WO2011056981A2

WO2011056981A2 - Alternating circumferential bridge stent design and methods for use thereof

Info

Publication number: WO2011056981A2
Application number: PCT/US2010/055462
Authority: WO
Inventors: Craig Bonsignore; Stephen J. Kleshinski
Original assignee: Nitinol Devices And Components, Inc.
Priority date: 2009-11-04
Filing date: 2010-11-04
Publication date: 2011-05-12
Also published as: EP2496189A2; US10092427B2; EP2496189A4; US20190110913A1; WO2011056981A3; US20110106237A1

Abstract

A stent includes a first section and a second section. The first section and the second section each include a plurality of expandable modules and a plurality of bridging modules. Each expandable module includes a plurality of strut elements that join together at a plurality of apices, and each bridging module includes bridging elements that connect an apex of a first module with an apex of a second module. In some aspects, the first section is more flexible along the longitudinal axis of the stent than the second section and is configured to be placed in a specific region of a vessel that requires flexibility to accommodate surrounding anatomy. In some aspects, the first section is more radially stiff than the second section and is configured to be placed in a specific region of the vessel that requires radial stiffness to counteract crushing force caused by surrounding anatomy.

Description

ALTERNATING CIRCUMFERENTIAL BRIDGE STENT DESIGN AND

METHODS FOR USE THEREOF

CROSS REFERENCE TO RELATED APPLICATIONS

[0001] This application claims priority to U.S. Provisional Patent Application No.

61/258,145, filed November 4, 2009 entitled "Stent for Relief of Pelvic Venous Outflow

Obstruction and Methods for Use Thereof." This application also claims priority to U.S.

Provisional Patent Application No. 61/290,836, filed on December 29, 2009 entitled "Alternating Circumferential Bridge Stent Design and Methods of Use Therefore." This application also claims priority to U.S. Provisional Patent Application No. 61/391,462, filed on October 8, 2010 entitled "Alternative Circumferential Bridge Stent Design and methods of Use Therefore." These applications are herein incorporated by reference in their entirety.

INCORPORATION BY REFERENCE

[0002] All publications and patent applications mentioned in this specification are herein incorporated by reference to the same extent as if each individual publication or patent application was specifically and individually indicated to be incorporated by reference.

FIELD OF THE INVENTION

[0003] The present invention relates to stents and more particularly to stents having different modules that when combined provide advantages for the physiological challenges posed in particular anatomies.

BACKGROUND OF THE INVENTION

[0004] Generally, stents are used as an alternative to surgery to obtain and maintain the patency of a variety of body passageways, while maintaining the integrity of the passageway. The environments of human vasculature and body passageways are characterized by varied, dynamic, and mobile anatomy. Vessels vary from simple to complex shapes, can be uniform in diameter or change abruptly or gradually from one diameter to another, and are subjected to a range of forces exerted by an assortment of anatomical structures surrounding and adjacent to these body passageways. It is critical that stents be designed to accommodate significant variation in the shape and size of body passageways while providing structural support and flexibility as required by particular indications of use. [0005] The primary role of a stent is to provide radial expansion and scaffolding within the affected segment, thereby improving flow and preserving the viability and full function of distal tissues. In performing this primary function, however, a stent must exist in harmony with surrounding structures of the body, including vessels, nerves, muscles, organs, and other tissues. Each region of the anatomy presents a unique combination of loads, interactions, and constraints that will be experienced by the implant. In many regions of the anatomy, these boundary conditions will vary not only with location, but also with time. These temporal variations, including motions associated with the cardiac pulsatile cycle, gait cycle, respiratory cycle, or other dynamic events, are especially important considerations for the durability of the implant itself, as well as the efficacy of the therapy. Consequently, stent designs are needed that can (1) provide adequate outward radial support to remodel the lumen and improve distal perfusion, (2) provide adequate crush recoverability when subjected to compression by the surrounding muscles or external forces, (3) provide adequate flexibility to accommodate localized stretching, compression, bending, or torsion in mobile segments of the artery, (4) provide durability to survive the cyclic motions associated with limb flexion, and (5) provide uniform scaffolding throughout the treatment region, including the local regions adjacent to calcification that may be subjected to highly focal cyclic loading or displacement. These competing demands have proven difficult to resolve with a single design.

SUMMARY OF THE INVENTION

[0006] In general, in one aspect, a stent includes a first section and a second section aligned with the first section along a longitudinal axis of the stent. The first section and the second section each include a plurality of expandable modules and a plurality of bridging modules. Each expandable module includes a plurality of strut elements that join together at a plurality of apices. Each bridging module includes bridging elements that connect an apex of a first module with an apex of a second module. The first section is more flexible along the longitudinal axis than the second section and is configured to be placed in a specific region of a vessel that requires flexibility to accommodate surrounding anatomy.

[0007] This and other embodiments can include one or more of the following features. The second section can be configured to provide more radial stiffness than the first section and can be configured to be placed in a specific region of the vessel that requires radial stiffness to counteract crushing force caused by surrounding anatomy.

[0008] The plurality of bridging modules can be arranged to alternate along the longitudinal axis between clockwise bridging modules and counterclockwise bridging modules the clockwise bridging modules including bridging elements that extend at a clockwise angle with respect to the longitudinal axis, and the counterclockwise bridging modules including bridging elements that extend at a counterclockwise angle with respect to the longitudinal axis. The clockwise bridging modules can be configured to counterbalance any rotation caused by the

counterclockwise bridging modules.

[0009] There can be a greater number of bridging elements around a circumference of the first section than a circumference of the second section. A length of each bridging element of the first section can be greater than a length of each bridging element of the second section. A pitch of the bridging elements within each bridging module of the first section can be greater than a pitch of the bridging elements within each bridging module of the second section. A width of each bridging element of the first section can be less than a width of each bridging element of the second section. A thickness of each bridging elements of the first section can be less than a thickness of each bridging element of the second section.

[00010] There can be a greater number of strut elements around a circumference of the first section than a circumference of the second section. A length of each strut element of the first section can be less than a length of each strut element of the second section. A width of each strut element of the first section can be less than a width of each strut element of the second section. A thickness of each strut element of the first section can be less than a thickness of each strut element of the second section.

[00011] The vessel can be a left iliac vein, and the specific region can be proximate to where a left common iliac vein crosses an inguinal ligament. The vessel can be a superficial femoral artery, and the specific region can be between a profunda and an adductor hiatus. The vessel can be a coronary artery, and wherein the specific region can be near a branch vessel. The vessel can be a renal artery, and the specific region can be near an ostium. The vessel can be a carotid artery, and the specific region can be near a carotid sinus. The vessel can further be a trachea, a fistula, or a graft.

[00012] In general, in one aspect, a method of inserting a stent includes inserting a stent into a vessel. The stent includes a first section and a second section. The first section is more flexible along a longitudinal axis of the stent than the second section. The first section and the second section each include a plurality of expandable modules and a plurality of bridging modules.

Each expandable module includes a plurality of strut elements that join together at a plurality of apices. Each bridging module includes bridging elements that connect an apex of a first module with an apex of a second module. The method further includes aligning the first section with a specific region of the vessel that requires flexibility to accommodate surrounding anatomy. [00013] This and other embodiments can include one or more of the following features. The second section can be configured to provide more radial stiffness than the first section, and the method can further include aligning the second section with a specific region of the vessel that requires radial stiffness to counteract crushing force caused by surrounding anatomy.

[00014] The plurality of bridging modules can be arranged to alternate along the longitudinal axis between clockwise bridging modules and counterclockwise bridging modules, the clockwise bridging modules including bridging elements that extend at a clockwise angle with respect to the longitudinal axis, and the counterclockwise bridging modules including bridging elements that extend at a counterclockwise angle with respect to the longitudinal axis.

