Catheter Systems Enabling Improved Aspiration from Cerebral Arteries

Abstract

A distal entry point (DEP) to brain aspiration (D2BA) catheter for use in an endovascular procedure for gaining access to cervical and cerebral arteries in a brain of a patient and aspirating one or more intracranial clots from the cerebral arteries, comprising a soft distal tip region having a distal length sufficient to extend from a level 1 or level 2 arterial segment of a cerebral artery or equivalent to an upper neck arterial vessel, a stiffness enabling movement through the level 1 or level 2 arterial segment of the cerebral artery, and an outside diameter (OD) of 6F-10F, a proximal region having a stiffness greater than the stiffness of the soft distal tip region, the proximal region having a length sufficient to extend to outside the patient through the DEP.

Claims

1-60. (canceled)

61. A catheter for gaining access to cervical and cerebral arteries in a brain of a patient and for aspirating intracranial clots from the cerebral arteries, comprising: a catheter body having a distal tip section and proximal section, the catheter body having: a catheter body length of greater than 120 cm; a distal tip section length of 12-30 cm; and, a outside diameter (OD) greater than 6F and less than 10F.

62. The catheter as in claim 61 where the distal tip section has a stiffness enabling the distal tip section to ride over a guide wire (GW) and diagnostic catheter (DC) positioned beyond the aortic arch through the aortic arch without external support.

63. The catheter as in claim 62 where the stiffness of the distal tip section is less than a proximal section stiffness.

64. The catheter as in claim 61 where the outside diameter (OD) is 7F and the distal tip section length corresponds to a distance from an upper neck arterial vessel to level 2 segments of the middle cerebral artery or from the distal cervical vertebral artery to the basilar artery or equivalent.

65. The catheter as in claim 64 where the distal tip section length is 17-25 cm.

66. The catheter as in claim 61 where the OD is greater than 8F and the distal tip section length corresponds to a distance from an upper neck arterial vessel to distal level 1 segments of the middle cerebral artery.

67. The catheter as in claim 66 where the distal tip section length is 15-23 cm.

68. The catheter as in claim 61 where the OD is greater than 9F and the distal tip section length corresponds to a distance from an upper neck arterial vessel to proximal level 1 segments of the middle cerebral artery or equivalent.

69. The D2BA catheter as in claim 68 where the distal tip section length is 13-21 cm.

70. The catheter as in claim 61 where the outside diameter (OD) is 10 F and the distal tip section length extends from an upper neck arterial vessel to distal segments of the internal carotid artery or equivalent.

71. The D2BA catheter as in claim 70 where the distal tip section length is 12-16 cm.

72. The catheter as in claim 61 where the distal tip section has a distal tip with a radio opaque marker.

73. The catheter as in claim 61 where the catheter body has a radio opaque maker at a transition point between the distal tip section and proximal section.

74. The catheter as in claim 61 where the catheter body includes a transition zone between the proximal section and distal tip section and where the transition zone includes sub-zones having different stiffness properties.

75. A distal entry point (DEP) to brain aspiration (D2BA) catheter for use in an endovascular procedure for gaining access to cervical and cerebral arteries in a brain of a patient and aspirating one or more intracranial clots from the cerebral arteries, the D2BA catheter for advancement within the human vasculature of the patient between the DEP and the cerebral arteries in the brain over a guide wire (GW) and diagnostic catheter (DC) alone, comprising: a soft distal tip region having a distal length sufficient to extend from a level 1 or level 2 arterial segment of a cerebral artery or equivalent to an upper neck arterial vessel, the soft distal tip region having an outside diameter (OD) of greater than 6F to 10F; and a proximal region having a stiffness greater than the stiffness of the soft distal tip region, the proximal region having a length sufficient to extend to outside the patient through the DEP when the soft distal tip region is within the cerebral arteries; wherein after removal of the GW and DC, the D2BA catheter enables aspiration through the D2BA catheter to remove the one or more clots.

76. A kit for use in an endovascular procedure for gaining access to cervical and cerebral arteries and aspirating intracranial clots from the cerebral arteries, comprising: an endovascular catheter for placement within the human vasculature between a distal entry point (DEP) and cerebral arteries comprising a D2BA catheter having: a catheter body having a distal tip section and proximal section, the catheter body having: a catheter body length of greater than 120 cm; a distal tip section length of 12-30 cm; and, an outside diameter (OD) greater than 6F and less than 10F at least one diagnostic catheter (DC), each DC having an outside diameter to fit and slide within the D2BA catheter and each DC having a pre-shaped tip for accessing varying anatomies of an aortic arch and having a length longer than the D2BA catheter; and a guide wire (GW) having a diameter to fit and slide within the DC and having a length longer than the DC.

77. The kit as in claim 76 further comprising an internal support catheter (ISC), the ISC having an outside diameter to fit and slide within the D2BA catheter and a tapered distal zone for supporting and transitioning the distal tip of the D2BA catheter in tightly curved arteries during advancement of the D2BA catheter into the cerebral arteries.

78. The kit as in claim 76 having two or more DCs.

79. The kit as in claim 76 further comprising an aspiration catheter having an outside diameter maximized for operative movement within the D2BA catheter and having a length sufficient to extend to a position substantially equivalent to a distal tip of the D2BA catheter.

80. The kit as in claim 76 further comprising a cooling catheter having an outside diameter maximized for operative movement within the D2BA catheter and having a length sufficient to extend to a position substantially equivalent to a distal tip of the D2BA catheter.

81. The kit as in claim 76 further comprising a second D2BA catheter sized to fit within the D2BA catheter and a corresponding second ISC and second MW sized to fit in the second D2BA catheter each having lengths greater than the D2BA catheter.

82. An endovascular method for gaining access to cervical and cerebral arteries, the endovascular method for placing a catheter system within a human vasculature between a distal entry point (DEP) and cerebral arteries and aspirating a cerebral clot in one of the cerebral arteries, the method comprising the steps of: a) introducing a catheter system including a D2BA catheter, guide wire (GW) and diagnostic catheter (DC) through a DEP; b) advancing the catheter system to an aortic arch; c) advancing the GW and DC to a desired cervical artery and manipulating the GW into a desired cervical artery; d) advancing the D2BA catheter to a desired carotid artery over the DC and GW; e) removing the DC and GW; f) introducing an internal support catheter (ISC) having a tapered distal section for supporting a distal end of the D2BA catheter and adapted to facilitate movement of the distal end through tight curves in the cerebral vasculature and an ISC microwire (ISC MW); g) advancing the ISC and ISC MW to the cerebral artery with the clot; h) advancing the D2BA catheter to a proximal face of the clot and withdrawing the ISC and ISC MW; and, i) applying suction to the clot through the D2BA catheter.

