US20140142584A1 - Multichannel cannula and methods for using same - Google Patents
Multichannel cannula and methods for using same Download PDFInfo
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- US20140142584A1 US20140142584A1 US13/679,312 US201213679312A US2014142584A1 US 20140142584 A1 US20140142584 A1 US 20140142584A1 US 201213679312 A US201213679312 A US 201213679312A US 2014142584 A1 US2014142584 A1 US 2014142584A1
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- channel
- bone
- portal
- multichannel cannula
- substance
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/56—Surgical instruments or methods for treatment of bones or joints; Devices specially adapted therefor
- A61B17/58—Surgical instruments or methods for treatment of bones or joints; Devices specially adapted therefor for osteosynthesis, e.g. bone plates, screws, setting implements or the like
- A61B17/88—Osteosynthesis instruments; Methods or means for implanting or extracting internal or external fixation devices
- A61B17/8861—Apparatus for manipulating flexible wires or straps
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/56—Surgical instruments or methods for treatment of bones or joints; Devices specially adapted therefor
- A61B17/58—Surgical instruments or methods for treatment of bones or joints; Devices specially adapted therefor for osteosynthesis, e.g. bone plates, screws, setting implements or the like
- A61B17/88—Osteosynthesis instruments; Methods or means for implanting or extracting internal or external fixation devices
- A61B17/8802—Equipment for handling bone cement or other fluid fillers
- A61B17/8805—Equipment for handling bone cement or other fluid fillers for introducing fluid filler into bone or extracting it
- A61B17/8816—Equipment for handling bone cement or other fluid fillers for introducing fluid filler into bone or extracting it characterised by the conduit, e.g. tube, along which fluid flows into the body or by conduit connections
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/34—Trocars; Puncturing needles
- A61B17/3472—Trocars; Puncturing needles for bones, e.g. intraosseus injections
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/34—Trocars; Puncturing needles
- A61B17/3417—Details of tips or shafts, e.g. grooves, expandable, bendable; Multiple coaxial sliding cannulas, e.g. for dilating
- A61B17/3421—Cannulas
- A61B2017/3445—Cannulas used as instrument channel for multiple instruments
- A61B2017/3447—Linked multiple cannulas
Definitions
- the present invention relates generally to the field of devices and methods for delivering substances to bone. More particularly, the present invention concerns devices and methods for delivering substances to the interior of fractured or otherwise injured bones, especially to the fracture interface. The present invention further relates to devices and methods for removing material from the interior of a bone.
- a bone implant may be a bone screw, nail, or other device implanted into a bone to stabilize portions of a fractured bone.
- a bone implant may be a bone screw, nail, or other device implanted into a bone to stabilize portions of a fractured bone.
- At least three techniques are currently available to deliver substances to bone.
- One technique involves delivering the substance into a drilled hole in a fractured bone without fracture stabilization. The lack of fracture stabilization causes difficulties in delivering substances to an intended location using this technique.
- a second technique includes drilling a separate hole in a bone for the substance to be delivered after implant placement. Drilling a separate hole causes additional trauma to the bone, and may also limit accessibility to the intended delivery location.
- the substance is delivered through the implant. This technique requires the use of a fenestrated or slotted implant.
- the embodiments described herein allow delivery of a substance (e.g., medication) to a fracture site after stabilization of the bone. Furthermore, the embodiments described herein allow delivery of a substance to bone through the same hole that will receive the bone implant, without requiring a separate hole to be drilled into the bone. The devices and methods described herein also allow material to be removed from the interior of a bone.
- a substance e.g., medication
- One embodiment of the invention relates to a method for delivering a substance to bone.
- the method includes placing a stabilizing wire in a bone and creating a hole in the bone around the stabilizing wire.
- a multichannel cannula is provided that includes a first channel having an open proximal end and an open distal end, the first channel being configured to receive the stabilizing wire.
- the multichannel cannula further includes a second channel having an inlet portal and an exit portal that are in fluid communication.
- the method further includes inserting the multichannel cannula into the hole in the bone such that the first channel receives the stabilizing wire, and delivering the substance into the bone by introducing the substance into the inlet portal of the second channel such that the substance exits the second channel through the exit portal.
- a multichannel cannula is provided that includes a first channel having an open proximal end and an open distal end, the first channel being configured to receive a stabilizing wire.
- the multichannel cannula further includes a second channel having an inlet portal and an exit portal that are in fluid communication.
- the method further includes inserting the multichannel cannula into the hole in the bone such that the first channel receives the stabilizing wire.
- the method further includes coupling a suction device to the multichannel cannula, and removing a material from an interior of the bone by activating the suction device such that the material is drawn into the second channel through the exit portal of the second channel and the material exits the second channel through the inlet portal of the second channel.
- the multichannel cannula for delivering a substance to bone.
- the multichannel cannula includes a first channel having an open proximal end and an open distal end.
- the first channel is configured to receive a stabilizing wire.
- the multichannel cannula further includes a second channel having an inlet portal and an exit portal that are in fluid communication.
- FIG. 1 illustrates a bone with a stabilizing wire and a hole in the bone around the stabilizing wire, according to an exemplary embodiment.
- FIGS. 2-5 illustrate cross-sectional views of various exemplary embodiments of a multichannel cannula.
- FIG. 6 illustrates a multichannel cannula having a side port and a delivery portal, according to an exemplary embodiment.
- FIG. 7 illustrates a multichannel cannula with a plurality of exit portals, including open distal ends of channels and multiple side ports, according to an exemplary embodiment.
- FIG. 8 illustrates the bone and stabilizing wire shown in FIG. 1 with a multichannel cannula introduced over the stabilizing wire, according to an exemplary embodiment.
- FIG. 9 illustrates a multichannel cannula with a stabilizing wire within a first channel and a delivery insert within a second channel.
- a bone 10 includes a fracture 2 .
- the fracture 2 separates the bone into portions 10 A and 10 B.
- a stabilizing wire 4 may be used to hold bone portions together.
- the stabilizing wire 4 may be any type of wire used to temporarily or permanently secure portions of bone together, such as Kirschner wires or Steinmann pins.
- the stabilizing wire 4 is often placed in a fractured bone 10 prior to insertion of a more permanent bone implant, such as a bone screw, nail, or other fixation structure.
- the stabilizing wire 4 may serve as a guide for a drill or bone implant.