[00015] The vessel can be a left iliac vein, and the specific region can be proximate to where a left common iliac vein crosses an inguinal ligament. The vessel can be a superficial femoral artery, and the specific region can be between a profunda and an adductor hiatus. The vessel can be a coronary artery, and the specific region can be near a branch vessel. The vessel can be a renal artery, and the specific region can be near an ostium. The vessel can be a carotid artery, and the specific region can be near a carotid sinus. The vessel can further be a trachea, a fistula, or a graft.

[00016] In general, in one aspect, a stent includes a first section and a second section aligned with the first stent section along a longitudinal axis of the stent. The first section and the second section each include a plurality of expandable modules and a plurality of bridging modules. Each expandable module includes a plurality of strut elements that join together at a plurality of apices. Each bridging module includes bridging elements that connect an apex of a first module with an apex of a second module. The first section is more radially stiff than the second section and is configured to be placed in a specific region of the vessel that requires radial stiffness to counteract crushing force caused by surrounding anatomy.

[00017] This and other embodiments can include one or more of the following features. The second section can be more flexible along the longitudinal axis than the first section and can be configured to be placed in a specific region of a vessel that requires flexibility to accommodate surrounding anatomy.

[00018] The plurality of bridging modules can be arranged to alternate along the longitudinal axis between clockwise bridging modules and counterclockwise bridging modules, the clockwise bridging modules including bridging elements that extend at a clockwise angle with respect to the longitudinal axis, and the counterclockwise bridging modules including bridging elements that extend at a counterclockwise angle with respect to the longitudinal axis. The clockwise bridging modules can be configured to counterbalance any rotation caused by the counterclockwise bridging modules.

[00019] There can be a smaller number of bridging elements around a circumference of the first section than a circumference of the second section. A length of each bridging element of the first section can be greater than a length of each bridging element of the second section. A pitch of the bridging elements within each bridging module of the first section can be greater than a pitch of the bridging elements within each bridging module of the second section. A width of each bridging element of the first section cam be greater than a width of each bridging element of the second section. A thickness of each bridging element of the first section can be greater than a thickness of each bridging element of the second section.

[00020] There can be a smaller number of strut elements around a circumference of the first section than a circumference of the second section. A length of each strut element of the first section can be less than a length of each strut element of the second section. A width of each strut element of the first section can be greater than a width of each strut element of the second section. A thickness of each strut element of the first section can be greater than a thickness of each strut element of the second section.

[00021] The vessel can be a left iliac vein, and the specific region can be proximate to where a right iliac artery crosses a left common iliac vein. The vessel can be a left iliac vein, and the specific region is proximate to where a left internal iliac artery crosses a left common iliac vein. The vessel can be a superficial femoral artery, and the specific region can be proximate to an inguinal ligament. The vessel can be the superficial femoral artery, and the specific region can be proximate to a Hunters canal. The vessel can be a coronary artery, and the specific region can be distant from a branch vessel. The vessel can be a renal artery, and the specific region can be distant form an ostium. The vessel can be a carotid artery, and the specific region can be distant from a sinus. The vessel can further be a trachea, a fistula, or a graft.

[00022] In general, in one aspect, a method of inserting a stent includes inserting a stent into a vessel. The stent includes a first section and a second section. The first section is more radially stiff than the second section. The first section and the second section each include a plurality of expandable modules and a plurality of bridging modules. Each expandable module includes a plurality of strut elements that join together at a plurality of apices. Each bridging module includes bridging elements that connect an apex of a first module with an apex of a second module. The method further includes aligning the first section with a specific region of the vessel that requires radial stiffness to counteract crushing force caused by surrounding anatomy. [00023] The second section can be more axially flexible than the first section, the method further comprising aligning the second section with a specific region of the vessel that requires flexibility to accommodate surrounding anatomy.

[00024] The plurality of bridging modules can be arranged to alternate along the longitudinal axis between clockwise bridging modules and counterclockwise bridging modules, the clockwise bridging modules including bridging elements that extend at a clockwise angle with respect to the longitudinal axis, and the counterclockwise bridging modules including bridging elements that extend at a counterclockwise angle with respect to the longitudinal axis.

[00025] The vessel can be a left iliac vein, and the specific region can be proximate to where a right iliac artery crosses a left common iliac vein. The vessel can be a left iliac vein, and the specific region is proximate to where a left internal iliac artery crosses a left common iliac vein. The vessel can be a superficial femoral artery, and the specific region can be proximate to an inguinal ligament. The vessel can be the superficial femoral artery, and the specific region can be proximate to a Hunters canal. The vessel can be a coronary artery, and the specific region can be distant from a branch vessel. The vessel can be a renal artery, and the specific region can be distant form an ostium. The vessel can be a carotid artery, and the specific region can be distant from a sinus. The vessel can further be a trachea, a fistula, or a graft.

BRIEF DESCRIPTION OF THE DRAWINGS

[00026] The novel features of the invention are set forth with particularity in the claims that follow. A better understanding of the features and advantages of the present invention will be obtained by reference to the following detailed description that sets forth illustrative

embodiments, in which the principles of the invention are utilized, and the accompanying drawings of which.

[00027] FIG. 1 shows an exemplary stent as described herein.

[00028] FIG. 2 is a close up of a portion of an expandable ring member described herein.

[00029] FIGS. 3A-3B are depictions of the relationship of the stent to vessel and lesion diameters.

[00030] FIG. 4 is a close up of a portion of a bridging member described herein.

[00031] FIG. 5 shows a stent as described herein bent axially.

[00032] FIG. 6A shows a stent having bridge elements arranged axially.

[00033] FIG. 6B shows a stent having bridge elements arranged circumferentially.

[00034] FIG. 6C shows a chart of variables vs. module characteristics for the stents described herein. [00035] FIG. 7A is an illustration of the anatomy of the venous system within the pelvic region.

[00036] FIG. 7B is an illustration showing the spatial relationship of the anatomy of the right common iliac artery and the left common iliac vein whereby portions of the left common iliac vein are pinched by the right common iliac artery.

[00037] FIG. 7C is an illustration demonstrating the compression of the left common iliac vein between the spine and the right common iliac artery.

[00038] FIG. 8 shows an exemplary stent for treatment of IVCS.

[00039] FIGS. 9A-9C show the femoral arteries and surrounding anatomy.

[00040] FIG. 10 shows an exemplary stent for a femoral artery.

[00041] FIG. 11 shows the coronary arteries.

[00042] FIGS. 12A-12B show an exemplary stent for a coronary artery.

[00043] FIG. 13 shows the renal arteries.

[00044] FIG. 14 shows an exemplary stent for a renal artery.

[00045] FIG. 15 shows the carotid arteries.

[00046] FIG. 16 shows an exemplary stent for a carotid artery.

[00047] FIGS. 17A-17B show hemodialysis access grafts and fistulae.

[00048] FIGS . 18 A- 18B show the trachea and bronchi.

[00049] FIGS. 19A-19B show the response of the trachea during coughing.

DETAILED DESCRIPTION OF THE INVENTION

[00050] Embodiments of the present invention are directed toward stents having a modular architecture that permits regions of the stent to be specifically tailored to the specific anatomical challenges of the vessel undergoing treatment. While applicable to other portions of the body where compression resistive and/or flexible stents are well suited, the illustrative embodiments described herein are directed at stents designed to resolve obstructive lesions of the pelvic veins, femoral arteries, coronary arteries, renal arteries, carotid arteries, fistulae, and the trachea.

[00051] Embodiments of the stent described herein include a combination of a number of different modules. The physical and engineering properties of each module are tailored depending upon the required function of the module with respect to the rest of the stent.

Examples of different types of modules include: (1) modules designed to provide radial stiffness to anchor the stent or to resist external compressive forces; and (2) modules configured to provide added flexibility to the stent within the treated vessel in order to maintain patency of the vessel. Stent embodiments according to the present invention include one or more modules that are specifically sized and positioned with respect to one another so as to conform to a specific anatomical position.

