Intravascular lithotripsy

Abstract

A medical device may include an elongated body having a distal elongated body portion and a central longitudinal axis. The medical device may include a balloon positioned along the distal elongated body portion. The balloon may be configured to receive a fluid to inflate the balloon such that an exterior balloon surface contacts a calcified lesion within a patient's vasculature. The medical device may include one or more pressure wave emitters positioned along the central longitudinal axis of the elongated body. The one or more pressure wave emitters may be configured to propagate at least one pressure wave through the fluid to fragment the calcified lesion. At least one pressure wave emitter may include an optical fiber configured to transmit laser energy into the balloon. The laser energy may be configured to create a cavitation bubble in the fluid.

Claims

1. A device, comprising: an optical fiber configured to pass laser energy therethrough, the optical fiber having an emitting location configured to transmit laser energy into a fluid causing a cavitation bubble to propagate a pressure wave; an elongated body having a proximal portion and a distal portion opposite the proximal portion, the elongated body extending along a central longitudinal axis, the optical fiber extending at least partially along the elongated body and spaced from the central longitudinal axis; and a controller configured to translate the optical fiber longitudinally independently from the elongated body, the optical fiber extending at least partially through the controller and therefrom towards the elongated body, the controller comprising: a lower telescope fixedly coupled to at least a portion of the optical fiber; an upper telescope telescopically coupled to the lower telescope, such that the lower telescope is configured to translate longitudinally within and from the upper telescope; a longitudinal actuator configured to translate the lower telescope with respect to the upper telescope, thereby translating the optical fiber longitudinally; a proximal stopping feature associated with a proximal treatment location; a distal stopping feature associated with a distal treatment location; and at least one stopping feature located between the proximal stopping feature and the distal stopping feature, wherein the proximal stopping feature, the distal stopping feature, and the at least one stopping feature are configured to i) prevent longitudinal movement of the lower telescope in at least one direction, ii) provide a resistance for longitudinal movement of the lower telescope in at least one direction, or iii) both, and wherein the stopping features are located along the path on which the longitudinal actuator moves.

2. The device of claim 1, wherein the lower telescope defines a fiber lumen therethrough, wherein the optical fiber is disposed within the fiber lumen.

3. The device of claim 1, wherein the lower telescope, the upper telescope, or both, comprise stainless steel.

4. The device of claim 1, further comprising a slack feature configured to manage slack of the optical fiber as it is longitudinally translated.

5. The device of claim 4, wherein the slack feature comprises a pin.

6. The device of claim 1, further comprising a proximal support fixedly coupled to the lower telescope, the proximal support configured to provide structural support to each of the lower telescope and the optical fiber.

7. The device of claim 6, wherein the proximal support is configured to encapsulate at least a portion of the lower telescope.

8. The device of claim 1, further comprising a seal configured to prevent fluid flow to the upper telescope.

9. The device of claim 8, wherein the seal includes a perforation sized for longitudinal movement therethrough by the lower telescope.

10. The device of claim 1, wherein the longitudinal actuator comprises a slider.

11. The device of claim 1, wherein the longitudinal actuator is configured to be translated a distance that is proportional to a distance translated by the lower telescope.

12. The device of claim 11, wherein the proportional distance translated by the lower telescope relative to the longitudinal actuator is based on a gear ratio, the longitudinal actuator comprising or coupled to one or more gears that are coupled to the lower telescope, wherein the gear ratio is defined by the one or more gears.

13. The device of claim 1, wherein each of the proximal stopping feature, the distal stopping feature, and the at least one stopping feature located between the proximal stopping feature and the distal stopping feature correspond to a predetermined position of the emitting location along the elongated body.

14. The device of claim 1, wherein an increased force on the longitudinal actuator overcomes the resistance of a respective stopping feature, thereby allowing further longitudinal translation of the lower telescope and optical fiber.

15. The device of claim 1, further comprising one or more numeric indicators, each corresponding to a predetermined position of the emitting location about the elongated body.

16. The device of claim 15, wherein the controller comprises the one or more numeric indicators.

17. The device of claim 1, wherein the at least one stopping feature is configured to provide tactile feedback indicative of a longitudinal position of the emitting location.

18. The device of claim 1, further comprising a distal hub configured to align the optical fiber about the elongated body.

19. The device of claim 1, further comprising a light emitting diode (LED) configured to backlight the longitudinal actuator.

20. The device of claim 1, further comprising a gear, wherein the longitudinal actuator comprises a rack for interacting with the gear in order to provide a gear ratio between longitudinal movement of the longitudinal actuator and longitudinal movement of the lower telescope.

Description

BRIEF DESCRIPTION OF THE DRAWINGS

(1) These and other features, aspects, and advantages are described below with reference to the drawings, which are intended to illustrate, but not to limit, the invention. In the drawings, like characters denote corresponding features consistently throughout similar embodiments.

(2) FIG. 1 illustrates a diagrammatic view of an intravascular lithotripsy (IVL) system as it may appear inserted into a patient's vasculature.

(3) FIGS. 2A and 2B illustrate two diagrammatic views of a medical device in or near a calcified lesion in a vessel.

(4) FIG. 3 is a diagram illustrating an IVL system.

(5) FIG. 4 illustrates an embodiment of the IVL system of FIG. 3 as it may appear in a use-case scenario.

(6) FIG. 5 illustrates a block diagram of the laser energy source system, such as the generator of FIG. 1, according to some examples.

(7) FIG. 6 illustrates a side view of an example IVL catheter, including the IVL balloon at the distal end and the connector for coupling the IVL catheter to a generator.

(8) FIGS. 7A and 7B illustrate two cross-sectional views of the medical device in FIG. 6.

(9) FIG. 8 illustrates a perspective view of the IVL balloon, along with an inset view illustrating a position for the distal fiber end of an optical fiber according to the IVL catheter of FIG. 6.

(10) FIGS. 9A and 9B illustrate perspective views of a portion of the IVL catheter at the distal fiber end of two optical fibers, according to some examples.

(11) FIGS. 10A, 10B, 10C, and 10D illustrate diagrams of an IVL device with the distal fiber end of an optical fiber held in place with or without targets of various-shaped profiles.

(12) FIGS. 11A, 11B, 11C, and 11D illustrate profile views of three possible configurations of a fiber positioner for holding the optical fiber in place, as depicted in FIGS. 10A-10D.

(13) FIG. 12 illustrates a diagram of two optical fibers traversing an IVL catheter along a guidewire lumen and terminating inside an IVL balloon, according to some examples.

(14) FIG. 13 illustrates a profile view of a shroud for protecting a balloon from an optical fiber.

(15) FIGS. 14A and 14B illustrate perspective views of a single optical fiber traveling along an IVL catheter and a cavitation bubble forming at the distal fiber end.

(16) FIG. 15 illustrates a cross-sectional view of the elongated body and optical fiber of FIGS. 14A and 14B.

(17) FIGS. 16A and 16B illustrate perspective views of a single optical fiber traveling along an IVL catheter with scores cut into the optical fiber.

(18) FIG. 17 illustrates a cross-sectional view of the elongated body and optical fiber of FIGS. 16A and 16B.

(19) FIGS. 18A, 18B, and 18C illustrate various perspective views of a multiple optical fiber embodiment of the IVL catheter.

(20) FIGS. 19A-19H illustrate side views of various distal fiber ends for an optical fiber, as may be provided in an IVL catheter.

(21) FIG. 20 illustrates a flowchart depicting a method of generating a cavitation bubble in a balloon catheter.

(22) FIG. 21 illustrates a flowchart depicting a method of generating a cavitation bubble within a vessel.

(23) FIG. 22 illustrates another side view of an example IVL system.

(24) FIGS. 23A, 23B, and 23C illustrate diagrams of an IVL device including a movable fiber positioner, according to some examples.

(25) FIG. 24 illustrates a cross-sectional view of the IVL device of FIG. 23A.

(26) FIG. 25 illustrates a cross-sectional view of the IVL device of FIGS. 23B and 23C.

(27) FIG. 26 illustrates a diagram of an IVL device with the distal fiber end of an optical fiber held in place.

(28) FIGS. 27A, 27B, 27C, 27D, and 27E illustrate various examples of cross-sections of the IVL device of FIG. 26.

(29) FIGS. 28A and 28B illustrate diagrams of an IVL device including a fiber positioner lumen.

(30) FIG. 29 illustrates a cross-sectional view of the IVL device of FIGS. 28A and 28B.

(31) FIG. 30 illustrates a diagram of an IVL device including a track.

(32) FIG. 31 illustrates a cross-sectional view of the IVL device of FIG. 30.

(33) FIG. 32 illustrates a perspective view of a controller, according to some examples.

(34) FIG. 33 illustrates a perspective view of an additional example controller.

(35) FIGS. 34, 35, 36, 37, and 38 illustrate bottom views of various example controllers including optical fiber movement capabilities.

(36) FIG. 39 illustrates a side view of an internal mechanism of a controller, according to some examples.

(37) FIG. 40 illustrates a side view of an internal portion of a proximal hub, according to some examples.

(38) FIG. 41A illustrates a side view of a controller, according to some examples.

(39) FIG. 41B illustrates a top view of the controller of FIG. 41A, according to some examples.

(40) FIG. 42A illustrates a bottom view of a controller including interior components, according to some examples.

(41) FIG. 42B illustrates an additional bottom view of a controller, including interior components, according to some examples.

(42) FIG. 43 illustrates a front view of a controller, according to some examples.

(43) FIGS. 44A-44E illustrate a controller and a distal elongated body portion in multiple positions relative to one another, according to some examples.

(44) FIG. 45A illustrates a side view of a controller, according to some examples.

(45) FIG. 45B illustrates a top view of the controller of FIG. 45A, according to some examples.

(46) FIG. 46 illustrates a side view including interior components, according to some examples.

(47) FIGS. 47A-47E illustrate a controller and a distal elongated body portion in multiple positions relative to one another, according to some examples.

DETAILED DESCRIPTION

(48) Although specific examples are disclosed below, inventive subject matter extends beyond the specifically disclosed examples to alternative examples and/or uses and modifications and equivalents thereof. Thus, the scope of the claims appended hereto is not limited by any of the particular examples described below. For example, in any method or process disclosed herein, the acts or operations of the method or process may be performed in any suitable sequence and are not necessarily limited to any particular disclosed sequence. Various operations may be described as multiple discrete operations, in turn, in a manner that may be helpful in understanding specific examples; however, the order of description should not be construed to imply that these operations are order-dependent. Additionally, the structures, systems, and/or devices described herein may be embodied as integrated or separate components.

(49) For purposes of comparing various examples, certain aspects and advantages of these examples are described. Not necessarily all such aspects or advantages are achieved by any particular example. Thus, for example, various examples may be carried out in a manner that achieves or optimizes one advantage or group of advantages as taught herein without necessarily achieving other aspects or advantages as may also be taught or suggested herein.

(50) During an intravascular lithotripsy (IVL) procedure, a clinician uses the formation and subsequent collapse of cavitation bubbles to generate high-energy pressure waves to disrupt calcified-plaque lesions within a patient's vasculature. Typical IVL procedures include the generation of shock waves through electrode emitters or electrode pairs. Such systems may have larger crossing profiles and increased manufacturing complexity.

(51) Traditional IVL catheters also lack the capacity to finely control the directionality of the delivered energy. The use of fiber optics to create cavitation bubbles can help to rectify these detriments of prior art devices, as well as increase the delivered power, which can enhance the efficacy of the treatment, improve consistency of energy delivery, increase the durability of the IVL catheter as a whole, and decrease the manufacturing cost due to its lower complexity.

(52) The present disclosure describes systems and techniques for producing and directing high-energy intravascular pressure waves for fragmentation and/or disintegration of calcified lesions within a patient's vasculature. For illustration purposes, the techniques herein are described primarily with respect to optical (e.g., laser) based systems and respective applications thereof, such as coronary-vessel applications. However, it is understood that the techniques described herein may be assumed to be likewise applicable to similar systems based on other forms of energy, such as electrical-based systems, and respective applications, such as peripheral-treatment applications, except where explicitly noted below. Additionally, while the treatment site is described as including calcified lesions throughout this specification, it is understood that the present disclosure also enables the treatment of restenotic lesions.

(53) The systems described herein generally include an energy source, an IVL catheter having a distal IVL device, and an optical fiber. In some examples, the systems include an interventional balloon. During a lesion-disintegration procedure, a clinician may advance the interventional balloon to a target treatment site within a patient's vasculature and inflate the balloon with an inflation fluid, such as a saline/contrast-fluid mixture, until the balloon contacts at least a portion of the local vessel wall. The saline/contrast-fluid mixture is understood to include a viscosity suitable for the perpetration of cavitation bubbles through the introduction of electrical or optical energy. Because the saline/contrast-fluid mixture will often be mixed at the time of treatment, the ratio between saline and contrast-fluid may fluctuate. Still, laser-based energy delivery may be relatively insensitive to these changes. The clinician may then actuate the energy generator, causing the catheter to generate a cavitation bubble within the fluid-filled balloon, propagating a high-energy pressure wave through the balloon and the calcified lesion. A second pressure wave can also result from the subsequent collapse of the fluid cavitation, further destabilizing the internal structure of the lesion.

(54) In examples that do not include an interventional balloon, the saline/contrast-fluid mixture is discharged into the patient's vasculature near the treatment site to displace the blood in the local area. Once this saline/contrast-fluid mixture has at least partially displaced the blood in this area, the clinician may actuate the energy generator, causing the catheter to generate a cavitation bubble in the region of the saline/contrast-fluid mixture, propagating a high-energy pressure wave through this region and into the calcified lesion.

(55) Additional examples, both with and without an interventional balloon, include the introduction of a photosensitive agent into the saline/contrast-fluid mixture. This photosensitive agent may provide a target for the energy source to aim toward, permitting greater control of where the cavitation bubble is formed within the interventional balloon and/or the saline/contrast-fluid mixture that has displaced blood in the local area.

(56) Superheating as used herein means to heat a liquid, under pressure, above its boiling point without vaporization. In some examples, the device as disclosed in this application does not superheat the fluid within the balloon in order to form cavitation bubbles. In alternative examples, the device of this disclosure does superheat the fluid within the balloon in order to form these cavitation bubbles.

(57) Additionally, as used herein, user and operator are considered to be synonymous, and either is understood to be an individual that makes use of the systems and devices of the present disclosure.

(58) Moreover, as used herein, devices that cause a cavitation bubble and propagate a pressure wave and devices that cause a plasma breakdown that propagate a pressure wave and associated cavitation bubble may be the same device or separate devices. That is to say, devices that cause a plasma breakdown may be the same as devices that cause a cavitation bubble. In other embodiments, devices that cause a cavitation bubble do not cause a plasma breakdown.

(59) FIG. 1 illustrates a diagrammatic view of an intravascular lithotripsy (IVL) system 10 as it may appear inserted into a patient's vasculature. The IVL system 10 may include a medical device 12, perhaps including an interventional balloon, as depicted in later figures. During a lesion-disintegration procedure, a clinician may advance the medical device through an access point 14 in the patient 20, such as the femoral or common femoral arteries, as depicted in FIG. 1. Other access points may include the radial artery, tibial artery, pedal artery, axial artery, peroneal artery, etc. The medical device 12 may then be advanced through the vasculature of the patient 20 until it reaches the vessel 30 containing the treatment area 40. For IVL, the treatment area may include a calcified lesion 50. FIGS. 2A and 2B show a close-up view of two examples of IVL systems located in or adjacent to the treatment area 40 including a calcified lesion 50.

(60) FIG. 2A illustrates a diagrammatic view of a medical device 12 within a treatment area 40 including a calcified lesion 50 in a vessel 30. In this example, the medical device 12 includes a balloon 204. During an IVL procedure, the clinician may inflate the balloon 204 so that it physically contacts at least a portion of the calcified lesion 50 and the wall of the vessel 30 in the treatment area 40. This inflation of the balloon 204 may include using a saline/contrast-fluid mixture for propagating pressure waves or shock waves when superheated by a laser. This saline/contrast-fluid solution may be any percentage ratio, as no discernable difference has been observed during testing. While any saline/contrast-fluid solution may be used, it may be desirable to include at least a small percentage of contrast-fluid in said solution, as saline does not show up under fluoroscopic guidance, and thus would not indicate the inflation, or issues with the inflation, to an operator. As will be discussed in FIGS. 10A-10B, specific wavelengths of laser energy may be capable of superheating the saline/contrast-fluid mixture without assistance (FIG. 10A). Still, other wavelengths are less absorptive in saline/contrast-fluid mixtures and may necessitate a target block that will superheat and cause the deployment of the pressure waves.