- the bone 10 of FIG. 1 includes a hole 6 created to eventually receive a bone implant.
- a cannulated drill or reamer can be used to create a hole around the stabilizing wire 4 while the tip of the stabilizing wire 4 remains fixed in bone portion 10 B.
- the hole 6 passes through the fracture 2 .
- a bone implant to further secure bone portions 10 A and 10 B together can then be guided over stabilizing wire 4 and into the hole 6 .
- a multichannel cannula 800 having two or more channels may be introduced over the stabilizing wire 4 to deliver substances to the interior of bone 10 .
- the multichannel cannula is introduced over the stabilizing wire 4 after creation of hole 6 , but prior to placement of a bone implant into the hole 6 .
- a first channel of the multichannel cannula receives the stabilizing wire 4 .
- the other channels of the multichannel cannula may be used for delivering substances to the interior of bone 10 , as described in more detail below.
- the substance delivered using the multichannel cannulas described herein may be any type of substance a user desires to deliver to the interior of a bone, including medication such as calcium phosphate paste, an antibiotic, or a chemotherapeutic agent.
- the multichannel cannulas described herein are substantially elongated structures with two or more channels, as can be seen in FIGS. 6-8 (reference numbers 600 , 700 , and 800 , respectively).
- the multichannel cannulas described herein include a first channel having an open proximal end (e.g., 824 shown in FIG. 8 ) and an open distal end (e.g., 822 shown in FIG. 8 ).
- the open proximal end and open distal end allow the first channel to be threaded over a stabilizing wire 4 .
- the first channel is configured to receive a stabilizing wire 4 .
- the first channel is substantially cylindrical and has a diameter slightly larger than the diameter of the stabilizing wire.
- the side wall of the cylindrical first channel (as distinguished from the open ends of the first channel) may be continuous, meaning there are no open portals or other openings along the side wall of the first channel. In one embodiment, liquid cannot penetrate the side wall of the first channel.
- the multichannel cannulas described herein further include a second channel (e.g., 802 shown in FIG. 8 ).
- the second channel includes at least one inlet portal (e.g., 820 shown in FIG. 8 ) and at least one exit portal (e.g., open distal end 810 shown in FIG. 8 ; side exit portals 708 shown in FIG. 7 ).
- the inlet portal of the second channel serves as an inlet for a substance to be delivered to the interior of a bone.
- the exit portal of the second channel serves as an outlet for the substance.
- the exit portal of the second channel serves as an inlet for material being drawn into the second channel and removed from the interior of a bone.
- the inlet portal of the second channel serves out an outlet for this removed material.
- the inlet portal and exit portal of the second channel are thus in fluid communication to allow substances or materials to be delivered to or removed from the interior of a bone.
- FIGS. 2-5 illustrate cross-sectional views of various embodiments of multichannel cannulas.
- the multichannel cannulas shown in FIGS. 2-5 each include at least two interior channels.
- the channels of a multichannel cannula may be structured in a variety of ways to enhance a user's ability to precisely deliver a substance to an intended location within a bone.
- the multichannel cannula 200 shown in FIG. 2 includes a first channel 201 and a second channel 202 .
- first channel 201 is smaller than second channel 202
- first channel 201 is contained within the bounds of second channel 202 .
- the cross-section of multichannel cannula 200 is substantially circular.
- channel 201 receives a stabilizing wire 4 during a surgical procedure.
- the multichannel cannula 300 shown in FIG. 3 also includes two channels—first channel 301 and second channel 302 .
- first channel 301 and second channel 302 have substantially circular cross-sections and have approximately the same diameter.
- first channel 301 and second channel 302 are arranged next to each other such that the multichannel cannula 300 has a substantially ovular cross-section.
- either first channel 301 or second channel 302 may receive a stabilizing wire 4 .
- multichannel cannula 400 includes a first channel 401 , a second channel 402 , and a third channel 403 .
- the first channel 401 has a substantially circular cross-section, while second channel 402 and third channel 403 have crescent-shaped cross-sections.
- Second channel 402 and third channel 403 are arranged on either side of first channel 401 such that multichannel cannula 400 has a substantially ovular cross-section.
- first channel 401 receives a stabilizing wire 4 during a surgical procedure.
- Multichannel cannula 500 shown in FIG. 5 , includes five separate channels.
- the cross-section of first channel 501 is substantially circular.
- Second channel 502 , third channel 503 , fourth channel 504 , and fifth channel 505 have crescent-shaped cross-sections and are arranged around first channel 501 .
- the cross-sectional shape of multichannel cannula 500 is thus an irregular shape, as illustrated in FIG. 5 .
- first channel 501 receives a stabilizing wire 4 during a surgical procedure.
- the multichannel cannulas described herein can be made of any material suitable for placement into a bone without harmful effects on the patient.
- the multichannel cannula is made of stainless steel or other type of metal.
- the multichannel cannula is made of a rigid plastic, such as polyethylketone, that cannot be easily bent or manipulated into alternative configurations.
- a rigid cannula may be advantageous to provide stability when introducing the cannula into a hole 4 in a bone 10 .
- a rigid cannula provides stability for various procedures that a more flexible multichannel cannula may not provide.
- a rigid cannula may be more desirable.
- a rigid cannula is able to withstand more significant forces than a flexible cannula (e.g., forces applied to the cannula by a delivery device 628 or a suction device 826 , and the forces resulting from movement of substances through the channels and through any open portals in the cannula).
- FIG. 6 provides a perspective view of another embodiment of a multichannel cannula.
- Multichannel cannula 600 includes a first channel 601 , a second channel 602 , a delivery portal 604 , and a side exit portal 608 .
- the multichannel cannula 600 is threaded over a stabilizing wire 4 , such as stabilizing wire 4 in bone 10 (as shown in FIG. 8 ).
- the stabilizing wire therefore lies within the first channel 601 .
- the delivery portal 604 is coupled to an inlet portal 620 of the second channel 602 such that a substance can flow from the delivery portal 604 , through the inlet portal 620 , and into the second channel 602 .
- the delivery portal 604 may be angled relative to the multichannel cannula 600 , as shown in FIG. 6 .
- the longitudinal axis of the delivery portal 604 is aligned parallel to the longitudinal axis of the multichannel cannula 600 .
- the delivery portal 604 may include a removable plug 606 .
- a user removes plug 606 to couple a delivery device 628 (illustrated schematically in FIG. 6 ) to delivery portal 604 .