STENT DESCRIPTION

[00052] Referring to FIG. 1, a stent 100 can include a series of expandable ring members 102 connected by bridging members 104. Each expandable ring member 102 can include a series of strut elements 120 disposed around the circumference of the stent 100. Moreover, each bridging member 104 can include circumferential bridging elements 140 connecting the struts 120 of adjacent expandable ring members 102. The pitch of the circumferential bridging elements 140 can alternate between bridging members 104. The number, design, order, and connection of the expandable ring members 102 and bridging members 104 define the overall architecture of the stent 100. The strength, stiffness, flexibility, and inner rotation of the stent can be controlled by the selection and design of these expandable ring members 102 and bridging members 104. Expandable Ring Members

[00053] Referring to FIGS. 1 and 2, the expandable ring members 102 can include a series of struts 120 arranged in a zig-zag shape around the circumference of the stent 100. That is, the struts 120, arranged around the circumference of the stent 100, can connect together at apices 122.

Radial Stiffness

[00054] The zig-zag shape of the expandable members 102 can be designed to provide a specific radial stiffness. Such radial stiffness can be important for resisting concentric or eccentric radial forces and maintaining the shape of the stent 100 once deployed.

[00055] The stiffness, k, of a ring member 102 when subjected to a hoop load, e.g., as a result of a perfectly concentric lesion, can be approximated by the following relationship:

[1] khoop O E w^ / Cn L³)

where each expandable ring member 102 include a series of n struts 120 disposed around the circumference of the stent 100, each strut having a length L, a width w, a thickness t, and made of a material having a Young's Modulus E. In this mode of loading, the "hoop" stiffness is dominated by the cube of the strut width, and inversely related to the cube of the strut length.

[00056] Moreover, the stiffness, k, of a ring member 102 when subject to a pinching or buckling load, e.g., as a result of eccentric loads, can be described by a different stiffness formulation:

[2] kp_inching (X (E w t³) / (n L³)

In this mode of loading, "pinching" stiffness is dominated by the cube of wall thickness, rather than strut width as it was for hoop stiffness. An effective stent for treatment of a vessel subject to pinching or buckling, therefore, will maximize wall thickness to maximize resistance to the pinching load experienced.

[00057] The zig-zag shape of the expandable members 102, in combination with the radial stiffness, can be further designed to provide a specific restorative force, acting in a radially outward direction to restore the patency of the a constricted lumen. Having a high restorative force can be important for providing the initial expansion force and for resisting concentric or eccentric radial forces placed on the stent 100 after implantation.

[00058] Referring to FIGS. 3A-3B, to increase the force applied, the diameter Ds of each expandable member can be chosen to be somewhat larger than the largest effective diameter Dv of the reference vessel. Referring to FIG. 3 A, for areas having concentric lesions, the

expandable member can be designed to have a uniform expansion force. As such, Ds - Dv > 0, and the inserted expandable member can remain in contact with the vessel at all times and all locations. In contrast, referring to FIG. 3B, for areas having eccentric lesions, such as in areas where compression, luminal webbing, or spurs further constrict the effective lumen diameter to Dc, the expandable member 7 can be designed to provide additional force at a particular location. Accordingly, the inserted expandable member will be more constrained (or "oversized") in this area of constriction than in the area of normal lumen: (Ds - Dc) > (Ds - Dv).

[00059] The amount of restorative force generated by a strut deflected by a distance δ can be expressed by the following equation for hoop force:

F_h00p = [ (12 * E * I) / (L³) ] * δ

where E is Young's Modulus for the material, I is the moment of inertia of the strut with respect to its axis of bending as the stent expands or contracts, L is the length of the strut, and δ is the magnitude of strut deflection. Thus, the amount of force that a particular module can apply is enhanced by maximizing the number of struts around the circumference

Axial Flexibility

[00060] It is commonly desirable to provide a stent structure that allows for smooth contouring and apposition in curved vessels or lumens following an irregular axial path. In such cases, the ideal stent can vary its local curvature in a continuous manner to accommodate any state of vessel bending. To maximize axial flexibility, it is desirable to decrease the axial length of strut elements 120, as bending is more likely to occur at the transition between the adjacent expandable members 102. Generally, axial flexibility of the stent is improved by minimizing the width w and thickness t of these strut elements 120, as this decreases the overall stiffness of the structure. Similarly, as the number of struts 120 around the circumference increases, strut width typically decreases, as there is a finite amount of material from which to form the struts, which also tends to improve axial flexibility.

Bridging Members

[00061] Referring back to FIG. 1, adjacent bridging members 104 can have bridging elements 140 that extend between apices 122 of adjacent expandable members 102. The bridging elements 140 can extend in a circumferential direction, i.e. between 0° and 90° from the longitudinal axis 1 10 of the stent.

[00062] As shown in FIG. 1, the bridging elements 140 of adjacent bridging members 104 along the longitudinal axis 106 of the stent can have an opposite pitch from one another. The bridging members 104 can thus alternate between bridging elements 140a that extend from a first apex 122a to a second apex 122b at a clockwise angle (otherwise known as a negative angle) with respect to the longitudinal axis 110 and bridging elements 140b that extend from a first apex 122c to a second apex 122d at a counter-clockwise angle (otherwise known as a positive angle) with respect to the longitudinal axis 1 10 of the stent.

[00063] The alternating pitch of the circumferential bridge members 104 advantageously prevents the stent 100 from responding with a bias to torsional loading. If all of the bridging elements 104 were alternatively oriented with the same pitch, a torsional load of a given direction may cause the stent to twist and/or to preferentially expand or contract in diameter. With an alternating pitch, the bias to torsional loading can be partially removed. That is, alternating the pitch allows the tendency for one bridging member 104 to rotate clockwise to be balanced by the adjacent bridging member's tendency to rotate counterclockwise. Further, having alternating pitch allows the stent 100 to accommodate significant axial, bending, or torsional deformation with relatively low amounts of strain because the loads can be distributed across the bridging elements 140. In some embodiments, the pitch of adjacent bridging members 104 is exactly opposite so as to fully balance out the torsional load across the stent 100. In other embodiments, a desired amount of twist can be purposefully imparted into a first section of the stent 100 and balanced out in another section of a stent 100. In still other embodiments, the stent can include an overall twist caused by an unbalanced pitch. Imparting an intentional twist into all or a section of the stent 100 might be important for matching a twist in a particular anatomy.

[00064] Referring to FIG. 4, a bridging element 140 can extend between each pair of internal apices 122c and 122d of expandable members 102. The circumferential bridging element 140 can have a length 1 as measured from apex 122 A to apex 122B. Moreover, the angle between the length of the strut element 601 and a line extending parallel with the longitudinal axis of the strut can be offset by a circumferential angle Θ. The angle Θ can be used to describe the change in circumferential position traversed by a circumferential bridging element 140.

Flexibility

[00065] The bridging members 104 can be used to influence the axial flexibility of the stent 100 when subjected to various loads. Flexibility is particularly important for those portions of the stent that approach or cross a ligament, bone, muscle or other anatomical feature that may alter or influence the response characteristics of the treated vessel.

[00066] Referring to FIG. 5, as the stent 100 bends axially, the bridging elements along the outer curve 502 will spread apart, while the bridging elements along the inner curve 504 will draw closer together. Thus, as the length of a bridging element is increased, the longitudinal flexibility of the stent will increase because the bridging elements will be able to spread apart further along the outer curve 540. Likewise, the greater the angle Θ, the greater the longitudinal flexibility of the stent because each bridging member 140 has a greater ability to stretch along the outer curve 540. As with the strut elements 120 described above, increasing the width w and thickness t of the bridging elements 140 tends to increase the overall stiffness of the structure, and thus adversely impact axial flexibility of the structure. Again, increasing the number of such elements 140, while correspondingly reducing the width of individual elements, allows for bending loads to be distributed more uniformly throughout the structure, and generally improve axial flexibility.

