This invention relates generally to medical devices and more particularly to devices for sealing percutaneously formed punctures or incisions.
As will be appreciated by those skilled in the art various surgical procedures are now being carried out intravascularly or intralumenally. For example, in the treatment of vascular disease, such as atherosclerosis, it is a common practice to invade the artery to insert an instrument, e.g. a balloon or other type of catheter to carry out the procedure within the artery. Such procedures usually involve the percutaneous puncture of the artery so that an introducer sheath can be inserted into the artery and thereafter the instrument, e.g. catheter, itself can be inserted through the sheath to the operative position within the artery. Such procedures unavoidably present the problem of stopping the bleeding at the percutaneous puncture after the procedure has been completed and after the instrument (and any introducer sheaths used therewith) have been removed. At present such bleeding is stopped by the application of direct digital pressure over the puncture site by a trained physician or other suitably trained medical personnel. Such direct pressure has to be applied for a sufficiently long time for hemostasis to occur so that the opening is effectively closed against further bleeding. In the case of punctures into femoral or superficial femoral arteries the pressure may have to be applied for as long as forty-five minutes for hemostasis to occur. Not only is this direct digital pressure application procedure wasteful of time by highly skilled medical professionals, the procedure results in a substantial reduction, if not virtual arrest, of the flow of blood through the vessel. Since thrombosis is one of the major calamities that can occur in the immediate post operative period, any reduction in blood flow, such as caused by the application of digital pressure, is undesirable.
Applicator devices have been disclosed in the patent literature for inserting an absorbent plug or member into the vagina. Such devices basically comprises a tubular element adapted to be inserted into the vagina and having a plug of absorbent material located therein. The device also includes a plunger to push the plug out of the tubular element into the vagina. The plug also includes a thread or string attached to it to enable the plug to be retrieved from the vagina. Examples of such devices are shown in United States Patents Nos. 1,191,736 (Roberson) and 1,794,221 (Washburn et al).
While such devices are suitable for their intended purposes, there is no suggestion of their use, nor are they suitable for insertion into an opening in the wall of a blood vessel or other bodily lumen or duct to seal that opening.
The patent literature also includes devices for closing an opening in a blood vessel using sutures, see United States Patent No. 4,587,969 (Gillis). Other means and techniques for closing a wound are disclosed in United States Patent No. 4,606,337 (Zimmermann et al).
SU-A- 782 814 discloses a closure device for heart tissue according to the preamble of Claim 1 below.
None of the prior art teaches the use of simple means for effecting the closure of an opening, e.g. puncture, in the wall of a blood vessel, duct or lumen, by plugging the opening and without requiring sutures or the application of digital pressure.
A need also exists for devices and methods of sealing percutaneously formed punctures or incisions in other body tissues such as in the gall bladder, the liver, the heart, the lung, etc.
Accordingly, it is a general object of the instant invention to provide a device which overcomes the disadvantages of the prior art.
It is a further object of the invention to provide a device that is effective for closing off a puncture or other opening in a blood vessel, duct or lumen without the need for the application of digital pressure thereto and without resulting in any substantial reduction of blood flow through the vessel.
It is still a further object of the instant invention to provide an instrument which is simple in construction and whose method of use entails the ready insertion into a blood vessel, duct or lumen to position a closure therein for hemostatically sealing the puncture and without substantially blocking the flow of fluid through the vessel, duct or lumen.
It is yet a further object of the invention to provide a device for sealing percutaneously formed punctures or incisions in tissue separating two portions of the body of a living being from the flow of a body fluid therebetween.
These and other objects of the instant invention are achieved by providing a device for sealing a puncture or incision formed percutaneously in tissue separating two internal portions of a living being, such as punctures or incisions in blood vessels, ducts or lumens, gall bladders, livers, hearts, etc. Accordingly, the invention provides a closure device for sealing a puncture or incision formed percutaneously in tissue separating two internal portions of a living being, the puncture or incision having an opening and a puncture tract extending through the skin and underlying tissue, the closure comprising a holding portion being adapted to engage portions of the tissue adjacent the puncture or incision, a sealing portion for disposition within the puncture tract and disposed behind the holding portion, and retraction means in the form of a filament for retracting the closure to a position where the holding portion engages the tissue on that side of the puncture remote from the user of the device, characterised in that the holding portion is constructed like a toggle whereby it is orientable for insertion through the percutaneous puncture tract into a first condition in which it lies parallel to the sealing portion and into a second condition in which it extends transversely to its first condition to engage the tissue adjacent the puncture contiguous with the opening, and the sealing portion is formed of material which expands automatically in response to the ambient surroundings inside the being.