- the delivery device 628 may include a syringe, a pump, or a reservoir.
- Tubing 629 may be used to connect the delivery device 628 to the delivery portal 604 .
- the type of delivery device selected by a user may depend on the type of substance to be delivered to the bone.
- the substance exits second channel 602 via a side exit portal 608 located on an outer wall of the second channel 602 .
- the distal end 610 of second channel 602 is closed, preventing the substance from exiting the distal end 610 of the second channel 602 .
- the distal end 610 of the second channel 602 may be open to create an exit portal such that the substance can exit the second channel 602 through both the side exit portal 608 and the open distal end 610 .
- a user can align the side exit portal 608 with the area of the bone to be treated with the substance.
- multichannel cannula 700 includes five channels ( 701 - 705 ), each with an open distal end that can serve as an exit portal for substance delivery.
- the fourth channel 704 includes a plurality of side exit portals 708 , although any of the other channels 702 - 705 may include one or more side exit portals.
- the first channel 701 is configured to receive stabilizing wire 4 during a surgical procedure.
- a substance can be delivered to the inlet portals of any of channels 702 - 705 via a delivery portal, such as the delivery portal 604 described in connection with FIG. 6 . In one embodiment, the substance is delivered to fourth channel 704 .
- the substance then travels through fourth channel 704 , exiting through side exit portals 708 and the exit portal created by the open distal end 710 of the fourth channel 704 .
- the distal end 710 of fourth channel 704 is closed to prevent substance from exiting the distal end 710 .
- the multiple exit portals 708 , 710 in the embodiment of FIG. 7 allow the substance to be delivered to multiple areas within the interior of a bone.
- the open distal end 710 may deliver the substance to a distal end of a hole 6 in a bone (e.g., in bone 10 shown in FIG. 8 ) while the exit portals 708 deliver the substance to one or more fracture sites 2 .
- FIG. 8 illustrates a multichannel cannula 800 placed within bone 10 for substance delivery.
- the multichannel cannula 800 illustrated in FIG. 8 includes at least a first channel 801 and a second channel 802 .
- First channel 801 is shown threaded over stabilizing wire 4 .
- Second channel 802 is therefore used for substance delivery or to remove material from the interior of a bone.
- Any of the embodiments of multichannel cannulas described herein e.g., 200 , 300 , 400 , 500 , 600 , 700 , and 900 ), and any combination of the features of these embodiments, may be utilized in the manner shown in FIG. 8 to either deliver a substance to bone or remove material from the interior of a bone.
- references and disclosures related to methods for using multichannel cannula 800 are to be understood to be references and disclosures related to methods for using any of the other structural embodiments of multichannel cannulas described herein.
- One method of delivering a substance to bone includes placing stabilizing wire 4 into bone 10 and creating a hole 6 in the bone 10 around the stabilizing wire 4 , as described above.
- the method further includes providing a multichannel cannula 800 having a first channel 801 with an open proximal end 824 and an open distal end 822 .
- the proximal end 824 and distal end 822 of the first channel 801 are open so that the first channel 801 can receive the stabilizing wire 4 .
- the multichannel cannula 800 further includes a second channel 802 having an inlet portal 820 and an exit portal 818 that are in fluid communication.
- the multichannel cannula 800 may be inserted into the hole 6 in the bone 10 such that the first channel 801 receives the stabilizing wire 4 .
- the multichannel cannula 800 can be inserted into the proximal end 6 A of hole 6 to any desired depth.
- a substance is then delivered to the interior of bone 10 by introducing the substance into the inlet portal 820 of the second channel 802 such that the substance exits the second channel 802 through the exit portal 818 (i.e., the open distal end 810 of second channel 802 ).
- the multichannel cannula 800 is inserted into hole 6 such that the distal end 809 of the multichannel cannula 800 is near fracture 2 .
- the substance can therefore be delivered to the fracture site through the open distal end 810 of the second channel 802 .
- the multichannel cannula 800 is inserted farther into hole 6 such that substance is delivered through the open distal end 810 of the second channel 802 closer to the distal end 6 B of hole 6 .
- a user may select a multichannel cannula having a particular configuration and number of exit portals depending on a patient's bone fracture. For example, some types of fractures may be most easily treated by delivering a substance to a location that can be aligned with a distal end of a multichannel cannula.
- a user may select a multichannel cannula 800 in which the distal end 810 of a second channel 802 is open such that the substance can be delivered to bone 10 through this open distal end 810 .
- the user may desire to treat the bone 10 by delivering medication to one or more locations along the periphery of a hole 6 in the bone 10 .
- a user may select a multichannel cannula 800 in which distal end 810 of second channel 802 is closed, and a substance is delivered to the bone through side exit portals such as those described in connection with FIGS. 6 and 7 .
- a substance may be delivered to bone 10 through a channel in multichannel cannula 800 having both an open distal end 810 and one or more side exit portals.
- the multichannel cannula 800 may also be used during treatment of a patient with a weakened, but unfractured bone.
- a patient's bone can be weakened due to osteoporosis, metastasis of a cancer, or other disease that causes bone deterioration.
- a surgeon may be able to analyze the state of the patient's bone and determine areas that are likely to sustain a fracture in the future.
- a stabilizing pin 4 is inserted and a hole is drilled into the bone.
- the multichannel cannula 800 is then threaded over the stabilizing pin 4 .
- a cement e.g., calcium phosphate paste, methylmethacrylate
- the cement penetrates the surrounding bone and strengthens the area.
- the hole in the bone may be filled with cement or a bone implant.
- a user may rotate the multichannel cannula 800 around the stabilizing wire 4 .
- Rotating the multichannel cannula 800 may help a user align an exit portal with an intended delivery location within the bone in order to direct substance delivery to the intended delivery location.
- the ability to rotate the multichannel cannula 800 around a stabilizing wire 4 may help during guidance of the multichannel cannula 800 proximally and distally within hole 6 .
- Fluoroscopic guidance may increase a user's ability to precisely deliver a substance to a desired location within bone 10 .
- the ability to view the multichannel cannula 800 during insertion allows a user to adjust the position of multichannel cannula 800 to precisely align any exit portals of the multichannel cannula 800 with the intended delivery sites within bone 10 .
- the user can use fluoroscopic guidance to determine whether any adjustments to the position of the multichannel cannula 800 should be made to more precisely deliver the substance. For example, based on fluoroscopic guidance, the user may determine that the multichannel cannula 800 should be inserted farther into hole 6 .