83. The method as in claim 82 further comprising the steps of: j) after applying suction to withdraw a clot in step i, conducting a check angiogram to determine if the entire clot has been withdrawn and if one or more distal emboli are present and if present; k) advancing a second D2BA catheter sized for co-axial movement within the D2BA catheter together with a second ISC and second ISC MW to a proximal face of the distal emboli; and, l) applying suction to the second D2BA catheter to withdraw the distal emboli via aspiration or by withdrawing the second D2BA catheter.

84. The method as in claim 82 where step i includes applying one or more first pressure pulses through the D2BA catheter to assist in engaging the distal tip of the D2BA catheter against the clot followed by at least one second aspiration pulse to aspirate the clot.

85. The method as in claim 84 further comprising the step of comparing a pre-determined pressure pulse against a measured response pressure at a suction pump and adjusting subsequent pressure pulses based on the measured response pressure.

86. The method as in claim 85 wherein the step of adjusting subsequent pressure pulses considers pressure response data from a plurality of patients collected and analysed from similar procedures.

87. The method as in claim 82 wherein suction is applied via a suction pump operatively connected to the internet and a central computer system and wherein pressure response data from different pumps is received and analysed by the central computer system and wherein pump pressure algorithms are updated via the internet to the different pumps.

88. The method as in claim 87 wherein pump pressure algorithms consider catheter materials, brand and/or size.

89. The method as in claim 82 wherein if aspiration has been unsuccessful further comprising the step of introducing an aspiration catheter into the D2BA catheter and advancing the aspiration catheter to the distal tip of the D2BA catheter and applying suction through the D2BA catheter.

90. The method as in claim 82 wherein if aspiration has been successful further comprising the step of introducing a cooling catheter into the D2BA catheter and advancing the cooling catheter to the distal tip of the D2BA catheter and flushing a cooling fluid through the cooling catheter to effect cooling of brain tissue.

91. The method as in claim 90 further comprising the step of flushing brain nourishing solution through the cooling catheter.

92. The method as in claim 90 where the cooling catheter is an ISC having proximal insulation and where after the ISC has been withdrawn and aspiration has been completed, the ISC is re-introduced and brain nourishing solution is flushed through the ISC.

Description

BRIEF DESCRIPTION OF THE DRAWINGS

[0164] The invention is described with reference to the drawings in which:

[0165] FIG. 1A is a sketch of a typical aortic arch and associated vessels in accordance with the prior art.

[0166] FIG. 1B is a schematic diagram showing medium vessel occlusion sites (MeVO) in accordance with the prior art. These are generally defined as sites in the anterior circulation including (A): proximal M2 segment, distal M2 segment, M3 segment, A2 segment, and A3 segment. MeVO sites in the posterior circulation are generally defined as the P2 segment or P3 segment (B).

[0167] FIG. 1C is a schematic diagram of a clot Y lodged within the MCA at the M1 segment in accordance with the prior art.

[0168] FIG. 2A is a schematic diagram showing advancement of a guide wire, diagnostic catheter and G2BA through the aortic arch and into the common carotid artery (CCA) in accordance with one embodiment of the invention.

[0169] FIG. 2B is a schematic diagram showing features of a G2BA in accordance with the invention including structural parameters of axial stiffness, radial compressibility, axial compressibility and torquability.

[0170] FIG. 3 is a schematic diagram showing the steps of a procedure in accordance with one embodiment of the invention to position a G2BA catheter within the cerebral arteries of a patient.

[0171] FIG. 3A is a schematic diagram showing additional steps of a procedure in accordance with one embodiment of the invention to position a G2BA catheter at a higher level within the cerebral arteries of a patient.

[0172] FIG. 4 is a schematic diagram showing the use of an integrated support catheter (ISC) is an assisting a G2BA catheter through a tortuous section of the cerebral vaculature in a accordance with one embodiment of the invention.

[0173] FIG. 4A is a schematic diagram showing the use of two microcatheters as an integrated support catheter (ISC) is an assisting a G2BA catheter through a tortuous section of the cerebral vaculature in a accordance with one embodiment of the invention.

[0174] FIG. 5A is a schematic diagram showing the potential engagement of an aspiration catheter and clot in accordance with the prior art.

[0175] FIG. 5B is a schematic diagram showing the potential engagement of an aspiration catheter and clot in accordance with the prior art after suction has been applied.

[0176] FIG. 5C is a schematic diagram showing the potential engagement of a G2BA catheter and clot in accordance with one embodiment of the invention after suction has been applied.

[0177] FIG. 5D is a schematic diagram showing a G2BA catheter having an oblique tip that is torquable.

[0178] FIG. 6A is a schematic diagram showing a clot corked in a G2BA and an aspiration catheter proximal to the distal tip of the G2BA.

[0179] FIG. 6B is a schematic diagram showing a G2BA catheter and a second G2BA catheter being used to conduct a secondary aspiriation of a distal emboli.

[0180] FIG. 6C is schematic diagram of an insulated/cooling catheter within a G2BA catheter.

DETAILED DESCRIPTION OF THE INVENTION

Rationale

[0181] The inventor understood that aspirating blood clots from the cerebral arteries had limitations using current catheter designs and methods.

Terminology

[0182] The terminology used herein is for the purpose of describing particular embodiments only and is not intended to be limiting of the invention. As used herein, the singular forms “a”, “an” and “the” are intended to include the plural forms as well, unless the context clearly indicates otherwise. It will be further understood that the terms “comprises” and/or “comprising,” when used in this specification, specify the presence of stated features, steps, operations, elements, and/or components, but do not preclude the presence or addition of one or more other features, steps, operations, elements, components, and/or groups thereof. As used herein, the term “and/or” includes any and all combinations of one or more of the associated listed items.

[0183] Spatially relative terms, such as “distal”, “proximal”, “forward”, “rearward”, “under”, “below”, “lower”, “over”, “upper” and the like, may be used herein for ease of description to describe one element or feature's relationship to another element(s) or feature(s) as illustrated in the figures. It will be understood that the spatially relative terms are intended to encompass different orientations of the device in use or operation in addition to the orientation depicted in the figures. For example, if a feature in the figures is inverted, elements described as “under” or “beneath” other elements or features would then be oriented “over” the other elements or features. Thus, the exemplary term “under” can encompass both an orientation of over and under. A feature may be otherwise oriented (rotated 90 degrees or at other orientations) and the spatially relative descriptors used herein interpreted accordingly. Similarly, the terms “upwardly”, “downwardly”, “vertical”, “horizontal” and the like are used herein for the purpose of explanation only unless specifically indicated otherwise.

[0184] It will be understood that when an element is referred to as being “on”, “attached” to, “connected” to, “coupled” with, “contacting”, etc., another element, it can be directly on, attached to, connected to, coupled with or contacting the other element or intervening elements may also be present. In contrast, when an element is referred to as being, for example, “directly on”, “directly attached” to, “directly connected” to, “directly coupled” with or “directly contacting” another element, there are no intervening elements present.