(61) Also shown in FIG. 2A is a central lumen 208 located within an elongated body (302 below). Along the elongated body 302 are pressure wave emitters 206. As shown in FIGS. 2A and 2B, five pressure wave emitters (206a, 206b, 206c, 206d, and 206e) are present in the medical device 12. While five pressure wave emitters 206 are illustrated in FIGS. 2A and 2B, the emitter 206 array of the medical device 12 may include as few as one individual emitter unit 206 and up to as many emitter units 206 as could reasonably fit within the balloon 204. It is also to be noted that individual emitter units 206 are also referred to throughout this disclosure as emitters 206 (e.g., in reference to an emitter unit 206 as a whole).

(62) FIG. 2B illustrates a diagrammatic view of a medical device 12 adjacent to a treatment area 40 including a calcified lesion 50 in a vessel 30. The medical device 12, balloon 204, and the pressure wave emitters 206 may be similar to those described in FIG. 2A. However, the central lumen 208 of the elongated body 302 in FIG. 2B is shown as deploying or injecting a fluid 212 into the treatment area 40. This fluid 212 may displace blood in the treatment area 40 prior to inserting the medical device 12 into the treatment area 40, facilitating the expansion of the balloon 204 and increasing the efficacy of the IVL procedure.

(63) FIG. 3 is a diagram illustrating an IVL system 10. As shown in FIG. 3, IVL system 10 may include at least an energy generator 310 and an elongated body 302 removably coupled to the energy generator 310, such as via an electrical connector 312. The elongated body 302 may include a medical device 12 positioned at a distal elongated body portion 306. In some examples, the elongated body 302 is configured to navigate a tortuous vasculature of a patient 20 toward a target treatment site 40, e.g., a calcified-plaque lesion 50 within a vessel 30.

(64) In some examples, the elongated body and the distal elongated body portion may be separate components, with the distal elongated body portion being coupled to the elongated body. In other examples, the distal elongated body portion is representative, or indicative of a portion of the elongated body. Throughout the present disclosure, these interpretations may be provided interchangeably.

(65) While the term elongated body is used throughout the present specification, it is understood that an elongated body may refer to a catheter, such as an IVL catheter. Additionally, while the connector 312 is described as an electrical connector 312 in the description of FIG. 3, it is understood that the connector 312 may also be an optical connector 312. In fact, in some examples, the IVL system 10 may not necessitate an electrical connector 312. In these examples, a therapy button may be present on the console, and there may be no electrical interrogation of the catheter itself. While an electrical connector 312 may not be necessary in all examples, an optical connector 312 is necessary in order to provide the laser energy to the catheter.

(66) As shown in FIG. 3, the medical device 12 may include a fluid-inflatable interventional balloon 204 and a pressure wave emitter 206 array, shown but not labeled due to size constraints, positioned within the balloon 204. The emitter 206 array may include one or more individual emitter units 206. For instance, the interventional balloon 204, or a distal elongated body portion 306 passing therethrough, may define a central longitudinal axis 308, and emitter units 206 may be distributed longitudinally along the central longitudinal axis 308.

(67) Each emitter unit 206 is configured to receive energy from the energy generator 310 and use the received energy to generate and transmit high-energy pressure waves through the balloon 204 and across a treatment site. As detailed further below, the energy generator 310 may generate and transmit energy in the form of electrical energy, optical energy, or a combination thereof. For instance, the emitter unit(s) 206 may use the received energy to generate a cavitation bubble 1404 within the fluid inside the balloon 204, propagating one or more high-energy pressure waves radially outward through the balloon and the calcified lesion.

(68) In some cases, but not all cases, a secondary set of high-energy pressure waves can subsequently result from the collapse of the fluid cavitation bubble 1404 (as shown in FIG. 14), further destabilizing the internal structure of the calcified-plaque lesion. In some examples, one or more emitters 206 can include an optical-based emitter 206 configured to receive a high-energy optical (e.g., light) signal from the generator 310, such as via one or more optical fibers 802 (as shown in FIG. 8), and direct the optical signal to trigger the initial cavitation. Additionally, one or more emitters 206 can include an electrical-based emitter 206 configured to receive electrical energy from the generator 310, such as via one or more conductive wires, and generate a spark between a pair of electrodes, thereby triggering the initial cavitation.

(69) According to some examples, a cooling mechanism functions in tandem with the energy generator 310. However, flashlamp systems may provide energy to the optical fibers 802 without necessitating said cooling mechanism. Additionally, diode systems may be used as an alternative to flashlamp systems, which may also not require a cooling mechanism.

(70) FIG. 4 illustrates an embodiment of the IVL system 10 of FIG. 3 as it may appear in use. A medical post may be provided to facilitate movement of the IVL system 10 between rooms as necessary. A power supply 402 may be situated near the base of the medical post, coupled to a power cord 408 for receiving wall power or power from a generator 310, as well as an umbilicus for electrically coupling to a console 404. As shown in FIG. 4, the console 404 allows a user, such as a clinician, to operate the IVL system 10. The elongated body 302 may be coupled to the console 404 via a power cable for receiving energy from the power supply 402 to transmit energy to the emitters 206 within the IVL balloon 204. A separate line dedicated to the inflation of the IVL balloon 204 may also be present.

(71) According to some examples, a detection line 406 is present. The detection line 406 may offer a few methods of providing feedback about the integrity of the individual components within the IVL balloon 204. For instance, a safety pressure sensor may be provided. If a sudden pressure drop is detected, a failure may have occurred, such as a rupture of the IVL balloon 204. This suggests to the clinician that the procedure should be halted, and the IVL balloon 204 should be retrieved immediately and safely from the patient's vasculature. According to some examples, once a pressure sensor in the IVL balloon 204 detects a balloon 204 rupture, energy emission through the elongated body 302 may be halted immediately. It is understood that the term halted may be used to issue an error code to the operator for a manual shutdown or an auto-system shut-off.

(72) Additionally, the pressure sensor may be present anywhere within the pressure pathway, wherein the pressure pathway defines a path beginning at the generator and ending at the balloon 204. In some examples, the pressure sensor may be within the generator 310. According to some examples, the pressure sensor may be within a hub, which is the intermediary component connecting the elongated body 302 to the generator 310 (in examples including a separate generator 310). The pressure sensor may be present within the elongated body 302. In some examples, as described in the preceding paragraph, the IVL balloon 204. The pressure sensor may be present outside of these distinct components (generator 310, hub, elongated body 302) but within the pressure pathway.

(73) Furthermore, in some examples, the pressure sensor may be present anywhere within the IVL system 10, including outside of the previously described pressure pathway. This could include a separate device outside of the medical device 12, such as an inflation device which is either a part of, or attached to, a hub connector. This inflation device may be adjacent, but outside of, the guidewire lumen 208. The pressure sensor may be a part of or attached to, such an inflation device.

(74) Additionally, a fiber interrogation mechanism may be present. According to some examples, the purpose of the fiber interrogation mechanism is to sense or detect if the optical fiber, or at least one of the optical fibers 802 (see FIG. 8), has broken, or in other ways become disconnected. This may be achieved by reflecting at least a portion of the energy back down the optical fiber 802 once a pulse has been emitted, and any obstruction of this return pulse would indicate to the clinician that something has gone awry, and the IVL balloon 204 should be retrieved, and the issue fixed.

(75) FIG. 5 illustrates a block diagram of the laser energy source system 502, according to some examples. As can be seen by the dotted line surrounding a majority of the components, the laser energy source system 502 includes an energy source. Power, such as power from a wall, as shown by the arrow leading through the 120 V (IN), may be provided to the power supply 402 within the energy source. The power supply 402 provides power to a flashlamp power supply 504 and a central processing unit (CPU) 518. The flashlamp power supply 504 may be controlled by the CPU 518.

(76) The CPU 518 includes a user interface, which may involve tactile buttons and switches or other means of user communication, such as a touch screen. A power on switch 516 is shown in electronic communication with the CPU 518, as well as push buttons 520 for resetting the CPU 518 (reset) and initiating the treatment once the elongated body 302 is in place (therapy). The CPU 518 also controls the lamps 514 (On, RDY (Ready), E (Emission), and F (Fault)). The on lamp 514 indicates that the system 502 is turned on. The RDY lamp 514 indicates that the system 502 is connected and ready to actuate the laser energy. The E lamp 514 indicates that the laser energy is currently active. The Flamp 514 indicates that a fault has occurred, and the system 502 needs to be reset. In IVL systems 10, including safety features such as a safety pressure sensor as described above, the CPU 518 receives this feedback from the pressure sensor 522, which, as it is located in the IVL balloon 204, exists outside of the energy source.

(77) The flashlamp power supply 504 includes lamp leads 506 that electrically couple the flashlamp power supply 504 to a laser head 508. The laser head 508 is aimed at a shutter 510, which is in electronic communication with and controlled by the CPU 518. The shutter 510 is an additional safety to prevent premature emission of the laser through the elongated body 302. The shutter 510 is commanded by the CPU 518 just prior to triggering the flashlamp, which initiates the laser energy. In the case of a laser source such as an excimer laser, the trigger for the shutter 510 may be a high-voltage switch and not a flashlamp. The shutter 510 separates the laser head 508 from the optical fibers 802, as indicated by the fiber out 512. The optical fibers 802 then travel the length of the elongated body 302 to the treatment site. In IVL systems 10, including safety features such as a fiber interrogation mechanism described above, the CPU 518 receives feedback from the optical fiber 802 through the fiber interrogation mechanism 524, as shown. Because the fiber interrogation mechanism may operate from anywhere along the fiber line (a break anywhere in the line can be detected anywhere else along the line, as long as the detection is occurring prior to the break), the fiber interrogation mechanism 524 is shown as being conveniently located within the energy source.

(78) FIG. 6 illustrates a side view of an example elongated body 302, including the IVL balloon 204 at the distal elongated body portion 306 and the connector 312 for coupling the elongated body 302 to a generator 310. In some examples, the elongated body 302 includes an inner shaft and an outer shaft surrounding the inner shaft. The inner shaft may include a guidewire lumen 208, or another type of lumen 208, depending on the clinician's needs.

(79) According to FIG. 6, an IVL balloon 204 may be present. The IVL balloon 204 may be inflated with a saline/contrast-fluid mixture when the elongated body 302 has been advanced to the treatment site. Within the IVL balloon 204 is at least one emitter. As described previously, as few as a single emitter 206 may be present (as described in FIGS. 14A, 14B, 16A, and 16B), or a multitude of emitters 206 may be present (as shown in greater detail in FIGS. 18A, 18B, and 18C).

(80) According to some examples, a single emitter, such as an optical fiber, may be scored to create multiple locations of light or signal emission for the laser, causing a single optical fiber 802 to act functionally as a multitude of emitters 206. Such an embodiment is explored in greater detail in FIGS. 14A and 14B.

(81) At the proximal elongated body portion 304, the connection point between the elongated body 302 and generator 310 can be seen. This connection point may occur through direct coupling of the elongated body 302 to the generator 310 or an adaptor suited to couple one end to the elongated body 302 and the opposing end to the generator 310. At this proximal elongated body portion 304, a fiber bundle may also be present in examples where multiple fibers 802 are utilized as emitters 206. This fiber bundle is in optical communication, or optically coupled, to the generator 310 to provide laser energy to the optical fibers 802 that will be emitted into the fluid-filled IVL balloon 204.

(82) As disclosed previously, in some examples, the IVL balloon 204 may not be present nor necessitated for the elongated body 302. In these embodiments, the inner shaft may include a lumen 208 configured to deliver the saline/contrast-fluid mixture to the treatment area of the vasculature. Introducing this saline/contrast-fluid mixture may displace the local blood of this vasculature, thus permitting the energy emitted by the optical fibers 802 to create cavitation bubbles 1404 without the need for an external structure like the IVL balloon 204.

(83) FIGS. 7A and 7B illustrate two cross-sectional views of the medical device 12 of FIG. 6. Specifically, FIG. 7A illustrates a balloon 204 having a metalized coating 706 on the interior balloon surface 702 and FIG. 7B illustrates a balloon 204 having a metalized coating 706 on the exterior balloon surface 704. Both FIGS. 7A and 7B also show the elongated body 302 and the central lumen 208. The radii and proportions of each feature are exaggerated to simplify the expression of each independent structure in the drawing.

(84) The metalized coating 706 may be configured to increase the damage threshold of the balloon 204 from laser energy. That is to say, the resistance of the balloon 204 from perforating and collapsing due to too much laser energy may increase because of a present metalized coating 706 on either the interior balloon surface 702 or the exterior balloon surface 704. The metalized coating 706 may also offer additional safety, in case of balloon 204 failure or deflation. This metalized coating 706 may prevent the optical fiber (802 below) from contacting or penetrating the balloon 204. Without additional safety measures, should the balloon be perforated during a procedure, there is the potential for pieces of the balloon to be unintentionally left in situ, which might then migrate through the patient's vessels. Furthermore, this additional measure may facilitate the prevention of unwanted balloon deflation.

(85) This metalized coating 706 may be created from aluminum, nickel, chromium, gold, alloys, a dielectric reflective coating, and the like. It is understood that this list of metalized coatings 706 is not comprehensive, and equivalent metalized coatings 706, while not named herein, may be used. The metalized coating 706 may be deposited in extremely thin layers. These layers may be only a few microns thin, making the metalized coating 706 almost transparent, and permitting the slimmest change possible to the thickness of the balloon 204 while also garnering the benefits listed herein.

(86) In both FIGS. 7A and 7B, the metalized coating would not significantly change the compliance or any other balloon properties. The additional thickness added to the balloon 204 may depend on whether the metalized coating 706 is on the interior balloon surface 702 or the exterior balloon surface 704. For instance, in FIG. 7A, the metalized coating 706 may be folded, which could increase the thickness of the balloon 204 by up to two times. In FIG. 7B, an additional layer may be situated outside the metalized coating 706 on the exterior balloon surface 704 to prevent particulate migration. This could suggest an increase in the thickness of the balloon 204 by up to six times.

(87) FIG. 8 illustrates a perspective view of the IVL balloon 204 and an inset view illustrating a position for the distal fiber end (1402 below) of an optical fiber 802 according to the elongated body 302 of FIG. 6. In this example, and the examples following, any present optical fibers 802 act as the pressure wave emitters 206 as detailed in previous figures. According to the example of FIG. 8, a protective sleeve may contain the inner shaft and/or any present lumens 208 and protect these surfaces from any energy emissions from the distal fiber end 1402 of the optical fibers 802. While not shown in the figures, the optical fiber 802 may include a toe or blunt feature on its terminal portion to prevent accidental perforation of the balloon 204 by the optical fiber 802. It is understood that such a toe or blunt feature would not impede the passage of laser energy from the distal fiber end 1402.

(88) FIGS. 9A and 9B illustrate perspective views of a portion of the elongated body 302 at the distal fiber end 1402 of two optical fibers 802, according to some examples. At least one optical fiber 802 may terminate at least partially adjacent to a target 902. In situations of shorter wavelength emissions, such as an Nd:YAG laser, the target 902 may provide a safety feature, and a component in the formation of cavitation bubbles 1404.

(89) As far as safety is concerned, the higher energy provided by an Nd:YAG laser, after causing cavitation, may proceed into a patient's vasculature if left uninterrupted. In such situations, and at high enough energy levels, this may be detrimental to the patient. The target 902 can prevent the energy from surpassing the boundaries of the IVL balloon 204 and/or the effective treatment area in situations where no IVL balloon 204 is provided.