- the image guidance may indicate that multichannel cannula 800 should be rotated about stabilizing wire 4 to increase delivery accuracy.
- the multichannel cannulas described herein may include radiopaque markers to facilitate image guidance.
- the radiopaque markers may be located on or near the distal tip of the multichannel cannula. In one embodiment, separate radiopaque markers are provided near the distal opening of multiple channels of the multichannel cannula. Radiopaque markers may also be provided near side portal openings in the cannula.
- the radiopaque markers assist a user in accurately positioning the multichannel cannula during a surgical procedure to deliver or remove a substance from a bone. Furthermore, the markers allow a user to see where a substance is exiting or entering the multichannel cannula.
- a multichannel cannula 900 in accordance with another exemplary embodiment includes a first channel 901 and a second channel 902 .
- the second channel 902 includes a side exit portal 908 for the substance to exit the second channel 902 .
- an insert 912 having an exit portal 914 is used in combination with multichannel cannula 900 to deliver a substance to bone.
- the insert 912 includes multiple side exit portals (not shown).
- the insert 912 may be one of the embodiments of inserts described in U.S. patent application Ser. No. 13/270,072, titled “Method and Device for Delivering Medicine to Bone,” filed Oct.
- the insert 912 is inserted into the second channel 902 .
- a substance is then introduced into the proximal end 916 of the insert 912 .
- the substance then exits the exit portal 914 of the insert and the exit portal 908 of the second channel 902 of the multichannel cannula 900 .
- the insert 912 can be adjusted within second channel 902 to alter the amount of substance ultimately delivered through side exit portal 908 of the multichannel cannula 900 .
- the insert 912 may be pulled in a proximal direction (i.e., away from the multichannel cannula 900 ) such that only a portion of side exit portal 914 is aligned with side exit portal 908 .
- the insert 912 can be pushed in a distal direction to fully align side exit portal 914 with side exit portal 908 , as shown in FIG. 9 , which maximizes the amount of the substance delivered through side exit portal 908 .
- the insert 912 may also be rotated around its longitudinal axis to alter the alignment of side exit portal 914 of the insert 912 and side exit portal 908 of the multichannel cannula 900 , thus adjusting the amount of the substance delivered.
- a delivery device 628 shown schematically in FIG. 6 ), such as a syringe, a pump, or a reservoir, may be attached to the proximal end 916 of the insert 912 .
- any of the multichannel cannulas described herein may be used to remove material, such as bone marrow or blood, from the interior of a bone 10 .
- a suction device 826 may be coupled to the proximal end of multichannel cannula 800 to aid in the removal of material.
- the suction device 826 is coupled to the proximal end of second channel 802 by tubing 829 or via a delivery portal (e.g., the delivery portal 604 shown in FIG. 6 ).
- material being removed from the bone 10 travels through the multichannel cannula 800 in an opposite manner from the embodiments in which a substance is being delivered to the bone through multichannel cannula 800 .
- activation of suction device 826 causes material to enter the multichannel cannula 800 through the exit portal created by open distal end 810 or through any side exit portals in the multichannel cannula 800 .
- the material then travels through second channel 802 and exits the multichannel cannula 800 through the inlet portal 820 at the proximal end of the second channel 802 .
- the exit portals of the multichannel cannula 800 may be aligned within bone 10 to remove material from intended locations near the exit portals.
- a user may use the multichannel cannula 800 to both deliver substances to bone 10 and remove materials from the interior of a bone 10 during the same surgical procedure.
- a user first uses the multichannel cannula 800 to remove material from the interior of the bone 10 .
- the multichannel cannula 800 is used to deliver substances to areas within the bone 10 .
- a user may first deliver a substance to the interior of bone 10 using the multichannel cannula 800 . After substance delivery, the user may remove excess substance (e.g., medication) or other materials (e.g., blood) by utilizing a suction device 826 coupled to the proximal end of the multichannel cannula 800 .
- a multichannel cannula and an insert such as the multichannel cannula 900 and insert 912 shown in FIG. 9
- a suction device 826 to remove material from the interior of a bone 10 .
- the suction device 826 can be coupled via tubing or via a delivery portal (e.g., the delivery portal 604 shown in FIG. 6 ) to the proximal end 916 of the insert 912 .
- the multichannel cannulas described herein can be used to irrigate the interior of a bone by simultaneously delivering a substance to the bone 10 using one channel and applying a suction force to a separate channel. Irrigation may be useful for reducing the risk of infection or contamination within a bone.
- a solution containing antibiotics or other medication is introduced into a first channel of a multichannel cannula. The solution travels through the first channel and enters the interior of a bone through one or more exit portals of the first channel. Simultaneously or shortly thereafter, a suction force is applied to a second channel of the multichannel cannula using a suction device, such as suction device 826 shown in FIG. 8 .
- the suction draws the solution from the interior of the bone and back into the multichannel cannula through an open portal of the second channel.
- the interior of the bone can be irrigated using a multichannel cannula.
- the channel used to deliver the substance to the bone may or may not contain a stabilizing wire 4 .
- the channel used to draw the substance back out of the bone may or may not contain a stabilizing wire 4 .
- the presence of a stabilizing wire 4 within a channel does not prevent substances from flowing through the channel.
- the various multichannel cannula embodiments can be used in surgical procedures other than in connection with delivering or removing substances from bone.
- the multichannel cannulas can be used in procedures requiring insertion of a cannula into a vessel.
- a guidewire is inserted into the patient's vessel, and a first channel of the multichannel cannula is then threaded over the guidewire.
- the cannula can then be used as described in connection with the various methods disclosed herein to deliver or remove a substance from the vessel through a channel of the cannula.
- the multichannel cannula is used in ear, nose, and throat procedures, with or without the use of a guidewire.
Abstract
Description
- The present invention relates generally to the field of devices and methods for delivering substances to bone. More particularly, the present invention concerns devices and methods for delivering substances to the interior of fractured or otherwise injured bones, especially to the fracture interface. The present invention further relates to devices and methods for removing material from the interior of a bone.