The invention is further described by way of example only with reference to the accompanying drawings in which:
- Figure 1 is a side elevational view in section of a device of the invention;
- Figure 2 is a sectional view taken along line 7-7 of Figure 1;
- Figure 3 is a side elevational view of the embodiment of the device shown in Figure 1 during the expulsion of its puncture sealing closure into an artery;
- Figure 4 is a side elevational view similar to that of Figure 3 but showing the puncture sealing device in place within the puncture in the artery;
- Figure 5 is a sectional view taken along line 10-10 of Figure 4;
- Figure 6 is a sectional view through the body of the being showing the sealing of a percutaneous incision or puncture in the gall bladder and liver; and
- Figure 7 is a sectional view through the body of the being showing the sealing of a wound in the lung and heart.
There is shown generally at 20 in Figure 1 an instrument for effecting the closure of a puncture or other opening in a blood vessel, duct or lumen in a living being. The device 20 thus has particular utility when used in connection with intravascular procedures, such as angiographic dye injection, balloon angioplasty and other types of recanalization of atherosclerotic arteris, in-situ valvulectomy, etc. However, it should be appreciated that the device 20 can be used to hemostatically close a puncture or other opening in other types of duct or lumens within the body. Thus, it is to be understood that while the description of the invention as contained herein is directed to closing off percutaneous punctures in arteries, the device 20 has much more wide-spread application.
Before describing the instrument 20 itself a brief description of a typical, conventional, intravascular surgical procedure, e.g. catheter instrumentation of an artery, utilizing a percutaneous incision or puncture will be given to best appreciate the features of the device 20. In such a procedure a cannula of an instrument, such as an angiographic needle (not shown), is inserted percutaneously through the skin into the artery, such as the femoral artery 24 at the situs for the instrument's insertion. The needle cannula is held in place and the flexible end of a mini-guide wire (not shown) is then passed through the cannula into the artery to the desired depth (i.e., longitudinal position therealong). Once the mini-guide wire is in place the needle cannula is removed leaving the guide wire in place. A conventional introducer sheath 26 and an arterial dilator (not shown) are then passed over the guide wire through the puncture 28 and into the artery 24. The guide wire and then the dilator are removed leaving the sheath 26 in place. The catheter (not shown) or other intravascular instrument (not shown) is then inserted through introducer sheath 26 and threaded down the artery to the desired intravascular location, e.g. the situs of an atherosclerotic occlusion. Once the intravascular procedure (e.g., angioplasty) has been completed the catheter is removed. Thereafter the sheath is removed and the surgeon or other trained person applies digital pressure to the percutaneous puncture until hemastasis has occurred.
The device 20 effects the hemostatic closure of a percutaneous or other type of puncture, incision or opening in an artery or other body duct or lumen without necessitating the application of pressure thereto. Thus, once the catheter or other intravascular instrument has been removed but with the sheath 26 left in place, the device 20 of the subject invention is inserted through the sheath 26 into the artery 24 and operated to expel a closure member (to be described later) into the artery. The closure is arranged to be drawn back into the puncture 28 to seal it. The sheath is removed and the closure left in place. Due to its construction the closure is ultimately absorbed by the surrounding tissue.
In Figure 1 there is shown an embodiment of the closure utilized in a device 20 for sealing a percutaneous puncture or incision. The closure is designated by the reference numeral 100 and basically comprises three components, namely, a holding member 106, a suture or filament 104, and a sealing member 102. The holding member 106 is an elongated body constructed like a toggle and is preferably formed of a biodegradable, thermoplastic polymer, such as polyglactide. This material will degrade within the body within a short period of time, e.g. approximately 45 days. The toggle is molded onto the distal end of the filament 104 which is slightly bulbous to hold the toggle in place thereon. The filament is also preferably formed of polyglactide (e.g. it will degrade within the body in approximately 90 days). The filament is quite flexible so that the toggle can pivot to various orientations with respect to it. Disposed promixally behind the toggle 106 is the sealing member 102. That member basically comprises a cylindrical plug preferably formed of a compressed foam which is highly absorbent and which, when disposed within the body, swells in excess of its compressed diameter, e.g. swells to twice its compressed diameter. The plug is preferably formed of gelatin or collagen foam so that it also degrades quickly within the body, e.g. in approximately ten days or so. One particular effective material is a porous homeostatic absorbable gelatin sold by Johnson & Johnson, Inc. under the name Gelfoam. The filament extends fully through the plug.
