JP5496766B2 - Fixture and medical catheter - Google Patents

Description

  The present invention relates to a fixture included in a medical catheter and the medical catheter itself.

  In recent years, patients who cannot take a meal from the mouth use a gastrointestinal catheter for nutrition (nutrition). An example of a gastrointestinal catheter is a gastrostomy catheter. The gastrostomy catheter is a hollow member that communicates between the stomach and the outside of the body. In order to prevent such a gastrostomy catheter from falling off the body, the stomach wall and abdominal wall are sandwiched between the inner (intragastric) stopper and the outer (outside body) stopper.

  There are two types of gastrostomy catheters: “button type” and “tube type” (see Patent Documents 1 and 2 and Non-Patent Document 1).

  The advantage of the button-type gastrostomy catheter is that it does not stand out and does not interfere with daily operations, thereby improving the patient's quality of life (QOL). Conversely, the disadvantages of the button-type gastrostomy catheter are that it is difficult to operate (open / close) the button for the feeding port of the nutrient in the gastrostomy catheter with the fingertip, or the connection between the feeding port and the feeding tube is difficult, or It is mentioned that the flow path for nutrients and the like is narrow.

  On the other hand, the advantage of the tube-type gastrostomy catheter is that it can be easily connected to the feeding tube. On the other hand, the disadvantages of the tube-type gastrostomy catheter are that it is easy to cause infection in the tube due to the long catheter tube, and that the catheter tube exposed outside the body is obstructive and easy to remove accidents (for example, The gastrostomy catheter is easily pulled out of the body when it is pulled or hooked).

  In other words, both button-type gastrostomy catheter and tube-type gastrostomy catheter have room for improvement.

  Incidentally, a gastrostomy catheter (for example, a tube-type gastrostomy catheter) may have a problem such as an embedded bumper syndrome during indwelling. The bumper burying syndrome is a symptom in which the internal stopper is buried in the stomach mucosa when the distance between the internal stopper and the external stopper is shorter than the distance from the stomach cavity to the body surface. For example, over-tightening of the external bumper causes this bumper buried syndrome.

  When this bumper burying syndrome occurs, it becomes impossible to administer nutrients or the like to the patient's stomach, and for example, reconstruction of the gastrostoma becomes necessary. This places a great burden on the patient.

  In order to prevent such a buried bumper syndrome, it is possible to firmly fix the external stopper with a catheter tube at a distance of 0.5 cm or more from the body surface. An example of an external stopper that can be firmly fixed to the catheter tube is the external stopper described in Patent Document 3.

  More specifically, the external stopper (fixing tool) has an opening for inserting a catheter tube in the gastrostomy catheter. And since the extension direction of this opening bends instead of a straight line, the inner wall of the opening and the outer wall of the catheter tube are firmly adhered, and the external stopper is not easily displaced by the catheter tube.

JP 2004-215804 A JP 2007-167082 A JP 2006-305025 A

http://www.peg.or.jp/eiyou/peg/about.html

  However, in the case of the external stopper described in Patent Document 3, the external stopper is firmly fixed to the catheter tube, but the distance from the external stopper to the body surface is difficult to grasp. In addition, since the external stopper is firmly fixed to the catheter tube, it is difficult to move the external stopper away from the body surface.

  The present invention has been made to solve the above problems. And the objective is to provide the fixing tool etc. which can be positioned easily and correctly, without measuring the distance with a body surface.

  The fixture is movably attached to the main body of the medical catheter, and regulates the movement of the medical catheter itself by contacting the body. The fixture includes a deviation distance adjusting device for changing a distance from one end of the main body to the fixture.

  This deviation distance adjusting device desirably uses the lever principle.

  For example, the deviation distance adjusting device preferably includes a support shaft and a lever supported by the support shaft so as to rotate forward and backward. In addition, the contact end that is one end of the lever that is separated from the support shaft contacts the main body, and the non-contact end that is the other end of the lever that is separated from the support shaft is on the opposite side to the contact end. It is preferable that the non-contact end moves backward along the main body part by rotating in the reverse direction with respect to the support shaft while proceeding along the main body part.

  The distance that the lever moves while contacting the main body is preferably 0.5 cm or more and 2.0 cm or less.

  In addition, it is preferable that the fixture includes at least one support shaft and includes a number of levers corresponding to the support shaft.