- As techniques for delivering substances to bone progress, there remains an imprecision during substance delivery prior to bone implant placement. A bone implant may be a bone screw, nail, or other device implanted into a bone to stabilize portions of a fractured bone. At least three techniques are currently available to deliver substances to bone. One technique involves delivering the substance into a drilled hole in a fractured bone without fracture stabilization. The lack of fracture stabilization causes difficulties in delivering substances to an intended location using this technique. A second technique includes drilling a separate hole in a bone for the substance to be delivered after implant placement. Drilling a separate hole causes additional trauma to the bone, and may also limit accessibility to the intended delivery location. In a third technique, the substance is delivered through the implant. This technique requires the use of a fenestrated or slotted implant.
- The embodiments described herein allow delivery of a substance (e.g., medication) to a fracture site after stabilization of the bone. Furthermore, the embodiments described herein allow delivery of a substance to bone through the same hole that will receive the bone implant, without requiring a separate hole to be drilled into the bone. The devices and methods described herein also allow material to be removed from the interior of a bone.
- One embodiment of the invention relates to a method for delivering a substance to bone. The method includes placing a stabilizing wire in a bone and creating a hole in the bone around the stabilizing wire. A multichannel cannula is provided that includes a first channel having an open proximal end and an open distal end, the first channel being configured to receive the stabilizing wire. The multichannel cannula further includes a second channel having an inlet portal and an exit portal that are in fluid communication. The method further includes inserting the multichannel cannula into the hole in the bone such that the first channel receives the stabilizing wire, and delivering the substance into the bone by introducing the substance into the inlet portal of the second channel such that the substance exits the second channel through the exit portal.
- Another embodiment of the invention relates to a method for removing material from a bone. The method includes placing a stabilizing wire in a bone and creating a hole in the bone around the stabilizing wire. A multichannel cannula is provided that includes a first channel having an open proximal end and an open distal end, the first channel being configured to receive a stabilizing wire. The multichannel cannula further includes a second channel having an inlet portal and an exit portal that are in fluid communication. The method further includes inserting the multichannel cannula into the hole in the bone such that the first channel receives the stabilizing wire. The method further includes coupling a suction device to the multichannel cannula, and removing a material from an interior of the bone by activating the suction device such that the material is drawn into the second channel through the exit portal of the second channel and the material exits the second channel through the inlet portal of the second channel.
- Yet another embodiment of the invention relates to a multichannel cannula for delivering a substance to bone. The multichannel cannula includes a first channel having an open proximal end and an open distal end. The first channel is configured to receive a stabilizing wire. The multichannel cannula further includes a second channel having an inlet portal and an exit portal that are in fluid communication.
- Alternative exemplary embodiments relate to other features and combinations of features as may be generally recited in the claims.
- The disclosure will become more fully understood from the following detailed description, taken in conjunction with the accompanying figures, wherein like reference numerals refer to like elements, in which:
-
FIG. 1 illustrates a bone with a stabilizing wire and a hole in the bone around the stabilizing wire, according to an exemplary embodiment. -
FIGS. 2-5 illustrate cross-sectional views of various exemplary embodiments of a multichannel cannula. -
FIG. 6 illustrates a multichannel cannula having a side port and a delivery portal, according to an exemplary embodiment. -
FIG. 7 illustrates a multichannel cannula with a plurality of exit portals, including open distal ends of channels and multiple side ports, according to an exemplary embodiment. -
FIG. 8 illustrates the bone and stabilizing wire shown inFIG. 1 with a multichannel cannula introduced over the stabilizing wire, according to an exemplary embodiment. -
FIG. 9 illustrates a multichannel cannula with a stabilizing wire within a first channel and a delivery insert within a second channel. - Before turning to the figures, which illustrate the exemplary embodiments in detail, it should be understood that the application is not limited to the details or methodology set forth in the description or illustrated in the figures. It should also be understood that the terminology is for the purpose of description only and should not be regarded as limiting. For example, a femur is illustrated in the drawings, but the devices and methods described herein may be used in connection with any bone in the body, including but not limited to bones in the spine, arms, hands, legs, and feet.
- Referring to
FIG. 1 , abone 10 includes afracture 2. Thefracture 2 separates the bone intoportions wire 4 may be used to hold bone portions together. The stabilizingwire 4 may be any type of wire used to temporarily or permanently secure portions of bone together, such as Kirschner wires or Steinmann pins. The stabilizingwire 4 is often placed in a fracturedbone 10 prior to insertion of a more permanent bone implant, such as a bone screw, nail, or other fixation structure. In addition to stabilizing thebone portions wire 4 may serve as a guide for a drill or bone implant. For example, thebone 10 ofFIG. 1 includes ahole 6 created to eventually receive a bone implant. To create thehole 6, a cannulated drill or reamer can be used to create a hole around the stabilizingwire 4 while the tip of the stabilizingwire 4 remains fixed inbone portion 10B. Thehole 6 passes through thefracture 2. A bone implant to further securebone portions wire 4 and into thehole 6. - Referring to
FIG. 8 , according to an exemplary embodiment, amultichannel cannula 800 having two or more channels may be introduced over the stabilizingwire 4 to deliver substances to the interior ofbone 10. In one embodiment, the multichannel cannula is introduced over the stabilizingwire 4 after creation ofhole 6, but prior to placement of a bone implant into thehole 6. A first channel of the multichannel cannula receives the stabilizingwire 4. The other channels of the multichannel cannula may be used for delivering substances to the interior ofbone 10, as described in more detail below. The substance delivered using the multichannel cannulas described herein may be any type of substance a user desires to deliver to the interior of a bone, including medication such as calcium phosphate paste, an antibiotic, or a chemotherapeutic agent. - The multichannel cannulas described herein are substantially elongated structures with two or more channels, as can be seen in
