Then The delivery pipe 440 is Until flap 438a (but not flap 438b) is distal to the distal end of this delivery tube Pulled closer. This allows Flap 438a As shown in FIG. It can warp radially. Then Tube 420 Until balloon 422 is just distal of flap 438a, Drawn out. Then Balloon 422 is inflated, The state shown in FIG. 21 is obtained. The next stage is (1) deflating the distal balloon 214, (2) pulling the catheter 210 slightly closer, (3) Pull out the tube 420 to the vicinity, Flap 438a, Pressing against the outer surface of this aortic wall, And (4) the amount required for the flap 438b to bow out of the catheter 210, Withdrawing the delivery tube 440 to the near side, They are, all, This is shown in FIG. As a result of the close withdrawal of tube 420, The hook or barb 439 on the flap 438a Is encouraged to enter the tissue of the aortic wall, Helps maintain the mesh between flap 438a and the wall of this aorta. The inflation balloon 422 When pulling the tube 420 close, Help place hooks or barbs 439 in this tissue. The next stage is As shown in FIG. 22a, Inserting the distal portion of delivery tube 440 into the proximal end of conduit 430. The distal end of conduit 440 is It may be inserted all the way to the proximal end of balloon 422 (for this depiction, See FIG. 23). The purpose of this stage is Subsequently, It is intended to help control the rate at which blood begins to flow through conduit 430. The next stage is As shown in FIG. The amount needed to release the flap 438b and warp into the wall of the aorta 30, Withdrawing the catheter 210 proximally. The catheter 210 is As shown in FIG. Pushed back against flap 438b, The flaps may help ensure that they engage the aortic wall. At the moment, Between the aortic region 34 and the coronary artery region 24, The artificial graft conduit 430 is fully established. Therefore, The next stage is Deflating balloon 422 and pulling tube 420 closer, Crushing the tip 412 and pulling out the tube 410, And withdraw the delivery tube 440 to the near side. The proximal end of conduit 430 is At the moment, This is shown in FIG. As a possible alternative to that shown in FIG. 24, The distal end of the catheter 210 Can be pressed against the proximity flap 438b, And / or the distal portion of the delivery tube 440 It may be left inside a proximal portion of the conduit 430. If you use the latter possibility, Delivery of the natural graft conduit (below) Can be made by tube 440. Several schematic embodiments of the collapsible tip 412 As shown in FIGS. In the first embodiment (shown in FIGS. The frame of Wire Stretch 412a is From the distal end of hypotube 410, Radially extending proximally (especially, See FIG. 15a). This frame Covered with a somewhat elastic polymer cover 412b (Figure 15b), This cover is It has a thread indicated by 412c. For example, The thread 412c is It may be formed from one or more spirals of Nichirol wire or other metal. When it is desirable to collapse tip 412, As shown in FIG. In order to flip the tip 412 and crush it, Another hypotube 410a (this is (Disposed around hypotube 410) is shifted distally with respect to hypotube 410. In another embodiment, shown in FIGS.15d and 15e, Tip 412 is It has a central main part 412e attached to the hypotube 410. Around the vicinity of the main part 412e, There are multiple triangle parts 412f, Each of them By hinge 412g, It is connected to the main part 412e. The outer surface of this tip As shown at 412h, Screws are cut. For example, In this embodiment, Tip 412 is It may be manufactured from a plastic polymer material, Also, The hinge 412g is There may be so-called "living" hinges between the various masses of the polymer. As you pull tip 412 closer, As soon as triangle 412f encounters some resistance, They are, Around those hinges 412g, Turn to the position shown in FIG. Thereby, The outer peripheral size of this tip is significantly reduced. In yet another embodiment, shown in FIGS.15f and 15g, Metal strut 412j, As they extend radially closer, Attached to the distal end of hypotube 410. Although not shown in FIGS. 15f and 15g, Stretch 412j, Covered with a cover, As shown in FIG. As mentioned above, It is threaded similarly to cover 412b and thread 412c. Wire 412k By the opening in the hypotube 410, The adjacent part of each strut 412j, Another hypotube 410b (this is (Located inside hypotube 410). Wire 412k When relaxed as shown in FIG. Stretch 412j, It extends radially beyond the outer circumference of the delivery pipe 440. When it is desirable to collapse tip 412, The hypotube 410b is As shown in FIG. The hypotube 410 is pulled back closer. This allows Wire 412k So that the outer circumference of the tip 412 is much smaller than the outer circumference of the delivery tube 440, Pull the tension 412j inward. again, The use of the threaded collapsible tip 412 described above simply, Please note that this is only one of several possibilities. Other alternatives are Schematic procedure (this is Described here, Also, Referring to FIG. 25 and subsequent drawings, As soon as the discussion of It is described below. As mentioned above, The schematic procedure described here is Natural body conduits (e.g., The saphenous vein of a fixed length patient collected for this purpose) Inside the artificial conduit 430, It is assumed to be installed after the installation of the latter conduit. A schematic assembly 500 for delivering a length of natural body conduit to the installation conduit 430, As shown in FIG. As shown in FIG. Assembly 500 So that the tube 510 is freely movable in either direction along the wire 150; Includes tube 510 disposed around wire 150. Tube 510 Having an inflatable annular balloon 512a near its distal end, And has another inflatable annular balloon 512b spaced proximally from balloon 512a. Tube 510 As these balloons can be inflated and deflated separately, For each balloon 512, Includes a separate inflation lumen (not shown). Around balloon 512a, An annular collar structure or ring 520a is concentrically arranged, Also, Around balloon 512b, A similar annular collar structure or ring 520b is arranged concentrically. Balloon 512 May partially expand. Each ring 520 It may have hooks or barbs 522 that extend