  In addition, it is desirable that the fixture includes an electric motor that automatically rotates the lever.

  In addition, it can be said that the medical catheter containing the above fixing tool is also this invention.

  A gastric fistula catheter, a jejunostomy catheter, an esophageal fistula catheter, a cecal fistula catheter, a rectal fistula catheter, a renal fistula catheter, a tracheostomy catheter, or a drainage catheter can be exemplified as a medical catheter.

  According to the present invention, when a fixture is attached to a medical catheter, the fixture is easily and accurately positioned without measuring the distance from the body surface.

FIG. 4 is a perspective view showing an external stopper and a catheter tube. FIG. 3 is a front view of an external stopper. FIG. 2B is a cross-sectional view of the external stopper (a cross-sectional view taken along line B-B ′ in FIG. 2A). FIG. 3B is a cross-sectional view (cross-sectional view taken along the line C-C ′ in FIG. 2A) of the external stopper. FIG. 3B is a cross-sectional view of the external stopper (a cross-sectional view taken along line D-D ′ in FIG. 2A). FIG. 4 is a perspective view of an external stopper. These are sectional drawings which show the state which the holding end of the lever approached the body surface contact part. These are sectional drawings which showed the state which the holding end of a lever tends to leave | separate from the body surface contact part, or the state which tries to approach. These are sectional drawings which show the state which the holding end of the lever left | separated from the body surface contact part. FIG. 5 is a cross-sectional view showing an opening (cavity) of an external stopper. FIG. 5 is a cross-sectional view showing an opening (cavity) of an external stopper. FIG. 3 is a perspective view of a gastrostomy catheter.

[Embodiment 1]
The following describes one embodiment with reference to the drawings. For convenience, hatching, member codes, and the like may be omitted, but in such a case, other drawings are referred to.

  As an example of a medical catheter, a gastrostomy catheter that is placed in the stomach that is the digestive tract (a catheter that is placed in the digestive tract can also be referred to as a digestive tract placement catheter) will be described. However, the present invention is not limited to this. Absent.

  FIG. 6 is a perspective view showing the gastrostomy catheter 59. A gastrostomy catheter {PEG (Percutaneous Endoscopic Gastrostomy) catheter} 59 includes a catheter tube [main body part] 41, a funnel 51, an inlet cap 52, an internal stopper [internal fixing part] 53, a valve 54, and an external stopper [fixing tool]. 11 is included.

  The catheter tube 41 is a shaft-like member having a hollow 42, that is, a tube (a portion of the catheter tube 41 surrounding the hollow 42 is referred to as a wall portion 41W; see FIG. 2B). The hollow 42 is used to flow, for example, a nutrient supplied to the stomach, and serves as a main lumen 42. At both ends of the extended main lumen [main hollow] 42, an inlet 43A and an outlet 43B, which are mouth portions 43, are formed, and the mouth portion 43 into which a nutrient or the like is inserted is defined as an inlet port 43A. An outlet 43B from which nutrients and the like flow out is defined as an outlet 43B (note that the side where the outlet 43B is located is the tip side and the side where the inlet 43A is located is the end side (hand side)).

  An inflation lumen 45 is formed on the wall 41W of the catheter tube 41, but details will be described later (although not shown, an X-ray opaque line is formed on the wall 41W of the catheter tube 41. It may be formed along the longitudinal direction).

  The funnel 51 is a part of the catheter tube 41 in the vicinity of the inlet 43A of the main lumen 42, and has a larger outer diameter than the other part of the catheter tube 41 (for example, near the middle of the catheter tube 41). Specifically, since the funnel 51 has a relatively large outer diameter, the wall portion 41W increases in thickness, and the inner diameter of the main lumen 42 in the vicinity of the inlet 43A is different from that of the main lumen 42 (for example, the outlet 42B). Of the inner diameter). Thereby, for example, the feeding tube can be easily connected to the input port 43A.

  The input port cap 52 closes the input port 43 </ b> A of the main lumen 42. As shown in FIG. 6, it is desirable that the insertion port cap 52 is connected to the gastrostomy catheter 59 because it is not lost.