Radial Stiffness

[00067] The bridging elements contribute to radial stiffness by a relation of /*0. As Θ varies from an axial orientation to a circumferential orientation, the contribution to radial stiffness ranges from low to high. Bridging elements that are axially oriented have no impact, as they simply translate in a radial direction as the stent is expanded, contracted, or exposed to hoop forces. Bridging elements that are circumferentially oriented, however, are oriented in the same direction as hoop forces, contribute to carrying hoop loads, and therefore increase hoop stiffness of the structure. The magnitude of this effect is proportional to the length 1 of the bridging element 140; very short bridging elements have little impact at all, while longer bridging elements have an increasing impact.

Rotating/Foreshortening

[00068] Stents commonly experience changes in orientation or length during the transition from constrained to expanded, or the vice versa. For example, a decrease in length can occur between the constrained stent and the expanded stent, called foreshortening. One component of foreshortening results from the change in angle of the struts 120 comprising the expandable members 102 as the strut is expanded.

[00069] The bridging members 140 can compensate for some of the foreshortening experienced by the structural elements. As the length 1 and the angle 0 of the bridging elements 140 decrease, the difference in length between the constrained and expanded condition of the stent 100 also decreases. Minimizing the amount of foreshortening is generally desirable to improve the predictability and accuracy of deployment and positioning. Thus, compensating for foreshortening provides motivation to moderate the length 1 and angle Θ of the bridging members 104.

[00070] Further, as length 1 and angle 0 decrease, the expandable ring members 102 will have a decreasing tendency to rotate relative to each other as the stent expands or contracts. Relative rotation between expandable ring members 102 can cause the stent to be unstable, disrupt the surrounding tissue, and/or exert undesirable forces or strain on the surrounding structures, providing further motivation to moderate the length and angle Θ. Moreover, because the angle Θ changes as the stent is expanded or constrained, the relative rotational twisting experienced between adjacent expandable ring members 102 during expansion or constraining also increases. Examples

[00071] As an extreme example, consider holding the length 1 constant and varying the angle Θ in a hypothetical series of different designs. In a first design, referring to FIG. 6A, as the angle Θ approaches 0°, the bridging elements 140 approach an orientation parallel to the longitudinal axis of the stent. At this extreme, the bridging elements 140 have virtually no contribution to the radial strength of the stent. As the stent expands or contracts, assuming that the bridging elements 140 maintain their horizontal orientation, there is zero relative rotation between adjacent expandable ring members. Further, these horizontally oriented bridging elements inhibit bending flexibility.

[00072] In a second design, referring to FIG. 6B, as the angle Θ approaches 90°, the bridging elements 601 approach a circumferential orientation. At this extreme, the bridging elements 601 have a significant contribution to the radial strength of the stent. Moreover, as the stent expands or contracts, the relative rotation between expandable ring members can be significant (it increases with increasing bridging element length). And at this extreme, the circumferentially oriented bridging elements 140 promote bending flexibility.

Stent Characteristics as a Whole

[00073] The stent 100 can be formed from a superelastic material. In one specific aspect, the superelastic material is Nitinol, an intermetallic compound having approximately 50.8 atomic percent Nickel and the balance Titanium. Nitinol has the unique properties of shape memory and superelasticity, and in this application is designed to take advantage of the material's ability to withstand unusually high levels of strain (up to 8% or more), without experiencing plastic deformation. The material can have an unusually pronounced hysteresis effect in its stress-strain relationship: when subjected to loading, stresses are relatively high, as they reach the upper plateau (UP) where a phase change from austenite to martensite occurs. When the material is unloaded, stresses are relatively low, as seen in the lower plateau (LP) where the material transforms from martensite to austenite. The magnitude of the difference between UP and LP stresses is determined by material composition, as well as thermal and processing history. In some embodiments, the transition temperature for the material, known as the Austenite Finish (Af) temperature is preferably set between 10 degrees and 37 degrees C. Preferentially, the Af temperature is set close to body temperature to maximize the hysteresis effect of the material, increasing the difference between UP and LP. As such, forces exerted by the stent as it unloads (expands) from its constrained state are minimized. This force, described as Chronic Outward Force (COF), is controlled by the LP stress. Conversely, the forces exerted by the stent when it is loaded (subjected to external compression) are maximized. This force, described as Radial Resistive Force (RRF), is controlled by the UP stress.

[00074] When all internal apices 122 of a stent are connected together through a bridging element 140, as shown in FIG. 1, the stent can be termed a "closed cell" strut. Advantageously, by having a "closed cell" as opposed to an "open cell" stent can prevent webbing or spurs of a lesion from prolapsing through the struts to compromise the lumen. Conversely, if a stent is "open cell," in which some internal apices are unconnected, the stent can move more freely for enhanced flexibility. In some embodiments, the modules of the stents described herein can be modified such that a closed cell architecture is provided in some stent regions and an open cell architecture is provided in other regions. For example, the areas of the stent expected to lie within the regions of localized constriction can have a closed cell architecture while other areas have an open structure.

[00075] Stents are typically placed within a lumen to restore patency of a compromised lumen, resolve obstructions caused by disease or anatomical formations, and thereby improve flow. Obstructions within the lumen are often irregular or non-uniform in nature, and

consequently it is desirable for the stent to provide uniform support throughout its contact area with the vessel, and minimize the area of any unsupported regions. "Scaffolding performance" is a term used to describe the ability of a stent to serve this purpose. Cell size, the area bounded by a closed region of struts or bridges, is one measure of scaffolding performance. Minimum inscribed circle (MIC), the smallest circle (or more properly, sphere) that can fit through the structural elements of the stent, passing from inside its cylindrical form to outside, is another measure. Both cell size and MIC can vary as the stent is expanded, stretched, twisted, or otherwise deformed. Ideally, both are minimized throughout any expected loading conditions experienced by the stent. Scaffolding performance tends to improve with the number of elements around the circumference and along the length; more elements of a smaller size will provide more uniform coverage and support for small and irregular obstructions that the stent may appose in the lumen.

[00076] Typically, designs that provide excellent scaffolding characteristics and outward support are also relatively axially stiff, and therefore experience high local strains with localized axial displacement, bend, or torsional loads. Conversely, designs that offer excellent axial and bend flexibility typically suffer from poor local scaffolding performance as local regions of the stent may flex apart to accommodate a bend, this same local flexion typically exposes a gap in scaffolding support, often at the very region where it is most needed. The stents described herein addresses each of the concerns to provide a superior platform for treatment of various anatomical areas of the body.

[00077] Advantageously, the properties of the stents described herein can be customized along the length of the device to correspond to the physiology that is common with a particular anatomy or condition. Thus, each stent can have multiple sections, each section including modules that are modified to have a particular property.

[00078] FIG. 6C shows a chart of the effect of several variables on the flexibility, stiffness, rotation, and scaffolding, where + indicates positive correlation, ++ indicates strong positive correlation, - indicates negative correlation,— indicated a strong negative correlation, and 0 indicates no influence. Thus, for example, to make a section more axially flexible, the bridge members can include a greater number of bridge elements circumferentially or have elements with a longer length, a higher pitch, a lower width, or a lower thickness. Likewise, expandable members can have a higher number of struts circumferentially, or have struts elements with a longer length, lower width, or lower thickness. To make a section more radially stiff, there can be fewer strut elements in the expandable ring member, or each strut element can have a shorter length, a higher width, or a higher thickness. Likewise, the bridging members can have a lower number of bridging elements circumferentially, or each bridging element can have a higher length, a higher pitch, a higher width, or a higher thickness. To make a section less rotatable, the bridging elements can have a shorter length or a lower pitch. Scaffolding performance is improved by increasing the number of elements around the circumference, and along the length, and minimizing the freedom of these elements to move apart from each other as the stent is expanded, placed in a bend, or otherwise deformed. These parameters can be adjusted and balanced so as to optimize the performance of the stent for a given indication.

IVCS Stents

[00079] Chronic venous insufficiency (CVI) is a disease in which the function of the venous system is compromised. As a result of CVI, blood tends to pool in the lower extremities, and insufficient blood may be returned to the heart for re-oxygenation. The patho-physiology of CVI commonly involves veins of the lower extremities and/or pelvic area: the femoral veins, iliac veins, and inferior vena cava. CVI is associated with deep vein thrombosis (DVT), a condition resulting from clotting of stagnant blood in the deep vein system. CVI is also associated with varicose veins in the superficial venous system, a condition relating to incompetent venous valves. CVI is a progressive condition that can result in leg pain and swelling, edema, and ulcers of the leg or ankle.