[0185] It will be understood that, although the terms “first”, “second”, etc. may be used herein to describe various elements, components, etc., these elements, components, etc. should not be limited by these terms. These terms are only used to distinguish one element, component, etc. from another element, component. Thus, a “first” element, or component discussed herein could also be termed a “second” element or component without departing from the teachings of the present invention. In addition, the sequence of operations (or steps) is not limited to the order presented in the claims or figures unless specifically indicated otherwise.

[0186] Structural parameters such “axial stiffness”, “radial compressibility”, “axial compressibility” and “torquability” may be described as relating to various functional properties that a catheter in relation to a catheter's performance or behaviour in the human body during endovascular procedures as would be understood by those skilled in the art. That is, catheters as described herein, being sophisticated pieces of medical equipment that are used in complex medical procedures that use an assortment of other equipment (including the absence of various pieces of equipment) are more clearly and broadly defined in terms of their performance as opposed to specific definitions utilizing number ranges.

[0187] Other than described herein, or unless otherwise expressly specified, all of the numerical ranges, amounts, values and percentages, such as those for amounts of materials, elemental contents, times and temperatures, ratios of amounts, and others, in the following portion of the specification and attached claims may be read as if prefaced by the word “about” even though the term “about” may not expressly appear with the value, amount, or range. Accordingly, unless indicated to the contrary, the numerical parameters set forth in the following specification and attached claims are approximations that may vary depending upon the desired properties sought to be obtained by the present invention. At the very least, and not as an attempt to limit the application of the doctrine of equivalents to the scope of the claims, each numerical parameter should at least be construed in light of the number of reported significant digits and by applying ordinary rounding techniques. Generally, outer diameters of catheters are referred to in French (FR) units whereas the inner diameters (IDs) of catheters are referred to in inches. When reference is made to the dimensions of a “sheath”, French units are used to refer to an inner diameter.

[0188] Unless otherwise defined, all technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art to which this invention belongs.

[0189] Various aspects of the invention will now be described with reference to the figures. The invention may, however, be embodied in many different forms and should not be construed as limited to the embodiments set forth herein; rather, these embodiments are provided so that this disclosure will be thorough and complete, and will fully convey the scope of the invention to those skilled in the art. Moreover, the drawings are not necessarily drawn to scale and are intended to emphasize principles of operation rather than precise dimensions.

INTRODUCTION

[0190] FIG. 1A shows a typical aortic arch 5 and associated vasculature including the ascending aorta 5a, descending aorta 5b, left subclavian artery 5c, common carotid artery 5d, brachiocephalic artery 5e, right subclavian artery 5f and internal carotid artery 5g. FIG. 1B is a schematic diagram showing medium vessel occlusion sites (MeVO). These are generally defined as sites in the anterior circulation including (A): proximal M2 segments, distal M2 segments, M3 segments, A2 segments, and A3 segments. MeVO sites in the posterior circulation (B) are generally defined as the P2 segments or P3 segments. FIG. 10 is a schematic diagram of a clot lodged in the M1 segment of the MCA. Associated vessels include the common carotid artery (CCA), ophthalmic artery (OA), internal carotid artery (ICA), anterior cerebral artery (ACA) and middle cerebral artery (MCA) including M1 and M2 segments.

[0191] In accordance with the invention, with reference to FIGS. 2A and 3, large size aspiration (LSA) catheters 10 are described having 1) a distal zone 10a having a distal end 10b that can be positioned adjacent a typical clot within particular zones of the cerebral vasculature including level 2 segments of the middle cerebral artery and basilar artery (or higher) (collectively the “target levels”) 2) a proximal zone 10c having a proximal end 10d where the LSA catheter does not require external (eg. via a guide catheter (GC) or balloon guide catheter (BGC)) support when it is being advanced through the aortic arch and into the cervical arteries and 3) outside diameters (ODs) greater than 6 French and less than or equal to 10 French.

[0192] In the context of this description, in various embodiments, the LSA catheter is referred to as a groin to brain aspiration catheter (G2BA) which refers to the most common access point (i.e. the groin) for conducting cerebral endovascular procedures. However, the LSA catheter may also be referred to as a distal entry point (DEP) to brain catheter (D2BA), which contemplates distal entry points including both the femoral artery (groin) and the radial artery. That is, it is understood that other entry points for cerebral endovascular procedures besides the groin are contemplated in accordance with the invention. Generally, as noted below, the length dimensions of the proximal zone of a D2BA are adjusted based on the DEP having consideration to the respective distance from a groin entry point vs. a radial artery entry point. As such, reference to LSA, G2BA and D2BA catheters are used within the description.

[0193] Generally, the G2BA catheter is defined as a catheter useful to conduct endovascular procedures in the brain having a larger OD (7-10F) and a corresponding larger lumen (internal diameter) extending from the proximal end 10d to the distal end 10b wherein the ID of the lumen is in the range of 0.066″ to 0.105″ (preferrably 0.072″ to 0.105″ and more preferably 0.078″ to 0.105″ determined on basis of the intended target level).

[0194] In general, the outer diameter of the G2BA catheter at its distal end is expected to closely match the lumen diameter of the target vessel and where the inner diameter of the G2BA is the largest possible (i.e having a minimized wall thickness) that provides the necessary rigidity to conduct an aspiration procedure as described herein.

[0195] As such, at one level the invention seeks to enhance clot capture by aspiration by minimizing the diameter difference between the clot and G2BA catheter. In this regard, it is recognized that the ID of the G2BA catheter cannot equal the vessel lumen (due to the catheter wall thickness) but that clot capture can be substantially improved by minimizing this difference. Moreover, it is also recognized that a clot usually has some degree of compressibility and that the placement of a catheter having an OD substantially the same as a target vessel results in the catheter being effectively wedged in the target vessel which improves suction pressure to the clot as will be described in greater detail. It is also recognized that a larger G2BA lumen enables a higher aspiration force to be applied without damage to the vessel intima.

[0196] Importantly, in the past, advancement of larger size aspiration catheters within the brain was often not possible as aspiration catheters require larger guide catheters to be advanced into the neck to externally support the aspiration catheters when being advanced. The use of external guide catheters reduces the effective size of aspiration catheters that can be advanced through the guide catheters. In addition, heretobefore, aspiration catheters could not be advanced over DCs/GW due to the relative distal stiffness of such catheters. Moreover, in the past, it has been difficult to advance aspiration catheters through certain vessels (eg. the ophthalmic artery) due to the tortuosity of such vessels and their relative distal tip stiffness. While U.S. Pat. No. 10,456,552 teaches that advancement of certain catheters through tortuous sections of the cerebral vasculature can be improved utilizing internal support catheters (ISCs), there are limits given the structure of an aspiration catheter.

[0197] As shown in Table 3, the G2BA is designed in different lengths and outside diameters (i.e. French sizes; referred to as “catheter size”) that enable access to particular levels of the brain. These parameters are identified and discussed in Table 3.