  The internal stopper 53 is a balloon that is inflated by injection of a medium (for example, a liquid or a gas such as air), and is formed on the distal end side of the catheter tube 41. Then, when the balloon is inflated, it engages with the periphery of the gastrostomy 73 inside the stomach (in short, the internal stopper 53 is caught by the stomach inside the body). As a result, the gastrostomy catheter 59 does not fall out of the stomach.

  The internal stopper 53 is connected to an inflation lumen 45 formed on the wall 41W of the catheter tube 41. The inflation lumen 45 is connected to the outside via a valve 54. Then, the medium injected from a syringe or the like (not shown) inserted into the valve 54 enters the internal stopper 53 through the inflation lumen 45, and the internal stopper 53 is expanded.

  The valve 54 allows the medium from the syringe or the like to pass through the inflation lumen 45 by insertion of the syringe or the like, while blocking the connection between the inflation lumen 45 and the outside when the syringe or the like is pulled out.

  The external stopper 11 is a disk having an opening 12 into which the catheter tube 41 is inserted {the inner diameter of the opening (cavity) 12 of the external stopper 11 is slightly smaller than the outer diameter of the catheter tube 41}. The external stopper 11 is located between the internal stopper 53 and the funnel 51. Then, an interval is generated between the internal stopper 53 located inside the stomach and the internal stopper 53 located outside the body, and the abdominal wall 71 and the stomach wall 72 are accommodated in this interval (see FIGS. 4A to 4C).

  When the external stopper 11 is fixed to the catheter tube 41 relatively firmly, the external stopper 11 is engaged with the body surface (in short, the external stopper 11 is caught on the body surface). The gastrostomy catheter 59 does not excessively enter the stomach. That is, when the internal stopper 53 and the external stopper 11 sandwich the abdominal wall 71 and the stomach wall 72, the gastrostomy catheter 59 not only falls out of the stomach but also does not excessively enter the stomach.

  The shortest distance between the internal stopper 53 and the external stopper 11 in the gastrostomy catheter 59 may be equal to or greater than the total thickness of the gastric wall 72 and the abdominal wall 71. For example, 15 cm or less (preferably 10 cm or less) is assumed.

  Here, the external stopper 11 is demonstrated using FIG. 1, FIG. 2A-FIG. 2D, and FIG.

  FIG. 1 is a perspective view showing the external stopper 11. FIG. 2A is a front view of the external stopper 11. FIG. 2B is a cross-sectional view (a cross-sectional view taken along line B-B ′ in FIG. 2A) in which two later-described support shafts 21 can be visually recognized at the same time. FIG. 2C is a cross-sectional view (a cross-sectional view taken along line C-C ′ in FIG. 2A) in which only one support shaft 21 described later can be visually recognized. FIG. 2D is a cross-sectional view (a cross-sectional view taken along line D-D ′ in FIG. 2A) in which a bottom of a groove 17 described later can be visually recognized. FIG. 3 is a perspective view of the external stopper 11 (more specifically, the external stopper 11 from which the support shaft 21 and the lever 22 are omitted).

  The external stopper 11 includes a body surface contact portion 13, a non-slip portion 16, and a deviation distance adjusting device 20.

  The body surface contact portion 13 is a disk having an opening 12 into which the catheter tube 41 is inserted. By contacting the body surface, the gastrostomy catheter 59 is prevented from moving, and the gastrostomy catheter 59 is excessively advanced into the stomach. prevent. The body surface contact portion 13 is not limited to a shape like a disk (ring), and may be a polygonal shape that is rounded or a leg shape.

  Further, in the body surface contact portion 13, one surface that contacts the body surface may include an opening, may be an uneven surface, or is subjected to a graining process in order to suppress the contact area. It does not matter.

  The non-slip portion 16 is a member having an opening 12 like the body surface contact portion 13, and is formed on one surface of the body surface contact portion 13 (on the side away from the body surface in the body surface contact portion 13). The anti-slip portion 16 includes a groove 17 for attaching the deviation distance adjusting device 20. The groove 17 extends in the same direction as the extension direction of the cylindrical anti-slip portion 16, and a deficient portion 18 leading to the opening 12 is formed at the bottom of the groove 17. In addition, although the position of the defect | deletion part 18 is not specifically limited, The example formed in the location comparatively away from the body surface contact part 13 in the groove | channel 17 is given.