[00080] A condition known as iliac vein compression syndrome (IVCS), also known as May- Thurner syndrome, or pelvic spur syndrome is recognized as a cause of venous thrombo- occlusive disease. Referring to FIG. 7A, IVCS is commonly observed at the confluence of the common iliac veins, where the right iliac artery 702 crosses the left common iliac vein (LCIV) 704. As shown in FIGS. 7B and 7C, the IVCS can cause compression of the LCIV 704 between the artery 716 and the spine 718. Symptomatic chronic nonmalignant obstructive lesions most commonly occur in region 101 between the confluence of the iliac veins to the inguinal ligament. Further, compression and consequent webbing or spurs are most common at region 101 A where the right iliac artery 702 crosses the left common iliac vein. A similar anatomical condition can occur at region 101C where the left internal iliac artery crosses the external iliac vein. In these regions, chronic pulsatile compression is believed to cause the formation of intraluminal venous webs or spurs. These anomalies have been described as chronic nonmalignant obstructive lesions.

[00081] Such obstructive lesions may be observed in clinical practice by diagnostic procedures including venography or intravascular ultrasound. It is believed that these lesions are an important contributor to the cascade of events leading to CVI of escalating severity. These lesions may be dilated by balloon venoplasty in an attempt to restore venous flow, but this technique has been found to provide inadequate resolution in many cases. Studies have found that treating these lesions with intravenous stents is a safe and effective therapy that is more durable than balloon venoplasty alone. To date, no stent has been designed specifically to treat obstructive lesions of the pelvic veins. Therefore, stents to help treat the particular issues related to obstructive lesions of the pelvic veins are needed.

[00082] Referring to FIG. 8, a stent 800 for treatment of IVCS may be preferentially designed by varying the parameters described herein. The stent 800 can have a length that covers the region 101 , e.g., be at least 130mm in length. The expanded diameter of the stent 800 can be between 120nm and 20mm, such as approximately 14mm.

[00083] The stent 800 can include several expandable members 102 connected by bridging modules 104. The stent can include sections 801A, 801B, 801C, and 801D that are configured to line up with regions 101 A, 101B, 101C, and 101D, respectively, of the artery.

[00084] Section 801 A can be configured to maximize stiffness or resistance to compressive force in the region of the right iliac artery compression 101 A. Likewise, section 801C can be configured to maximize stiffness or resistance to compressive force in the region of the left internal artery compressions 101C. Thus, for example, the strut length of the strut elements in the ring members 102 can be decreased and/or the strut thickness can be increased in sections 801 A and 801 C relative to section 801 B so as to maximize stiffness in those areas. For example, there can be 30 to 60 struts, such as 48 struts in each ring member 102 of sections 801 A and 801 C. Further, the length of the struts in each ring member 102 of sections 801 A, 801 C can be between 1 and 4mm, such as approximately 2.1mm. The width of the struts in each ring member 102 of sections 801A and 801C can be between 0.1mm and 0.3mm, such as approximately 0.15mm. The thickness of the struts in each ring member 102 of sections 801 A, 801 C can be between 0.1mm and 0.5mm, such as between 0.2mm and 0.4mm, such as approximately 0.36mm. Moreover, the length of the bridging elements 140 of bridging members 104 in sections 801 A and 801C can be increased and/or the angle Θ can be increased relative to bridging members 104 in section 801B.

[00085] Further, section 80 ID can be configured to maximize flexibility in the region where the LCIV approaches or crosses the inguinal ligament (region 101D). In one embodiment, the total expanded circumference of the stent is 14mm * π = 44mm, and the length of the bridging elements of the bridging modules 104 of section 80 ID is approximately 4.4mm. The angle Θ, therefore, is approximately 10% of the circumference, or 36°, when the stent is in its expanded configuration. In the constrained condition, the circumference of this stent is 3.2mm * π = 10mm, so the constrained Θ of bridging modules 104 in section 80 ID is 44% of the

circumference, or 160°. As this stent is expanded or constrained, adjacent expandable ring segments in section 80 ID undergo rotation of the difference in the expanded and contracted Θ, 160° minus 36°, or 124°. Further, the struts of the ring members 102 can be configured to have a length of approximately l-4mm. These design parameters are chosen so as to enhance flexibility without compromising scaffolding performance.

Femoral Artery Stents

[00086] Arterial disease occurs when the natural lumen of an artery narrows or closes, such as when fibro-fatty deposits or calcified plaques grow within the layers of the artery and spread throughout the arterial system. Consequences of coronary arterial disease may range from angina to myocardial infarction and sudden death.

[00087] The superficial femoral artery (SFA) is commonly affected by peripheral arterial disease that may be associated with symptoms ranging from mild claudication and difficulty walking to chronic limb ischemia and partial amputation. FIGS. 9A-9C show the femoral arteries 900 in relation to surrounding muscles 902 and skeletal landmarks 904. As the external iliac artery passes posterior to the inguinal ligament 906, its name changes to the common femoral artery 910, which branches (at 912) into the profunda 914 and the superficial femoral artery 916. The profunda 914 supplies blood to the thigh and the superficial femoral artery 916 carries blood to the lower limb.

[00088] The SFA is unique in the human arterial system, as it traverses the thigh region with few branches, serving to deliver oxygenated blood to the lower limb by way of the popliteal and tibial arteries. Transiting from the region of the hip to the knee, the SFA passes through several muscle groups, and is subjected to one of most dynamic and mobile environments in the human anatomy. While disease in the SFA can be localized, it is frequently diffuse, commonly spanning 10cm or more.

[00089] The superficial femoral artery is effectively pinned in two major locations: in area 93 OA near its origin in the area of the inguinal ligament 910 and the branch 912, and in area 930C near its terminus in the area of first genicular arteries 922 and the Hunters canal 924. Between these points, in region 930C, the vessel can be quite mobile, limited to some extent by minor branch vessels, often to a greater extent by rigid calcifications within the diseased regions of the vessel. The areas of the vessel that are less constrained - for example, the area 930B between the inguinal ligament and hunters canal and the area 930D, and away from areas of localized calcification - may be subjected to highly localized deformations including twisting, stretching, and/or compression with flexion of the limb.

[00090] The dynamic challenges of this disease prone area of the SFA create a severe fatigue environment for metallic implants intended to improve lumen diameter and distal perfusion. Stents placed in this region have commonly been found to fracture, raising concern about such implants failing to perform their function, creating injury, or causing additional risks to the patient. Accordingly, a stent that is capable of withstanding such an environment is needed.

[00091] Referring to FIG. 10, a stent 1000 for treatment of the femoral arties includes alternating circumferential bridging members 104 and expandable ring members 102. The stent can include sections 1030A, 1030B, 1030C, and 1030D that are configured to line up with regions 930A, 930B, 930C, and 930D, respectively, of the artery. Thus, the stent 1000 can have an expanded diameter of slightly more than the diameter of the femoral artery to provide sufficient outward force. For example, the stent 1000 can have an expanded diameter of greater than 7mm, such as approximately 8mm.

[00092] The sections 1030A and 1030C intended to be placed in the pinned area of the adductor hiatus and canal can be configured to be of higher strength or stiffness relative to sections 1030B and 1030D. For example, the wall thickness can be increased relative to sections 1030B and 1030D and/or the ratio between the wall thickness and the strut width can be increased relative to sections 1030B and 1030D. Furthermore, to increase the hoop stiffness in this area, the length and angle of the bridging elements may be increased. Furthermore, to increase the hoop stiffness in this area, the length and angle of the bridging elements may be increased.