(90) As for the formation of cavitation bubbles 1404, the target 902 may receive the energy emitted by the optical fiber 802 and begin to heat up. As the target 902 heats up further, a cavitation bubble 1404 may be formed on the target 902. In this scenario, the wavelength of the laser is not, nor is it intended to be, absorbed by the saline/contrast fluid mixture, as all of the energy may be delivered into the target 902 to facilitate the creation of the superheated cavitation bubbles 1404 on the surface of target 902 due to the subsequent heating of the surrounding saline/contrast fluid mixture.

(91) FIGS. 10A, 10B, 10C, and 10D show diagrams of a medical device 12 having an IVL balloon 204 with the distal fiber end 1402 of an optical fiber 802 held in place by a fiber positioner 1002 while aimed at a target 902.

(92) FIG. 10A illustrates a side view of a medical device 12 without a target. In this example, the wavelength of the energy from the laser is such that the saline/contrast-fluid mixture superheats from the laser itself, propagating the cavitation bubbles without necessitating an additional component in the form of the target. In FIGS. 10B-10D, various other wavelengths of laser energy may be used, as the saline/contrast-fluid mixture is not the intended recipient of said energy, and the target 902 is used to receive the laser energy and superheat, causing the surrounding saline/contrast fluid mixture to heat up in turn, and subsequently instigating the propagation of the cavitation bubbles.

(93) FIG. 10B illustrates a side view of a target 902a as a trapezoid, with the flat side facing the distal fiber end 1402. FIG. 10C shows the side view of target 902b as an elongated octagon, wherein an angled or sloped surface may be in the path of the optical signal. FIG. 10D shows an example of a target 902c having a fiber-facing surface that is sloped or angled with respect to the angle of travel of the laser energy. This angled surface may permit the cavitation bubble 1404 to be emitted substantially perpendicular to this angle of travel of the laser energy and toward the calcified lesion.

(94) In elongated bodies 302 of FIGS. 10A, 10B, 10C, and 10D, the optical fibers 802 are locked into place by a fiber positioner 1002. This fiber positioner 1002 may ensure that the relationship between the optical fiber 802 and the target 902 is consistent, both in the distance from one another and the distance the distal fiber end 1402 is from the central lumen 208.

(95) According to some examples, the fiber may be repositioned within the balloon 204, and thus the distance to the target 902 may be modulated by the clinician. As described in other figures, this ability to reposition the optical fiber 802 is not dependent upon a target 902 being present in the elongated body 302. A sliding mechanism may be included on a handle or control interface coupled to the optical fibers 802, permitting axial movement and control of said optical fibers 802. Separate sliding mechanisms may be included should a clinician want to independently control each optical fiber 802 present in the elongated body 302. Should only a single optical fiber 802 be present in the elongated body 302, only a single sliding mechanism may be needed. Fiber positioners are shown and described in FIGS. 11A, 11B, 11C, and 11D.

(96) FIGS. 11A, 11B, 11C, and 11D illustrate profile views of three possible configurations of a fiber positioner for holding the optical fiber in place, as depicted in FIGS. 10A-10D. Specifically, FIG. 11A illustrates a marker band 1102 with a top-component fiber positioner 1002a that holds onto the optical fiber 802 and has a chamfer at the end in which the tip of the optical fiber may sit but not make contact. Such a fiber positioner 1002 may be injection molded or extruded.

(97) FIG. 11B illustrates the fiber positioner 1002 of FIG. 11A, but without the marker band 1102. This fiber positioner 1002b may also be extruded or injection molded, but because of the lack of marker band 1102, fiber positioner 1002b may be attached, such as with an adhesive, to a premade marker band 1102 or another component. The fiber positioner 1002b is radiused on the bottom to permit attachment to a circular mechanism, such as an elongated body 302, marker band 1102, or another component.

(98) FIG. 11C illustrates another example of a fiber positioner 1002c. This fiber positioner 1002c is simpler in construction than those of FIGS. 11A and 11B, as it does not include multiple apertures or a radiused bottom portion. This fiber positioner 1002c may be held in place with respect to the elongated body 302 or may include laser-cut slits in its flared section to permit it to crimp down onto an elongated body 302, marker band 1102, or another component. Additional implementations include attaching the fiber positioner 1102c to the inner mechanism (i.e., elongated body 302, marker band 1102, etc.) via an ultraviolet (UV) adhesive, heat shrink, or a swagged marker band. It is understood that these attachment implementations may also be used with the fiber positioner 1002b of FIG. 11B. These attachment implementations are unnecessary in the fiber positioner 1002a of FIG. 11A, as the fiber positioner 1002a and the marker band 1102 are molded together in such an example.

(99) FIG. 11D illustrates another example of a fiber positioner 1002, shown as marker band 1102b. In this example, two marker bands 1102 are presentan inner marker band 1102a about the guidewire lumen 208, and an outer marker band 1102b which surrounds the inner marker band 1102a, as well as any present optical fibers 802. In this way, the inner marker band 1102a separates the optical fiber 802 a predetermined distance away from the guidewire lumen 208, and the outer marker band 1102b keeps the optical fibers 802 in place.

(100) While not present in FIGS. 11A-11D, a flare, similar to the shroud as shown and described in FIG. 13 below, may be present in any of FIGS. 11A-11D. This flare may act as a safety feature, facilitating the prevention of any laser energy from contacting either the surface of the balloon or the guidewire lumen.

(101) FIG. 12 illustrates a diagram of two optical fibers 802, represented as optical fiber 802a and optical fiber 802b, traversing an elongated body 302 along a guidewire lumen 208 and terminating inside of an IVL balloon 204, according to some examples. As seen in FIG. 12, the optical fiber 802a shown above the guidewire lumen 208 describes an angled distal tip end. According to some examples, this angled distal tip end is angled at greater than one hundred and fourteen degrees to the longitudinal axis of the guidewire lumen 208. Stated another way, if the distal fiber end 1402 travels substantially parallel to the vasculature through which it moves, the distal tip end may be angled at greater than twenty-four degrees to a plane perpendicular to the longitudinal axis of the lumen 208. This angled distal tip end may facilitate avoidance of the laser energy impinging upon the outer surface of the guidewire lumen 208. This may assist with the safety of the guidewire lumen 208, ensure that all of the laser energy is delivered into a target 902, or both.

(102) As can be seen in the optical fiber 802b below the guidewire lumen 208, the optical fiber 802b may also terminate radially off-center from the guidewire lumen 208. Similar to the angled distal tip end, this radially off-center terminating optical fiber 802b may facilitate avoidance of the laser energy impinging upon the outer surface of the guidewire lumen 208. The distance at which the optical fiber 802b may be presented radially off-center from the guidewire lumen 208 depends upon the diameter of the optical fiber, as well as the location at which the optical fiber 802b is permitted to begin bending. Larger bends in the optical fiber 802b may necessitate larger balloons 204, which could be problematic for smaller diameter vasculature.

(103) FIG. 13 illustrates a profile view of a shroud 1302 for protecting a balloon 204 from an optical fiber 802. The shroud 1302 may be a laser-cut nitinol structure bonded to a skirt made of a material such as fabric, polymer, or anything else that is flexible. The skirt may expand when the balloon 204 is inflated. The nitinol structure may include tines with curved ends to provide smooth points of contact with the balloon 204 to prevent accidental perforation of said balloon 204. The skirt may also be expanded using a different mechanism within a handle proximal to the elongated body 302.

(104) As used with the examples of FIGS. 11A, 11B, 11C, and 11D, the shroud 1302 may be used to protect the balloon 204 from the tip of the optical fiber 802, preventing accidental perforation of the balloon 204. The shroud 1302 may also be used with any of the fiber positioners 1002.

(105) The solid portion of the shroud 1302 may be crimped or potted over the optical fiber 802, with the optical fiber 802 extending to a point just within the portion of the shroud 1302 where the skirt begins. This would permit the nitinol structure (arms) and the skirt to collapse down about and past the tip of the optical fiber 802. While the shroud 1302 is presented as a 180-degree structure, it is understood that the shroud 1302 may present any amount of circumferential coverage between 0 degrees (no coverage) and 360 degrees (full circumferential coverage).

(106) FIGS. 14A and 14B illustrate perspective views of a single optical fiber 802 traveling along an elongated body 302 and an elongated cavitation bubble 1404 being created at the distal fiber end 1402. Specifically, FIG. 14A illustrates the distal elongated body portion 306, while FIG. 14B illustrates a close-up view of the distal fiber end 1402 of the optical fiber.

(107) While an elongated cavitation bubble 1404 is shown in FIGS. 14A and 14B, in some examples, a smaller cavitation bubble 1404 may be created. In either case, a single optical fiber 802 may travel the length of the elongated body 302 and terminate near the distal elongated body portion 306. In examples including an IVL balloon 204, the optical fiber 802 may terminate within the IVL balloon 204. If a small cavitation bubble 1404 is used, the distal fiber end 1402 may be located at least partially concentrically with the treatment site. Here, the cavitation bubble 1404 is formed through energy generation and subsequent directing of the energy along the optical fiber. This energy is dispelled from the distal fiber end 1402 and then interacts with the saline/contrast-fluid mixture to create the cavitation bubble. Once this cavitation bubble 1404 collapses, a shockwave is propelled radially away from the point of collapse, striking or penetrating the treatment site, and damaging any present calcification.

(108) In the case of an elongated cavitation bubble, such as shown in FIGS. 14A and 14B, the process is very similar. The difference, however, is in the pulse width and frequency generated to produce a Moses effect. The Moses effect is a propagating cavitation bubble. The forming cavitation bubble 1404 enables subsequent laser energies to travel through the forming cavitation bubble to deposit the laser energy at the distal-most end of the cavitation bubble 1404, i.e., the end of the cavitation bubble 1404 furthest from the distal fiber end 1402. The cavitation bubble 1404 will continue propagating and collapsing through the length of the treatment site (the area of saline/contrast-fluid mixture, such as that of the portion of vasculature that has had the blood displaced or up to the length of the IVL balloon 204) permitting the treatment of a longer lesion than would a single cavitation bubble.

(109) A target 902, such as that described in FIGS. 9B, 10B, 10C, and 10D, would likely not be used in conjunction with an elongated body 302 implementing the Moses effect, as this would significantly limit the distance the cavitation bubble 1404 may propagate. In some examples, a longer wavelength energy source may be utilized, such as Ho:YAG or CTH:Yag.

(110) FIG. 15 illustrates a cross-sectional view of the elongated body 302 and optical fiber 802 of FIGS. 14A and 14B. As can be seen in FIG. 15, the optical fiber 802 includes a core 1502 and a cladding 1504. The cladding 1504 prevents laser energy from egressing the optical fiber 802 from the core 1502. Not present in FIG. 15, but shown and described in FIGS. 16A-18C is a score in the cladding 1504 to permit egress of laser energy from the optical fiber 802 premature to the distal fiber end 1402, as in some examples, such as the examples of FIGS. 14A, 14B, and 15, the system may not have this laser energy exit the optical fiber 802 prematurely. While not shown, according to some examples, the core may end up being scored a minor amount as well. Similar to FIGS. 7A and 7B above, the radii and proportions of each feature are exaggerated to simplify the expression of each independent structure in the drawing.

(111) FIGS. 16A and 16B show perspective views of a single optical fiber 802 traveling along an elongated body 302 with scores 1602 cut into the optical fiber. Specifically, FIG. 16A illustrates the distal elongated body portion 306, while FIG. 16B illustrates a close-up view of two of the scores 1602 in the optical fiber 802. Both FIGS. 16A and 16B show cavitation bubbles 1404, initiating at the scores 1602 of the optical fiber 802.

(112) As shown in FIGS. 16A and 16B, each score 1602 presents an exit point for the energy. This may effectively turn a single optical fiber 802 into a multiple-emitter laser fiber. In these examples, the energy is reflected within the optical fiber 802 until finding a natural termination point through which it may emit, such as each of the scores 1602. As shown in FIG. 16B, the energy may also be released through an opening at the distal fiber end 1402 in addition to the scores 1602.

(113) Similar to the single optical fiber 802 examples of FIGS. 14A and 14B, once the energy is emitted from a score, it reacts with the saline/contrast-fluid mixture to create a cavitation bubble. This cavitation bubble 1404 will then collapse, causing a shock wave that impacts or penetrates the treatment area to cause damage to any present calcification. Similar to the above-described Moses effect, the presence of multiple scores 1602 permits multiple cavitation bubbles 1404 throughout the treatment area, thus extending the length of applicable treatment.

(114) As shown in FIG. 16B, the distal fiber end 1402 may be used as an exit point, similar to the examples shown in FIGS. 14A and 14B. This distal fiber end 1402 may work the same way as the distal fiber end 1402 of the single optical fiber 802 in that a cavitation bubble 1404 may be formed here. Depending on the generator settings, such as pulse width and frequency, a Moses effect may be utilized at this distal fiber end 1402.

(115) FIG. 16A shows five scores 1602 and FIG. 16B shows the distal-most two scores 1602. As few as one score, or a plurality of scores 1602 (e.g., as many scores 1602 as may fit within the IVL balloon 204, in examples including an IVL balloon 204) may be present.

(116) FIG. 17 illustrates a cross-sectional view of the elongated body and optical fiber of FIGS. 16A and 16B. Similar to FIG. 15, the optical fiber 802 includes a core 1502 and a cladding 1504. The cladding prevents laser energy from exiting the optical fiber 802 from the core 1502 in unwanted locations. Dissimilar to FIG. 15, the cladding 1504 is depicted as including a score 1602 in FIG. 17. The score 1602 as shown and described above in FIGS. 16A and 16B, and below in FIGS. 18A, 18B, and 18C, permits laser energy to exit the optical fiber 802 prior to the distal fiber end 1402. This premature emission can permit multiple cavitation bubbles 1404 to form along the body of the optical fiber 802, increasing the length of efficacious treatment along a calcified lesion 50 in a treatment area 40. Similar to FIGS. 7A, 7B, and 15 above, the radii and proportions of each feature are exaggerated to simplify the expression of each independent structure in the drawing.

(117) FIGS. 18A, 18B, and 18C illustrate various perspective views of a multiple optical fiber 802 embodiment of the elongated body 302. In each of FIGS. 18A-18C, the point of termination at the distal fiber end 1402 for each of the present optical fibers 802 depicts the initiation of a cavitation bubble.

(118) According to the elongated body 302 of FIGS. 18A-18C, each optical fiber 802 acts similarly to the elongated body 302 of FIGS. 14A and 14B. Energy is transmitted from the generator 310 through each optical fiber. When the energy is emitted from each distal fiber end 1402a, 1402b, 1402c, and 1402d, it may interact with the saline/contrast-fluid mixture to create the cavitation bubbles 1404, as shown. Once the cavitation bubbles 1404 collapse, a shock wave is propelled substantially radially away from each point of collapse, striking and penetrating the treatment site and damaging any present calcification. Because there are multiple optical fibers 802, and the distal fiber ends 1402 are positioned a distance away from each other in the longitudinal direction, multiple cavitation bubbles 1404 may be formed along the length of the treatment area, thus extending the size of the lesion that can be treated.

(119) By controlling the pulse width and frequency of the delivered energy, an operator could also achieve a Moses effect from each optical fiber 802. However, the benefits of accomplishing this with multiple laser emitters 206 may be less efficacious than with a single laser emitter, as the multiple laser emitters 206 already achieve the goal of lengthening the treatment area.

(120) Depending on the energy source used, a target 902, or targets 902, may also be applied at the distal elongated body portion 306 to absorb the energy provided by the optical fibers 802. Similar to the example targets 902 of FIGS. 9B, 10B, 10C, and 10D, the target 902 may heat up due to absorbing this energy. As the target 902 continues to heat, a cavitation bubble 1404 may be formed on the target 902 as a result of the target heating up the surrounding saline/contrast solution. In this instance, the wavelength of the energy may not be intended to be absorbed directly by the saline/contrast-fluid mixture. All of the energy may be delivered into the target 902 to facilitate the creation of the superheated cavitation bubbles 1404 on the surface of the target 902 through absorption of this generated heat by the saline/contrast-fluid mixture.