FIGS. 6-8 (reference numbers FIG. 8 ) and an open distal end (e.g., 822 shown inFIG. 8 ). The open proximal end and open distal end allow the first channel to be threaded over a stabilizingwire 4. Thus, the first channel is configured to receive a stabilizingwire 4. In one embodiment, the first channel is substantially cylindrical and has a diameter slightly larger than the diameter of the stabilizing wire. The side wall of the cylindrical first channel (as distinguished from the open ends of the first channel) may be continuous, meaning there are no open portals or other openings along the side wall of the first channel. In one embodiment, liquid cannot penetrate the side wall of the first channel. - The multichannel cannulas described herein further include a second channel (e.g., 802 shown in
FIG. 8 ). The second channel includes at least one inlet portal (e.g., 820 shown inFIG. 8 ) and at least one exit portal (e.g., opendistal end 810 shown inFIG. 8 ;side exit portals 708 shown inFIG. 7 ). In some methods described herein, the inlet portal of the second channel serves as an inlet for a substance to be delivered to the interior of a bone. In these embodiments, the exit portal of the second channel serves as an outlet for the substance. In other methods of using a multichannel cannula, the exit portal of the second channel serves as an inlet for material being drawn into the second channel and removed from the interior of a bone. In these embodiments, the inlet portal of the second channel serves out an outlet for this removed material. The inlet portal and exit portal of the second channel are thus in fluid communication to allow substances or materials to be delivered to or removed from the interior of a bone. -
FIGS. 2-5 illustrate cross-sectional views of various embodiments of multichannel cannulas. The multichannel cannulas shown inFIGS. 2-5 each include at least two interior channels. The channels of a multichannel cannula may be structured in a variety of ways to enhance a user's ability to precisely deliver a substance to an intended location within a bone. - The
multichannel cannula 200 shown inFIG. 2 includes afirst channel 201 and asecond channel 202. In this embodiment,first channel 201 is smaller thansecond channel 202, andfirst channel 201 is contained within the bounds ofsecond channel 202. The cross-section ofmultichannel cannula 200 is substantially circular. In one embodiment,channel 201 receives a stabilizingwire 4 during a surgical procedure. - The
multichannel cannula 300 shown inFIG. 3 also includes two channels—first channel 301 andsecond channel 302. In the embodiment ofFIG. 3 ,first channel 301 andsecond channel 302 have substantially circular cross-sections and have approximately the same diameter. Furthermore,first channel 301 andsecond channel 302 are arranged next to each other such that themultichannel cannula 300 has a substantially ovular cross-section. During use of themultichannel cannula 300 ofFIG. 3 , eitherfirst channel 301 orsecond channel 302 may receive a stabilizingwire 4. - Referring to
FIG. 4 ,multichannel cannula 400 includes afirst channel 401, asecond channel 402, and athird channel 403. Thefirst channel 401 has a substantially circular cross-section, whilesecond channel 402 andthird channel 403 have crescent-shaped cross-sections.Second channel 402 andthird channel 403 are arranged on either side offirst channel 401 such thatmultichannel cannula 400 has a substantially ovular cross-section. In one embodiment,first channel 401 receives a stabilizingwire 4 during a surgical procedure. -
Multichannel cannula 500, shown inFIG. 5 , includes five separate channels. The cross-section offirst channel 501 is substantially circular.Second channel 502,third channel 503,fourth channel 504, andfifth channel 505 have crescent-shaped cross-sections and are arranged aroundfirst channel 501. The cross-sectional shape ofmultichannel cannula 500 is thus an irregular shape, as illustrated inFIG. 5 . In one embodiment,first channel 501 receives a stabilizingwire 4 during a surgical procedure. - The multichannel cannulas described herein can be made of any material suitable for placement into a bone without harmful effects on the patient. In one embodiment, the multichannel cannula is made of stainless steel or other type of metal. In another embodiment, the multichannel cannula is made of a rigid plastic, such as polyethylketone, that cannot be easily bent or manipulated into alternative configurations. A rigid cannula may be advantageous to provide stability when introducing the cannula into a
hole 4 in abone 10. Furthermore, a rigid cannula provides stability for various procedures that a more flexible multichannel cannula may not provide. For example, if a surgeon desires to use a plunger or other device to push a substance from the multichannel cannula and into the bone, a rigid cannula may be more desirable. As another example, a rigid cannula is able to withstand more significant forces than a flexible cannula (e.g., forces applied to the cannula by adelivery device 628 or asuction device 826, and the forces resulting from movement of substances through the channels and through any open portals in the cannula). -
FIG. 6 provides a perspective view of another embodiment of a multichannel cannula.Multichannel cannula 600 includes afirst channel 601, asecond channel 602, adelivery portal 604, and aside exit portal 608. Themultichannel cannula 600 is threaded over a stabilizingwire 4, such as stabilizingwire 4 in bone 10 (as shown inFIG. 8 ). The stabilizing wire therefore lies within thefirst channel 601. Thedelivery portal 604 is coupled to aninlet portal 620 of thesecond channel 602 such that a substance can flow from thedelivery portal 604, through theinlet portal 620, and into thesecond channel 602. Thedelivery portal 604 may be angled relative to themultichannel cannula 600, as shown inFIG. 6 . In an alternative embodiment, the longitudinal axis of thedelivery portal 604 is aligned parallel to the longitudinal axis of themultichannel cannula 600. - Various delivery devices can be coupled to the
delivery portal 604 to assist in delivering substances to thesecond channel 602 ofmultichannel cannula 600. Thedelivery portal 604 may include aremovable plug 606. In one embodiment, a user removesplug 606 to couple a delivery device 628 (illustrated schematically inFIG. 6 ) todelivery portal 604. Thedelivery device 628 may include a syringe, a pump, or a reservoir.Tubing 629 may be used to connect thedelivery device 628 to thedelivery portal 604. The type of delivery device selected by a user may depend on the type of substance to be delivered to the bone. - Once a substance has been delivered to
second channel 602 of themultichannel cannula 600 through theinlet portal 620, the substance exitssecond channel 602 via aside exit portal 608 located on an outer wall of thesecond channel 602. In this embodiment, thedistal end 610 ofsecond channel 602 is closed, preventing the substance from exiting thedistal end 610 of thesecond channel 602. However, in an alternative embodiment, thedistal end 610 of thesecond channel 602 may be open to create an exit portal such that the substance can exit thesecond channel 602 through both theside exit portal 608 and the opendistal end 610. During use ofmultichannel cannula 600, a user can align theside exit portal 608 with the area of the bone to be treated with the substance. - Referring to