[00093] Further, section 1030B of the stent 1000 that is intended to be placed in the highly mobile region 930B between the profunda 804 and the adductor hiatus 805 and in the mobile region 930D can be configured to be more flexible relative to sections 1030A, 1030C. For example, the alternating circumferential bridging members can be designed to allow increased flexibility by increasing the length and angle Θ of bridging elements in the bridging members 104 relative to sections 103 OA and 1030C.

Coronary Artery Stents

[00094] Coronary arterial disease is among the most important areas of interventional medicine. Traditional stenoses of the coronary arteries have been treated with balloon expandable stents because of their high strength, ease of use, and versatility. Referring to FIG. 1 1 , the modular stent described herein could be useful in the coronary arteries 1100 for bifurcation 1102 of the left main (LM) artery 1 101 to the left anterior descending (LAD) artery 1 104, the left main artery to the circumflex (CX) artery 1103, or are in the region of side branches between right coronary artery (RCA) 11 10, LAD 1 104, or CX 1103 and corresponding diagonal branches along their length. Similarly, self expanding stents could be used for stenting the LM 1101 itself, and potentially the ostium 1115 of the LM 1101 and RCA 1 1 10 at the location of the aortic root 1114. Particularly in these areas, it is critical that the stent accommodate significant variation in shape in-situ, i.e., the final contour of the implanted stent may need to be significantly non-cylindrical and include abrupt changes in local diameter or cross section.

[00095] Referring to FIGS. 12A-12B, a stent 1200 for treatment of coronary artery disease includes alternating circumferential bridging members 104 and expandable ring members 102. The stent 1200 is configured to abruptly change one or more of its shape, contour, local diameter, or cross sectional profile to accommodate for the changes of the coronary arteries. In one embodiment, shown in FIG. 12 A, the stent 1200 includes a section 1201 and a section 1202. Section 1201 can be configured to be positioned near an ostium or the origin of a branch vessel. Accordingly, section 1201 can be more flexible than section 1202. Thus, for example, the bridging elements of the bridging members 104 can be longer in section 1201 than in section 1202. Further, the pitch of the bridge members 104 can be increased relative to section 1202. Additionally, section 1202 can be configured to provide more uniform vessel support than section 1201 and/or can be configured to provide drug delivery to the remainder of the stented coronary artery. The shorter bridging elements and small pitch relative to section 1201 can provide increased support in section 1202.

[00096] In another embodiment, shown in FIG. 12B, the coronary artery stent 1200 includes a section 1203 between adjacent sections 1204A and 1204B. Section 1203 can be configured to be located at the site of a branch vessel, while sections 1204A and 1204B can be configured to be proximal and distal to the branch location. Accordingly, section 1203 can be configured to be more flexible than sections 1204 A and 1204B. Thus, bridging elements of the bridging members 104 in region 1203 can be longer and/or have a higher pitch than the bridging elements in regions 1204A and 1204B.

Renal Artery Stents

[00097] Referring to FIG. 13, the rental arteries are prone to arterial disease, particularly in the ostium 1304. However, stenting can be difficult because the renal arteries 1303 are relatively mobile during the respiratory cycle. The kidney 1 102 can move several millimeters during the respiratory cycle, while the aorta 1101 moves separately. The renal arteries 1303, joining the kidneys to the aorta, may therefore experience significant bending, angulation, or displacement between inhalation and expiration. Traditional inflexible stents may adversely impact the normal anatomy in this region, while flexible stents may experience large cyclic deformations and strains, potentially resulting in fracture. It is therefore important to provide a renal artery stent that can be sufficiently flexible, can accommodate the complex shape of the renal ostium, and can provide substantial radial stiffness for the body of the renal artery. [00098] Referring to FIG. 14, a renal artery stent 1400 includes alternating circumferential bridging members 104 and expandable ring members 102. The stent includes a section 1401 configured to be placed at the ostial end of the rental artery and a section 1402 configured to be placed along the rest of the artery. Thus, section 1401 can be more flexible than section 1402 to accommodate for the shape of the ostium. Conversely, section 1402 can be configured to provide higher strength or stiffness than section 1401 to adequately support the rest of the artery. Thus, for example, section 1401 can include longer bridging elements than section 1402, allowing for significant flaring of section 1401 to adequately cover the ostium 1304. Further, section 1402 can include feature shorter and stiffer struts than section 1401.

Carotid Artery Stents

[00099] Referring to FIG. 15, the carotid arteries 1500 include the common carotid artery 1501, the internal carotid artery 1503, and the external carotid arteries 1502. The common carotid artery 1201 splits into the internal carotid artery 1503 which delivers flow to the brain, and external carotid arteries 1502 that deliver flow to the other areas of the head and face. The bifurcation 1504, where the common branches into the internal and external carotid arteries, is also described as the carotid bulb or carotid sinus. Carotid arterial disease commonly involves substantial plaque deposits and flow limiting narrowing in the common, and branch carotid vessels, and therefore commonly involves the sinus region. There are several important structures in the region 1530B of the carotid sinus including the baroreceptors in the adventitial layer of the carotid sinus. These baroreceptors are mechanoreceptors modulate the activity of the sympathetic and parasympathetic nervous systems on the basis of pressure and/or stresses in the vessel wall. Angioplasty and stenting in this region can create hemodynamic instability, with detrimental effects on baroreflex, and consequent hypotension or hypertension. Conventional stents, with uniform outward force along the length of the structure, may exacerbate this effect. Accordingly, a stent is needed with enough support so support a lesion in the carotid artery, but enough flexibility to avoid hemodynamic instability.

[000100] Referring to FIG. 16, a carotid artery stent 1600 includes alternating circumferential bridging members 104 and expandable ring members 102. The stent includes sections 1630A, 1630B, and 1630C, which correspond to regions 1530A, 1530B, and 1530C, respectively, of the carotid artery. Region 1630B can be designed to allow for the abrupt change in diameter and shape in region 1530B while minimizing disruption of the carotid sinus. For example, the radial stiffness of section 1630B can be reduced and/or the flexibility of section 1630B can be increased relative to neighboring sections 1630A and 1630C. Fistula Stents

[000101] Referring to FIGS. 17A and 17B, the stent described herein could be used at the junction of hemodialysis fistulae 1301 or grafts 1302. In these applications, a stent may need to be placed at the junction of an artery, vein, and/or synthetic graft, and therefore assume an abrupt angle. Furthermore, the stent may have to accommodate a significant diameter change at the site where the fistula or graft joins the native artery, making the modular stent described herein advantageous over traditional stents.

Tracheal Stents

[000102] Referring to FIGS. 18A-18B, the trachea 1901 branches into the right and left main stem bronchi 1903, which further branch into lobar bronchi 1904 to feed the lungs. The main stem and lobar bronchi are circumferentially supported by irregular plates of hyaline cartilage. In the main stem, lobar bronchi and below, the cartilage 1910 is partially circumferential, taking the shape of the letter "C," with a fibrous membrane 1911 between the ends of the "C." When foreign matter, phlegm, or other debris becomes lorded in the bronchi or trachea, a cough reflex is triggered. The response of the human trachea during a cough is illustrated in FIGS. 19 A- 19B. When a cough occurs, the soft tissue in this region allows the substantially circular cross section of the trachea 2001 to collapse into a narrowed crescent shaped channel 2002. The reduced cross sectional area increases the velocity of the air exiting the lungs through this space, helping to propel material out of the trachea. The airways may become obstructed in the case of tumor growth in the region of the lungs or surrounding structures, causing compression of infiltration of the bronchi or trachea.