(121) While not shown in FIGS. 18A-18C, the optical fibers 802 may be locked into place by a fiber positioner 1002. This fiber positioner 1002 may ensure that the relationship between each distal fiber end 1402 and its related target 902 remains consistent, as well as the distance that each optical fiber 802 is offset from the central lumen 208.

(122) Each of FIGS. 18A-18C show five optical fibers 802. As few as one optical fiber 802 (such as that shown in FIGS. 14A and 14B), or as many optical fibers 802 that may fit within the IVL balloon 204 (in examples including an IVL balloon 204), or as many optical fibers 802 as can fit within the vasculature being treated may be present.

(123) The example elongated body 302 of FIGS. 18A-18C shows the optical fibers 802 surrounding the central lumen 208, with the distal fiber ends 1402 terminating at different points along the central lumen 208. For example, the optical fibers 802 may be spaced further from one another, or the optical fibers 802 may be provided as symmetrically dispositioned about the central lumen 208. Any configuration may be utilized.

(124) While a cross-sectional view is not illustrated for FIGS. 18A-18C, it is understood that the cross-section may appear similar to the unscored cross-section of FIG. 15 or the cross-section with scores 1602 of FIG. 17. In either case, the only change is the number of optical fiber 802 surrounding the elongated body 302.

(125) In all of the FIGS. 14A-18C, it is understood that the cavitation bubble 1404 formed, by any means disclosed herein, is considered to radiate outward from essentially the center of the elongated body 302, despite the short radius away each optical fiber 802 resides. The central lumen 208 does not interfere with the cavitation bubbles 1404 in any meaningful way. As such, each provided cavitation bubble 1404 is understood to radiate with complete, or approximately complete, 360-degree coverage about the vessel wall. In examples where the central lumen 208 does create some shadowing, the cavitation bubbles 1404 will still radiate with 360-degree coverage about the vessel wall, but some variance in the magnitude of strength of the bubble about this periphery may be observed.

(126) FIGS. 19A-19H illustrate side views of various distal fiber ends 1402 for an optical fiber 802, as may be provided in an elongated body 302. In examples of distal fiber ends 1402 that are intended for collecting light or an optical signal (such as FIGS. 19A, 19C, 19D, 19E, and 19H), the shape of the fiber tip at the distal fiber end 1402 may improve the capabilities of the aforementioned fiber interrogation mechanism 524. By increasing the probability that light or the optical signal reflected back at the optical fiber 802 is captured by the distal fiber end 1402 through the use of these various fiber tips, it becomes more likely that a false negative of a problem with the fiber, such as a break is not reported. Thus the clinician will not prematurely remove the elongated body 302 due to faulty data reporting an issue with the optical fiber.

(127) In examples of distal fiber ends 1402 that are intended for the emission of light or the laser energy in a certain direction (FIGS. 19B, 19C, 19D, 19F, and 19G), the shape of the fiber tip at the distal fiber end 1402 may facilitate directional discharge of the laser, redirection of the laser without the use of bending the optical fiber, or narrowing or broadening of the light beam or optical signal to affect the amount of energy delivered to a point.

(128) Of note, the examples illustrated in FIGS. 19C and 19D can facilitate the collection of light or an optical signal from a laser, as well as the emission of light or an optical signal from a laser. The fiber tips include functionality to improve both of these actions, and thus, depending on the user's needs, may assist in both a means of delivery of the laser and safety in the form of sensing the laser being reflected back.

(129) FIG. 19A shows a distal fiber end 1402 including a conical frustum 1902 (an increase in the radial dimension), according to some examples. A conical frustum 1902 may increase the laser's spot size to decrease power density at the interface between the distal fiber end 1402 and the saline/contrast-fluid mixture or the target 902. FIG. 19B illustrates a distal fiber end 1402 having a taper 1904 (a decrease in radial dimension). A tapered 1904 profile may decrease the spot size of the laser and increase the laser's fluence or energy density.

(130) FIG. 19C shows an optical fiber 802 with a distal fiber end 1402 including a convex lens 1906. A convex lens 1906 may increase light or optical signal collection from the laser while decreasing divergence. FIG. 19D illustrates a distal fiber end 1402 including a concave lens 1908, according to some examples. A concave lens 1908 may increase the laser's light or optical signal divergence.

(131) FIG. 19E illustrates an optical fiber 802 with a distal fiber end 1402 including a spherical ball lens 1910. A spherical ball lens 1910 may increase the angle of potential light collection by the optical fiber. FIG. 19F shows a distal fiber end 1402 including a diffuser-type tip 1912. The diffuser-type tip 1912 may permit full peripheral illumination through all sides of the distal fiber end 1402.

(132) FIG. 19G shows an optical fiber 802 where the distal fiber end 1402 includes a side-fire tip 1914. The angle of the side-fire tip 1914 redirects the laser, at least partially, with respect to the elongated body 302 angle of traverse through the vasculature. This redirection may be any angle, including substantially perpendicular angles, as well as 180-degree redirection of the laser. FIG. 19H illustrates a distal fiber end 1402 including an angled end 1916. The angled end 1916 may reduce back reflection when collecting light or laser energy.

(133) In any of FIGS. 19A-19H, where an IVL balloon 204 is present on the elongated body 302, the polished distal fiber end 1402 terminates within the IVL balloon 204. The polished distal fiber end 1402 may be cleaved, shaped, or flame-polished. In all examples, including a balloon 204, rough edges of the distal fiber end 1402 may be undesirable, as they can create wear and tear on the interior wall of the balloon 204, which may decrease the life expectancy of the balloon 204. It is understood, however, that it is not required to have the distal fiber end 1402 polished in any way without affecting the capabilities of the IVL system 10 as a whole.

(134) Any energy source suitable for providing energy through an optical fiber 802 to produce a cavitation bubble, either through interaction with the saline/contrast-fluid mixture or a target 902, may be used in conjunction with any of the example IVL systems 10 and features depicted in FIGS. 1-19H. Some examples include the use of a lasing medium such as Nd:YAG (neodymium-doped: yttrium aluminum garnet), Ho:YAG (Holmium), or CTH:YAG (chromium, thulium, holmium). Lasing mediums such as Nd:YAG with a short wavelength (3124 nanometers for Nd:YAG) may benefit from using the target 902 described in FIGS. 9B, 10B, 10C, and 10D. Lasing mediums such as CTH:YAG with a longer wavelength (2.1 microns for CTH:YAG) may benefit from IVL systems 10, where the cavitation bubble 1404 is formed through interaction with the saline/contrast-fluid mixture. Additionally, different types of pumped lasers may be used with any of the example IVL systems 10 and features depicted in FIGS. 1-19H, such as discharge-pumped excimer lasers or flashlamp-pumped lasers.

(135) Dimensions for the provided laser include wavelengths ranging from 308 nanometers to 2.1 microns (examples include 308 nanometer excimer lasers and 355 nanometer tripled Nd:YAG lasers), but any suitable wavelength may be used. Pulse widths may be long (about 300 to 600 microseconds) or short (less than 100 nanoseconds). The pulse repetition rate may be approximately 1-2 hertz (HZ), but any pulse repetition rate may be used. Optical fiber 802 diameters include 150 micrometers, 175 micrometers, and 200 micrometers. Again, any functional optical fiber 802 diameter may be used. The provided energy levels may be between 40 and 1500 milliJoules (mJ) and the like.

(136) FIG. 20 illustrates a flowchart depicting a method of generating a cavitation bubble in a balloon catheter. In some examples, the method includes providing a medical device according to the description and the figures herein (at step 2000). The medical device may be a medical device as shown and described in FIGS. 1-19H, or any combination of these examples. According to some examples, the method includes disposing a balloon within a patient's vasculature adjacent to a calcified lesion (at step 2002). The balloon may surround, or partially surround, a distal end of a catheter.

(137) The method may include inflating the balloon using a fluid (at step 2004). This inflation may serve multiple purposes. For example, inflating the balloon with the fluid may cause the balloon to make contact with a calcified lesion in the treatment area. Additionally, the fluid used to inflate the balloon may serve as a receptacle for incoming energy from a laser source, should one be provided. In this case, the fluid may be a saline/contrast-fluid mixture of any percentage composition. In some examples, the method includes transmitting laser energy through an optical fiber (at step 2006). This laser energy is delivered through a catheter and toward the distal end of said catheter. The laser energy is intended to heat a target, be it a physical target (as described in step 2008b) or the fluid within the balloon (as described in step 2008a).

(138) According to some examples, the method includes heating the fluid (at step 2008a). The laser energy is absorbed by the fluid, such as a saline/contrast-fluid mixture, and subsequently, the absorbed energy heats up the fluid. The method may include generating a cavitation bubble (at step 2010). As a result of the fluid heating up, a cavitation bubble may form and subsequently collapse. This cavitation bubble may generate high-energy pressure waves, which can be utilized to disrupt calcified lesions in a treatment area.

(139) Alternatively, in some examples, the method includes heating a target (at step 2008b). This physical target may act as a receptacle for the laser energy in this case. As the target heats up, it may impart its heat to the surrounding fluid, thus causing the surrounding fluid to heat up as well. According to some examples, the method includes generating a cavitation bubble (at step 2010). In a similar manner as expressed above, as a result of the fluid heating up, a cavitation bubble may form and subsequently collapse. To reiteratethis cavitation bubble may then generate high-energy pressure waves, which can be used to disrupt calcified lesions in a treatment area.

(140) FIG. 21 illustrates a flowchart depicting a method of generating a cavitation bubble within a vessel. In some examples, the method includes providing a medical device according to the description and the figures herein (at step 2100). Again, the medical device may be a medical device as shown and described in FIGS. 1-19H, or any combination of these examples. According to some examples, the method includes transmitting a fluid through a central lumen (at step 2102). The provided fluid may be used to inflate a balloon, if present, as described in FIG. 20. The provided fluid may also be used as a receptacle for incoming energy from a laser source, should one be provided. In this case, the fluid may be a saline/contrast-fluid mixture of any percentage composition.

(141) The method may include emitting the fluid through a distal elongated body portion of the central lumen into a treatment area (at step 2104). In this case, a balloon is not present, and the fluid is instead injected directly into the vasculature of a patient. In some examples, the method includes displacing blood in the treatment area (at step 2106). This blood displacement may facilitate better contact between the fluid and the walls of the treatment area, allowing the pressure waves emitted from the collapsing cavitation bubbles to better disrupt any present calcified lesions. By removing the blood from the treatment area, the fluid may fill the entirety, or a substantial portion of, the treatment area.

(142) According to some examples, the method includes transmitting laser energy through an optical fiber (at step 2108). This laser energy may be delivered through a catheter and toward the distal end of said catheter. In some examples, the laser energy is intended to heat a target, be it a physical target (as described in step 2108b) or the fluid within the balloon (as described in step 2108a).

(143) The method may include heating the fluid (at step 2110a). The laser energy may be absorbed by the fluid, such as a saline/contrast-fluid mixture, and subsequently, the absorbed energy heats up the fluid. In some examples, the method includes generating a cavitation bubble (at step 2112). As a result of the fluid heating up, a cavitation bubble may form and subsequently collapse. This cavitation bubble may generate high-energy pressure waves, which can be utilized to disrupt calcified lesions in a treatment area.

(144) Alternatively, according to some examples, the method includes heating a target (at step 2110b). This physical target may act as a receptacle for the laser energy in this case. As the target heats up, it may impart its heat to the surrounding fluid, thus causing the surrounding fluid to heat up as well. The method may include generating a cavitation bubble (at step 2112). In a similar manner as expressed above, as a result of the fluid heating up, a cavitation bubble may form and subsequently collapse. To reiteratethis cavitation bubble may then generate high-energy pressure waves, which can be used to disrupt calcified lesions in a treatment area.

(145) Included in the present disclosure is a medical device 12 including an elongated body 302 having a distal elongated body portion 306 and a central longitudinal axis 308. According to some examples, the medical device 12 includes a balloon 204 positioned along the distal elongated body portion 306, the balloon 12 having an interior balloon surface 702 and an exterior balloon surface 704 and configured to receive a fluid 212 to inflate the balloon 204 such that the exterior balloon surface 704 contacts a calcified lesion 50 within a vasculature of a patient 20. The medical device 12 may include one or more pressure wave emitters 206 positioned along the central longitudinal axis 308 of the elongated body 302 within the balloon 204, the one or more pressure wave emitters 206 configured to propagate at least one pressure wave through the fluid 212 to fragment the calcified lesion 50. In some examples, at least one of the pressure wave emitters 206 includes an optical fiber 802 configured to transmit laser energy into the balloon 204. According to some examples, the laser energy is configured to create a cavitation bubble 1404 in the fluid 212 upon contact with the fluid 212 to generate the at least one pressure wave.

(146) The optical fiber 802 may terminate near the distal elongated body portion 306. In some examples, the medical device 12 further includes a laser energy generator 310, wherein the laser energy generator 310 is configured to selectively pulse the laser energy. According to some examples, the pulsed laser energy is configured to generate a Moses Effect.

(147) The medical device 12 may further include a plurality of optical fibers 802, each optical fiber 802 configured to transmit laser energy and terminating at a distal fiber end 1402 at a different distance along the distal elongated body portion 306. In some examples, the laser energy is emitted from the distal fiber ends 1402.

(148) According to some examples, the optical fiber 802 includes a core and a cladding. In some examples, the cladding is disposed around the core, and the laser energy is emitted from the core through scores placed in the cladding. The medical device 12 may further include multiple optical fibers 802 disposed around the distal elongated body portion 306.

(149) In some examples, the laser energy is configured to have a wavelength of between about 1800 nanometers (nm) and 2100 nm. According to some examples, the wavelength is about 2000 nm. Isotopes of the doping elements may cause some small spread in the wavelength, and doping concentrations in the crystal may slightly shift the wavelengths as well. Because of this, about as used herein in conjunction with wavelength is intended to mean plus or minus 30 nm. In some examples, the wavelength is between 1970 nm and 2030 nm. In examples where a CTH:YAG laser is used, the wavelength may be selected from the group consisting of 1970 nm, 2030 nm, 2080 nm, 2091 nm, 2097 nm, and 2121 nm. In examples where a Ho:YAG laser is used, the wavelength may be about 2100 nm.

(150) In some examples, the laser energy is configured to have an energy between about 15 mJ and about 1500 mJ. According to some examples, the laser energy has a pulse width between about 10 nanoseconds and about 600 microseconds. The laser energy may have a pulse repetition rate between about 1 Hz and about 10 Hz.

(151) In some examples, the medical device 12 further includes an Nd-YAG laser configured to provide the laser energy. According to some examples, the medical device 12 further includes a Holmium laser selected from the group consisting of Ho:YAG and CTH:YAG, the Holmium laser configured to provide the laser energy. The medical device 12 may further include an excimer laser configured to provide the laser energy.

(152) In some examples, the medical device 12 further includes a pressure sensor 522 configured to detect ruptures in the balloon 204, wherein the pressure sensor 522 is configured to halt the laser energy upon detection of a balloon rupture. This detection may also occur due to any loss of pressure of a certain threshold. According to some examples, the medical device 12 further includes a fiber interrogation mechanism 524 configured to detect breakage of the optical fiber 802.

(153) The medical device 12 may further include a target 902 disposed distally of the optical fiber 802. In some examples, at least one of the pressure wave emitters 206 includes an optical fiber 802 configured to transmit laser energy into the balloon 204 and impact the target 902. According to some examples, the target 902 is configured to heat up upon being impacted by the laser energy, and the heat from the target 902 is configured to heat a fluid 212 causing emission of the pressure wave. The medical device 12 may further include the optical fiber 802 having a distal fiber end 1402 and a fiber positioner 1002 to maintain a constant distance between the distal fiber end 1402 and the target 902 such that the laser energy transmitted into the balloon 204 will impact the target 902.

(154) In some examples, the medical device 12 defines a central lumen 208 extending through the elongated body 302, the central lumen 208 having a proximal lumen end and a distal lumen end opposite the proximal lumen end. In some examples, the central lumen 208 is configured to transmit fluid 212 to displace blood in a treatment area 40 adjacent a calcified lesion 50 within a vasculature of a patient 20.

(155) According to some examples, a balloon surface selected from the group consisting of the interior balloon surface 702, the exterior balloon surface 704, and combinations thereof further includes a metalized coating 706 configured to increase a damage threshold of the balloon 204.