radially outward. A natural body conduit 5 30 of fixed length (for example, The saphenous vein mentioned earlier) Around the intervening part of tube 510, It extends from ring 520a to ring 520b. Hook or barb 522 The conduit 530 may extend through a portion of the conduit 530 that overlaps the ring 520 in the axial direction. The delivery pipe 540 is Around the conduit 530. In use, Tubes 510 and 540 To allow a physician to remotely control the distal portion of assembly 500, It extends close to the patient (to the right as seen in FIG. 25). Although not shown in FIG. 25, Assembly 500 To help keep conduit 530 open relative to delivery tube 540 and subsequently to conduit 430, It may include a spring coil (similar to coil 450 in FIG. 36) extending between rings 520 inside conduit 530. Instead of placing both balloons 512 in the same tube 510, Balloon 512a Whereas it can be placed in a relatively small first tube, Balloon 512b A larger second tube (this is (Concentrically surrounding the adjacent portion of the first tube). The first and second tubes are Can move axially with respect to each other, Thereby, For grafts 530 of different lengths, The distance between the balloons 512 can be adjusted. A schematic device of this kind is Goldsteen et al., U.S. Patent Application No. 08/839, filed April 17, 1997, No. 298, The contents are It is incorporated herein by reference. Assembly 500 That, By placing on the wire 150 leading to the catheter 210, used. Assembly 500 Then Proceed distally along wire 150, Through catheter 210, Then Until the distal end of conduit 530 is adjacent the distal end of conduit 430 and the proximal end of conduit 530 is adjacent the proximal end of conduit 430 Enter conduit 430. The condition of this device at the distal end of assembly 500 is At the moment, As shown in FIG. The condition of this device at the proximal end of conduit 530 is As shown in FIG. The next stage is So that the distal portion of the conduit 530 and the distal slave ring 520a are no longer inside the distal portion of the delivery tube 540 This is to pull out the delivery tube 540 in the vicinity. Then Distal balloon 512a is inflated, Expand the ring 520a in the outer circumferential direction, The hook or barb 522 is then secured through the conduit 530 to the surrounding portion of the conduit 430 and the coronary artery wall portion 24. This allows The distal end of conduit 530 is completely anastomosed to coronary artery 20. FIG. Shows the state of the device at this stage of the procedure. The next stage is As the proximal end of the conduit 530 and the proximal ring 520b are no longer inside the tube 540, This is to continuously withdraw the delivery pipe 540 to the vicinity (see FIG. 29). Then Proximity balloon 512b is inflated, Expand the ring 520b in the outer circumferential direction, Thereby, A hook or barb 522 is secured through conduit 530 to the surrounding portion of conduit 430 and coronary artery wall portion 34 (see FIG. 30). This allows The proximal end of conduit 530 is completely anastomosed to aorta 30. The next stage is Deflate balloons 512a and 512b, Then, the tube 510 and the delivery tube 540 are pulled out from the patient via the catheter 210. Then Wire 1 50, By pulling proximally from the catheter 210, Withdraw from the patient. Finally, The catheter 210 is withdrawn proximally from the patient, This procedure ends. The remaining bypass in the patient As shown in FIG. This bypass is It extends from the aorta 30 at location 34 to the coronary artery 20 at location 24. This bypass is The artificial graft conduit 430 includes a natural body conduit 530 inside. One end of this bypass is With hook 436 and ring 520a It is anchored to the coronary artery 20 and is anastomotic. The other end of this bypass With flap 438 and ring 520b It is anchored in the aorta and anastomotic. Particular applications of the present invention, which have been described in detail above, are: It is merely illustrative of the many possible uses of the present invention. Other examples include Same vessel bypass in coronary artery area, And other parts of the circulatory system (generally, Nervous area, Kidney area, Urology, (Including gynecological and peripheral nerve regions) and the same vascular bypass. With the same vascular bypass, A bypass that extends from one part of a blood vessel to another axially spaced part of the same blood vessel. In FIG. 32, Bypass 620 The same vascular bypass around the constriction 612 of the blood vessel 610. To facilitate comparison with the embodiments described above, The various components of the bypass 620 are: It is identified using the same reference numbers used for similar elements in FIG. The present invention also provides A procedure similar to any of the above can be applied, Applicable to non-circulating systems such as urinary tubing. For example, The collapsible tip structure shown in FIGS. It has been stated that this is only one example of several possible approaches to providing a structure that can penetrate the wall of the coronary artery 20 from outside the artery. Another example of a suitable structure is As shown in FIG. To facilitate comparison with Figure 15, FIG. For elements generally similar to those corresponding to the corresponding non-dashed reference number in FIG. 15, Use dashed reference numbers. In the embodiment shown in FIG. 33, The distal tip 412 ' As the tip 412 'rotates around the wire 150 due to the rotation of the proximally extending tubular shaft 410', It has external threads 414 that help grasp and expand tissue, such as the wall of the coronary artery 20. The thread 414 is Outside the distal portion of tube 440 ', Continues as thread 442. Thread 414 also There is a threaded connection with a thread 444 inside the distal portion of the tube 440 '. therefore, When both structures 410 'and 440' rotate together, Threads 414 and 442 Tends to pull the tip 412 ', Then The distal portion of tube 440 ' Enters and passes through the wall of the coronary artery 20. In this process, The thread 412 ' The tissue is moved to the screw 442. afterwards, Structure 4 10 ' For structure 440 ' By rotating the structure 410 'in a direction in which the threads 414 and 