TABLE-US-00003 TABLE 3 G2BA Features and Properties Feature Value Discussion Overall Length Approximately The overall length of a G2BA will be determined by the 120-140 cm desired brain location where the the physician wishes to place the distal tip of a G2BA. That is, smaller French size catheters will generally be longer and larger French size catheters will be shorter reflecting the total distance from extracorporeal access point to the target vessel in the brain. For groin access catheters this range will typically be 120- 140 cm. Radial artery access catheters will be proportionally shorter. Distal Tip Zone Length Approximately The length of the distal tip zone will also be determined by 20 cm the desired brain location where the the physician wishes Range 18-30 cm to place the distal tip of a G2BA. Similarly, a shorter distal tip region will be incorporated into a G2BA having a larger French size whereas longer distal tip regions will be incorporated into a G2BA having a smaller French size. End Cerebral arteries The overall length of the G2BA and distal tip zone length Anatomical (Anterior and are determined by different end anatomical positions. Position Posterior Generally, the furthest level of effectiveness of a primary circulations) G2BA will be Level 2 segments of the middle cerebral Level 2 artery and the basilar artery. Anatomical variants that lead segments max to very prominent Anterior cerebral artery, Posterior cerebral artery, Persistent Trigeminal artery may also be accessed using a G2BA. For example, a 7F G2BA is designed to reach Level 2 segments (M2 segment of the MCA), an 8F G2BA is designed to reach the mid-Level 1 segments (distal M1 segment of the MCA), a 9F G2BA is designed to reach Level 1 segments (proximal M1 segment of MCA) and a 10F G2BA is designed to reach the distal ICA level (or equivalent). Secondary G2BAs may access deeper regions including Level 3 segments or equivalents. Axial Stiffness Soft The axial stiffness of the distal tip region is sufficiently pliable to enable movement through cerebral arteries to the desired level and to be able to ride over a guide wire and diagnostic catheter and/or ISC and MW positioned between a DEP and cervical arteries without causing prolapse of the DC and GW. Distal Tip Preferably 6-10 F The distal tip OD corresponds to the G2BA catheter size, Outside namely 6 F-10 F. Diameter Distal Tip Preferred ID For each catheter size, the distal tip inside diameter will be Inside Range maximized whilst ensuring functionality as described. That Diameter 0.053-0.105 is, that is distal tip wall thickness is ideally minimized whilst inches ensuring the aspiration and deployment properties remain. In practical terms, catheters may have a wall thickness in the range of 0.009″. For a 7 F catheter having a wall thickness of approximately 1 F or 0.009″ and an OD of 0.092″, the distal tip ID is approximately 0.074″. Other IDs are shown in Table 4. Proximal same or The G2BA will generally have a consistent OD along its Diameter minimally larger length; however some tapering is not excluded. Tapering than distal may allow for a minimally larger distal diameter. diameter Tip Edge rounded/ The distal tip edge will be rounded/atraumatic to allow atraumatic/ contact with the vessel intima without damaging the intima. radio-opaque/ The tip will be radio-opaque to assist the physician in oblique angle or correctly positioning the G2BA. The radio-opaque portion bevelled tip will typically be a ring structure incorporated into the distal tip. The distal tip edge may have an oblique/bevelled end to facilitate clot capture as described below. Opening Semi-Rigid Enables retrograde flow and recovery of clot. Radial rigidity The radial rigidity will be sufficient to enable retrograde flow and clot capture without collapse. The radial rigidity is balanced with axial rigidity/flexibility. Axial rigidity/ The G2BA axial rigidity is sufficient to enable distal flexibility/ movement of the G2BA over an ISC, MC, MW and/or a DC compressibility without external support. The G2BA axial flexibility is /torquability. sufficient to enable distal movement around curves (potentially in conjunction with an ISC to assist as explained herein). The G2BA axial compressibility is sufficiently rigid to prevent axial buckling of the G2BA under deployment conditions. The G2BA may be torquable along its length. Proximal Zone Length Approximately The proximal zone length is determined having 100 cm for a consideration to the OD size of the G2BA, the DEP and G2BA end anatomical position. (90-110 cm) End Extracorporeal to The end anatomical position of the proximal zone region is Anatomical distal cervical variable and for a given G2BA will generally be determined Position arteries by the length of the distal tip region. In other words, the G2BA is primariliy designed by the length of distal tip region such that the end anatomical position of the proximal zone will be in the region of the base of the skull during deployment with a length sufficient to extend to the DEP and outside the body. Distal Junction same or The G2BA will generally have a consistent ID along its Internal minimally larger length. Diameter than distal zone The G2BA will generally not be characterized by a “hard” transition between the distal/proximal zones but rather has a zone of transition having a range of axial stiffness (i.e. flexibility) values throughout this zone. Proximal 7-10 F The G2BA will generally have a consistent OD along its External length. Diameter Radial Rigidity May be stiffer The G2BA radial rigidity in the proximal zone is the same than distal or higher than the radial rigidity of the distal tip region. Axial stiffness/ The G2BA axial stiffness/rigidity/flexibility in the proximal rigidity/ zone is the same or higher than the axial flexibility stiffness/rigidity/flexibility of the distal tip region and Axial sufficient to enable distal movement of the G2BA over an compressibility ISC, MC, a MW and/or a DC without external support. Axial The G2BA axial stiffness/rigidity/flexibility in the proximal torquability zone is the same or higher than the axial flexibility of the distal tip region and sufficient to enable distal movement around curves such as through the aortic arch. The G2BA axial compressibility in the proximal zone is the same or higher than the axial compressibility of the distal tip region and sufficiently rigid to prevent axial buckling of the G2BA under deployment conditions. The G2BA may be torquable along its length.

[0198] Importantly, it is understood that the transition between the proximal and distal zones is preferably not abrupt and that a transition zone may include a number of sub-zones that provide a transition between the properties of the proximal and distal zones. That is, the axial stiffness of the distal zone may progressively increase in the proximal direction such that the physical properties of the G2BA have sub-zones where the properties are consistent over a 4-8+cm segment and then step to a different sub-zone with different properties. For the proximal zone, these are shown representatively as P1, P2 and P3 (where stiffness may increase from P1-P3) and as D1, D2 and D3 (where stiffness may decrease from D1-D3) for the distal zone in FIG. 3. As such, the point of transition between the distal zone and the proximal zone is generally considered to be a measured distance from the distal tip (for a particular target level) where the transition point is the high cervical arteries. In some embodiments, a specific radio opaque marker 40a may be incorporated into the transition point to assist the physician in visualizing the location of the transition point as well as at a radio-opaque distal tip marker 40.

TABLE-US-00004 TABLE 4 Typical OD and ID sizes of Catheters Typical Wall Typical Thickness ID OD French (inches) (inches) (inches) 7 0.009-0.013 0.066 0.092 8 0.009-0.013 0.079 0.105 9 0.009-0.013 0.092 0.118 10 0.009-0.013 0.105 0.131

[0199] The relative size of the G2BA catheter and the ability to deploy the G2BA to a level where the distal tip is substantially engaged with the ID of the vessel and in close proximity to a clot provides numerous advantages over past systems and specifically improves the time to access and the ability to capture clots via aspiration.