(156) FIG. 22 illustrates another side view of an example IVL system including a medical device 12. As shown, the medical device 12 extends from a proximal end 2204 to a distal end 2206. An elongated body 302, such as a catheter, may be implemented in the medical device 12 and extend the length of the medical device 12. A portion of the elongated body 302 near the distal end 2206 is referred to here as the distal elongated body portion 2202. The distal elongated body portion 2202 may extend from where the elongated body 302 enters the balloon 204 all the way to the distal end 2206, as seen in FIG. 22. In some examples, the distal elongated body portion 2202 may extend proximal to the balloon 204, or terminate at the same location as the point at which the balloon 204 comes back into contact with the elongated body 302 at its distal end.

(157) In any case, the distal elongated body portion 2202 may be of a different cross-sectional size than the rest of the elongated body 302. This may provide benefits such as decreasing the crossing profile of the medical device 12 due to additional components along this distal elongated body portion 2202, such as the balloon 204 or fiber positioners as have been, and will be further shown and described in this disclosure. Additionally, the distal elongated body portion 2202 may have a different cross-sectional shape than the rest of the elongated body 302.

(158) One of the problems seen in the prior art is how to manipulate the optical fiber such that it moves longitudinally. It is desirable to move the optical fiber with respect to the catheter, because once a balloon has been filled, it is more difficult to move the entire device. Especially in instances where the balloon is intended to make contact with a vessel, or, in this case, a calcified lesion in the vessel, the balloon may need to be deflated, or partially deflated, in order to reposition the entire device. Thus, moving the optical fiber within the balloon would remedy this problem. While devices are known to be capable of moving the optical fiber longitudinally, one of the problems left unresolved in the prior art is how to effectuate this longitudinal movement, which the present disclosure seeks to solve.

(159) FIGS. 23A, 23B, and 23C illustrate diagrams of an IVL device including a movable fiber positioner, according to some examples. Specifically, FIG. 23A shows an IVL device including a spring 2308a attached to the fiber positioner 2302 proximal to the fiber positioner 2302. This spring 2308a may be attached to a permanent or semi-permanently fixed component of the IVL device, such as a marker band 2306a (as shown) or other component. A marker band 2306a may assist an operator with locating the IVL device within the vasculature of a patient.

(160) In this example, the fiber positioner 2302 may rest at a nominal position with respect to the IVL device. An operator may then effectuate longitudinal movement on the fiber positioner 2302, either by interacting with the fiber positioner 2302 itself, or manipulating something fixedly coupled to the fiber positioner 2302, such as the optical fiber 802. When the fiber positioner 2302 is moved distally, it places the spring 2308a under tension, such that the spring 2308a wants to return to its nominal position. The operator may then lock the fiber positioner 2302, or the spring 2308a, in place while they perform a procedure. The operator may then unlock the fiber positioner 2302 or spring 2308a once the procedure is completed, allowing the spring 2308a to return to its nominal position prior to retracting the IVL device.

(161) Likewise, when the fiber positioner 2302 is moved proximally, it places the spring 2308a under compression, such that the spring 2308a wants to return to its nominal position. Again, the operator may then lock the fiber positioner 2302, or the spring 2308a, in place while they perform a procedure. The operator may then unlock the fiber positioner 2302 or spring 2308a once the procedure is completed, again allowing the spring 2308a to return to its nominal position prior to retracting the IVL device.

(162) In some examples, the nominal position of the spring 2308a may be a fully compressed state. In such examples, the operator would only be capable of pushing the fiber positioner 2302 distally, thus placing the spring 2308a under tension.

(163) FIG. 23B illustrates a similar IVL device, however, in this example the spring 2308b is distal to the fiber positioner 2302. Also in this example, the fixed component, in this case a marker band 2306b, is also distal to the fiber positioner 2302. Once again, the marker band 2306b may assist an operator with locating the IVL device within the vasculature of a patient.

(164) This means that, should the fiber positioner 2302 be moved distally, the spring 2308b would be placed under compression. Alternatively, should the fiber positioner 2302 be moved proximally, the spring 2308b would be placed under tension. In both cases, the spring 2308b would want to return to its nominal position, but the operator may lock the spring 2308b and/or the fiber positioner 2302 in place during the procedure.

(165) As discussed with reference to FIG. 23A above, the nominal position of the spring 2308b may be a fully compressed state. However, due to the different position of spring 2308b as compared to spring 2308a, the operator may only be capable of pulling the fiber positioner 2302 proximally, thus placing the spring 2308b under tension.

(166) In either case-a spring 2308 under compression or under tension-once an operator releases the spring 2308 (or component holding the spring 2308 in position), this compression or tension will want to release, returning the spring 2308 to its nominal position. This may assist returning the fiber positioner 2302, and the optical fiber 802, to this nominal position. In the case of spring 2308a, because the tension is formed by moving the fiber positioner 2302 distally, this tension may facilitate the return of the fiber positioner 2302 and optical fiber 802 proximally to its nominal position. In this case of spring 2308b, because the tension is formed by moving the fiber positioner 2302 proximally, this tension may facilitate the return of the fiber positioner 2302 and the optical fiber 802 distally to its nominal position.

(167) FIG. 23C combines the features of FIGS. 23A and 23B. In this example, proximal spring 2308a and distal spring 2308b are both coupled to the fiber positioner 2302. Once again, the permanent or semi-permanent fixtures to which these springs 2308 are coupled are marker bands 2306, in this case proximal marker band 2306a and distal marker band 2306b.

(168) In this example, moving the fiber positioner 2302 proximally would place the spring 2308a under compression and the spring 2308b under tension. This may cause more resistance, with the springs 2308 wanting to return to their nominal position. Alternatively, moving the fiber positioner distally would place the spring 2308a under tension and the spring 2308b under compression.

(169) In other examples, springs with lower spring constants could be used due to this additive resistance. As springs with lower spring constants could be smaller, this may facilitate the creation of a smaller crossing profile for the IVL device.

(170) In the example shown in FIG. 23C, the nominal position for the fiber positioner 2302 could see the spring 2308a fully compressed or the spring 2308b fully compressed, but not both. If the nominal position of the fiber positioner 2302 had both spring 2308a and spring 2308b under full compression, the fiber positioner would likely not be capable of longitudinal movement.

(171) FIG. 24 illustrates a cross-sectional view of the IVL device of FIG. 23A. In this example, as the spring 2308a and the marker band 2306a are proximal to the fiber positioner 2302, they would not be seen.

(172) FIG. 25 illustrates a cross-sectional view of the medical device of FIGS. 23B and 23C. In this example, because the spring 2308b and the marker band 2306b are distal to the fiber positioner 2302, they would be seen.

(173) Another problem found in prior art solutions to longitudinal movement of the optical fiber is that the optical fiber may also want to move rotationally with respect to the guidewire lumen (or central axis, or IVL device as a whole, etc.) Especially in instances where the optical fiber is manipulated itself by the operator, the optical fiber may try to kick, where it wants to move at an angle in addition to moving longitudinally. This is a problem, because, as the optical fiber becomes more radially offlinei.e., rotationally misaligned from its nominal position with respect to the central axisthe longitudinal translation of the optical fiber may see increased resistance, making it more difficult for an operator to longitudinally displace the optical fiber. Permitting the optical fiber to move rotationally may also increase wear and tear on the optical fiber, potentially causing issues with durability in the optical fiber.

(174) The present disclosure also seeks to remedy this deficiency in prior art solutions. Through the below disclosures, a fiber positioner may be rotationally fixed to a catheter. Because a provided optical fiber would run through the fiber positioner, or be otherwise coupled to the fiber positioner, this would prevent the optical fiber from rotating with respect to the catheter. Thus, by knowing the position of the catheter, through means such as a provided marker band, an operator would be able to know the exact position of the optical fiber, longitudinally and axially, in order to deliver the most efficacious treatment.

(175) FIG. 26 illustrates a diagram of an IVL device with the distal fiber end of an optical fiber 802 held in place. The purpose of FIG. 26 is to orient a viewer as to where the cross-sectional depictions of fiber positioner 2602 as seen in FIGS. 27A, 27B, 27C, 27D, and 27E take place. However, it is understood that previous perspective views of the fiber positioner 2602, such as fiber positioners as shown in FIGS. 11A, 11B, 11C, and 11D may also be used in conjunction with this disclosure.

(176) FIGS. 27A, 27B, 27C, 27D, and 27E illustrate various examples of cross-sections of the IVL device of FIG. 26. Specifically, FIG. 27A illustrates a circular fiber positioner 2602a including a circular distal elongated body portion 2604a. In this example, the fiber positioner 2602a includes a protrusion 2702a for receiving the optical fiber 802. This example fiber positioner 2602a and distal elongated body portion 2604a are each shown with an eccentricity of zero, which may allow for the aforementioned rotation of the optical fiber 802.

(177) In other embodiments, alternate methods of rotationally fixing the optical fiber 802 with respect to the distal elongated body portion 2604a while still permitting longitudinal translation of the optical fiber 802 may be used. For example, additional fiber positioners may be provided, either along the distal elongated body portion 2604a, along the rest of the elongated body, or both, in order to prevent the optical fiber 802 from rotating about the distal elongated body portion 2604a. In such examples, the optical fiber 802 may slide through these additional fiber positioners, or the additional fiber positioners may also move with the optical fiber.

(178) Alternatively or additionally, a portion of the optical fiber 802 that is located along the distal elongated body portion 2604a may be made to be more rigid, or treated in another manner to increase this portion of the optical fiber's 802 rigidity without affecting the optical fiber's 802 ability to be inserted through vasculature of a patient to a treatment location. In such examples, the rigidity of this portion of the optical fiber 802 may prevent the optical fiber 802 from rotating about the distal elongated body portion 2604a due to its now inability, or reduced ability, to flex (or bend, or twist, etc.)

(179) The above additional methods of rotationally fixing the optical fiber 802 with respect to a distal elongated body portion may also be incorporated into the below disclosure regarding the shapes of fiber positioners without detracting from the fiber positioners ability to also rotationally fix the optical fiber 802 with respect to the distal elongated body portion, while still allowing for longitudinal translation of the optical fiber 802.

(180) FIG. 27B illustrates an oval-shaped fiber positioner 2602b surrounding an oval-shaped distal elongated body portion 2604b. The specific shape of the oval for both the fiber positioner 2602b and the distal elongated body portion 2604b is not important, so long as the eccentricity of each is greater than zero and less than one. This is because, with an eccentricity of greater than zero and less than one, the fiber positioner 2602b is unable to rotate about the distal elongated body portion 2604b, thus preserving the axial location of the optical fiber 802 with respect to the distal elongated body portion 2604b. Also shown in FIG. 27B is a protrusion 2702b for receiving the optical fiber 802 in the fiber positioner 2602b.

(181) FIG. 27C illustrates a distal elongated body portion 2604c including a longitudinal depression 2706. In this example, the fiber positioner 2602c includes an indentation 2708 configured to be accepted by the longitudinal depression 2706. In this way, the fiber positioner 2602c is prevented from rotating about the distal elongated body portion 2604c, thus preserving the axial location of the optical fiber 802 with respect to the distal elongated body portion 2604c. Additionally, the longitudinal depression 2706 may run the entire length of the distal elongated body portion 2604c, or it may only run for a portion of the distal elongated body portion 2604c. In such examples where the longitudinal depression 2706 does not extend the entire length of the distal elongated body portion, the longitudinal depression 2706 may prevent the fiber positioner 2602c from moving longitudinally further than this longitudinal depression 2706 length.

(182) Also shown in FIG. 27C is a protrusion 2702c for receiving the optical fiber 802 in the fiber positioner 2602c. In all of FIGS. 27A, 27B, and 27C, these protrusions 2702 are by way of example only, and it is understood that other solutions for maintaining the optical fiber 802 in the fiber positioner 2602 would be equally operable.

(183) For example, FIG. 27D illustrates another distal elongated body portion 2604d including a longitudinal depression 2706, along with another fiber positioner 2602d including an indentation 2708 configured to be accepted by the longitudinal depression 2706. However, in this case, the optical fiber 802 may nest in the indentation 2708 of the fiber positioner 2602d on the side opposite the longitudinal depression 2706 of the distal elongated body portion 2604d. While the illustration of FIG. 27D is simplified, it is understood that the indentation 2708 may further surround the optical fiber 802 in order to prevent the optical fiber 802 from decoupling from the fiber positioner 2602d. Decoupling in this context is intended to be interpreted as one object becoming not coupled from another object, either actively or passively.

(184) FIG. 27E illustrates a distal elongated body portion 2604e including a longitudinal depression 2706, but in this example, the surrounding fiber positioner 2602e does not include an indentation. Instead, the optical fiber 802 extends near the longitudinal depression 2706 through the fiber positioner 2602e. In this example, the fiber positioner 2602e is prevented from rotating about the distal elongated body portion 2604e because the longitudinal depression 2706 prevents the optical fiber 802 itself from rotating. This is another method by which the axial location of the optical fiber 802 with respect to the distal elongated body portion 2604e may be preserved.

(185) FIGS. 28A and 28B illustrate diagrams of an IVL device including a fiber positioner lumen. In both FIGS. 28A and 28B, a fiber positioner 2802 is shown coupled to a distal elongated body portion 2808. In these examples, however, the fiber positioner 2802 does not surround the distal elongated body portion 2808. Instead, multiple lumens run through the catheter, one being a guidewire lumen 2804, and the other being a fiber positioner lumen 2806.

(186) Specifically, in FIG. 28A, the fiber positioner lumen 2806a terminates proximal to the distal end 2206. This point of termination may prevent the fiber positioner 2802 from moving distally any further. In FIG. 28B, the fiber positioner lumen 2806b extends the length of the distal elongated body portion 2808. In both the fiber positioner lumen 2806a and the fiber positioner lumen 2806b, a slit may be present in order to fluidly couple an inner portion of the fiber positioner lumen 2806 to an exterior of the distal elongated body portion 2808. This is illustrated in FIG. 29, which is a cross-sectional view of the IVL device of FIGS. 28A and 28B.

(187) As seen in FIG. 29, a slit 2902 is present through which a portion of the fiber positioner 2802 may extend. The purpose of this is so that the optical fiber 802 is exterior the distal elongated body portion 2808 such that any emitted laser energy is not interfered with by the distal elongated body portion 2808. As can also be seen in FIG. 29, a portion of the fiber positioner 2802 may be shaped such that it aligns at least partially with the fiber positioner lumen 2806. This is another manner in which the fiber positioner 2802 may be at least partially, if not fully, rotationally fixed with respect to the distal elongated body portion 2808, thus preserving the axial location of the optical fiber 802 with respect to the distal elongated body portion 2808.

(188) Additionally, the slit 2902 may only extend a certain distance along the distal elongated body portion 2808. In this manner, the proximal and distal termination points of the slit 2902 may act as stopping points for the longitudinal movement of the fiber positioner 2802. That is to say, the proximal termination point of the slit 2902 may prevent the fiber positioner 2802 from moving longitudinally any further proximally, and the distal termination point of the slit 2902 may prevent the fiber positioner 2802 from moving longitudinally any further distally.

(189) FIG. 30 illustrates a diagram of an IVL device including a track 3006. The track 3006 may share some similarities to the fiber positioner lumen 2806, but does not extend proximally back to a controller in a way a lumen might. The track 3006 includes proximal and distal points of termination, thus controlling how far the fiber positioner 3002 may move longitudinally in both the proximal and distal directions.

(190) FIG. 31 illustrates a cross-sectional view of the IVL device of FIG. 30. From this perspective, one example of how a fiber positioner 3002 is rotationally fixed with respect to the distal elongated body portion 3008 can be seen. A slit 3108, running either a portion of the length of the track 3006 or the entire length of the track 3006 permits the fiber positioner 3002 to extend from inside the track 3006 to outside the distal elongated body portion 3008.