[000103] Stents can be placed in the trachea as a palliative or restorative therapy. Such a stent may provide outward forces to expand the lumen of the airways, prevent compression and/or ingrowth of the tumor, and/or deliver chemotherapeutic or other agents locally. Stents commonly used in this indication have several shortcomings. For example: silicone or polymer based stents have low outward force and can migrate or be expectorated; other stents designed primarily for cardiovascular use have been deployed with limited success, as these devices lack sufficient radial stiffness, thus allowing undesirable compression. Importantly, conventional stents are typically designed to have uniform radial outward forces along the length of the stent, which creates an incompatibility with the normal physiological and/or biomechanical movement of the airway. Furthermore, conventional stents may interrupt or degrade the normal mucociliary transport system of the bronchi and trachea with struts or coverings that are oriented in such a way as to inhibit the normal flow of mucus. Accordingly, a stent is needed that addresses some or all of these limitations. [000104] Accordingly, a modular stent as described herein could be used in the trachea. The circumferential bridging elements could accommodate the need for the airways to transform between a substantially circular cross section to a substantially crescent shaped cross section during a cough. For example, an array of struts axially aligned in a circumferential band ranging up to 180 degrees of the circumference, and oriented toward the dorsal aspect of the airway, can be designed to be more flexible than the struts in an axial band oriented toward the ventral aspect of the airway. The normal configuration of the mucosal epithelium is spiral in nature. Further, the smooth muscle surrounding the airways tissue is arranged in a helical orientation. The epithelium and cilia follow the orientation of the innermost smooth muscle layer. In a preferred embodiment of the present invention, the circumferential bridge elements are oriented in such a way as to be consistent with this orientation. As such, an embodiment for this indication may favor circumferential bridges that are all oriented in the same direction, rather than alternating in direction along the length. Furthermore, the bridges are preferentially oriented in a direction that is closer to axial than circumferential, thus promoting functional mucociliary transport.

METHODS OF USE

[000105] In operation, the stents described herein can be placed in the anatomy of interest. In some embodiments, the physician can first inject a radiopaque contrast medium into the vessel of interest to visualize the path and caliber of the subject veins. Alternatively, or in addition, the physician may introduce an intravascular ultrasound (IVUS) catheter into the vessel of interest to study the cross section of the lumen at all points along its length. The IVUS catheter can be specifically designed to work in conjunction with the stent and delivery system described herein. Preferentially, the IVUS probe would be contained within the profile of a standard 0.035" guidewire, and could therefore be used to replace the conventional guidewire for balloon and stent delivery while providing opportunity for imaging throughout the procedure.

[000106] Using the radiopaque markers and/or IVUS guidance, the physician can place a high pressure balloon at the site of the constriction and inflate to a pressure sufficient to dilate the narrowed area. This procedure may be repeated multiple times and at multiple locations to achieve a satisfactory result.

[000107] The stent can be constrained within a flexible sheath, preferably such that the sheath is compatible with an introducer sheath having a profile of 10 French or less. In some embodiments, the stent is constrained within this sheath at the time of manufacturing and packaging. Alternatively, the stent can be constrained within a capsule that is packaged separately from the delivery sheath, and coupled with the delivery device before insertion into the patient. [000108] The physician can place a guidewire, such as a .035" guidewire, across the site of the target vessel. The delivery system can then be advanced over the guidewire to the target site. The stent can be positioned in the desired location using X-Ray and/or ultrasound guidance.

[000109] An actuation mechanism at the proximal end of the delivery system can then be used to retract the outer constraining sheath and allow the stent to expand to its memory diameter. Preferably, the stent will be held fixed relative to the vessel by means of an inner member that engages the stent and is held axially fixed during sheath retraction. The constraining sheath may be designed to retract in a "tip to hub" direction, thereby first expanding and anchoring the end of the stent farthest from the operator. Alternatively, the constraining sheath may be designed to retract from "hub to tip" direction, thereby first expanding and anchoring the end of the stent closest to the operator first. Because placement at the confluence is critical, the direction of approach determines the preferred direction of unsheathing. With the typical antegrade approach, the hub end of the delivery system is near the femoral vein, the tip end is near the confluence, and the preferred direction of deployment is therefore tip to hub. For a more unusual jugular or contralateral approach, the tip end of the stent would be near the femoral vein, the hub end near the confluence, and the preferred direction of deployment would therefore be hub to tip.

[000110] After the stent has initially expanded and anchored, it may be advantageous to confirm accurate placement with ultrasound or X-Ray guidance. Further, the stent may contain markers to aid the physician to locate the proximal and distal ends of the stent, as well as any unique features along the length of the stent, or around its circumference. This can be particularly important to denote the location of stent regions with modulated stiffness or flexibility as described above. Radiopacity enhancing features may include coatings, tabs, rivets, inserts, or other features composed of metals including tantalum, platinum, gold, palladium, silver, or combinations thereof. Alternatively or in addition, it may also be advantageous to similarly provide enhanced echogenecity at certain locations of the stent to enhance visualization of selected features during ultrasound diagnostic procedures.

[000111] Using visualization techniques, if the placement of the stent is not optimal, the physician may readvance the constraining sheath to recapture the deployed segment of stent, reposition the delivery system, and attempt the deployment again. The ability to recapture the stent is another benefit of the closed cell architecture described above, and is another advantage to connecting all of the internal apices, particularly in the region of the stent that is first expanded. After the stent has been confirmed to be anchored in the intended location, the sheath is fully retracted, releasing the stent from the delivery system into position within the target vessel. [000112] Once the stent has unloaded from its constrained diameter, it will contact the vessel. The chronic outward force of the stent will cause the vessel diameter, particularly at the point of the lesion, to enlarge to restore flow through the vessel. As a final step, it can be advantageous to inflate a balloon within the stent, particularly in the region of the subject obstructive lesions. The balloon can assist in expanding the stent, even past its normal expanded diameter. When the balloon is deflated, the stent is again subjected to loading stresses, and therefore resists recoil of the vessel according radial resistive force (RRF) driven by the higher stress response of the upper plateau. With this method, the outward forces localized in the area of the obstructive lesion are maximized to ensure maximum luminal gain and relief from the symptoms associated with IVCS.

[000113] While numerous embodiments of the present invention have been shown and described herein, one of ordinary skill in the art will appreciate that such embodiments are provided by way of example only. Numerous variations, changes, and substitutions will now occur to those skilled in the art without departing from the invention. In addition, the intended uses of the present invention include a variety of medical applications as well as other applications where highly precise, compact devices for fluid transport are needed. It should be understood that various alternatives to these embodiments of the invention described herein may be employed in practicing the invention. It is intended at the following claims defined the scope of the invention and it methods and structures within the scope of these claims and their equivalents be covered thereby.

Claims

Attonwo 2011/056981705·600 PCT/US2010/055462WHAT IS CLAIMED IS:

1. A stent comprising:

a first section and a second section aligned with the first section along a longitudinal axis of the stent, the first section and the second section each including:

a plurality of expandable modules, each expandable module including a plurality of strut elements that join together at a plurality of apices; and

a plurality of bridging modules, each bridging module including bridging elements that connect an apex of a first module with an apex of a second module;

wherein the first section is more flexible along the longitudinal axis than the second section and is configured to be placed in a specific region of a vessel that requires flexibility to accommodate surrounding anatomy.

2. The stent of claim 1, wherein the second section is more radially stiff than the first section and is configured to be placed in a specific region of the vessel that requires radial stiffness to counteract crushing force caused by surrounding anatomy.

3. The stent of claim 1, wherein the plurality of bridging modules are arranged to alternate along the longitudinal axis between clockwise bridging modules and counterclockwise bridging modules, the clockwise bridging modules including bridging elements that extend at a clockwise angle with respect to the longitudinal axis, and the counterclockwise bridging modules including bridging elements that extend at a counterclockwise angle with respect to the longitudinal axis.

4. The stent of claim 3, wherein the clockwise bridging modules are configured to counterbalance any rotation caused by the counterclockwise bridging modules.

5. The stent of claim 1, wherein there are a greater number of bridging elements around a circumference of the first section than a circumference of the second section.

6. The stent of claim 1 , wherein a length of each bridging element of the first section is greater than a length of each bridging element of the second section.

7. The stent of claim 1 , wherein a pitch of the bridging elements within each bridging module of the first section is greater than a pitch of the bridging elements within each bridging module of the second section. ^AttorWO 2011/056981 PCT/US2010/055462

8. The stent of claim 1 , wherein a width of each bridging element of the first section is less than a width of each bridging element of the second section.

