the current invention may take any one of several forms , but the preferred embodiment is that of a catheter ( hereinafter meant to generally refer to any guide wire , infusible wire , or similar conduit ) which is capable of delivering a thrombolytic agent and creating mechanical disruption of the clot while the thrombolytic agent is being delivered . the mechanical motion or mechanical action can take one of several forms which are described below . the mechanical motion is intermittent and more gentle than prior art devices to prevent hemolysis and endothelial damage . the mechanical motion is slower ( e . g ., less than 200 rpm , more preferably less than about 600 rpm , and most preferably less than about 55 rpm ) than prior art devices and the mechanical motion occurs intermittently , at preselected intervals . the mechanical action is therefore of a non - rapid type which can be adjusted for different slow speeds . as an example , the mechanical action may be activated for two seconds and then inactive for five minutes , activated for two seconds and then inactive for five minutes , and so on until thrombolysis occurs . various factors influence the choice of the parameters of speed of action ( rpm &# 39 ; s or cycles / sec ), time of activation , time of inactivation , total treatment time ( time of activation plus time of inactivation ), repetition time , as well as the infusion rate of the lytic agent . these factors include the location of the clot , as more aggressive thrombolysis with rapid speed of action , longer activation times and shorter inactivation times can be achieved within grafts as there is no concern of damaging the endothelium . however if the thrombus is within a native artery or vein , the speed would be slower , time of activation shorter , and time of inactivation longer to keep from damaging the endothelium . the age of the clot or thrombus is a critical determinant in the total treatment time , as fresh or subacute clot ( hours to a few days ) will dissolve more quickly and easier than a clot which has been present for longer than 10 days or so . the size of the clot also is a determinant in the choices . a less aggressive ( shorter activation times ) and shorter total treatment time is chosen for a relatively small clot of recent vintage . the parameters for the lytic therapy infusion may be varied as well depending on the site , age of thrombus , size of thrombus , etc . therefore , the preferred embodiment and preferred parameters may be site specific . generally , the device of the present invention comprises an infusion pump which infuses the lytic agent at a continuous selected rate . the device of the present invention is simply placed into the clot and the patient sent to an observation area where the lytic agent and mechanical action occur . the interventionalist , team , and suit are free to perform other cases while the intermittent mechanical action and lytic agent infusion are being achieved . in one alternative embodiment , the lytic agent is infused intermittently ( e . g ., over a period of minutes , such as every 5 - 15 minutes , or even longer time periods , such as every ½ hour , etc .). the mechanical action may be selected from a range of 0 . 1 - 600 rpms with activation times of about 0 . 1 second to about 60 seconds , and inactivation times of 5 seconds to 20 minutes . typically , the parameters chosen for a relatively fresh long segment lower extremity venous thrombus are : a ) continuous infusion of the lytic agent , b ) mechanical action speed of about 55 rpm &# 39 ; s , c ) activation time of at least about 3 seconds , and d ) inactivation time of 3 minutes . preferred parameters for a long segment arterial occlusion are : a ) continuous infusion of the lytic agent , b ) mechanical action speed of action speed of about 30 rpms ( 0 . 5 cycle / sec ), c ) activation time of at least about 2 seconds , and d ) inactivation time of at least about 3 minutes . a preferred parameter setting for a graft is : a ) continuous infusion of the lytic agent , b ) mechanical action speed of about 300 rpms , c ) activation time of about about 5 seconds , and d ) inactivation time of about 1 . 5 minutes . of course , as discussed above , the clinical setting and patient condition may require alternative parameters , and the above are suggested only as examples . intermittent action provides for relatively long periods of no mechanical action in which the endothelium is not contacted , scraped , or damaged . the slower action of 30 - 55 rpm &# 39 ; s ( less than 1 cycle / second ) and the short activation times of 2 - 3 seconds prevents abrasion and damage of the endothelium as well . it is the intent of the current invention to provide a time of inactivity which is at least as great , and preferably substantially greater , than the time of activity of the device . this serves to protect the endothelium , but also creates an environment for accelerated thrombolysis by the lytic agent . the slower speed of the mechanical action along with the very short activation times with relatively long periods of inactivation allows the mechanical action to continue for at least several hours while the lytic agent is acting to dissolve the clot . as an example , if the total treatment time is three hours , and a mechanical action speed of 30 rpm &# 39 ; s is used with an activation time of 2 seconds , and inactivation time of 3 minutes , a total of only 60 cycles of mechanical action would occur in the entire treatment . this will be sufficient to create the environment for accelerated thrombolysis , but not sufficient to cause endothelial damage . the endpoint