[0200] The G2BA catheter obviates the need for a GC or BGC by preventing (or substantially stopping) antegrade flow during a procedure and the attendant risk of micro-emboli being carried away. That is, the effective size of the G2BA relative to the ID of the vessel can substantially prevent antegrade flow after the G2BA catheter has been positioned due to gentle wedging of the distal tip within the target vessels.

G2BA Construction

[0201] Catheters used to access regions of the brain are constructed using a variety of techniques to give the catheter the desired performance properties including pushability, torquability, trackability and stiffness. Generally, a catheter may be constructed from engineered polymers including polyurethanes, nylons, silicone rubber, polyethylene terephthalate (PET), latex, thermoplastic elastomers and polyimides. Microfilaments of polymers and metals may be incorporated.

[0202] Typically, catheters are manufactured from an assembly of smaller sections of various formulations of the polymers that have been extruded, thermoformed and/or thermoset using a wide range of techniques including casting and/or assembly over a mandrel. Each formulation has been engineered to include different properties; hence, different sub-zones may have for example slightly different stiffness properties along the length of either the proximal or distal zones as noted above.

Deployment Methods and Use

[0203] In accordance with a method of the invention, procedures for introducing a G2BA catheter are described (referred to as “the G2BA method”) with reference to FIGS. 2A, 3 and 3A. For the purposes of description, FIGS. 2A, 3 and 3A assume access from the femoral artery and desired access to the M1 segment through the ICA. It should also be noted that the lengths of each piece of equipment in FIGS. 3 and 3A are not specifically drawn to scale and specifically, for clarity, sections of each piece of equipment outside the body are not drawn to show a consistent overall length in each of the steps outlined below.

[0204] Initially, after arterial puncture, a sheath 20 is deployed (Step 1). A femoral artery sheath will have a maximum ID of about 12F (typically 9-10F). Access through the radial or brachial artery will utilize a sheath having a maximum ID of about 7F-8F.

[0205] Thereafter or concurrently, an assembly of a G2BA 10, a diagnostic catheter (DC) 24 with tip 24a and guide wire (GW) 26 (typically 0.035″) is assembled and progressively introduced into the sheath (Step 2) and advanced to the aortic arch. The chosen assembly of G2BA, DC and GW will be based on the location of the clot together with the physician's assessment of the aortic arch access vessel and the patient's aortic arch anatomy/variability. That is, in planning the procedure, the physician will have determined where the clot is located and how access to the clot is to be achieved. In this example, if the clot is at the M1 level requiring access through the common carotid artery (CCA) and ICA, an 8F G2BA may be selected in combination with a preferred DC for accessing the CCA. Alternatively, if the clot is located at the P1 level of the basilar system requiring access through the right subclavian, a smaller (eg. 7F) G2BA and different DC may be selected and assembled.

[0206] As the GW and DC are advanced to the aortic arch, the distal tip 10b of the G2BA will also be advanced and held in a position typically no more than 20 cm behind.

[0207] The DC and GW are manipulated to gain access to the desired cervical artery (Step 2). The GW is generally held at substantially the same position as the DC during the steps where access to the cervical artery is being obtained. During this step, the DC and GW are torqued, pushed and/or pulled in order to hook the tip of the DC into the desired vessel. When the DC/GW are in the desired vessel, by a combination of advancing the GW and DC, the two can be advanced to the base of the skull (Step 3). In the presence of severe tortuousity or stenosis or occlusion of the origin of the internal carotid artery (ICA) for example, initial access to the external carotid artery (ECA) could be obtained. In certain situations, the use of a second “buddy wire”, that is a second GW may also be deployed to assist the physician in providing support to the system.

[0208] With the GW and DC being held at roughly the base of the skull, the G2BA is also advanced over the DC/GW such that the G2BA follows the DC and GW until the distal tip of the G2BA is adjacent the distal tip of the DC and GW (Step 3). The soft distal tip and the lack of a pre-determined shape of the G2BA makes it conducive to follow the DC and GW. At this point, the soft distal tip is fully within the cervical arteries and the stiffer proximal portion of the G2BA is within the cervical arteries and approximately 10 cm (8-12 cm) past the aortic arch. The GW and DC would typically not be advanced past the base of the skull and would be removed (Step 4).

[0209] Importantly, with the stiffer portion of the G2BA in the cervical arteries, and the removal of the DC and GW (step 4), the risk of prolapse of the G2BA into the ascending aorta is substantially eliminated when further equipment is introduced into the G2BA (Step 5).

[0210] In Step 5, a microcatheter (MC) or an integrated support catheter (ISC) 28 and a microwire (MW) 30 are introduced and are advanced to the clot Y. When the clot is reached with the MC or ISC and MW, the G2BA 10 is advanced over the MC or ISC to the face of the clot. For reasons explained below, it is preferred that an ISC is used. As shown in FIG. 4, ISCs 28 are characterized as having a distal taper 28a, straight section 28b and proximal taper 28c (in various embodiments, an ISC may not have a proximal taper and the straight section 28b may extend along the entire proximal length of the ISC) that supports and otherwise provides an effective transition between the distal end 10b of a catheter and a microcatheter to form a smooth extension of the distal end 10b of a catheter. That is, an ISC fills the distal end of the G2BA catheter and provides a smooth extension to a catheter particularly as the catheter assembly is moved through tight curved areas of the vasculature 50. By extending and engaging with the vessel wall 50, the vessel wall exerts a force F1 against the ISC that is transmitted through the ISC such that the ISC exerts a force F2 against the distal tip 10b of the G2BA that then aligns the G2BA within the vessel 50 allowing the G2BA to be more effectively pushed through the vessel. Thus, through selective manipulation of each of the G2BA, ISC and MW, the physician can advance the G2BA past the tortuous section.

[0211] An ISC is not required in that a physician may believe that it will be unlikely that the G2BA will get stuck but in most cases it is preferable to introduce an ISC instead of a MC in anticipation of the G2BA potentially getting stuck.

[0212] Further still, as shown in FIG. 4A, an alternative may be for the physician to use two or more microcatheters (29a, 29b) to ease the G2BA around a tight curve. In this case, each MC may be selectively advanced short distances from the distal tip of the G2BA to provide the alignment to prevent the G2BA from becoming stuck.

[0213] The MC/ISC and MW are pushed forward to extend from the distal tip of the G2BA. The MC or ISC and MW and G2BA are progressively advanced to the clot through sequential manipulation of each.

[0214] Importantly, it should again be noted that in comparison to past aspiration catheters, the OD of the G2BA is larger and a comparatively larger distal tip has been advanced further.