  The divergence distance adjusting device 20 is configured such that one end of the catheter tube 41 {for example, one end of the catheter tube 41 to which the internal stopper 53 is connected (for example, the position located on the most distal side among the connection points between the internal stopper 53 and the catheter tube 41). )} To the external stopper 11 and adjusts the distance (deviation distance), and includes the support shaft 21 and the lever 22.

  The support shaft 21 supports the lever 22 so as to rotate in the forward and reverse directions (for example, a cylindrical member), and spans the opposing wall surfaces at the groove 17 of the anti-slip portion 16. The support shaft 21 is located at a location overlapping the defect portion 18 in a direction orthogonal to the direction in which the cavity 12 extends.

  The lever 22 is supported by the support shaft 21 so as to be accommodated in the groove 17 of the anti-slip portion 16. The lever 22 moves the anti-slip portion 16 and thus the external stopper 11 in the catheter tube 41 by bringing the one end 22T into contact with the catheter tube 41 via the defect 18 formed in the groove 17. .

  More specifically, the support shaft 21 is inserted near one end of both ends of the rod-shaped lever 22, and one end 22T of the lever 22 contacting the catheter tube 41 near the support shaft 21 becomes the contact end 22T. The contact end 22T is a curved surface (cam surface)}.

  On the other hand, the other end (that is, the end opposite to the contact end 22T) 22N of the lever 22 is a grip end 22N gripped by a person, for example. In addition, since the gripping end 22N is an end that does not contact the catheter tube 41 itself in order to move the external stopper 11 along the catheter tube 41, it can also be said to be a non-contact end 22T.

  The gripping end 22N (and thus the lever 22) rotates forward P or reverse Q with reference to the support shaft 21, so that the external stopper 11 moves the catheter tube 41. That is, the distance from one end of the catheter tube 41 to the external stopper 11 changes according to the rotation of the lever 22.

  Therefore, the movement of the external stopper 11 will be described with reference to FIGS. 4A to 4C (in the description using FIGS. 4A to 4C, the catheter tube 41 is not moved). 4A is a cross-sectional view showing a state where the gripping end 22N of the lever 22 is close to the body surface contact portion 13, and FIG. 4C is a state where the gripping end 22N of the lever 22 is separated from the body surface contact portion 13. FIG. 4B is a cross-sectional view showing a state in which the grip end 22N of the lever 22 is about to be separated from or approached to the body surface contact portion 13.

  In FIG. 4A, the external stopper 11 contacts the body surface. That is, the distance between the internal stopper 53 and the external stopper 11 may be as long as the total thickness of the abdominal wall 71 and the stomach wall 72 (that is, a bumper buried syndrome may occur).

  Therefore, for example, a person moves the external stopper 11 while holding the grip end 22N. More specifically, the grip end 22N rotates so as to deviate from the body surface contact portion 13 with respect to the support shaft 21 (this rotation is defined as a normal rotation P).

  Then, as shown in FIG. 4B, the contact end 22T, which is one end 22T of the lever 22, passes through the defect 18 and approaches the surface of the catheter tube 41, and then comes into contact. When the lever 22 and the catheter tube 41 come into contact with each other in this way, a place where the contact occurs becomes a base point (engagement point) MP.

  Then, when the gripping end 22N is rotated forward P as it is, the lever 22 is tilted toward the distal end side of the catheter tube 41 with reference to the base point MP as shown in FIG. 4C. Then, the support shaft 21 moves to the end side from the base point MP, and the external stopper 11 also moves to the end side in accordance with the movement. Therefore, a constant interval is generated between the external stopper 11 and the body surface.

  That is, when the support shaft 21 and the lever 22 are included in the external stopper 11 attached to the catheter tube 41 via the opening 12, the contact end 22T of the lever 22 contacts the catheter tube 41, The gripping end 22N located on the opposite side to the contact end 22T rotates forward P with respect to the support shaft 21, so that the external stopper 11 moves along the catheter tube 41 (note that the end of the catheter tube 41 is the end of the catheter tube 41). The movement of the external stopper 11 toward the side is assumed to be progress).

  In this case, the external stopper 11 moves by the distance that the lever 22 moves while contacting the catheter tube 41. Therefore, for example, when the lever 22 is rotated forward in a state where the internal stopper 53 of the gastrostomy catheter 59 touches the stomach wall and the external stopper 11 touches the body surface, as shown in the order of FIG. 4A → FIG. 4B → FIG. The external stopper 11 is separated from the body surface by the distance that the lever 22 has moved in contact with the catheter tube 41.