is resolution of the clot , which will vary from patient to patient , location to location , and depend on the age and size of the clot amongst other factors . typically , however , a total treatment time of about one to three hours is anticipated to lyse fresh venous and arterial thrombus with the above techniques , although total treatment times of about 30 minutes to about 36 hours are generally anticipated . the slower , intermittent mechanical action of the device augments the action of the lytic agent by enhancing admixture of the lytic agent and clot , by creating more surface area within the clot , and by mechanical disruption of the clot , while avoiding damage to the endothelium . alternative embodiments include a catheter ( preferably a single catheter ) with just a means to create the mechanical action , without any means to treat the thrombus pharmacologically . another embodiment allows the infusion of the thrombolytic agent after the mechanical portion is activated . both the mechanical and the pharmacological delivery elements preferably are effective over a substantial length of the catheter , rather than just concentrated at the tip , as is the case with prior art devices . the mechanical element may be one of several types , i . e ., ultrasonic , vibrational , rotational , bi - rotational , longitudinal motion , expansile , and the like . a suitable mechanical element may be a wire or a smooth wall catheter , have apertures for the injection of the thrombolytic agent , or projections from the side of the device to better disrupt the thrombus . a preferred embodiment uses wave like undulations or vibrations to disrupt the clot slowly while the pharmacological agent is being infused . since the mechanical motion is intended to be used for some protracted period of time , it is advantageous for the mechanical motion to be one which does not promote hemolysis nor damages the endothelium . a slower motion rather than a rapid motion is therefore desirable . in one embodiment , a motor that causes the catheter to vibrate or undulate is attached to a wire that is inserted within a lumen of the catheter or to the catheter itself . braiding within the wall of the catheter to enhance transmissions of the vibrations may be utilized , and this may obviate the need to insert a wire within the catheter . a stiff segment of the catheter proximally is desirable , as the efficiency of transmitting the vibrations from the motor to the mechanical element segment is then enhanced . one may compare this stiffer or more rigid proximal segment to a fly rod transferring energy to a fly line or the handle of a bullwhip causing the action of the whip . again , it is the intent that a substantial length of the intravascular portion of the catheter is provided with the mechanical action . a separate sheath component through which the device is inserted may be used to keep the entire device from being mechanically active . in this case , the outer sheath houses a proximal portion of the device and the mechanically active portion of the device extends distal to the tip of the outer sheath . in one embodiment , the catheter , at least in the mechanically active segment , contains only one lumen , although more than one lumen is feasible . another method to accomplish an effective mechanical motion is to place two wires in a catheter wall so that they are disposed on opposite sides of the lumen . the wires are moveable within the catheter wall proximally and affixed at a point at which the mechanical motion is to begin . an alternating to and fro motion of the two wires causes the catheter to undulate distal to the fixation point . a motor provides the desired motion of the two wires . still another method of effective mechanical motion involves a catheter having a spiral shape in the distal desired length . such a catheter is straight proximally , but of a spiral configuration in the desired mechanical element segment . a motor causes the catheter to spin at a rather slow rate ( approximately one to 300 times per minute ). the proximal portion , because it is straight , does not have any substantial mechanical disruptive motion . the distal portion , because of the spiral configuration , spins in a corkscrew manner against the clot or wall of the vessel , disrupting the clot . where the catheter includes a guide wire to stiffen it , and where a lytic agent may be infused through side holes , the guide wire may by spiral shaped as well . a guide wire with a removable inner straight mandrel and an outer cylinder of shaped memory alloy may be utilized to create the spiral or corkscrew configuration . when the inner mandrel is within the outer sleeve or cylinder of the guide wire , the guide wire is stiff and more or less straight . when the inner core is removed the guide wire assumes a spiral configuration causing the infusion catheter over it to also assume a spiral or corkscrew configuration . a variation of the above entails rotating the spiral catheter one way and then the other , similar to an agitator in a washing machine . a motor is provided to effect such motion . yet another modification involves a serpentine or other shape to the catheter . any motion can be employed with any different shape . complex motions , such as a longitudinal wave like motion of the catheter combined with axial rotation , may be advantageous . in another embodiment , an intermittent motion of the catheter is provided by a pump that delivers lytic agent forcefully in programmable pulses . such a pump is commercially available ( angiodynamics , queensbury , n . y .). it generates abrupt pulse waves which cause the