[0215] The larger distal tip diameter generally means that the G2BA will essentially occlude the vessel it is in and hence, due to a support pressure from the vessel walls, it will be more likely that the distal tip of the G2BA is aligned perpendicularly to the vessel as shown in FIG. 5C as opposed to be marginally deflected as shown in FIG. 5A. That is, as shown in FIG. 5A, an AC in accordance with the prior art that is smaller than the vessel may have unequal push forces being applied along inside and outside edges of the catheter such that an outside edge where there is a greater force F3 has extended one side of the distal tip ACt further through the vessel as compared to an inside edge and force F4 resulting in a deflection of the distal tip to an angle θ. As shown in FIG. 5A, if the distal tip ACt is not aligned, applying an aspiriation pressure P1 can result in less effective pressure being applied as blood may flow back into the catheter as shown by P2 and P3.

[0216] Furthermore, techniques of improving clot capture with a smaller AC include the step of introducing suction to the AC and waiting a period of time (typically 90 seconds) to allow the clot to potentially align with the AC and/or deform to engage with the distal tip of the AC. However, as shown in FIG. 5B, the application of aspiration pressure P1 may cause the clot Y to deform around the AC thus preventing the clot from being aspirated and/or causing the clot to fragment.

[0217] As shown in FIG. 5C, there is a greater likelihood of alignment of the distal tip of the G2BA with the clot which in a number of situations will improve the likelihood of clot capture.

[0218] The G2BA, with its larger distal tip opening, and hence improved likelihood of being perpendicular to the vessel is more likely to be aligned and sealed against the vessel wall. Hence, the application of suction can be more effective in that there may be less “leakage” from around the distal tip.

Method to Prevent Clot Fragmentation/Emboli in New Territory

[0219] In other aspects, the invention provides a method to reduce clot fragmentation and/or a method to reduce emboli in new territory. As is known, clots may be comprised of different zones or segments having different compositions that affect the overall rigidity/cohesion of the clot. Generally, a blood clot may range in composition and consistency between tougher fibrin-rich zones/fragments and softer zones/fragments where the cohesion between these zones may be relatively strong or relatively weak. Fibrin-rich zones will generally have greater cohesive forces that hold the clot together whereas other zones may be less cohesive and be more susceptible to fragmentation. It is a common occurrence when using smaller aspiration catheters and/or when the clot is fibrin-rich that the clot will “cork” in the end of the catheter and cannot be withdrawn through aspiration into the catheter. If a clot is corked, it requires withdrawal of the AC which has two main potential downsides. Firstly, the act of withdrawing results in a loss of position which will require time to regain if necessary. Secondly, the act of withdrawing can cause a clot to fragment wherein only a part/fragment of the clot is withdrawn and leaves a portion/fragment of the clot at the clot site. This clot fragment may be smaller and go into distal vessels making retrieval even tougher. Also as the clot is being withdrawn, it comes across the origin of other big vessels. For example, when the catheter is being withdrawn from the MCA, it will cross the origin of ACA: at that time the clot may fragment and a part of the clot may go into the ACA resulting in a new stroke, commonly called: infarct in new territory (INT).

[0220] If fragmentation occurs, this then requires that after withdrawal of the first piece, the AC must be readvanced back to the clot face to remove the one or more remaining fragments which is a significant time delay to reperfusion.

[0221] As such, the G2BA also provides a method of reducing clot fragmentation by improving the aspiration forces being applied to a clot at the intended levels of the G2BA, which are more likely to fully ingest the clot which then reduces the likelihood of requiring G2BA withdrawal which can cause fragmentation.

[0222] Similarly, a clot that is not fully aspirated or withdrawn may fragment into one or more additional pieces/emboli that travel to distal sites. Thus, the G2BA also provides a method of reducing emboli in new territory by applying an improved aspiration pressure to a clot that increases the likelihood that any smaller fragments that would otherwise create distal emboli are aspirated together with the main fragments of the clot.

Oblique G2BA Tip and Torquable G2BA

[0223] FIG. 5A shows that the tip of an AC may be deflected as it pushed around a curve such that the distal tip may have an angle θ, with respect to the vessel wall. Depending on the particular orientation of the distal tip and the particular proximal surfaces of the clot, this contact angle between the distal tip and the clot may assist aspiration or alternatively negatively affect aspiration. For example, aspiration can be enhanced if the distal tip forms an elliptical opening and the distal tip is oriented in such a was so as to improve the contact angle with the clot; however, equally the contact angle between the distal tip and the clot may impair aspiration if the oblique surface is not “parallel” to the proximal surface of the clot. Generally, oblique surfaces can increase the surface area of contact further increasing the chance of the clot being ingested. In the past, aspiration catheters were not designed to be torquable and hence, be able to control or change the contact angle.

[0224] Current catheters are not torquable as they are made of soft material and torqueing (applying a rotational force) at the part of the catheter that is outside the body does not transmit the force to the distal end but instead damages the catheter itself.

[0225] In one embodiment, the G2BA is constructed such that the proximal portion of approximately 100-120+cm is torquable and hence, there is the only the distal 15-20+cm of the softer distal portion where the torque force is transmitted resulting in a greater likelihood where the application of a torque force is successful in rotating the distal tip. FIG. 5D shows a G2BA 10 having a torquable distal portion with an oblique distal tip 10b that can be torqued to improve the contact angle between the oblique distal tip and the clot. Generally, in many cases, it would be desirable to ensure that the outer distal tip is placed on the outside of a curve and/or is positioned adjacent the most proximal edge of the clot. In order to enable visualize placement of the distal tip, a radio opaque marker 40 is placed in the visual tip.

[0226] In some cases, the physician may not fully know the position of the distal tip relative to the vessel and it will be rotational movement of the oblique tip under suction pressure that causes the most favorable orientation of the tip in the vessel and which causes sudden ingestion of the clot.

Further Distal Procedures

[0227] In other embodiments, methods of enhancing capture of a corked clot are described. In one example, after attempts to aspirate a clot have been made with a G2BA, the clot may have corked in the distal tip. The physician may choose to withdraw the G2BA and hope that the clot does not fragment and/or result in distal emboli which under either scenario would require losing position if the G2BA is withdrawn. As shown in FIG. 6A, one solution that the G2BA provides is the option to run a further aspiration catheter AC through the G2BA 10 such that it reaches the distal tip of the G2BA and the corked clot (while maintaining a negative/suction pressure through the smaller AC to hold the corked clot). In a typical G2BA deployment, the G2BA is an 8F catheter, thus enabling an approximately 6F AC to be run up the G2BA. Preferably, the 6F catheter is designed such that the catheter cannot protrude out of the G2BA and hence cannot accidentally dislodge the clot that is corked at the tip. Importantly, by placing the 6F AC on the corked clot as shown in FIG. 6A, a substantially larger suction force P5 can be applied through the 6F AC. Higher suction pressures in the center of the corked clot can enhance the ability to aspirate albeit into a smaller catheter. Even if it cannot be aspirated into the smaller catheter, the additional suction force would allow it to be held firmly at the tip and when the 6F catheter is withdrawn, it facilitates the process of the entire clot getting ingested by the bigger catheter. Thus, with the application of this additional suction pressure and withdrawing the 6F AC, may cause the corked clot to be eased into the 8F G2BA which can then be withdrawn all the way out within the G2BA or the entire assembly can be withdrawn. In one embodiment, if a clot gets stuck in a G2BA during suction, an AC can be advanced within the G2BA to apply suction pressure and potentially dislodge and/or assist in drawing the clot out without losing position.