9. The stent of claim 1, wherein a thickness of each bridging element of the first section is less than a thickness of each bridging element of the second section.

10. The stent of claim 1, wherein there are a greater number of strut elements around a circumference of the first section than a circumference of the second section.

11. The stent of claim 1, wherein a length of each strut element of the first section is less than a length of each strut element of the second section.

12. The stent of claim 1, wherein a width of each strut element of the first section is less than a width of each strut element of the second section.

13. The stent of claim 1, wherein a thickness of each strut element of the first section is less than a thickness of each strut element of the second section.

14. The stent of claim 1, wherein the vessel is a left iliac vein, and wherein the specific region is proximate to where a left common iliac vein crosses an inguinal ligament.

15. The stent of claim 1, wherein the vessel is a superficial femoral artery, and wherein the specific region is between a profunda and an adductor hiatus.

16. The stent of claim 1, wherein the vessel is a coronary artery, and wherein the specific region is near a branch vessel.

17. The stent of claim 1, wherein the vessel is a renal artery, and wherein the specific region is near an ostium.

18. The stent of claim 1, wherein the vessel is a carotid artery, and wherein the specific region is near a carotid sinus. ^AttonWO 2011/056981⁷⁰⁵·⁶⁰⁰ PCT/US2010/055462

19. A method of inserting a stent, comprising:

inserting a stent into a vessel, the stent comprising a first section and a second section, wherein the first section is more flexible along a longitudinal axis of the stent than the second section, the first section and the second section each including:

a plurality of bridging modules, each bridging module including bridging elements that connect an apex of a first module with an apex of a second module; and

aligning the first section with a specific region of the vessel that requires flexibility to accommodate surrounding anatomy.

20. The method of claim 19, wherein the second section is more radially stiff than the first section, the method further comprising aligning the second section with a specific region of the vessel that requires radial stiffness to counteract crushing force caused by surrounding anatomy.

21. The method of claim 19, wherein the plurality of bridging modules are arranged to alternate along the longitudinal axis between clockwise bridging modules and counterclockwise bridging modules, the clockwise bridging modules including bridging elements that extend at a clockwise angle with respect to the longitudinal axis, and the counterclockwise bridging modules including bridging elements that extend at a counterclockwise angle with respect to the longitudinal axis.

22. The stent of claim 19, wherein the vessel is a left iliac vein, and wherein the specific region is proximate to where a left common iliac vein crosses an inguinal ligament.

23. The stent of claim 19, wherein the vessel is a superficial femoral artery, and wherein the specific region is between a profunda and an adductor hiatus.

24. The stent of claim 19, wherein the vessel is a coronary artery, and wherein the specific region is near a branch vessel.

25. The stent of claim 19, wherein the vessel is a renal artery, and wherein the specific region is near an ostium. ^mlorWO 2011/056981 ^{U3 ουυ} PCT/US2010/055462

26. The stent of claim 19, wherein the vessel is a carotid artery, and wherein the specific region is near a carotid sinus.

27. A stent comprising:

a first section and a second section aligned with the first stent section along a longitudinal axis of the stent, the first section and the second section each including:

a plurality of expandable modules, each expandable module comprising a plurality of strut elements that join together at a plurality of apices; and

wherein the first section is more radially stiff than the second section and is configured to be placed in a specific region of the vessel that requires radial stiffness to counteract crushing force caused by surrounding anatomy.

28. The stent of claim 27, wherein the second section is more flexible along the longitudinal axis than the first section and is configured to be placed in a specific region of a vessel that requires flexibility to accommodate surrounding anatomy.

29. The stent of claim 27, wherein the plurality of bridging modules axe arranged to alternate along the longitudinal axis between clockwise bridging modules and counterclockwise bridging modules, the clockwise bridging modules including bridging elements that extend at a clockwise angle with respect to the longitudinal axis, and the counterclockwise bridging modules including bridging elements that extend at a counterclockwise angle with respect to the longitudinal axis.

30. The stent of claim 29, wherein the clockwise bridging modules are configured to counterbalance any rotation caused by the counterclockwise bridging modules.

31. The stent of claim 27, wherein there are a smaller number of bridging elements around a circumference of the first section than a circumference of the second section.

32. The stent of claim 27, wherein a length of each bridging element of the first section is greater than a length of each bridging element of the second section. ^Atto WO 2011/056981⁷⁰⁵·⁶⁰⁰ PCT/US2010/055462

33. The stent of claim 27, wherein a pitch of the bridging elements within each bridging module of the first section is greater than a pitch of the bridging elements within each bridging module of the second section.

34. The stent of claim 27, wherein a width of each bridging element of the first section is greater than a width of each bridging element of the second section.

35. The stent of claim 27, wherein a thickness of each bridging element of the first section is greater than a thickness of each bridging element of the second section.

36. The stent of claim 27, wherein there are a smaller number of strut elements around a circumference of the first section than a circumference of the second section.

37. The stent of claim 27, wherein a length of each strut element of the first section is less than a length of each strut element of the second section.

38. The stent of claim 27, wherein a width of each strut element of the first section is greater than a width of each strut element of the second section.

39. The stent of claim 27, wherein a thickness of each strut element of the first section is greater than a thickness of each strut element of the second section.

40. The stent of claim 27, wherein the vessel is a left iliac vein, and wherein the specific region is proximate to where a right iliac artery crosses a left common iliac vein.

41. The stent of claim 27, wherein the vessel is the left iliac vein, and wherein the specific region is proximate to where a left internal iliac artery crosses a left common iliac vein.

42. The stent of claim 27, wherein the vessel is the superficial femoral artery, and wherein the specific region is proximate to an inguinal ligament.

43. The stent of claim 27, wherein the vessel is the superficial femoral artery, and wherein the specific region is proximate to a Hunters canal. ^AttonWO 2011/056981⁷⁰⁵·⁶⁰⁰ PCT/US2010/055462

44. The stent of claim 27, wherein the vessel is a coronary artery, and wherein the specific region is distant from a branch vessel.

45. The stent of claim 27, wherein the vessel is a renal artery, and wherein the specific region is distant form an ostium.

46. The stent of claim 27, wherein the vessel is a carotid artery, and wherein the specific region is distant from a sinus.

47. A method of inserting a stent, comprising:

inserting a stent into a vessel, the stent comprising a first section and a second section, wherein the first section is more radially stiff than the second section, the first section and the second section each including:

aligning the first section with a specific region of the vessel that requires radial stiffness to counteract crushing force caused by surrounding anatomy.

48. The method of claim 47, wherein the second section is more axially flexible than the first section, the method further comprising aligning the second section with a specific region of the vessel that requires flexibility to accommodate surrounding anatomy.

49. The method of claim 47, wherein the plurality of bridging modules are arranged to alternate along the longitudinal axis between clockwise bridging modules and counterclockwise bridging modules, the clockwise bridging modules including bridging elements that extend at a clockwise angle with respect to the longitudinal axis, and the counterclockwise bridging modules including bridging elements that extend at a counterclockwise angle with respect to the longitudinal axis.

50. The stent of claim 47, wherein the vessel is a left iliac vein, and wherein the specific region is proximate to where a right iliac artery crosses a left common iliac vein. ^AtrorWO 2011/056981 ^U3'^0UU PCT/US2010/055462

51. The stent of claim 47, wherein the vessel is the left iliac vein, and wherein the specific region is proximate to where a left internal iliac artery crosses a left common iliac vein.

52. The stent of claim 47, wherein the vessel is the superficial femoral artery, and wherein the specific region is proximate to an inguinal ligament.

53. The stent of claim 47, wherein the vessel is the superficial femoral artery, and wherein the specific region is proximate to a Hunters canal.

54. The stent of claim 47, wherein the vessel is a coronary artery, and wherein the specific region is distant from a branch vessel.

55. The stent of claim 47, wherein the vessel is a renal artery, and wherein the specific region is distant form an ostium.

56. The stent of claim 47, wherein the vessel is a carotid artery, and wherein the specific region is distant from a sinus.