lytic agent to be sprayed into the thrombus through side holes in the catheter . generally , the connecting tubes dissipate the motion caused when this abrupt and forceful pulse of medicine occurs . by more rigidly connecting the pulse - spray pump to the device of the current invention and preventing the dissipation of the pulse wave forces in the connecting tube , the pulse wave forces are transferred to the device of the current invention , causing it to move within the body . the connecting elements may be made of steel or any other rigid substance that is capable of transferring the forces from the pulse - spray machine to the catheter efficiently so that the catheter is mechanically active as described above . since the frequency and duration of pulses are programmable on the pump , a separate motor to move the catheter will not be needed . alternatively , a flexible catheter may be provided which is serpentine or spiral in shape . the pulse of the pulse - spray pump will straighten the catheter from its original shape , causing desired motion within the clot while the lytic agent is being dispersed . an intermittent motion may be provided to any of the embodiments , i . e ., so that the mechanical motion is activated every few seconds , every few minutes , or for any given time period . in fact , this is desirable to prevent damage to the vessel endothelium , but allows for enough clot disruption to enhance the action of the thrombolytic agent . the present invention is intended to provide a slow , intermittent motion over several hours to allow a lytic agent to work completely while not damaging the endothelium . of course , the device may employ mechanical motion without the addition of a thrombolytic drug . therefore , the current invention differs from prior art devices in many respects , including shape , length of mechanically active segment , the rapidity of the motion , the programmability of the motor drive , shorter periods of activity , longer periods of inactivity , the ratio of periods of inactivity to periods of activity , the number of total cycles of mechanical action during a treatment , as well as other features described herein . in one embodiment , a catheter is constructed with multiple apertures ( side holes , slits , or other openings ) through which a thrombolytic drug , when utilized , is injected or delivered . a separate pump controls the rate and duration of drug administration . the apertures are positioned throughout the mechanical motion segment of the catheter , which may include much of the body of the catheter in addition to the area near the catheter tip . the apertures preferably occupy about 20 - 60 cm . of the distal aspect of the catheter , rather than the typical distal 10 cm . of other prior art devices , although the apertures may occupy from 5 - 60 cm . of the distal aspect of the catheter . the motor which drives the mechanical portion of the device are typically different than those of the prior art , which are designed to be utilized for a short time during a procedure and are typically hand held devices with a finger activation , which rotate at very high rpm &# 39 ; s . the motor of the current invention may be programmable to rotate at slower rates ( about 0 . 1 - 600 rpms ) over much longer periods of time ( 30 minutes - days .) in a preferred embodiment , the motor may be programmed to rotate , or have other mechanical action , at a mechanical action rate , or speed , of about 0 . 5 to 55 rpms and a total treatment time of about 30 minutes to 5 hours . the activation times may vary from about 0 . 1 - 60 seconds and the inactivation times may vary from about 5 sec to 20 minutes in the preferred embodiment . the program may contain an intermittent mode in which there would be no motion provided by the catheter for specified periods of time . a motor controller , which is programmable , may be incorporated into the motor or may be separate . the motor housing is designed to accompany the patient to the ward or critical care unit so that it can be monitored while the pharmacomechanical thrombolysis proceeds . a battery and / or electrical connections are provided . another aspect of the present invention relates to an element which occludes a vessel distal to the catheter or , at least , distal to the mechanical and pharmacologic segments of the catheter . this occluding element can take any one of several forms , including an inflatable balloon , a deformable mesh braid with a membrane , a malecot with a membrane , or other suitable configuration . a preferred embodiment consists of a deformable mesh braid mounted on the outer surface of a movable core guide wire . when the inner core is retracted in relation to the outer surface , the braid changes from a longitudinal tubular structure to a radially expanded disc like structure which occludes the lumen of the vessel . the membrane covers or is disposed in the interstices of the braid . the wire is preferentially inserted through the catheter and may or may not be designed so as to assist in the motions of the catheter described above . a primary purpose of this element is to keep the pharmacologically active thrombolytic drug from washing out of the area of the clot once some of the clot has been dissolved . the prior art infusion catheters frequently are effective in restoring a channel within the clot , but subsequently the thrombolytic drug is washed away from the clot secondary to the success of re - establishing flow . further thrombolysis is the result of a systemic effect of the drug , rather than the desired local drug delivery of the infusion catheter . this situation