(191) In this example, the fiber positioner 3002 includes a top portion 3102, a middle portion 3104, and a bottom portion 3106. The top portion 3102 can be seen surrounding the optical fiber 802, thus keeping the optical fiber 802 fixed to the fiber positioner 3002. The bottom portion 3106 can be seen seated within the track. The middle portion 3104 is shown having a width that is less than a width of the top portion 3102 and the bottom portion 3106, and this middle portion 3104 is located where the slit 3108 may be. By having larger widths than the middle portion 3104, the bottom portion 3106 is prevented from sliding out of the track 3006, and the top portion 3102 is prevented from sliding into the track 3006. The fiber positioner 3002 is unable to move rotationally in the track 3006, thus preserving the axial location of the optical fiber 802 with respect to the distal elongated body portion 3008.

(192) In any or all of the preceding disclosure pertaining to fiber positioners, it is understood that the optical fiber 802 may either be fixedly coupled or slidably coupled to the fiber positioner.

(193) FIG. 32 illustrates a perspective view of an example controller 3202, and FIG. 33 illustrates a perspective view of another example controller 3302. Specifically, FIG. 32 shows a controller 3202 including a slider 3204. The slider 3204 may be coupled to a catheter, the elongated body 302, and/or the optical fiber 802. This slider 3204 may permit longitudinal translation of any or all of these elements. In some cases, the slider 3204 may be used for repositioning the elongated body 302 when at or near a treatment site. In additional cases, the slider 3204 may be used for repositioning the optical fiber 802 within the elongated body 302, such that the elongated body 302 may not need to be moved, at often or at all, during a treatment.

(194) FIG. 33 specifically shows a controller 3302 including a rack 3306 and pinion 3304. The rack 3306 and pinion 3304 achieve the longitudinal translation of the catheter, elongated body 302, and/or the optical fiber 802 in an additional manner. Instead of moving a slider 3204, an operator may turn the pinion 3304 to effectuate longitudinal movement on the rack 3306. While not shown in FIG. 32 or 33, any additional methods of imparting longitudinal movement on the catheter, the elongated body 302, and/or the optical fiber 802 are considered operable with the rest of the present disclosure.

(195) FIGS. 34-38 illustrate bottom views of various example controllers including optical fiber 802 movement capabilities. These controllers may feature the slider 3204 of FIG. 32, and/or the rack 3306 and pinion 3304 of FIG. 33 for imparting movement on the optical fiber 802. These are manners in which the solution to the problems in the prior art mentioned with reference to FIGS. 23A, 23B, and 23C may be located external to a catheter.

(196) Specifically, FIG. 34 shows a controller 3402 including a telescoping tube 3404. The telescoping tube 3404 may include an inner tube slidably coupled to an outer tube. Either or both of the outer tube and the inner tube may be stainless steel hypotubes. In such an example, the outer tube may be fixedly coupled to the controller 3402 or an optical fiber lumen. The inner tube may be fixedly coupled to the optical fiber 802. In such examples, when the inner tube slides through the outer tube, this longitudinal movement would be imparted on the optical fiber 802. The purpose of such a telescoping tube 3404 may be permit pushing of the optical fiber 802 longitudinally without permitting the optical fiber 802 to buckle.

(197) FIGS. 35, 36, and 37 illustrate possible examples of controllers that include mechanisms to passively manage slack that may occur in the optical fiber as it is moved longitudinally. Specifically, FIG. 35 illustrates a controller 3502 including a pin 3504. As shown in FIG. 35, the pin 3504 may lay longitudinally with respect to the controller 3502. In such examples, the optical fiber 802 winds around the pin 3504, such that any slack in the optical fiber 802 is taken by the pin 3504. Rotation of the pin 3504 may wind or unwind the optical fiber 802 to impart longitudinal movement on the optical fiber 802.

(198) FIG. 36 illustrates a controller 3602 including a spring 3604. According to such examples, the spring 3604 may be extended or contracted through an actuator on the controller 3602 accessible by an operator. When the spring 3604 is extended or contracted, the optical fiber 802 may be similarly moved, thus imparting longitudinal movement on the optical fiber 802. In some examples, the spring 3604 is directly coupled to the optical fiber 802. In other examples, an intermediary material, such as a movable pin, is coupled to the spring 3604. In such examples, the optical fiber 802 may be wound about the pin (multiple times or a single time) in order to translate the movement of the spring 3604 to the optical fiber 802.

(199) It is understood that, while only a single spring 3604 is illustrated in FIG. 36, multiple springs could be used, and these springs could additionally be separated across the housing of the controller to thereby take up further slack from the optical fiber 802.

(200) Additionally, while a spring 3604 is specifically named, it is understood that equivalent mechanisms may be used to achieve the same results. These include but are not limited to conventional springs, braided shafts (either metallic or polymeric), elastic bands, nitinol bands, and nitinol stent-like structures.

(201) FIG. 37 illustrates a controller 3702 including a pin 3704. Dissimilar to the pin 3504 of FIG. 35, this pin 3704 may lie vertically with respect to the controller 3702. The optical fiber 802 may wind around this pin 3704 in such a way that slack is introduced. When the optical fiber 802 is moved from proximal to distal, the slack will be reduced until the optical fiber 802 is eventually stopped from movement by the pin 3704.

(202) FIG. 38 illustrates a controller 3802 including another variation of a telescoping tube, similar to that shown in FIG. 34. In FIG. 38, a small hypotube 3806 is slidably coupled to a large hypotube 3804. Additionally, a spring 3808 may be coupled to each of the small hypotube 3806 and the large hypotube 3804. This spring 3808 may assist longitudinal movement of the small hypotube 3806. In some examples, the spring 3808 returns the small hypotube 3806 to its initial position. According to some examples, the optical fiber 802 is coupled to the small hypotube 3806, thereby imparting the longitudinal motion of the small hypotube 3806 to the optical fiber 802.

(203) Additionally, while a spring 3808 is specifically named, it is understood that equivalent mechanisms may be used to achieve the same results. These include but are not limited to conventional springs, braided shafts (either metallic or polymeric), elastic bands, nitinol bands, and nitinol stent-like structures.

(204) In any or all of the example controllers of FIGS. 34-38, locking mechanisms may be included in or on the controllers. For example, ball detent pins or housing notches may be included such that, once the optical fiber 802 has been longitudinally moved to the desired location, it is locked into that position until an operator wishes to move it.

(205) Additionally, in FIGS. 34-38, the optical fiber 802 is named and numbered in more than one location. This is to facilitate understanding that this is the same component, as it is shown broken up by other features, and should not be construed as meaning that more than one optical fiber 802 needs to be present in this disclosure. That is not to say, however, that more than one optical fiber 802 could not be present if desired.

(206) FIG. 39 illustrates a side view of an internal mechanism of a controller, according to some examples. This internal mechanism may be used with any of the controllers as shown and described above (e.g., FIGS. 32-38) or below (e.g., FIGS. 40-47E). As seen in FIG. 39, the internal mechanism includes a longitudinal actuator 3902 which is configured to impart longitudinal motion on other components of the device, as will be explored in greater detail in FIG. 40 below. Such components may be within a proximal hub 3904 including a proximal hub cap 3906 for enclosing distinct components.

(207) While appearing as a slider in FIG. 39, such as the slider 4104 shown and described in FIGS. 41A and 41B below, in additional or alternate examples, the longitudinal actuator 3902 may be any mechanism by which motion can occur. One such example is the thumbwheel as shown and described in FIGS. 45A and 45B below. Additionally, the longitudinal actuator may be powered, such as via electricity, to automate any movement.

(208) FIG. 40 illustrates a side view of an internal portion of a proximal hub 3904, according to some examples. For illustrative purposes, the view of FIG. 40 is presented upside-down with respect to FIG. 39.

(209) FIG. 40 shows a telescopic assembly, including a lower telescope 4006 and an upper telescope 4008. The lower telescope 4006 may be telescopically coupled to the upper telescope 4008 to thereby longitudinally traverse through and beyond the upper telescope 4008. Also shown in FIG. 40 is a proximal support 4004 which fits over the lower telescope 4006 and is fixed in place with respect to the lower telescope 4006. That is to say, the proximal support 4004 longitudinally translates with any motion of the lower telescope 4006.

(210) The proximal support 4004 may maintain alignment of the optical fiber 4002. In some examples, the proximal support 4004 provides structural support to and prevents buckling of the optical fiber 4002 and the lower telescope 4006. The proximal support 4004 may also direct stresses associated with the translation of the optical fiber 4002 into the intermediate cable jacket 4014 instead of the optical fiber 4002, acting as stress relief in this manner.

(211) The proximal hub also includes an intermediate cable jacket 4014, from which the upper telescope 4008 partially extends. A dynamic seal 4010 is also provided and may prevent any fluid transmission into the upper telescope 4008 or intermediate cable jacket 4014. The dynamic seal 4010 may also trap any fluid present within the fiber lumen 4012 to prevent the fluid from egressing the fiber lumen 4012 and affecting components such as the lower telescope 4006, the proximal support 4004, and other portions of the controller where the electronics and longitudinal actuator may be present.

(212) A fiber lumen 4012 extends through the controller (and through the proximal hub). This fiber lumen 4012 allows for the passage of any present optical fiber 4002. In additional or alternate examples, multiple fiber lumens may be provided for multiple optical fibers. In some embodiments, the fiber lumen 4012 allows for the transmission of laser energy therethrough, with the laser energy generated from the generator (as described herein). The optical fiber, or other means of laser energy transmission may be disposed within the fiber lumen, such as other forms of cable, or an optical connector as described herein. The optical fiber 4002 may extend from the fiber lumen 4012 within the proximal hub, as described herein.

(213) The intermediate cable jacket 4014, fiber lumen 4012, dynamic seal 4010, and upper telescope 4008 are fixed in place with respect to the controller. The optical fiber 4002 may be coupled to the proximal support 4004, the lower telescope 4006, or both, such that the optical fiber 4002 also longitudinally translates with any motion of the proximal support 4004 and/or the lower telescope 4006.

(214) The longitudinal actuator (such as the longitudinal actuator 3902 of FIG. 39 above) may impart longitudinal translation on the lower telescope 4006, thereby imparting this longitudinal movement on each of the proximal support 4004 and the optical fiber 4002. For example, at least a portion of the optical fiber may be fixedly coupled to the lower telescope 4006, such that movement by the lower telescope 4006 will move the optical fiber as well. The optical fiber may be bonded or attached using fastening means to fixedly couple with the lower telescope 4006. The optical fiber may be disposed within the lower telescope 4006, which defines a lumen (e.g., a fiber lumen or other lumen) therewithin.

(215) In additional or alternate examples, the longitudinal actuator imparts the longitudinal translation on the proximal support 4004. In further additional or alternate examples, the longitudinal actuator imparts the longitudinal translation on the optical fiber 4002 directly.

(216) The lower telescope 4006 may include a feature in its proximal portion to prevent it from detaching completely (extending so far as to no longer make contact with) the upper telescope 4008. The upper telescope 4008 may include a matching feature in its distal portion to interact with this feature of the lower telescope 4006. An exemplary feature includes a protrusion or ridge disposed about both the lower and upper telescopes, that contact each other and prevent further longitudinal movement by the lower telescope away from the upper telescope.

(217) Alternatively or additionally, a perforation (e.g., hole or other opening) through the dynamic seal may be sized to only pass the lower telescope (or a portion thereof) therethrough. For example, an outer edge of the lower telescope may be flush with the edge of the perforation through the dynamic seal, thereby helping prevent or reduce an amount of fluid that could flow to the upper telescope. In some embodiments, movement of the lower telescope to the upper telescope is restricted by i) a proximal portion of the lower telescope reaching a proximal end of the upper telescope (thereby contacting an interior portion of the upper telescope, for example), ii) the proximal support contacting the dynamic seal, where the proximal support has a diameter or thickness greater than the perforation of the dynamic seal, or iii) both.

(218) In some examples, multiple lower telescopes may be provided, telescopically coupled to one another, with the outermost lower telescope telescopically coupled to the upper telescope. These multiple lower telescopes may permit further longitudinal translation of the optical fiber while presenting shorter-in-length telescopes.

(219) FIG. 41A illustrates a side view of a controller 4102, according to some examples. As seen in FIG. 41A, the controller 4102 includes a slider 4104 as the longitudinal actuator. Such a slider 4104 may directly impart longitudinal translation on the optical fiber (for example, via the lower telescope and proximal support). Stated another way, when the slider 4104 moves, longitudinally, the optical fiber (and lower telescope and proximal support) also move, longitudinally.

(220) FIG. 41B illustrates a top view of the controller 4102 of FIG. 41A, according to some examples. Here, the slider 4104 is still present on the top of the controller 4102. Stopping features 4108 are shown along the path on which the slider 4104 longitudinally traverses. These stopping features 4108 may cause the slider 4104 to stop completely, slow down, or require additional force from the user in order to continue longitudinally translating the slider 4104. The stopping features 4108 may also correlate to specific treatment locations within the medical device (or distal elongated body portion, or balloon) and thereby provide tactile feedback to an operator when a treatment location is reached. For example, the stopping features 4108 may correlate to a specific location of the optical fiber (for example, a distal end or an emitting location) with respect to the distal elongated body portion.

(221) In some embodiments, sub-stops, or half-stops, are located between each of the stopping features 4108. These sub-stops may permit an operator to stop movement of the slider, and thereby stop movement of the optical fiber, at locations between the aforementioned specific treatment locations. This may allow the operator to finetune the locations at which the treatment is being delivered.

(222) Additionally or alternatively, these stopping features 4108 may be inside the controller 4102, and therefore not visible on the surface of the controller 4102. The stopping feature(s) may include protrusion(s) or ridge(s) that are configured to interact with a portion of the slider (e.g., a slider protrusion or ridge). Accordingly, each time the slider protrusion (or ridge) interacts with a stopping feature, a tactile feedback is provided to the operator. Final stopping features at both the proximal and distal ends may include a larger protrusion or ridge that prevents further proximal or distal movement of the slider.

(223) FIG. 41B shows five stopping features 4108. In alternate examples, as few or as many stopping features may be present as desired. In alternate examples, there are no stopping features present causing smooth, uninterrupted motion of the slider.

(224) In some examples, the stopping features 4108 may be accompanied by position indicators, such as Arabic numerals, to indicate what position the slider 4104 is in and, therefore, what position the optical fiber is in. According to some examples, while not shown in FIG. 41B, a positional indicator may be present on a portion of the housing of the controller 4102, such as on the side of the controller 4102, similar to the positional indicator 4506 as shown and described in FIG. 45A below. In additional or alternate examples, the slider 4104 is backlit, via means such as an internal light emitting diode (LED).

(225) Also shown in FIG. 41B on the top of the controller is an actuator 4106. The actuator 4106 may be communicatively coupled with any present hub (such as the distal hub 4406 as seen in FIGS. 44A-44E below) and/or any present generator as shown and described above. In some examples, the actuator 4106 is capable of communicating with the generator such that, when the actuator 4106 is depressed (or toggled, etc.), the generator sends a pulse, or multiple pulses, of energy (e.g., laser energy) which may be passed through any present optical fiber(s).

(226) In some examples, the actuator 4106 is backlit, via means such as an internal LED. The actuator 4106 may include different colors, flashing patterns, or both in order to convey information to the operator, such as when the system is ready for actuation of the actuator 4106 or when treatment is currently being delivered.

(227) Prior art systems in the IVL space include the ability to manually activate an actuator in order to deliver single pulses of energy through an optical fiber, as well as the ability to hold the actuator down in a depressed (activated) state in order to continually deliver pulses of energy. However, these prior art systems still depend on the manual activation of the device during operation, thus causing the operator to focus partial attention, as well as at least one of their hands, on the actuator itself.

(228) In some examples of the present disclosure, the actuator 4106 is capable of both manual activation for selectively sending pulses of energy down the optical fiber(s), as well as holding down (continually activating) the actuator 4106 in order to deliver a continual stream of pulses to the optical fiber(s). The rate at which the pulses are sent may be predetermined by the type of elongated body coupled to the generator.