444 cooperate to shift the tip 412' closer to the structure 440 ', It can be removed from structure 440 '. When the tip 412 'is shifted so close beyond the thread 444, Elements 410 'and 412' are Can be pulled closer from the patient. Tube 440 ' It remains in place through this coronary artery wall, afterwards, Graft structure (e.g., 430 (FIGS. 15-17) and associated equipment (e.g., Structure 420 (e.g., 15 and 17)) can be used as a guide tube for delivering to the operating site. Another schematic alternative embodiment of some of the devices shown in FIG. 15, As shown in FIGS. again, To facilitate comparison with Figure 15, Figures 34 and 35 For elements generally similar to those corresponding to the corresponding non-dashed reference number in FIG. 15, Use dashed reference numbers. In the embodiment shown in FIGS. 34 and 35, Stretch 436 ' Connected to the distal end of the serpentine ring 439, This ring is next, Connected to the distal end of frame 432 '. Stretch 436 ' Initially, Bendable band 437a, 437b, By 437c and 437d, It is held in the shape of a distally cut cone. As elsewhere along the graft conduit 430 ', The gap between the struts 436 ' In effect, High elasticity materials (for example, Silicone rubber). Band 437 It can be made from a polymeric material or other suitable flexible material. On the other hand, Band 437 It may be a meandering metal member that yields by straightening. Band 437 Initially, As Strut 436 'flexes flexibly, This strut is strong enough to prevent it from radiating outwardly from conduit 430 '. However, Band 437 By inflating the balloon 422 '(on the distal end of the tube 420') inside the annulus of the strut 436 ', It can be formed to be bent. Stretch 436 ' In its first cone shape, It can be pushed through tissue such as the wall of the coronary artery 20. Stretch 436's cone In either style, Sufficient pressing force can be applied. For example, Tube 420 ' Metal (for example, (Stainless steel) hypotube, this is, By inflating the balloon 422 ', The thrust is transmitted to the strut 436 'cone, The base of this cone can be captured between balloon 422 'and tube 440. Then Another pressing force is also Applicable via tube 440 itself. When enough of the height of the conical 436 'cone has passed through the coronary artery wall, Balloon 422 ' As shown in FIG. 35, Inflated inside this cone, The band 437 is bent. This allows Stretch 436 ' Project radially outward inside the coronary artery, Thereby, The distal end of conduit 430 'is anchored in this artery. Band 437 Progressively weaker in the distal direction, For relatively slight inflation of balloon 422 ', Distal bands such as 437a and 437b may be readily flexed immediately, On the contrary, Closer bands, such as 437c and 437d, In response to the larger inflation of balloon 422 ', Until some time later, Does not bend. The progress of such bending is The ring of the strut part, It may help to ensure that the desired trumpet-bell shaped hooks protrude inside the coronary artery. Figures 34 and 35 If the structure used to enlarge the initial hole (formed by wire 150) through the wall of coronary artery 20 is sharp enough, It explains that it may not be necessary to thread the structure or rotate the structure. instead of, This enlarged hole structure simply, It can be pushed through this coronary artery wall. This same principle is Penetrate this coronary artery, Subsequently, All embodiments of the structure for enlarging its wall opening (e.g., Figure 13, 15-15g, 33 and 36-39). Figures 36 and 37 Not only describes possible uses for conical structures similar to those shown in FIGS. 34 and 35, Figure 3 illustrates another possible aspect of the invention. These drawings are Artificial graft conduit, Or natural graft conduit, Or both the artificial graft conduit and the natural graft conduit at the same time (e.g., This natural conduit is Fig. 3 shows a structure that can be used for delivery (coaxially inside the artificial conduit). In the specific case shown in FIGS. 36 and 37, Assuming that only the native graft conduit is delivered, Replace this natural graft conduit with an artificial graft conduit, Or you can add an artificial graft conduit outside it It is readily apparent. In the embodiment shown in FIGS. 36 and 37, The cone of strut 436 ' Attached to the distal end of a very elastic coil spring 450. The proximal end of coil 450 is Attached to ring 460. Barb 436's cone Near the proximal base of this cone, Additional relatively short radially outwardly projecting hooks or barbs 436 "are provided. As shown in FIG. 37, Hook or barb 436 " Extending into and / or through the distal portion of the length of graft tubing 530; this is, (As mentioned above), In this case, Natural body organ tubes (e.g., Saphenous vein). Ring 460 Similarly, A radially outwardly extending hook or barb 462, this is, Extending into and / or through a proximal portion of the graft conduit 530. Ring 460 also Including resilient, radially outwardly extending annular flaps 438a and 438b with hooks or barbs 439; Everything is It is similar to the elements numbered corresponding to FIG. Spring 450 Inside the conduit 530 between the cone of the barb 436 'and the ring 460, Support this graft conduit, Help keep this open. Structure 420 '(this is Similar to the structure 420 'of FIGS. 34 and 35, (Including the balloon 422 'shown in these figures) Structure 436 ', 450, Located around the wire 150 inside the 460 and 530. The delivery pipe 440 is Located around conduit 530. The embodiment shown in FIGS. 36 and 37 Without using any full length artificial graft conduit, Figure 2 illustrates a structure that can be used to deliver and install natural body organ conduits. In a manner similar to that shown in FIGS. 34 and 35, The structure shown in FIG. Via wire 150, Sent to the operation site. The cone of strut 436 ' Pushed through the wall of the coronary artery 20, Then Project radially outward inside this coronary artery, The distal end of the graft conduit is anchored in the artery. The distal end of the delivery tube 440 is Pushed back if necessary, Assist in mounting the distal end of the implant structure. Attachment of the proximal end of this graft structure to the wall of