FIG. 7 , multichannel cannula 700 includes five channels (701-705), each with an open distal end that can serve as an exit portal for substance delivery. In this embodiment, thefourth channel 704 includes a plurality ofside exit portals 708, although any of the other channels 702-705 may include one or more side exit portals. Thefirst channel 701 is configured to receive stabilizingwire 4 during a surgical procedure. A substance can be delivered to the inlet portals of any of channels 702-705 via a delivery portal, such as thedelivery portal 604 described in connection withFIG. 6 . In one embodiment, the substance is delivered tofourth channel 704. The substance then travels throughfourth channel 704, exiting throughside exit portals 708 and the exit portal created by the opendistal end 710 of thefourth channel 704. In an alternative embodiment, thedistal end 710 offourth channel 704 is closed to prevent substance from exiting thedistal end 710. Themultiple exit portals FIG. 7 allow the substance to be delivered to multiple areas within the interior of a bone. For example, the opendistal end 710 may deliver the substance to a distal end of ahole 6 in a bone (e.g., inbone 10 shown inFIG. 8 ) while theexit portals 708 deliver the substance to one ormore fracture sites 2. -
FIG. 8 illustrates amultichannel cannula 800 placed withinbone 10 for substance delivery. Themultichannel cannula 800 illustrated inFIG. 8 includes at least afirst channel 801 and asecond channel 802.First channel 801 is shown threaded over stabilizingwire 4.Second channel 802 is therefore used for substance delivery or to remove material from the interior of a bone. Any of the embodiments of multichannel cannulas described herein (e.g., 200, 300, 400, 500, 600, 700, and 900), and any combination of the features of these embodiments, may be utilized in the manner shown inFIG. 8 to either deliver a substance to bone or remove material from the interior of a bone. Thus, references and disclosures related to methods for usingmultichannel cannula 800 are to be understood to be references and disclosures related to methods for using any of the other structural embodiments of multichannel cannulas described herein. - One method of delivering a substance to bone according to an exemplary embodiment includes placing stabilizing
wire 4 intobone 10 and creating ahole 6 in thebone 10 around the stabilizingwire 4, as described above. The method further includes providing amultichannel cannula 800 having afirst channel 801 with an openproximal end 824 and an opendistal end 822. As also described above, theproximal end 824 anddistal end 822 of thefirst channel 801 are open so that thefirst channel 801 can receive the stabilizingwire 4. Themultichannel cannula 800 further includes asecond channel 802 having aninlet portal 820 and anexit portal 818 that are in fluid communication. - The
multichannel cannula 800 may be inserted into thehole 6 in thebone 10 such that thefirst channel 801 receives the stabilizingwire 4. During the step of inserting themultichannel cannula 800 into thehole 6, themultichannel cannula 800 can be inserted into theproximal end 6A ofhole 6 to any desired depth. A substance is then delivered to the interior ofbone 10 by introducing the substance into theinlet portal 820 of thesecond channel 802 such that the substance exits thesecond channel 802 through the exit portal 818 (i.e., the opendistal end 810 of second channel 802). In one embodiment, themultichannel cannula 800 is inserted intohole 6 such that thedistal end 809 of themultichannel cannula 800 is nearfracture 2. The substance can therefore be delivered to the fracture site through the opendistal end 810 of thesecond channel 802. In another embodiment, themultichannel cannula 800 is inserted farther intohole 6 such that substance is delivered through the opendistal end 810 of thesecond channel 802 closer to thedistal end 6B ofhole 6. - A user may select a multichannel cannula having a particular configuration and number of exit portals depending on a patient's bone fracture. For example, some types of fractures may be most easily treated by delivering a substance to a location that can be aligned with a distal end of a multichannel cannula. In this scenario, a user may select a
multichannel cannula 800 in which thedistal end 810 of asecond channel 802 is open such that the substance can be delivered tobone 10 through this opendistal end 810. In connection with other types of fractures, the user may desire to treat thebone 10 by delivering medication to one or more locations along the periphery of ahole 6 in thebone 10. Thus, a user may select amultichannel cannula 800 in whichdistal end 810 ofsecond channel 802 is closed, and a substance is delivered to the bone through side exit portals such as those described in connection withFIGS. 6 and 7 . In yet another embodiment, a substance may be delivered tobone 10 through a channel inmultichannel cannula 800 having both an opendistal end 810 and one or more side exit portals. - The
multichannel cannula 800 may also be used during treatment of a patient with a weakened, but unfractured bone. A patient's bone can be weakened due to osteoporosis, metastasis of a cancer, or other disease that causes bone deterioration. A surgeon may be able to analyze the state of the patient's bone and determine areas that are likely to sustain a fracture in the future. To treat the weakened bone, a stabilizingpin 4 is inserted and a hole is drilled into the bone. Themultichannel cannula 800 is then threaded over the stabilizingpin 4. A cement (e.g., calcium phosphate paste, methylmethacrylate) is injected through a channel of themultichannel cannula 800. The cement penetrates the surrounding bone and strengthens the area. After removal of themultichannel cannula 800, the hole in the bone may be filled with cement or a bone implant. - Prior to or during substance delivery, a user may rotate the
multichannel cannula 800 around the stabilizingwire 4. Rotating themultichannel cannula 800 may help a user align an exit portal with an intended delivery location within the bone in order to direct substance delivery to the intended delivery location. Furthermore, the ability to rotate themultichannel cannula 800 around a stabilizingwire 4 may help during guidance of themultichannel cannula 800 proximally and distally withinhole 6. - Fluoroscopic guidance may increase a user's ability to precisely deliver a substance to a desired location within
bone 10. The ability to view themultichannel cannula 800 during insertion allows a user to adjust the position ofmultichannel cannula 800 to precisely align any exit portals of themultichannel cannula 800 with the intended delivery sites withinbone 10. Once themultichannel cannula 800 is positioned and substance delivery has begun, the user can use fluoroscopic guidance to determine whether any adjustments to the position of themultichannel cannula 800 should be made to more precisely deliver the substance. For example, based on fluoroscopic guidance, the user may determine that themultichannel cannula 800 should be inserted farther intohole 6. As another example, the image guidance may indicate thatmultichannel cannula 800 should be rotated about stabilizingwire 4 to increase delivery accuracy. - The multichannel cannulas described herein may include radiopaque markers to facilitate image guidance. The radiopaque markers may be located on or near the distal tip of the multichannel cannula. In one embodiment, separate radiopaque markers are provided near the distal opening of multiple channels of the multichannel cannula. Radiopaque markers may also be provided near side portal openings in the cannula. The radiopaque markers assist a user in accurately positioning the multichannel cannula during a surgical procedure to deliver or remove a substance from a bone. Furthermore, the markers allow a user to see where a substance is exiting or entering the multichannel cannula.