(229) In addition, some examples of the present disclosure permit a hands-free operation of the actuator 4106. In these examples, the operator may double-click the actuator 4106 in quick succession in order to command the generator to deliver the continual stream of pulses down the optical fiber(s). This may be the same frequency of pulses as those delivered through the continuous activation of the actuator 4106 as described in the preceding paragraph, or a distinct frequency of pulses. The frequency at which an operator must activate the actuator 4106 in order to enter this continual pulse mode may be selected so as not to interfere with the operator selectively sending pulses down the optical fiber(s) (i.e., the frequency that the operator selectively activates the actuator 4106 may be lower than the frequency needed to place the generator in continual pulse mode).

(230) FIGS. 42A and 42B illustrate additional side views of the controller 4102 of FIGS. 41A and 41B, depicting interior components, according to some examples. The interior components that include the actuator 4106 and its relative components are shown in FIG. 42A, but not 42B.

(231) In each of FIGS. 42A and 42B a proximal hub 4202 is shown. The proximal hub 4202 may be the same or similar to the proximal hub 3904 as shown and described in FIG. 39 above, and include the interior components including an intermediate cable jacket, dynamic seal, upper telescope, lower telescope, proximal support, and a portion of each of the fiber lumen and optical fiber as shown and described in FIG. 40 above.

(232) In this example, a fiber lumen 4206 is present in the controller 4102. An optical fiber may extend through the controller 4102 via this fiber lumen 4206, extending proximally from the controller to connect to a generator for providing light or energy through the optical fiber, as well as extending distally from the controller to a medical device where the distal-most portion of the optical fiber emits, or generates, a pulse for causing a cavitation bubble to occur.

(233) The slider 4104 may be coupled to, or a part of, a longitudinal actuator 4204 as seen in FIG. 42B. The longitudinal actuator 4204 may couple to one or more of the lower telescope, proximal support, and optical fiber in order to impart longitudinal movement on these components relative to the slider 4104. The longitudinal actuator may be configured to allow for a proportional distance moved by the optical fiber (e.g., via the lower telescope) relative to a distance moved by the longitudinal actuator (e.g., a longitudinal movement of the slider, as described herein). For example, the longitudinal actuator 4204 may include a rack for interacting with a gear in order to provide a gear ratio between longitudinal movement of the slider 4104 and longitudinal movement of the lower telescope, proximal support, and/or optical fiber. Additionally or alternatively, the longitudinal actuator 4204 may include a rack for interacting with a gear in order to provide a gear ratio between the longitudinal movement of the longitudinal actuator 4204 and the longitudinal movement of the slider 4104. As will be discussed below, these gear ratios may allow for a non-one-to-one relationship to be formed between the slider 4104 and the lower telescope, proximal support, and/or optical fiber.

(234) In examples where no gear ratio is present, longitudinal movement of the longitudinal actuator (e.g., via a slider) may constitute a one-to-one relationship with longitudinal movement of the optical fiber (and lower telescope and proximal support). Stated another way, the distance the longitudinal actuator travels may cause the optical fiber (and lower telescope and proximal support) to move this same distance.

(235) In other examples, the longitudinal actuator may interact with one or more gears in order to provide a gear ratio. As disclosed above, the longitudinal actuator, when configured as a slider or similar, may be provided on a rack. The rack may translate along with the longitudinal actuator such that a stationary gear, or pinion, rotates. This gear may then be rotationally coupled to a subsequent gear via interlocking teeth of each gear, or by a band.

(236) By changing the size of the relative gears, the distance traveled by the optical fiber (and lower telescope and proximal support) may be greater than, less than, or equal to the distance traveled by the longitudinal actuator. Through these ratios, more precise movements of the optical fiber (and lower telescope and proximal support) may be realized, as greater movements of the longitudinal actuator may cause the optical fiber (and lower telescope and proximal support) to move smaller distances.

(237) FIG. 43 illustrates a front view of a top portion of the controller 4102, according to some examples. The slider 4104 is shown at the top of the controller 4102. The fiber lumen 4206 is seen in the middle of the figure, and this is the location from which the optical fiber would extend.

(238) FIGS. 44A-44E illustrate a controller 4402 and a distal elongated body portion 4404, wherein a distal end of the optical fiber (which may be an emitting location) is shown in multiple positions relative to the distal elongated body portion 4404, according to some examples. Also seen in FIGS. 44A-44E is a distal hub 4406 located between the controller 4402 and the distal elongated body portion 4404. This distal hub 4406 may include a port (or input, or receiver, etc.) for receiving i) the optical fiber, optical connector, or other transmission means for the laser energy (e.g., from the controller), and/or ii) a syringe to provide fluid to any present balloon and thereby inflate such a balloon.

(239) In some examples, the controller 4402 is coupled to the distal hub 4406 via a catheter including a lumen through which an optical fiber may travel. In additional or alternative examples, the controller 4402 is coupled to the distal hub 4406 via the optical fiber directly. The controller 4402 may be coupled to the distal hub 4406 via a catheter, as well as an optical fiber traveling parallel to, or at least partially parallel to, the catheter.

(240) According to some examples, the distal hub 4406 is coupled to the distal elongated body portion 4404 via a catheter including a lumen through which an optical fiber may travel, as well as a lumen through which any injected fluid may travel. Additionally or alternatively, the distal hub 4406 may be coupled to the distal elongated body portion 4404 via a catheter, as well as an optical fiber traveling parallel to, or at least partially parallel to, the catheter (see, for example, FIG. 9A).

(241) FIGS. 44A-44E include a longitudinal actuator that shares similarities with the slider 4104 as shown and described above in FIGS. 41A and 41B, and longitudinal actuator 4204 as shown and described in FIGS. 42A and 42B. As the longitudinal actuator is moved, proximally or distally, the optical fiber may move in response (for example, via the lower telescope and/or proximal support, as described herein). Specific locations of the longitudinal actuator may correlate to specific locations of a distal-most end of the optical fiber (the portion from which the laser energy is emitted).

(242) Specifically, FIG. 44A illustrates a controller 4402 including a longitudinal actuator at a first position 4408a, and a distal-most end of the optical fiber at a respective first position 4408b. FIG. 44B illustrates a controller 4402 including a longitudinal actuator at a second position 4410a, and a distal-most end of the optical fiber at a respective second position 4410b. FIG. 44C illustrates a controller 4402 including a longitudinal actuator at a third position 4412a, and a distal-most end of the optical fiber at a respective third position 4412b. FIG. 44D illustrates a controller 4402 including a longitudinal actuator at a fourth position 4414a, and a distal-most end of the optical fiber at a respective fourth position 4414b. FIG. 44E illustrates a controller 4402 including a longitudinal actuator at a fifth position 4416a, and a distal-most end of the optical fiber at a respective fifth position 4416b.

(243) The longitudinal actuator may constitute a one-to-one relationship with the distal-most end of the optical fiber. Stated another way, the distance the longitudinal actuator travels may cause the distal-most end of the optical fiber (or the optical fiber as a whole) to move this same distance.

(244) In other examples, the longitudinal actuator may interact with one or more gears in order to provide a gear ratio. As disclosed above, the longitudinal actuator, when configured as a slider or similar, may be provided on a rack. The rack may translate along with the longitudinal actuator such that a stationary gear, or pinion, rotates. This gear may then be rotationally coupled to a subsequent gear via interlocking teeth of each gear, or by a band.

(245) By changing the size of the relative gears, the distance traveled by the distal-most end of the optical fiber may be greater than, less than, or equal to the distance traveled by the longitudinal actuator. Through these ratios, more precise movements of the distal-most end of the optical fiber may be realized, as greater movements of the longitudinal actuator may cause the distal-most end of the optical fiber to move smaller distances.

(246) FIG. 45A illustrates a side view of a controller 4502, according to some examples. As seen in FIG. 45A, the controller 4502 includes a thumbwheel 4504 as the longitudinal actuator. Such a thumbwheel 4504 may directly impart longitudinal translation on the optical fiber (via, for example, the lower telescope and proximal support as described herein). Stated another way, when the thumbwheel 4504 rotates (clockwise or counterclockwise, depending on the gears within the controller 4502, which can be adjusted based on user preference), the optical fiber (and lower telescope and proximal support) also moves, longitudinally.

(247) Also seen in FIG. 45A is a positional indicator 4506. This positional indicator may indicate the position the thumbwheel 4504, or optical fiber (for example, relative to the distal elongated body portion) is in. The positional indicator may be accompanied by symbols, such as Arabic numerals, for indicating what position the thumbwheel 4504 and/or optical fiber is in. Additionally or alternatively, symbols, such as Arabic numerals, may be present on the side of the thumbwheel 4504, or on the top of the thumbwheel 4504. In additional or alternate examples, the thumbwheel 4504 is backlit, via means such as an internal LED.

(248) FIG. 45B illustrates a top view of the controller 4502 of FIG. 45A, according to some examples. Here, the thumbwheel 4504 is still present on the top of the controller 4502. While not shown in FIG. 45B, stopping features, similar to those in FIG. 41B above, may be present along the rotational path of the thumbwheel 4504, either on the top of the controller 4502, inside of the controller 4502, or both. Alternatively or additionally, the stopping features may be present along the pathway of a rack (e.g., coupled to the thumbwheel or another pinion) that is displaced via the thumbwheel 4504. These stopping features may cause the thumbwheel 4504 to stop completely, slow down, or require additional force from the user in order to continue rotating the thumbwheel 4504. These stopping features may also correlate to specific treatment locations within the medical device (or distal elongated body portion, or balloon) and thereby provide tactile feedback to an operator when a treatment location is reached. In alternate examples, there are no stopping features present causing smooth, uninterrupted motion of the thumbwheel. Additionally, as many stopping features may present as desired.

(249) In some embodiments, sub-stops, or half-stops, are located between each of the stopping features. These sub-stops may permit an operator to stop movement of the thumbwheel, and thereby stop movement of the optical fiber, at locations between the aforementioned specific treatment locations. This may allow the operator to finetune the locations at which the treatment is being delivered.

(250) Also shown in FIG. 45B on the top of the controller is an actuator 4508. The actuator 4508 may be communicatively coupled with any present hub (such as the distal hub 4706 as seen in FIGS. 47A-47E below) and/or any present generator as shown and described above. In some examples, the actuator 4508 is capable of communicating with the generator such that, when the actuator 4508 is depressed (or toggled, etc.), the generator sends a pulse, or multiple pulses, of energy (e.g., laser energy) which is passed through any present optical fiber(s).

(251) In some examples, the actuator 4508 is backlit, via means such as an internal LED. The actuator 4508 may include different colors, flashing patterns, or both in order to convey information to the operator, such as when the system is ready for actuation of the actuator 4508 or when treatment is currently being delivered.

(252) In some examples of the present disclosure, the actuator 4508 is capable of both manual activation for selectively sending pulses of energy down the optical fiber(s), as well as holding down (continually activating) the actuator 4508 in order to deliver a continual stream of pulses to the optical fiber(s). The rate at which the pulses are sent may be predetermined by the type of elongated body coupled to the generator.

(253) In addition, some examples of the present disclosure permit a hands-free operation of the actuator 4508. In these examples, the operator may double-click the actuator 4508 in quick succession in order to command the generator to deliver the continual stream of pulses down the optical fiber(s). This may be the same frequency of pulses as those delivered through the continuous activation of the actuator 4508 as described in the preceding paragraph, or a distinct frequency of pulses. The frequency at which an operator must activate the actuator 4508 in order to enter this continual pulse mode may be selected so as not to interfere with the operator selectively sending pulses down the optical fiber(s) (i.e., the frequency that the operator selectively activates the actuator 4508 may be lower than the frequency needed to place the generator in continual pulse mode.)

(254) FIG. 46 illustrates a side view of the controller 4502 of FIGS. 45A and 45B illustrating interior components, according to some examples. The actuator 4508 is still illustrated electrically and mechanically coupled to the controller 4502.

(255) As shown in FIG. 46, the thumbwheel 4504 is coupled to a belt 4606. The belt 4606 is also coupled to a gear, labeled as pinion 4604. The teeth of the pinion 4604 are interlocked with, and thereby detachably coupled to a rack 4602.

(256) When the thumbwheel 4504 is turned (or rotated), the belt 4606 is also rotated, thereby imparting rotational movement on the pinion 4604. When the pinion 4604 rotates, the teeth of the pinion 4604 cause the rack 4602 to longitudinally translate. In this way, the rotation of the thumbwheel 4504 imparts longitudinal movement on the optical fiber (and lower telescope and proximal support).

(257) In alternate examples, the thumbwheel includes teeth and acts as the pinion directly, interacting with any present rack directly. In still additional examples, more gears are present, and may be used to change the direction the thumbwheel needs to be rotated in order to provide distal or proximal longitudinal movement of the rack (and thereby provide distal or proximal longitudinal movement of the optical fiber, lower telescope, and/or proximal support). Additional gears may also be present to adjust the ratio of rotation of the thumbwheel to distance longitudinally translated by the rack (and optical fiber, lower telescope, and proximal support).

(258) Rotational movement of the longitudinal actuator (e.g., thumbwheel 4504) may constitute a one-to-one relationship with longitudinal movement of the optical fiber (and lower telescope and proximal support). Stated another way, the distance the longitudinal actuator rotates may cause the optical fiber (and lower telescope and proximal support) to longitudinally translate a distance equivalent to the arc length of the longitudinal actuator rotation. In such examples, the longitudinal actuator may include, or be, a gear having teeth for interacting with a rack which translates this rotation to longitudinal movement.

(259) The longitudinal actuator may be configured to allow for a proportional distance moved by the optical fiber (e.g., via the lower telescope) relative to a distance moved by the longitudinal actuator (e.g., a rotational movement of the thumbwheel, as described herein). For example, the longitudinal actuator may interact with one or more gears in order to provide a gear ratio. As disclosed above, the longitudinal actuator, when configured as a thumbwheel, may include a rack and pinion. The longitudinal actuator may include teeth for interacting with another gear that interacts with a rack for converting the rotational movement to longitudinal translation. In some examples, the longitudinal actuator may be coupled to a belt which imparts the rotational movement of the longitudinal actuator on a second gear. Additionally or alternatively, more gears may be included for further controlling the ratio between the longitudinal actuator's rotational movement and the longitudinal movement of the rack.

(260) By changing the size of the relative gears, the distance traveled by the optical fiber (and lower telescope and proximal support) may be greater than, less than, or equal to the distance rotated by the longitudinal actuator. Through these ratios, more precise movements of the distal-most end of the optical fiber may be realized, as greater rotational movements of the longitudinal actuator may cause the optical fiber (and lower telescope and proximal support) to move smaller distances.

(261) FIGS. 47A-47E illustrate a controller 4702 and a distal elongated body portion 4704, wherein a distal end of the optical fiber (which may be an emitting location) is shown in multiple positions relative to the distal elongated body portion 4704, according to some examples. Also seen in FIGS. 47A-47E is a distal hub 4706 located between the controller 4702 and the distal elongated body portion 4704. This distal hub 4706 may include a port (or input, or receiver, etc.) for receiving i) the optical fiber, optical connector, or other transmission means for the laser energy (e.g., from the controller), and/or ii) a syringe to provide fluid to any present balloon and thereby inflate such a balloon.

(262) In some examples, the controller 4702 is coupled to the distal hub 4706 via a catheter including a lumen through which an optical fiber may travel. In additional or alternative examples, the controller 4702 is coupled to the distal hub 4706 via the optical fiber directly. The controller 4702 may be coupled to the distal hub 4706 via a catheter, as well as an optical fiber traveling parallel to, or at least partially parallel to, the catheter.

(263) According to some examples, the distal hub 4706 is coupled to the distal elongated body portion 4704 via a catheter including a lumen through which an optical fiber may travel, as well as a lumen through which any injected fluid may travel. Additionally or alternatively, the distal hub 4706 may be coupled to the distal elongated body portion 4704 via a catheter, as well as an optical fiber traveling parallel to, or at least partially parallel to, the catheter.

(264) FIGS. 47A-47E include a longitudinal actuator that shares similarities with the thumbwheel 4504 as shown and described above in FIGS. 45A, 45B, and 46. As the longitudinal actuator is rotated, clockwise or counterclockwise, the optical fiber may move in response. Specific rotational locations of the longitudinal actuator may correlate to specific locations of a distal-most end of the optical fiber (the portion from which the laser energy is emitted) relative to the distal elongated body portion.