  Therefore, when the deviation distance adjusting device 20 including the lever 22 using the lever principle as described above is included in the external stopper 11, the external stopper can be easily and accurately measured without measuring the distance from the body surface. 11 can be positioned.

  The distance that the lever 22 has moved while contacting the catheter tube 41 (movement distance) is preferably 0.5 cm or more and 5.0 cm or less.

  In this case, as shown in FIG. 4C, an interval corresponding to the movement distance is surely generated from the body surface to the external stopper 11. Therefore, the case where the distance from the body surface to the external stopper 11 is less than 0.5 cm does not occur, and the bumper burying syndrome does not occur.

  On the other hand, the case where the distance from the body surface to the external stopper 11 does not exceed 5.0 cm does not occur, and a dropout accident caused by hooking the gastrostomy catheter 59 or excessive entry of the gastrostomy catheter 59 into the stomach (Note that in order to prevent these accidents more reliably, the distance that the lever 22 moves while contacting the catheter tube 41 is preferably 0.5 cm or more and 2.0 cm or less).

  When the lever 22 rotates in the reverse direction Q, as shown in the order of FIG. 4C → FIG. 4B → FIG. 4A, the external stopper 11 moves toward the distal end side of the catheter tube 41 (this movement is referred to as retraction). .

  More specifically, as shown in FIG. 4C, the gripping end 22N rotates so as to approach the body surface contact portion 13 with the support shaft 21 as a reference (this rotation is referred to as reverse rotation Q).

  Then, as shown in FIG. 4B, the contact end 22T, which is one end 22T of the lever 22, passes through the defect 18 and approaches the surface of the catheter tube 41, and then comes into contact. When the lever 22 and the catheter tube 41 come into contact with each other in this way, the location where the contact occurs becomes the base point MP.

  Then, when the gripping end 22N is rotated in the reverse direction Q as it is, the lever 22 falls toward the distal end side of the catheter tube 41 with reference to the base point MP as shown in FIG. 4A. Then, the support shaft 21 moves to the tip side from the base point MP, and the external stopper 11 also moves to the tip side in accordance with the movement.

[Embodiment 2]
A second embodiment will be described. In addition, about the member which has the same function and effect as the member used in Embodiment 1, the same code | symbol is attached and the description is abbreviate | omitted.

  In the gastrostomy catheter 59 described in the first embodiment, the inner diameter of the opening 12 of the external stopper 11 is slightly smaller than the outer diameter of the catheter tube 41 and they are in close contact with each other, but a certain level of force is applied. In addition, the external stopper 11 has moved the catheter tube 41. However, the inner wall of the opening 12 of the external stopper 11 is not limited to a surface having no bulge.

  For example, the inner diameter of the opening 12 may be smaller than the outer diameter of the catheter tube 41 by forming a hemispherical ridge on the inner wall of the opening 12. Further, a semi-disc-shaped ridge may be formed on the inner wall of the opening 12, or a spiral ridge may be formed on the inner wall of the opening 12 as shown in the cross-sectional view of FIG. In FIG. 5A and FIG. 5B described later, the support shaft 21 and the lever 22 are omitted for convenience.

  In addition, as shown in the cross-sectional view of FIG. 5B, the ridge 12D has a surface 12Dv that faces the body surface side (that is, the body surface contact portion 13 side) rising vertically with respect to the inner wall of the opening 12, while The surface 12Di facing the side opposite to the side (that is, the anti-slip portion 16 side) may be tapered as a whole of the ridge 12D by inclining the surface 12Di with respect to the inner wall of the opening 12.

  In this case, when the external stopper 11 is to approach the body surface side, the one surface (vertical surface) 12Dv perpendicular to the inner wall of the opening 12 firmly contacts the outer wall of the catheter tube 41, so that the outer stopper 11 moves. It becomes difficult. Therefore, the bumper buried syndrome can be prevented more reliably. On the other hand, when the external stopper 11 is to be separated from the body surface, the one surface (inclined surface) 12Di that is inclined to the inner wall of the opening 12 does not come into strong contact with the outer wall of the catheter tube 41 and moves relatively easily. . That is, it can be said that such an external stopper 11 is easy to handle while preventing the bumper buried syndrome.