the aorta 30 The operation is performed in the same manner as that shown in FIGS. Therefore, With the distal flap 438a just outside the wall of the aorta 30, The delivery pipe 440 is Pushed back closer, The flap is exposed. Flap 438a Thereby, Being released, The outer surface of the aortic wall warps and meshes. After that happens, Proximity flap 438b Adjacent to the inner surface of this aortic wall. Tube 440 So that it can warp and mesh with the inner surface of this aortic wall, Pushed back closer, Expose flap 438b. Natural body organ graft 530 At the moment, Completely installed on the patient. Structure 436 ', 450 and 460 are Stay in the proper position in the patient, Help anchor the end of the graft conduit 530, Helps keep the middle portion of the conduit open. In embodiments such as FIGS. 36 and 37, The coil 450 is optional. If you use coil 450, The end is It may or may not be attached to structures 436 and / or 460. Coil like coil 450, It can be used in other embodiments of the present invention. For example, Coil like 4 50 In the embodiment as shown in FIG. 35, Can be used between rings 520a and 520b, In that embodiment, Helps keep graft conduit 530 open. Yet another alternative schematic embodiment of some of the devices shown in FIG. As shown in FIG. To facilitate comparison with Figure 15, FIG. For elements generally similar to those corresponding to the corresponding non-dashed reference number in FIG. 15, Use reference numbers with double dashes. In the embodiment shown in FIG. 38, The distal end of the artificial graft conduit 430 " Mounted on the expandable ring 430a. The slender stretch 436 " Extending distally from the distal end of ring 430a. The distal end of the strut 436 " Folded in that direction, Just far enough to be releasably held by that tube, It extends to the distal end of tube 420 ". Stretch 436 " Elastically bent, It extends radially outward from the ring 430a, Initially, Due to the presence of their distal end portions at the distal end of tube 420 ", That is being suppressed. therefore, Stretch 436 " Initially, In the same manner as described above in connection with FIGS. 34-37, It forms a distally sharpened cone that can be pushed through tissue such as the wall of the coronary artery 20. Structure 420 " Metal with an inflatable annular balloon 422 "near its distal end (e.g., (Stainless steel) can be a hypotube, To help push this cone through this tissue, Can be used. Stretch the distal portion of the 436 "cone, After pressing through the wall of the coronary artery 20, Tube 420 " Shifted proximally to this thrust, The distal end portion of the strut is released. This allows Stretch 436 " Can protrude radially outward from the inner ring 430a of the coronary artery 20, Thereby, In this coronary artery, The distal end of the graft conduit is anchored. Ring 430a Then To increase the size of the connection between the coronary artery 20 and the distal portion of the graft conduit, Can be expanded in the outer peripheral direction. If desired, Each strut 436 " As shown in FIG. Before putting it into the distal end of tube 420 ", You may twist 180 °. this is, When this tension is released from tube 420 " It facilitates turning the distal-most portion of the strut toward the coronary artery wall. Ring 430a and strut 436 " Any suitable material, For example, Any 300 series stainless steel (for example, 316L stainless steel). Other materials that may be suitable for struts 436 "include: There is Nitinol. In the embodiment described above, The elastic cover 434 forming part of the conduit 430 " Preferably, Extending into regions 430a and 436 ". For penetrating existing body organ tissue and connecting and / or fastening the graft structure to the existing body organ tissue, Illustrated herein, The structure described above is It is merely an example of a structure that can be used. Another example of such a structure is Bachinski et al., U.S. Patent Application No. 08/839, filed April 23, 1997, No. 199, The contents are It is incorporated herein by reference. In accordance with or for the purposes of the present invention, Although mentioning that more than one end of the graft site needs to be accessed intraluminally, To access the other end of the graft site intraluminally, Using other instruments also It is not inconsistent with the present invention. For example, To administer this coronary artery, During the above procedure, including FIG. 1 and the related drawings, Introducing a catheter into the coronary artery, This coronary artery is radioactive (for example, It may be desirable to introduce a (fluoroscopic) liquid. FIG. Peripheral structures (e.g., FIG. 18 illustrates a structure 700 that can be used as an alternative to an inflatable balloon to radially expand a connector between a natural or artificial implant and a patient's body tissue. For example, Structures such as structure 700 One or more balloons 422 (FIGS. 15 and 18-23); 512a / 512b (Figs. 25-30), At the 422 '(Figure 35) or 422 "(Figure 38) position, Or in any other location where a generally radially expandable structure is generally required, Can be used. Structure 700 (For example, Outer tube 710 (of metal hypotube). Near the distal end of tube 710, The pivotable members 720a and 720b It is pivotally mounted on a pin 730 that extends laterally across tube 710. The proximity of members 710a and 710b Respectively, It is pivotally connected to links 740a and 740b. The proximal end of link 740 is The wire 750 is pivotally connected to the distal end. For example, As shown in FIG. To allow members 720 and 740 to extend radially from tube 710, On the other side of tube 710, An axially extending slot 760 is formed. The distal end of member 720 By pulling wire 750 close to tube 710, Can be combined. Or, That part of the structure 700 By pushing wire 750 distally against tube 710, Can expand radially (ie, The distal portion of member 750 includes Can be spread out). Therefore, Structure 700 5 is another example of a selectively radially expandable structure that can be used in accordance with the present invention. If desired, In the structure 700, One or more optional inflatable balloons 780 may be disposed. Each such balloon 