(265) Specifically, FIG. 47A illustrates a controller 4702 including a longitudinal actuator at a first position 4708a, and a distal-most end of the optical fiber at a respective first position 4708b. FIG. 47B illustrates a controller 4702 including a longitudinal actuator at a second position 4710a, and a distal-most end of the optical fiber at a respective second position 4710b. FIG. 47C illustrates a controller 4702 including a longitudinal actuator at a third position 4712a, and a distal-most end of the optical fiber at a respective third position 4712b. FIG. 47D illustrates a controller 4702 including a longitudinal actuator at a fourth position 4714a, and a distal-most end of the optical fiber at a respective fourth position 4714b. FIG. 47E illustrates a controller 4702 including a longitudinal actuator at a fifth position 4716a, and a distal-most end of the optical fiber at a respective fifth position 4716b.

(266) A movement of the longitudinal actuator may constitute a one-to-one relationship with a longitudinal movement of the distal-most end of the optical fiber. Stated another way, the distance the longitudinal actuator rotates may cause the distal-most end of the optical fiber (or the optical fiber as a whole) to longitudinally translate a distance equivalent to the arc length of the longitudinal actuator rotation. In such examples, the longitudinal actuator may include, or be, a gear having teeth for interacting with a rack which translates this rotation to longitudinal movement.

(267) In other examples, the longitudinal actuator may interact with one or more gears in order to provide a gear ratio. As disclosed above, the longitudinal actuator, when configured as a thumbwheel, may include a rack and pinion. The longitudinal actuator may include teeth for interacting with another gear that interacts with a rack for converting the rotational movement to longitudinal translation. In some examples, the longitudinal actuator may be coupled to a belt which imparts the rotational movement of the longitudinal actuator on a second gear. Additionally or alternatively, more gears may be included for further controlling the ratio between the longitudinal actuator's rotational movement and the longitudinal movement of the rack.

(268) By changing the size of the relative gears, the distance traveled by the distal-most end of the optical fiber may be greater than, less than, or equal to the distance rotated by the longitudinal actuator. Through these ratios, more precise movements of the distal-most end of the optical fiber may be realized, as greater rotational movements of the longitudinal actuator may cause the distal-most end of the optical fiber to move smaller distances.

(269) Included in the present disclosure is a device including an elongated body having a proximal end and a distal end opposite the proximal end, the elongated body extending along a central longitudinal axis. In some examples, the device includes a distal elongated body portion extending from the elongated body and distal to the elongated body along the central longitudinal axis, the distal elongated body portion located adjacent the distal end. According to some examples, the device includes an optical fiber spaced from the central longitudinal axis and extending from the proximal end to the distal elongated body portion, the optical fiber being configured to transmit laser energy into a fluid causing a cavitation bubble to propagate a pressure wave. The device may include a fiber positioner at least partially circumferentially surrounding the optical fiber and circumferentially surrounding the distal elongated body portion, the fiber positioner being translationally coupled to the distal elongated body portion such that the fiber positioner can move between a first position to a second position located distal the first position, and the fiber positioner being rotationally fixedly coupled to the distal elongated body portion such that the fiber positioner maintains a fixed angle respective to the distal elongated body portion.

(270) In some examples, the optical fiber is fixedly coupled to the fiber positioner such that each of the optical fiber and the fiber positioner are translationally coupled and rotationally fixedly coupled to the distal elongated body portion. According to some examples, the distal elongated body portion includes an oval-shaped cross-sectional profile.

(271) The distal elongated body portion may include a longitudinal depression configured to rotationally fixedly couple the fiber positioner to the distal elongated body portion. In some examples, the fiber positioner includes an indentation configured to correspond with the longitudinal depression, whereby the longitudinal depression receives the indentation. The indentation may partially surround the optical fiber. In some examples, the longitudinal depression partially surrounds the optical fiber. According to some examples, the fiber positioner includes a protrusion at least partially circumferentially surrounding the optical fiber.

(272) Also included in the present disclosure is a device, including an elongated body having a proximal end and a distal end opposite the proximal end, the elongated body extending along a central longitudinal axis. In some examples, the device includes a distal elongated body portion extending from the elongated body and distal to the elongated body along the central longitudinal axis, the distal elongated body portion located adjacent the distal end. According to some examples, the device includes an optical fiber spaced from the central longitudinal axis and extending from the proximal end to the distal elongated body portion, the optical fiber being configured to transmit laser energy into a fluid causing a cavitation bubble to propagate a pressure wave. The device may include a fiber positioner at least partially circumferentially surrounding the optical fiber and partially circumferentially surrounding the distal elongated body portion, the fiber positioner being translationally coupled to the distal elongated body portion such that the fiber positioner can move between a first position to a second position located distal the first position, and the fiber positioner being rotationally fixedly coupled to the distal elongated body portion such that the fiber positioner maintains a fixed angle respective to the distal elongated body portion.

(273) In some examples, the distal elongated body portion includes a longitudinal track. According to some examples, the fiber positioner includes a top portion, a bottom portion opposite the top portion, and a middle portion therebetween, the top portion partially circumferentially surrounding the optical fiber. The middle portion may define a width that is less than each of a width of the top portion and a width of the bottom portion. In some examples, the longitudinal track includes a proximal track end and a distal track end opposite the proximal track end, the proximal track end and the distal track end each configured to stop a movement of the fiber positioner.

(274) According to some examples, the distal elongated body portion includes a guidewire lumen and a fiber positioner lumen. The distal elongated body portion may include a slit configured to fluidly couple the fiber positioner lumen to an outer edge of the distal elongated body portion. In some examples, the fiber positioner includes a protrusion configured to protrude from the fiber positioner lumen beyond the outer edge of the distal elongated body portion through the slit, the protrusion at least partially circumferentially surrounding the optical fiber.

(275) According to some examples, the fiber positioner lumen includes a proximal fiber positioner lumen end beginning at the proximal end and a distal fiber positioner lumen end opposite the proximal fiber positioner lumen end, the distal fiber positioner lumen end proximal to the distal end of the elongated body, the distal fiber positioner lumen end configured to stop a movement of the fiber positioner.

(276) Also included in the present disclosure is a device including an elongated body having a proximal end and a distal end opposite the proximal end, the elongated body extending along a central longitudinal axis. In some examples, the device includes a distal elongated body portion extending from the elongated body and distal to the elongated body along the central longitudinal axis, the distal elongated body portion located adjacent the distal end. According to some examples, the device includes a balloon positioned along the distal elongated body portion, the balloon having an interior balloon surface and an exterior balloon surface, the balloon being configured to receive an inflation fluid to inflate the balloon such that the exterior balloon surface contacts a calcified lesion within a vasculature of a patient. The device may include an optical fiber spaced from the central longitudinal axis and extending from the proximal end to the distal elongated body portion, the optical fiber being configured to transmit laser energy into the inflation fluid causing a cavitation bubble to propagate a pressure wave. In some examples, the device includes a fiber positioner at least partially circumferentially surrounding the optical fiber, the fiber positioner being translationally coupled to the distal elongated body portion such that the fiber positioner can move between a first position to a second position located distal the first position, and the fiber positioner being rotationally fixedly coupled to the distal elongated body portion such that the fiber positioner maintains a fixed angle respective to the distal elongated body portion.

(277) According to some examples, the fiber positioner includes a distal face and a proximal face opposite the distal face, the proximal face and the distal face of the fiber positioner longitudinally located within the balloon. The fiber positioner may include a distal face and a proximal face opposite the distal face, the proximal face of the fiber positioner distal to a proximal end of the balloon, and the distal face of the fiber positioner proximal to a distal end of the balloon.

(278) Also included in the present disclosure is a device, including an optical fiber configured to pass laser energy therethrough, the optical fiber having an emitting location configured to transmit laser energy into a fluid causing a cavitation bubble to propagate a pressure wave. In some embodiments, the device includes an elongated body having a proximal portion and a distal portion opposite the proximal portion, the elongated body extending along a central longitudinal axis, the optical fiber extending at least partially along the elongated body and spaced from the central longitudinal axis. According to some embodiments, the device includes a controller configured to translate the optical fiber longitudinally independently from the elongated body, the optical fiber extending at least partially through the controller and therefrom towards the elongated body. The controller may include a lower telescope fixedly coupled to at least a portion of the optical fiber. In some embodiments, the controller includes an upper telescope telescopically coupled to the lower telescope, such that the lower telescope is configured to translate longitudinally within and from the upper telescope. According to some embodiments, the controller includes a longitudinal actuator configured to translate the lower telescope with respect to the upper telescope, thereby translating the optical fiber longitudinally.

(279) The lower telescope may define a fiber lumen therethrough, the optical fiber disposed within the fiber lumen. In some embodiments, the lower telescope, the upper telescope, or both, include stainless steel. According to some embodiments, the device further includes a slack feature configured to manage slack of the optical fiber as it is longitudinally translated. The slack feature may include a pin, a spring, or any combination thereof.

(280) In some embodiments, the device further includes a proximal support fixedly coupled to the lower telescope, the proximal support configured to provide structural support to each of the lower telescope and the optical fiber. According to some embodiments, the proximal support is configured to encapsulate at least a portion of the lower telescope. The device may further include a seal configured to prevent fluid flow to the upper telescope. In some embodiments, the seal includes a perforation sized for longitudinal movement therethrough by the lower telescope.

(281) According to some embodiments, the longitudinal actuator includes a slider. The longitudinal actuator may include a thumbwheel. In some embodiments, the thumbwheel includes a rack and pinion configuration.

(282) The longitudinal actuator may be configured to be translated a distance that is proportional to a distance translated by the lower telescope. In some embodiments, the proportional distance translated by the lower telescope relative to the longitudinal actuator is based on a gear ratio, the longitudinal actuator including or coupled to one or more gears that are coupled to the lower telescope, the gear ratio defined by the one or more gears.

(283) According to some embodiments, the device includes one or more stopping features configured to i) prevent longitudinal movement of the lower telescope in at least one direction, ii) provide a resistance for longitudinal movement of the lower telescope in at least one direction, or iii) both. Each of the one or more stopping features may correspond to a predetermined position of the emitting location along the elongated body. In some embodiments, an increased force on the longitudinal actuator overcomes the resistance of a respective stopping feature, thereby allowing further longitudinal translation of the lower telescope and optical fiber.

(284) According to some embodiments, the device further includes one or more numeric indicators, each corresponding to a predetermined position of the emitting location about the elongated body. The device may further include one or more half-stops configured to provide a tactile alert, an audible alert, or both, of a longitudinal position of the emitting location. In some embodiments, the device further includes a locking feature configured to lock a longitudinal position of the emitting location in place. According to some embodiments, the locking feature includes a ball detent pin, a housing notch, or any combination thereof.

(285) The device may further include a distal hub configured to align the optical fiber about the elongated body. In some embodiments, the distal hub is in fluid communication with the elongated body, such that the distal hub is configured to deliver inflation fluid to the elongated body. According to some embodiments, the distal hub receives the inflation fluid from an external supply. The external supply may include a syringe.

(286) In some embodiments, the controller further includes an actuator configured to initiate transmittance of the laser energy to the optical fiber. According to some embodiments, the device further includes a balloon positioned along the distal portion of the elongated body, the balloon having an interior balloon surface and an exterior balloon surface, the balloon being configured to receive an inflation fluid to inflate the balloon such that the exterior balloon surface contacts a calcified lesion within a vasculature of a subject.

(287) The device may further include a fiber positioner at least partially circumferentially surrounding the optical fiber and circumferentially surrounding the distal elongated body portion, the fiber positioner being translationally coupled to the distal elongated body portion such that the fiber positioner can move between a first position to a second position located distal the first position, and the fiber positioner being rotationally fixedly coupled to the distal elongated body portion such that the fiber positioner maintains a fixed angle respective to the distal elongated body portion.

(288) In some embodiments, the elongated body is configured to be inserted within a subject to disrupt calcified-plaque lesions disposed about a tissue of the subject. According to some embodiments, the tissue includes a vasculature, an organ, a vessel, or any combination thereof.

(289) Also included in the present disclosure is a system, including any device as disclosed in the preceding paragraphs. In some embodiments, the system includes a generator configured to couple with the optical fiber to form an optical pathway between the generator and the emitting location.

(290) According to some embodiments, the generator is configured to generate the laser energy. The generator may be configured to selectively pulse the laser energy. In some embodiments, the laser energy is configured to have a wavelength of between about 1800 nm and 2200 nm. According to some embodiments, the system includes a power supply configured to provide electrical power to the generator.

(291) Also included in the present disclosure is a method for treating a subject, including inserting the elongated body of any of the devices or systems as disclosed in the preceding paragraphs to within a subject, wherein the optical fiber extends along the elongated body such that the emitting location is within a treatment area of the subject. In some embodiments, the method includes providing inflation fluid so as to expand a balloon located about the elongated body disposed within the treatment area. According to some embodiments, the method includes initiating transmission of the laser energy so as to allow pressure waves to be generated within the balloon and about the treatment area. The method may include longitudinally translating the optical fiber independent of the elongated body so as to target treatment to a different treatment area or a different position of the treatment area.

(292) None of the steps described herein is essential or indispensable. Any of the steps can be adjusted or modified. Other or additional steps can be used. Any portion of any of the steps, processes, structures, and/or devices disclosed or illustrated in one embodiment, flowchart, or example in this specification can be combined or used with or instead of any other portion of any of the steps, processes, structures, and/or devices disclosed or illustrated in a different embodiment, flowchart, or example. The embodiments and examples provided herein are not intended to be discrete and separate from each other.

(293) The section headings and subheadings provided herein are nonlimiting. The section headings and subheadings do not represent or limit the full scope of the embodiments described in the sections to which the headings and subheadings pertain. For example, a section titled Topic 1 may include embodiments that do not pertain to Topic 1 and embodiments described in other sections may apply to and be combined with embodiments described within the Topic 1 section.

(294) The various features and processes described above may be used independently of one another, or may be combined in various ways. All possible combinations and subcombinations are intended to fall within the scope of this disclosure. In addition, certain method, event, state, or process blocks may be omitted in some implementations. The methods, steps, and processes described herein are also not limited to any particular sequence, and the blocks, steps, or states relating thereto can be performed in other sequences that are appropriate. For example, described tasks or events may be performed in an order other than the order specifically disclosed. Multiple steps may be combined in a single block or state. The example tasks or events may be performed in serial, in parallel, or in some other manner. Tasks or events may be added to or removed from the disclosed example embodiments. The example systems and components described herein may be configured differently than described. For example, elements may be added to, removed from, or rearranged compared to the disclosed example embodiments.

(295) Conditional language used herein, such as, among others, can, could, might, may, e.g., and the like, unless specifically stated otherwise, or otherwise understood within the context as used, is generally intended to convey that certain embodiments include, while other embodiments do not include, certain features, elements and/or steps. Thus, such conditional language is not generally intended to imply that features, elements and/or steps are in any way required for one or more embodiments or that one or more embodiments necessarily include logic for deciding, with or without author input or prompting, whether these features, elements and/or steps are included or are to be performed in any particular embodiment. The terms comprising, including, having, and the like are synonymous and are used inclusively, in an open-ended fashion, and do not exclude additional elements, features, acts, operations and so forth. Also, the term or is used in its inclusive sense (and not in its exclusive sense) so that when used, for example, to connect a list of elements, the term or means one, some, or all of the elements in the list. Conjunctive language such as the phrase at least one of X, Y, and Z, unless specifically stated otherwise, is otherwise understood with the context as used in general to convey that an item, term, etc. may be either X, Y, or Z. Thus, such conjunctive language is not generally intended to imply that certain embodiments require at least one of X, at least one of Y, and at least one of Z to each be present.

(296) The term and/or means that and applies to some embodiments and or applies to some embodiments. Thus, A, B, and/or C can be replaced with A, B, and C written in one sentence and A, B, or C written in another sentence. A, B, and/or C means that some embodiments can include A and B, some embodiments can include A and C, some embodiments can include B and C, some embodiments can only include A, some embodiments can include only B, some embodiments can include only C, and some embodiments can include A, B, and C. The term and/or is used to avoid unnecessary redundancy.