necessitates longer infusion times utilizing more expensive thrombolytic drugs . this translates into added costs to achieve complete thrombolysis . the occluding element of the current invention would prevent the washout of the thrombolytic drug from the thrombus , accelerating the thrombolytic process . protection against embolization is a secondary purpose . balloons have been used for greater than 30 years to temporarily occlude vessels . filters are included in more recent prior art to protect against distal embolization , but the occluding device of the current invention , in the form of a malecot or deformable mesh braid containing a more or less impermeable elastomeric membrane , has not been utilized before . therefore , the foregoing description details a unique device and method that creates time and cost efficiencies in removing thrombus from the vascular channels of the human body . the device differs from prior art in addition to those previously listed features , in : 1 ) the length of the mechanically active segment , 2 ) the distribution of the apertures for drug insertion when combined with a mechanically active segment , 3 ) the configuration and programmability of the motor drive , 4 ) the presence of a motor controller , 5 ) the distal occluding element , 6 ) need to move the mechanically active segment within the clot ( prior art ), and 7 ) the inclusion of a combination of these features within one device . the device and method of the current invention also differs from prior art in that it expedites long segment thrombolysis , something that has never been achieved with prior art devices . the present invention provides for a short interventional procedure to place the device , begin infusion and initiate desired mechanical action . when the patient returns in one to several hours , the thrombolytic process is complete , the device can then be removed , and patient discharged shortly thereafter . the present invention is preferably used to clear long segment occlusions secondary to thrombus within arteries , veins , and grafts . in the case of iliofemoral deep venous thrombosis ( clot involving the iliac , superficial femoral , and popliteal veins ), a preferred procedure is to percutaneously enter the popliteal vein via a seldinger approach , insert a multipurpose angiographic catheter , and inject a small amount of contrast medium centrally . this will determine the extent of the thrombus in the iliac vein . the initial catheter is then exchanged for the device of the current invention that is positioned so that the mechanically active segment , and the aperture containing segment , span the entire length of the clot . the lengths of these segments are chosen from one of several different models of the device so that the length of the active segments matches the length of clot within the patient . if desired the distal occlusion element may be deployed at this time , or even before the catheter device of the invention is inserted . the mechanical portion of the catheter is connected to the drive motor , and the infusion lumen is connected to the drug infusion pump . appropriate desired frequencies , actions , motions , pauses , etc ., are programmed into the drive motor controller , and the motor initiated . the flow rate of the thrombolytic drug is selected and the drug infusion pump is begun . the patient is then transferred to a holding area , hospital room , or critical care unit for observation . the thrombolysis may be monitored by duplex compression ultrasound , but eventually the patient will return to the interventional suite to be evaluated with contrast injection , usually within three to five hours . in the case of superficial femoral artery thrombosis or femoropopliteal bypass graft occlusion from thrombus , either the ipsilateral femoral artery or contralateral femoral artery may be entered by seldinger technique . a contrast agent is injected to determine the extent of the clot , and the appropriate device of the invention is chosen to match the length of clot within the patient . it is positioned , with or without the distal occlusion device , so that the mechanically active and pharmacologically active segments essentially span the entire clot . the connections are made as above , and the appropriate parameters chosen and programmed . the mechanical segment and the pharmacological segment are initiated . the patient is then handled as in the prior paragraph . an endpoint is reached when pulses are detected clinically , or when the patient is returned to the angiography suite to be restudied . any residual debris within the vessel may be aspirated before removing the distal occlusion device . in addition to the description and guidance provided herein , the present inventor provides additional written description and enablement support for the present invention by incorporation by reference of u . s . pat . nos . 5 , 279 , 546 and 5 , 569 , 275 . it is obvious that variations of these methods may be employed to achieve the same desired effect . it is understood that various modifications of the device of the current invention and method may be accomplished within the scope of this invention .
a device and method to dissolve or eliminate blood clots from a patient relies upon a non - rapid moving mechanism to physically dissolve clots without damaging endothelium of the arteries and veins of a patient . in one embodiment , in addition to mechanical agitation of a clot , a thrombolytic agent is administered simultaneously with such agitation . preferably , intermittent agitation is utilized over a prolonged period of time to effectuate clot removal .