780, Preferably, It extends annularly around the structure 700. (For clarity, FIG. Only the rear half of the annular balloon 780 is shown). While using the structure 700 to transport the implant, For purposes such as helping to hold the implant in place around structure 700, Balloon 780 and / or similar balloons can be used. Balloon 780 or similar balloon With an inflation lumen extending proximally from this balloon along part 710, Can be selectively expanded. As an alternative to pushing the wire 750 to expand the distal portion of the member 720, Link 740 is Partly overlap with the adjacent part of the member 720, You can start from closer. Then When the wire 750 is pulled close to the tube 710, The distal portion of member 720 includes Spread at intervals. The foregoing is merely illustrative of the principles of the present invention, Without departing from the scope and spirit of the invention, By those skilled in the art, It can be seen that various improvements can be made. For example, The order of some steps in the described procedure is not important, If desired, Can be changed. To observe this device inside the patient, How to use radioactive elements and techniques You may change it. For example, To help monitor the position of various device components within the patient, Through the various lumens in this device, Radioactive liquid may be injected into the patient, And / or radioactive markers (of which, The above markers, such as 154 and 206, Is an example) It may be attached to a location on the device that is useful to the physician.

────────────────────────────────────────────────── ─── Continuation of front page    (81) Designated countries EP (AT, BE, CH, DE, DK, ES, FI, FR, GB, GR, IE, IT, L U, MC, NL, PT, SE), OA (BF, BJ, CF) , CG, CI, CM, GA, GN, ML, MR, NE, SN, TD, TG), AP (GH, KE, LS, MW, S D, SZ, UG, ZW), EA (AM, AZ, BY, KG) , KZ, MD, RU, TJ, TM), AL, AM, AT , AU, AZ, BA, BB, BG, BR, BY, CA, CH, CN, CU, CZ, DE, DK, EE, ES, F I, GB, GE, GH, HU, ID, IL, IS, JP , KE, KG, KP, KR, KZ, LC, LK, LR, LS, LT, LU, LV, MD, MG, MK, MN, M W, MX, NO, NZ, PL, PT, RO, RU, SD , SE, SG, SI, SK, SL, TJ, TM, TR, TT, UA, UG, UZ, VN, YU, ZW (72) Inventor Goldstein, David S.             United States Minnesota 55409, Mine             Apolis, East Lake Harriet               Parkway 4885

Claims (1)

[Claims]   1. Providing a tubular conduit between the first and second spaced apart positions of the patient's tubular body structure Apparatus, comprising:   An elongate device, wherein the device has a distal portion through the lumen of a tubular body structure. Designed to be inserted along and along the lumen to reach the first position Are:   A penetrating structure, wherein the penetrating structure defines the tubular body structure in the first position. Forming a first opening therethrough, extending through the first opening to the second position, and Designed to form a second opening through the tubular body structure at the second location Penetrating structure; and   A conduit delivery structure, wherein the conduit delivery structure comprises a first opening and the second opening; A guide designed to deliver the conduit to extend between the openings. A tube delivery structure.   2. The device of claim 1, wherein the penetrating structure comprises:   A vertical structure having a distal portion, wherein the vertical structure is in the first position. And a vertical structure designed to pass through a wall of the tubular body structure.   3. 3. The device of claim 2, wherein the vertical structure has a sharpened distal tip. .   4. A distal portion of the vertical structure when the vertical structure rotates about its longitudinal axis. Claim: A minute threaded threaded connection to a wall of the tubular body structure. 3. The device according to 2.   5. The vertical structure has a distal portion selected distally beyond the remainder of the elongated device. Axially reciprocable relative to a lumen in the elongate device so that it can be selectively extended 3. The device of claim 2, wherein the device is capable of.   6. 3. The device of claim 2, wherein the vertical structure comprises:   A plurality of substantially coaxial members, wherein the coaxial members are in a telescopic relationship with each other. Attached members.   7. The coaxial member is continuously inserted into the first opening to gradually reduce the first opening. 7. The device of claim 6, wherein the device is selectively extendable distally so as to be individually expandable. .   8. A distal end of at least a portion of the coaxial member tapers inward in a distal direction. Attached to facilitate entry of these members into said first opening. Item 8. The apparatus according to Item 7.   9. A distal portion of at least a portion of the coaxial member is threaded and has a central longitudinal Rotatable about an axis, the member being brought into contact with the wall of the tubular body structure to The thread of claim 7, wherein the thread is threadedly connected to the wall when the streaks are rotated. apparatus.   Ten. The device of claim 1, wherein the penetrating structure comprises:   A selectively operable fixed structure, wherein the fixed structure is formed of the penetrating structure. Removably securing a distal portion to the tubular body structure adjacent the first opening A fixed structure that is designed to be.   11． 11. The device of claim 10, wherein the anchoring structure comprises:   A selectively radially expandable structure around the remainder of the penetrating structure, The expandable structure is designed to be positioned adjacent the first opening. There is a penetrating structure.   12． The expandable structure of claim 11, wherein the expandable structure comprises an inflatable balloon. apparatus.   13. 11. The device of claim 10, wherein the anchoring structure comprises:   First and second structures selectively radially expandable around the remainder of the penetrating structure. Wherein the first and second expandable structures are each configured to include the tubular body structure. To be located on each opposing side of the first opening inside and outside the structure, Designed first and second structures.   