[0228] In a further embodiment, after aspiration of a clot, standard procedure is to conduct a check angiogram to determine if the entirety of the clot has been removed. In some cases, fragments of the clot may have embolized and travelled distally that will be detected by the check angiogram. In this case, a secondary distal procedure may be conducted.

[0229] For example, as shown in FIGS. 3A and 6B, if when aspirating a clot Y through an 8F catheter 10 from the M1 segment, a check angiogram conducted with the G2BA in position determines that a smaller emboli Y1 has broken away and has lodged distally within an M3 segment, the physician may decide to conduct an alternate secondary distal procedure in which the following steps are followed: [0230] a) While holding the first G2BA 10 in position, a second longer G2BA 11 (having an approximate 5F OD) is advanced through the first G2BA together with a second ISC (and second MW; 11a FIG. 3A). The second G2BA 11 is sized for co-axial movement within the first G2BA and is initially advanced to the distal tip of the first G2BA; [0231] b) The second MW and second ISC are advanced beyond the distal tip of the first G2BA by selective manipulation of the second ISC, second MW and second G2BA until the proximal face of the emboli Y1 is reached; [0232] c) The second ISC and second MW are removed; [0233] d) Suction P6 is applied to the second G2BA through a pump to aspirate the emboli into the second G2BA. If aspiration is not successful but there is no blood coming back, the clot has likely engaged with the distal tip but won't aspirate into the second G2BA. In this case, the second G2BA can be withdrawn (with the engaged clot fragment Y1) into the first G2BA and the second G2BA withdrawn through the first G2BA. [0234] e) A check angiogram is conducted; [0235] f) If clear, the first G2BA (and second G2BA if still in place) is/are removed. [0236] g) If not clear, further options may be evaluated.

[0237] The G2BA may also be used in pediatric cases in which case appropriately smaller G2BA catheters would be utilized based on the relative height/size of the patient.

Underlying Stenosis

[0238] In another application, periodically there may be a requirement to stent an underlying stenosis at the same time as removing a clot. Stenting may be required due to tight stenosis in the carotid or intracranial vessels. As a stent is relatively stiff, it can be problematic to push these stents across all the curves and tortuousity of the vasculature. Also if the external diameter of the stent is bigger than the traditional aspiration catheter of guide sheath, these have to withdrawn to allow for a bigger system. Hence, there can be an advantage to utilizing a G2BA for these procedures. In this case, stents having longer push wires to enable them to travel through the G2BA are required. That is, current stents would require longer push wires to enable them to be deployed through the longer G2BA catheter.

Radial Artery Access

[0239] As noted, a DEP may be the radial artery. Accessing the cervical arteries from the radial artery requires travel through the radial artery, brachial artery to the aortic arch which typically requires a 180 degree turn of the DC/GW to hook the desired carotid artery. As such, once placed, the G2BA provides advantages over past AC/GC systems as the distal section of the G2BA can more readily ride over the GW/DC and make the sharp turn at the aortic arch.

Brain Cooling

[0240] It is known that cooling the brain has a neuroprotective effect when the brain has been deprived of oxygen. In the case of stroke, cooling the brain prior to or after removal of a clot has been considered. Cooling the patient's entire body is generally complicated in that the effects of shivering will typically require general anesthetic and/or muscle relaxants. As a result, attempts have been made to effect cooling by direct cooling of the brain by introducing cooled fluids through catheters into the brain after a clot has been removed using the same catheter systems. However, introducing cold fluids (typically cold saline) directly into the brain through catheters has not been successful as the cold fluids cannot be adequately insulated from the warm body from the point of introduction while they travel to the brain. For example, a 6F catheter used as an aspiration catheter does not provide sufficient insulation to directly convey a cooling fluid to the brain and, hence requires further insulation if it is to be effective. However, a 6F catheter can only convey an approximate 4F catheter having a 2F lumen for carrying cooling fluids. Given the length of a typical aspiration catheter, by the time cold fluids (eg. Introduced at approximately 1 C) have travelled the length of the catheter, there is still insufficient insulation for there to be an effective cooling effect. That is, upon exit from the catheter injected fluids may exit the catheter at 15 C or greater which is insufficient to provide effective cooling. Furthermore, the problem cannot be solved by introducing a larger volume of fluid as there is a limit to the volume of fluids that can be introduced as increased fluid volumes can cause other effects including pulmonary edema.

[0241] In addition, adding insulation to the catheter wall changes its properties and makes it stiffer. Such an insulated catheter is generally not able to negotiate past the various curves to get to the brain vessels when being pushed through a 6F catheter. Also since the insulation takes space, the inner lumen is quite small and as such does not allow space for an ISC to facilitate getting past curves.

[0242] There have been attempts to design catheters where the distal 15 cm is thinner and without insulation while the proximal part is insulated to overcome the stiffness problem. However, even then there is substantial loss of cooling efficiency due to heating of the cold saline in the last 15 cm. However, with a larger G2BA catheter in the brain, the volume available to insulate is increased. In addition the insulation can be carried all the way to the tip of the cooling catheter as the cooling catheter has a greater volume to travel within which allows flexibility to be incorporated into the distal portion as well as increased insulation. For example, after an 8F G2BA catheter has been positioned in the M1 segment of the MCA and used to aspirate the clot, an insulated 6 F catheter with a larger and insulated wall is inserted into the G2BA and run to the distal tip of the G2BA. With greater insulation, fluids introduced at 1-3° C. may exit at a temperature of 2-8° C. which is sufficient to be effective for brain cooling.

[0243] The insulated catheter is substantially the same length (nominally longer) as the G2BA catheter and sized to fit within the G2BA. As shown schematically in FIG. 6C, an 8F G2BA 10 will have an OD of 0.105″ and a typical wall thickness of 0.013″ allowing a 6F insulated catheter 13 to travel within. The insulated catheter will have an OD of 0.079″ and may have a wall thickness in the range 0.026″ thus having a lumen of 0.027″. The thicker walls provide additional insulation sufficient to convey cold fluids to the distal tip of the G2BA and into the cerebral circulation. A lumen size of 1.5F is the approximate minimum lumen size for conveying a sufficient volume of fluid.

[0244] In one embodiment, a fluid cooling module is utilized to deliver cooling liquid to the proximal end of a cooling catheter. Generally, the fluid cooling module includes a fluid pump and controller for pumping a calculated volume of cooling liquid through the cooling catheter. The calculated volume is determined based on modelling of heat transfer through the cooling catheter, modelled data of a D2BA catheter as selected for a patient, patient data and a desired cooling liquid temperature at a distal end of the cooling catheter.