- Referring to
FIG. 9 , amultichannel cannula 900 in accordance with another exemplary embodiment includes afirst channel 901 and asecond channel 902. Thesecond channel 902 includes aside exit portal 908 for the substance to exit thesecond channel 902. In the embodiment ofFIG. 9 , aninsert 912 having anexit portal 914 is used in combination withmultichannel cannula 900 to deliver a substance to bone. In an alternative embodiment, theinsert 912 includes multiple side exit portals (not shown). Theinsert 912 may be one of the embodiments of inserts described in U.S. patent application Ser. No. 13/270,072, titled “Method and Device for Delivering Medicine to Bone,” filed Oct. 10, 2011, and hereby incorporated by reference herein in its entirety. In use, theinsert 912 is inserted into thesecond channel 902. A substance is then introduced into theproximal end 916 of theinsert 912. The substance then exits theexit portal 914 of the insert and theexit portal 908 of thesecond channel 902 of themultichannel cannula 900. Theinsert 912 can be adjusted withinsecond channel 902 to alter the amount of substance ultimately delivered throughside exit portal 908 of themultichannel cannula 900. For example, theinsert 912 may be pulled in a proximal direction (i.e., away from the multichannel cannula 900) such that only a portion ofside exit portal 914 is aligned withside exit portal 908. Alternatively, theinsert 912 can be pushed in a distal direction to fully alignside exit portal 914 withside exit portal 908, as shown inFIG. 9 , which maximizes the amount of the substance delivered throughside exit portal 908. Theinsert 912 may also be rotated around its longitudinal axis to alter the alignment ofside exit portal 914 of theinsert 912 andside exit portal 908 of themultichannel cannula 900, thus adjusting the amount of the substance delivered. A delivery device 628 (shown schematically inFIG. 6 ), such as a syringe, a pump, or a reservoir, may be attached to theproximal end 916 of theinsert 912. - In another exemplary method, any of the multichannel cannulas described herein may be used to remove material, such as bone marrow or blood, from the interior of a
bone 10. Referring toFIG. 8 , asuction device 826 may be coupled to the proximal end ofmultichannel cannula 800 to aid in the removal of material. In one embodiment, thesuction device 826 is coupled to the proximal end ofsecond channel 802 bytubing 829 or via a delivery portal (e.g., thedelivery portal 604 shown inFIG. 6 ). Upon activating thesuction device 826, material being removed from thebone 10 travels through themultichannel cannula 800 in an opposite manner from the embodiments in which a substance is being delivered to the bone throughmultichannel cannula 800. For example, in the embodiment shown inFIG. 8 , activation ofsuction device 826 causes material to enter themultichannel cannula 800 through the exit portal created by opendistal end 810 or through any side exit portals in themultichannel cannula 800. The material then travels throughsecond channel 802 and exits themultichannel cannula 800 through theinlet portal 820 at the proximal end of thesecond channel 802. The exit portals of themultichannel cannula 800 may be aligned withinbone 10 to remove material from intended locations near the exit portals. - A user may use the
multichannel cannula 800 to both deliver substances tobone 10 and remove materials from the interior of abone 10 during the same surgical procedure. In one embodiment, a user first uses themultichannel cannula 800 to remove material from the interior of thebone 10. Next, themultichannel cannula 800 is used to deliver substances to areas within thebone 10. Alternatively, a user may first deliver a substance to the interior ofbone 10 using themultichannel cannula 800. After substance delivery, the user may remove excess substance (e.g., medication) or other materials (e.g., blood) by utilizing asuction device 826 coupled to the proximal end of themultichannel cannula 800. The combination of a multichannel cannula and an insert, such as themultichannel cannula 900 and insert 912 shown inFIG. 9 , may similarly be used in connection with asuction device 826 to remove material from the interior of abone 10. In this embodiment, thesuction device 826 can be coupled via tubing or via a delivery portal (e.g., thedelivery portal 604 shown inFIG. 6 ) to theproximal end 916 of theinsert 912. - The multichannel cannulas described herein can be used to irrigate the interior of a bone by simultaneously delivering a substance to the
bone 10 using one channel and applying a suction force to a separate channel. Irrigation may be useful for reducing the risk of infection or contamination within a bone. In one embodiment, a solution containing antibiotics or other medication is introduced into a first channel of a multichannel cannula. The solution travels through the first channel and enters the interior of a bone through one or more exit portals of the first channel. Simultaneously or shortly thereafter, a suction force is applied to a second channel of the multichannel cannula using a suction device, such assuction device 826 shown inFIG. 8 . The suction draws the solution from the interior of the bone and back into the multichannel cannula through an open portal of the second channel. In this manner, the interior of the bone can be irrigated using a multichannel cannula. The channel used to deliver the substance to the bone may or may not contain a stabilizingwire 4. Similarly, the channel used to draw the substance back out of the bone may or may not contain a stabilizingwire 4. In other words, the presence of a stabilizingwire 4 within a channel does not prevent substances from flowing through the channel. - The various multichannel cannula embodiments can be used in surgical procedures other than in connection with delivering or removing substances from bone. For example, the multichannel cannulas can be used in procedures requiring insertion of a cannula into a vessel. In this embodiment, a guidewire is inserted into the patient's vessel, and a first channel of the multichannel cannula is then threaded over the guidewire. The cannula can then be used as described in connection with the various methods disclosed herein to deliver or remove a substance from the vessel through a channel of the cannula. In another embodiment, the multichannel cannula is used in ear, nose, and throat procedures, with or without the use of a guidewire.
- The construction and arrangement of the devices and methods as shown in the various exemplary embodiments are illustrative only. Although only a few embodiments have been described in detail in this disclosure, many modifications are possible (e.g., variations in sizes, dimensions, structures, shapes and proportions of the various elements, use of materials, orientations, etc.). For example, the position of elements may be reversed or otherwise varied and the nature or number of discrete elements or positions may be altered or varied. Accordingly, all such modifications are intended to be included within the scope of the present disclosure. The order or sequence of any process or method steps may be varied or re-sequenced according to alternative embodiments. Other substitutions, modifications, changes, and omissions may be made in the design, operating conditions and arrangement of the exemplary embodiments without departing from the scope of the present disclosure.
Claims (20)
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CN104853685B (en) | 2020-08-14 |
US10335218B2 (en) | 2019-07-02 |
EP2919680A1 (en) | 2015-09-23 |
WO2014078709A1 (en) | 2014-05-22 |
EP2919680B1 (en) | 2019-11-06 |
CN104853685A (en) | 2015-08-19 |
US20170325866A1 (en) | 2017-11-16 |
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