14. Wherein said first and second selectively radially expandable structures are arranged in said tube between them. When the radially expandable structure is expanded radially with the walls of the radial body structure, Bends elastically toward each other to clamp the wall between them 14. The device according to claim 13.   15． Each of the first and second radially expandable structures independently comprises a radial 14. The device of claim 13, wherein the device is expandable.   16． Each of the radially expandable structures includes an inflatable balloon; Apparatus according to claim 13.   17． The device of claim 1, wherein the penetrating structure comprises:   A distal portion that is selectively deflectable laterally under control from an axial remote location.   18． The device of claim 1, wherein the penetrating structure comprises:   A visible image transmitting structure, wherein the visible image transmitting structure is a penetrating patient. An image of the portion adjacent to the distal end of the structure can be visualized at an axially remote location. The transmission structure is designed as follows.   19. 19. The device of claim 18, wherein the visible image transfer structure comprises:   To transmit light from a distal portion of the penetrating structure to a proximal portion of the penetrating structure An optical fiber extending axially along said through structure.   20. 19. The device of claim 18, wherein the visible image transfer structure comprises:   To transmit light from a proximal portion of the penetrating structure to a distal portion of the penetrating structure An optical fiber extending axially along said through structure.   twenty one. The device of claim 1, wherein the penetrating structure comprises:   A tubular structure having a distal portion selectively anchorable through the first opening.   twenty two. 22. The device of claim 21, wherein the penetrating structure further comprises:   A vertical portion selectively extendable distally from a distal end of the tubular structure.   twenty three. 23. The device of claim 22, wherein the vertical portion comprises:   A distal portion that is selectively deflectable laterally under control from an axial remote location.   twenty four. 23. The device of claim 22, wherein the vertical portion comprises:   A visible image transmitting structure, wherein the visible image transmitting structure is the vertical shape of a patient. An image of a portion adjacent to the distal portion of the structure can be visualized at an axially remote location. A structure that is designed as follows.   twenty five. 23. The device of claim 22, wherein the vertical portion comprises:   A vertical structure having a distal portion, wherein the vertical structure is in the second position. And a structure designed to pass through a wall of said tubular body structure.   26. After the distal portion of the vertical structure passes through the wall at the second location, Designed to extend along the lumen of said tubular body structure adjacent to a location. 26. The device of claim 25, wherein   27. 26. The device of claim 25, wherein the vertical structure has a sharpened distal tip. .   28. A distal portion of the vertical structure when the vertical structure rotates about its longitudinal axis. Claim: A minute threaded threaded connection to a wall of the tubular body structure. An apparatus according to claim 25.   29. The vertical structure has a distal portion selected distally beyond the remainder of the vertical portion. Reciprocable axially relative to the lumen in the vertical section so that it can be selectively extended 26. The device of claim 25, wherein   30. 26. The device of claim 25, wherein the vertical structure comprises:   Initially wall the tubular body structure at the second position to create the second opening A first structure designed to perforate the first; and   A second structure designed to enlarge the second opening.   31. The first and second structures are in the second position on a wall of the tubular body structure. 31. The device of claim 30, wherein the device is separately movable toward.   32. The second structure is substantially coaxial about the first structure. 30. The device according to 30.   33. The device of claim 1, wherein the penetrating structure comprises:   A vertical structure, wherein the vertical structure is the tubular body adjacent the first position. From the lumen of the structure, exits the first opening to the second opening and the second opening Extending through the mouth into a lumen further beyond the tubular body structure adjacent the second location. A vertical structure that is designed to be long.   34. 34. The device of claim 33, wherein the penetrating structure further comprises: A tissue-piercing structure, wherein the tissue-piercing structure initiates formation of the second opening. Designed to first pierce the tubular body structure in the second position. Wherein the vertical structure is then the further tube of the tubular body structure A tissue-piercing structure that can pass into a cavity.   35. 35. The device of claim 34, wherein the tissue-piercing structure comprises:   A tubular member having a sharp distal protrusion from an outer peripheral portion of its distal end; A distal protrusion is designed to pierce the tissue-piercing structure at the second position. A tubular member.   36. The tubular member is disposed substantially coaxially about an axial portion of the vertical structure. 36. The device of claim 35, wherein the device is located.   37. The vertical structure is movable in a vertical direction with respect to the tubular member. The device of claim 36.   38. The vertical structure is initiated along and along the distal protrusion. Through said second opening, thereby to a lumen further beyond said tubular body structure 38. The device of claim 37, wherein the device is designed to enter.   39. A distal portion of the vertical structure is threadedly connected to the interior of the further lumen. 39. The device of claim 38, wherein the device is designed to:   40. The conduit delivery structure is axially movable along the vertical structure. 