[0245] In one embodiment, an ISC is also used as a cooling catheter referred to an integrated support and cooling catheter (ISCC). In this case, an ISCC having proximal insulation would be used to advance the G2BA catheter. Once the ISCC has been withdrawn and the aspiration procedure taken place, the ISCC would be re-introduced and cooling solution flow introduced. As with an ISC, the ISCC includes a tapered distal zone for supporting the distal tip of the G2BA during advancement through tortuous sections of a patient's cerebral vasculature and an insulated proximal zone enabling a cooling solution to introduced to a proximal end of the ISCC. From a performance perspective, cooling fluid introduced at the proximal end at 1-3° C. would exit the ISCC at 2-8° C.

Suction and Suction Pulses

[0246] Other procedures and devices may be employed to improve suction efficiency once a G2BA is in position.

[0247] The application of suction pulses can also be used to improve engagement of the G2BA with the clot. As a tighter seal with the vessel wall is likely higher, a short pressure pulse or pulses may cause the G2BA or the clot to move closer to the other and cause a more rapid engagement and/or ingestion, thus obviating the need to wait a time period for the catheter and clot to engage. For example, application of 1-3 short lower pressure pulses followed by a larger pressure pulse can successively align or partially ingest the clot followed by a higher pressure pulse(s) that fully ingests the clot.

[0248] Further still, measurement of the pressure wave at the pump can be utilized to quantify the effectiveness of the aspiration process by a comparison of the applied pressure wave vs. a response measured at the pump. Analysis of the response can be used to dynamically adjust a delivered pressure. That is, a pressure wave may be generated by the pump and a measure of the pressure/flow waveform received back from the G2BA can be compared to determine the effectiveness of the aspiration pressure in seating the G2BA against the clot and/or aspiration of the clot.

[0249] The pressure wave can also compensate for the compliance of the G2BA.

[0250] In a further embodiment, aspiration pumps could be wifi enabled thus capturing suction pulse data and using that data through machine learning and artificial intelligence based algorithms to improve the pressure pulse and using the information gained from the first pressure pulse to improve the next pressure pulse based on the A1 algorithms developed from the continuously growing database of past performance.

[0251] Further, the suction pressure on the aspiration pump may be higher given the increased diameter of the G2BA.

[0252] Preferably, the aspiration pump will include a filter that will capture any aspirated clot. Visual inspection of a clot at the aspiration pump together with or separate to flow rate data through the G2BA can provide effective information as to whether or not circulation has been established and the procedure has been successful.

[0253] Pulse pressure algorithms may also be applied to the further distal procedures described above.

G2BA Kits

[0254] Various kits may be provided in accordance as summarized in Table 5 where kits are assembled based on a target level (referred to here as Levels 1-4 where level 1 is deeper (eg. level 2 segments) and level 4 is lower in the vasculature.

TABLE-US-00005 TABLE 5 G2BA/DC and ISC Kits Target Level G2BA DC/MW ISC 1 FR 7  A FR 6 2 FR 8  A FR 7 3 FR 9  A FR 8 4 FR 10 A FR 9 1 FR 7  B FR 6 2 FR 8  B FR 7 3 FR 9  B FR 8 4 FR 10 B FR 9 1 FR 7  C FR 6 2 FR 8  C FR 7 3 FR 9  C FR 8 4 FR 10 C FR 9 1 FR 7  A, B, C FR 6 2 FR 8  A, B, C FR 7 3 FR 9  A, B, C FR 8 4 FR 10 A, B, C FR 9

[0255] Generally, a surgeon will select a kit based on the target level and an understanding of the vessel diameter at the clot. In addition, kits may be provided with specific DC/GW combinations selected on the basis of a surgeon's diagnostic assessment of a patient's aortic arch. Table 5 refers to DCs by generic placeholders A, B, C with each DC having particular tip/stiffness/shape characteristics.

[0256] As the cost difference between DCs vs. ISCs and G2BAs may be significant, kits may include multiple DCs.

[0257] Still further kits are described:

a) Kit containing 2nd G2BA, ISC and MW of appropriate diameters for use in conjunction with or included in kits shown in Table 5 for conducting secondary distal procedures.
b) Kits shown in Table 5 with an additional AC sized to fit within a G2BA. The AC would have a length that would prevent it from emerging from the distal tip of the G2BA
c) Any Kit described above together with a cooling catheter.

SUMMARY OF ADVANTAGES

[0258] The following advantages are realized by use of the G2BA and G2BA deployment methods together with an ISC in particular. [0259] a) Fewer catheters (importantly no GC or BGC). [0260] b) Fewer steps and faster. [0261] c) Bigger catheter further. [0262] d) Ability to advance through difficult sections. [0263] e) Better tip alignment when suction is applied. [0264] f) Reduced likelihood of introducing bubbles into the circulation as fewer catheters are utilized that may have been inadequately flushed. [0265] g) Reduce the need for larger groin sheaths. [0266] h) Reducing procedure costs especially by potentially obviating the need for a stent-retriever. [0267] i) Increasing the reperfusion rates thereby improving patient outcome. [0268] j) Reducing possible delays in the OR that have been caused by coronavirus by reducing equipment being passed from personnel to personnel. [0269] k) Improving the speed of procedures conducted using stiffer DCs by providing a softer G2BA distal zone that can ride over a stiffer DC. This may encourage a surgeon to choose DCs better suited for engaging the origin of the appropriate cervical artery. [0270] l) Decreasing the likelihood of clot fragmentation by allowing complete ingestion of the clot. [0271] m) Improving the overall ability to suck a non-heterogeneous clot. Some clots have different consistencies and may fragment between regions having the different consistencies. By having a suction catheter that is close in size to the clot (and the vessel), the likelihood of clot ingestion is much higher. By enabling stronger pulse pressures to be applied with an improved likelihood of sealing against the entire clot, both fibrous and non-fibrous clots may be more effectively ingested. [0272] n) Improving speed to access secondary distal emboli with a secondary G2BA and ISO and remove a distal emboli. [0273] o) Decreasing likelihood of causing secondary distal emboli. [0274] p) Improving access from radial artery. [0275] q) Providing easier access of a stiff stent system in case of significant intracranial or carotid atherosclerotic disease. [0276] r) Providing easier access for an insulated catheter to deliver cold solutions for local hypothermia if the ischemic territory.

[0277] From the foregoing, it is important to note that the structural and functional properties of a D2BA catheter are distinguished over the properties of other catheters. That is, while catheters enabling aspiration functions to be performed and catheters having a range of physical sizes and stiffnesses appear similar, the differences in sizes, lengths and performance characteristics in combination are significant in that the combination of physical and functional properties enable new procedures to be conducted that have real-world benefits to patients. Moreover, as a wide range of manufacturing techniques and materials can be combined in different ways to provide catheters having the unique combination of physical and functional properties, emphasis is made on the understanding of the need to balance specific mechanical and chemical properties of the materials that may be used in catheter construction to provide the desired end functional capabilities.