[Other embodiments]
The present invention is not limited to the above-described embodiment, and various modifications can be made without departing from the spirit of the present invention.

  For example, in the above description, the external stopper 11 includes two support shafts 21 and two levers 22, but is not limited thereto. For example, the external stopper 11 may include one support shaft 21 and one lever 22. In short, the external stopper 11 may include at least one support shaft 21 and the number of levers 22 corresponding to the support shaft 21.

  Further, the lever 22 is not necessarily rotated by being grasped by a human hand. For example, a known motor [electric motor] may be included in the external stopper 11, and the motor may automatically rotate the lever 22.

  The material of the gastrostomy catheter 59 is not particularly limited. As an example material, 2 arbitrarily selected from various resins such as silicone, polyvinyl chloride, polyurethane resin, polyester resin, polyamide resin, polyolefin resin, styrene resin, and polybutadiene resin A mixture of seeds or more can be mentioned. Further, one kind of resin selected from silicone, polyurethane resin, and styrene resin may be used as a material for the gastrostomy catheter 59.

  Various organic substances or inorganic substances may be mixed in the resin composition used as the material for the gastrostomy catheter 59 as long as the thermodynamic characteristics or the biocompatibility characteristics of the material are not significantly impaired. . For example, pigments, dyes, stabilizers, antioxidants, lubricants, nucleating agents, extenders, fillers, reinforcing agents, thickening agents, or compatibilizing agents can be mentioned as various organic or inorganic substances.

  When the gastrostomy catheter 59 is manufactured by molding, it is not particularly limited, but it is desirable to perform extrusion molding, compression molding, injection molding, LIM (Liquid Injection Molding) molding, or the like.

  In the above, the gastrostomy catheter 59 has been described as an example, but the present invention is not limited to this. For example, as other catheters, jejunostomy catheter {PEJ (Percutaneous Endoscopic Jejunostomy) catheter}, esophageal fistula catheter {PTEG (Percutaneous Trans-Esophageal Gastro-tubing) catheter}, cecal fistula catheter, rectal fistula catheter, renal fistula catheter, trachea An incision catheter, a drainage catheter, etc. are mentioned. That is, the catheter is not particularly limited as long as it can be fixed from at least one of the inside and outside of the body.

11 External stopper [fixing tool]
12 Opening (cavity)
12D protuberance 12Dv protuberance vertical surface 12Di protuberance inclined surface 13 body surface contact portion 16 anti-slip portion 17 groove 18 defect portion 20 deviation distance adjusting device 21 support shaft 22 lever 22T contact end 22N grasping end 41 catheter tube [main body portion]
41W Wall portion 42 Main lumen 43 Port portion 43A Input port 43B Outlet port 45 Inflation lumen 51 Funnel 52 Port cap 53 Internal stopper [Internal fixing portion]
54 valve 59 gastrostomy catheter [medical catheter]
71 Abdominal wall 72 Gastric wall 73 Gastrostomy

Claims (6)

In a fixing device that is movably mounted on a main body part of a medical catheter and that contacts the body to regulate the movement of the medical catheter itself,
A deviation distance adjusting device for changing a distance from one end of the main body part to the fixture is included ,
The deviation distance adjustment device uses the lever principle,
A spindle,
A lever supported by the support shaft so as to rotate forward and backward,
Including
A contact end that is one end of the lever separated from the support shaft contacts the main body portion,
On the opposite side of the contact end, the non-contact end, which is the other end of the lever that is separated from the support shaft, rotates forward with respect to the support shaft, and thus proceeds along the main body. ,
A fixing tool in which the non-contact end retreats along the main body by rotating in reverse with respect to the support shaft . Distance which the lever is moved in contact with the body portion, the fixture of claim 1 Ru der least 2.0cm below 0.5 cm. Including at least one of the support shafts,
The fixture according to claim 1, wherein the lever includes a number corresponding to the support shaft . The fixture according to any one of claims 1 to 3, further comprising an electric motor that automatically rotates the lever . The medical catheter containing the fixing tool of any one of Claims 1-4. 6. The medical catheter according to claim 5, which is a gastrostomy catheter, jejunostomy catheter, esophageal fistula catheter, cecal fistula catheter, rectal fistula catheter, nephrostomy catheter, tracheostomy catheter, or drainage catheter.

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