34. The device of claim 33, wherein   41. The conduit delivery structure is such that the vertical structure passes axially through the conduit delivery structure. 41. The device of claim 40, wherein the device is designed to:   42. 34. The device of claim 33, wherein the conduit delivery structure comprises:   An enlarged structure, wherein the enlarged structure is the second structure following the vertical structure. To the opening and to enlarge the second opening as it enters the second opening An enlarged structure that is designed.   43. The conduit delivery structure includes a distal portion of the conduit adjacent the second opening. The tubular body structure of claim 1, wherein the body is designed to be selectively secured to the tubular body structure. On-board equipment.   44. The conduit delivery structure defines a proximal portion of the conduit adjacent the first opening. The tubular body structure of claim 1, wherein the body is designed to be selectively secured to the tubular body structure. On-board equipment.   45. The conduit delivery structure is within the tubular body structure adjacent the second opening. Designed to selectively radially expand the distal portion of the conduit on the side. The device according to claim 1.   46. The conduit delivery structure is within the tubular body structure adjacent to the first opening. Designed to selectively radially expand a proximal portion of the conduit on the side. The device according to claim 1.   47. The apparatus of claim 1, wherein the conduit delivery structure comprises:   Inside thereof, a tubular structure designed to receive said conduit coaxially body.   48. 48. The device of claim 47, wherein the conduit delivery structure further comprises: :   Designed to selectively move the conduit axially relative to the tubular structure. A conduit connection structure.   49. The conduit coupling structure may be disposed substantially coaxially inside the conduit. 49. The device of claim 48, comprising a part designed to:   50. The conduit connection designed to be substantially coaxially disposed inside the conduit; 50. The device of claim 49, wherein said portion of the tie structure comprises:   Designed to selectively connect the interior of the conduit when radially expanded A selective radially expandable structure.   51. The radially expandable structure includes a selectively inflatable balloon. Item 50. The device according to Item 50.   52. A device for introducing a vertical structure into a lumen of a tubular body structure of a patient, Wherein the device comprises:   A tubular member having a sharp distal protrusion from a peripheral portion of its distal periphery; The distal protrusion initiates the formation of an opening through the tubular body structure and into the lumen A tubular member that is designed to pierce the tubular body structure;   A vertical structure disposed substantially coaxially inside the tubular member, wherein the vertical structure is The structure has a distal portion extending along the distal protrusion, through the opening, and into the lumen. Designed to move longitudinally relative to the tubular member so that it can enter Vertical structure.   53. 53. The device of claim 52, wherein the distal portion of the vertical structure comprises:   A coil of wire extending distally from a proximal portion of the vertical structure.   54. 54. The device of claim 53, wherein the distal end of the vertical structure comprises: Place:   From the proximity connection of the vertical structure to the proximity portion, the distance of the coil of the wire A safety ribbon extending distally to a distal connection to the post.   55. 53. The device of claim 52, wherein said tubular member comprises a hypotube.   56. 53. The device of claim 52, wherein the vertical structure comprises a wire.   57. A device for radially expanding a structure used in medicine, wherein the device is , Including:   A first elongate component having an axially spaced proximal portion and a distal portion;   A first member mounted for radial movement with respect to the distal portion of the first part; And a second member, wherein the first and second members are separate, distinct halves of the first part. First and second members movable along a diameter; and   A second elongate component substantially parallel to the first component, wherein the second component comprises the first and the second components. And operably connected to the first and second members, and radiating the first and second members. A second elongate part movable relative to the first part so as to produce a torsional movement.   58. Additionally, a selective inflatable balloon is wrapped over the distal portion of the first component. 58. The device of claim 57, comprising.   59. The balloon extends annularly around the distal portion of the first part. 59. The device of claim 58, wherein   60. The first and second members pivotally attach to the distal portion of the first component. 58. The device of claim 57, wherein the device is attached.   61. Each pivot axis of the first and second members traverses a longitudinal axis of the first part. 61. The device of claim 60, wherein   62. The second part causes radial movement of the first and second members, 58. The apparatus of claim 57, wherein the apparatus is vertically movable with respect to the first part.   63. 58. The method of claim 57, wherein the first and second parts are substantially coaxial with each other. On-board equipment.   64. 58. The device of claim 57, further comprising:   Operable connection between the first part and the first and second parts, respectively Are the first and second links.   65. Each of the first and second links is the second part and the respective 65. The device of claim 64, wherein the device is pivotally connected to the first or second member.   66. 58. The device of claim 57, wherein the first component comprises a tubular member.   67. The second part is disposed substantially coaxially in the tubular member. , The device of claim 66.   68. 70. The device of claim 67, wherein the second component comprises an elongated wire member.   69. Placing the tubular graft between the first and second spaced apart positions of the patient's tubular anatomy A method comprising:   Elongating the elongate structure with the tubular body structure so that its distal portion extends to the first position. Inserting into and along the lumen of the;   A first portion passing through the tubular body structure at the first location using a distal portion of the elongate structure; Forming one opening;   Extending a distal portion of the elongate structure from the first opening to the second position;   Using the distal portion of the elongate structure, at the second location, a first through the tubular body structure Forming two openings;   The implant is moved from one of the openings along the lumen of the tubular body structure into the opening. Passing to the other; and   The tubular body adjacent the first and second locations with an axially spaced portion of the implant The process of attaching to the structure.   70. An elongate structure wherein the elongate structure enters the tubular body structure through the second opening 70. The method of claim 69, comprising a member, wherein said passing comprises:   The implant follows the elongate member through the second opening and the tubular body Placing the implant around the elongate member so that it can proceed to a structure.   71. An axially extending lumen wherein the elongate structure is open at a distal portion of the elongate structure 70. The method of claim 69, wherein said passing comprises:   Placing the implant within the axially elongated lumen.   72. 70. The method of claim 69, further comprising:   Withdrawing the elongated structure from the tubular body structure after performing the mounting .   73. 70. The method of claim 69, wherein said mounting comprises:   The implant and the tubular body structure adjacent each of the first and second locations Forming a substantially fluid-tight seal between   74. Forming a second opening using the distal portion of the elongated structure comprises: 70. The method of claim 69, comprising:   Piercing the tubular body structure at the second location using a distal end of an elongate member Process.   75. The distal end of the elongate member is threaded, and the perforation comprises: 75. The method of claim 74, comprising:   Rotating the elongate member about its longitudinal axis to attach the thread to the tubular body structure Threading and drawing the elongate member into the tubular body structure.   76. Forming a second opening using the distal portion of the elongated structure, 75. The method of claim 74, comprising:   The elongated body along and into the lumen of the tubular body structure adjacent the second location Providing a distal portion of the member.   77. Forming a second opening using the distal portion of the elongated structure comprises: 75. The method of claim 74, comprising:   Radially expanding the opening formed by the perforation;   78. 78. The method of claim 77, wherein said radially expanding comprises:   Inserting an enlarged structure into the opening formed by the perforation.   79. A contractor, wherein the enlarged structure substantially coaxially surrounds the elongate member. 78. The method of claim 78.   80. 79. The method of claim 78, wherein said passing comprises:   Advancing the shaft portion of the implant to the second opening following the enlarged structure Process.   81. Forming a second opening using the distal portion of the elongated structure comprises: 70. The method of claim 69, comprising:   Using the distal portion of the elongate structure, at the second location, the tubular body structure Perforating; and   An elongate member is moved from the distal portion of the elongate structure through the perforation to the second position. Extending distally into the lumen of the tubular body structure adjacent to the device.   82. 82. The method of claim 81, wherein the distal extension comprises:   Along the lumen of the tubular body structure, away from the second location, the elongate portion Further extending the distal end of the material.   83. The distal end of the elongate member is threaded, and 83. The method of claim 82, wherein the elongation comprises:   The elongate member is rotated about its longitudinal axis to provide a thread on the distal portion of the elongate member. A muscle is threadedly connected within the lumen and within the lumen, the distal portion of the elongate member. Elongating the minute.   84. Forming a second opening using the distal portion of the elongated structure comprises: 81. The method of claim 81, comprising:   Radially enlarging the opening formed by the perforation.   85. 85. The method of claim 84, wherein the radial expansion comprises:   Inserting an enlarged structure into the opening formed by the perforation.   86. A contractor, wherein the enlarged structure substantially coaxially surrounds the elongate member. 90. The method according to claim 85.   87. 86. The method of claim 85, wherein said passing comprises:   Advancing the shaft portion of the implant to the second opening following the enlarged structure Process.   88. 70. The method of claim 69, wherein said mounting comprises:   Radially expanding the implant inside the tubular body structure adjacent to the second opening. Tensioning to prevent the implant from being pulled out of the second opening.   89. 70. The method of claim 69, wherein said mounting comprises:   Radially expanding the implant inside the tubular body structure adjacent to the first opening. Tensioning to prevent the implant from being pulled out of the first opening.   90. 70. The method of claim 69, wherein said mounting comprises:   A hook is extended from the implant to the tubular body structure around the second opening. The process of lengthening.   91. 70. The method of claim 69, wherein said mounting comprises:   A hook is extended from the implant to the tubular body structure around the first opening. The process of lengthening.   92. In the passage, one of the openings is the first opening, and 70. The method of claim 69, wherein the other of said openings is said second opening.