The closure 100 is located within the device 20 adjacent the outlet 34 of the tubular portion 32 thereof. In particular, the foam plug or sealing portion 102 is located immediately adjacent the free end 40 of the plunger 38, with the toggle or holding portion 106 located at the distal end of the portion 102. The toggle is oriented so that its longitudinal axis is parallel to the longitudinal axis of the device 20. When so disposed the toggle compresses a portion of the distal end of the plug portion. The filament 104 extends backward from the toggle portion through the plug portion and through a central passageway in the plunger 38 to a point outside the device 20. The closure is introduced into the artery, or into a puncture or incision in any body tissue, such as the liver (Figure 6), gall bladder (Figure 6), lung (Figure 7), heart (Figure 7), etc., until the insertion device's outlet is in the desired position.
In the case of the sealing of an artery, the outlet 34 of the device is positioned so that it is within the artery (see Figure 3) and just slightly beyond the introducer sleeve 26. This placement is controlled by stops (not shown) on the device 20. The plunger 38 is then operated as described earlier to expel the closure 100. Once the closure is expelled, the device 20 is held in this position for a short period of time, e.g. 15 to 60 seconds, to allow the foam at the tip of the closure, i.e. the distal end of portion 102, to swell. This action effectively tips the toggle. The insertion device 20 is then removed and the closure's filament 104 then retracted, that is, pulled in the direction of arrow 108 in Figure 4. This action pulls the closure's plug portion 102 back through the puncture or incision 28 in the artery wall until its toggle portion 106 engages the inner surface of the arterial wall to stop further retraction. As the toggle comes into engagement with the arterial wall, it effects the compression of the distal end portion 110 of the plug portion 102. Moreover, the proximal end portion of the plug 102 extends into the puncture or incision in the subcutaneous tissue 22A to a point closely adjacent the skin 22. These actions effectively seal the puncture or incision from the passage of blood therethrough.
It should be noted that the engagement of the toggle with the inner surface of the artery wall can either be direct or indirect, the latter being through the interposed deformed distal end portion of the plug 102. In either event, the toggle serves to act as a stop precluding the closure 100 from being pulled out of sealing engagement with the puncture or incision 28.
In lieu of the use of the toggle/foam plug closure 100, one can utilize an alternative closure 200. The closure 200 basically comprises a preformed foam plug having an enlarged distal end portion 106 (see Figures 6 and 7) serving as the heretofore described holding member, a proximally located rod-like portion 102 (see Figures 6 and 7) serving as the heretofore described sealing member and a retraction filament 104 secured thereto. The closure 200 is preferably formed of a dense collagen foam with long collagen fibre reinforcement so that it has a high expansion ratio (wet-to-dry) and good mechanical wet strength.
The closure 200, like closure 100, is held within the tubular portion 32 of the insertion device 20 in a compressed state and with its holding portion 106 located immediately adjacent the outlet 34. For sealing punctures or incisions in arteries the device 20 is introduced into the artery in the manner as described heretofore. The pusher member 38 then pushes the foam closure out of the outlet, whereupon the holding portion 106 swells upon contact with the blood in the artery. The insertion device 20 is then removed so that the closure 200, now swollen, hangs up at the puncture or incision 28 within the arterial wall, i.e. the enlarged holding member portion 106 engages the inner surface of the arterial wall and the sealing portion 102 extends fully through the puncture or incision into the subcutaneous tissue 22A. The retraction of the filament fully seats the closure in place so that the sealing portion extends fully through the puncture or incision in the artery wall and with its proximal end located within the subcutaneous tissue closely adjacent the skin.
The advantage of the preformed foam closure as just described over the toggle/plug closure 100 is that it is considerably simpler in construction, assembly and cost.
As mentioned earlier, it is frequently desirable to be able to seal a puncture or incision in body organs or tissue other than blood vessels. For example, in cases where percuteneous transhepatic punctures are made into the gall bladder for purposes of introducing chemicals or mechanical instruments, there exists a very real risk of bile leakage into the peritoneum via the liver puncture site, thereby resulting in a dangerous possibility of peritonitis. The closures 100 and 200, as described heretofore, can be utilized to seal such percutaneous punctures or incisions to eliminate the risks of bile leakage. For example, as shown in Figure 6 an insertion device 20 with a closure 100 or 200 disposed therein is introduced through the puncture or incision 28 in the right lobe of the liver and through the puncture or incision in the gall bladder so that the device's outlet 34 extends just beyond its introducer sheath 26. The plunger 38 is then pressed to eject the closure so that the holding portion 106 thereof is located within the gall bladder and in engagement with the inner surface thereof, while the sealing portion 102 extends through the puncture or incision in the gall bladder and into the puncture or incision in the liver. Alternatively, the closure 100/200 may be left in the incision or puncture 28 in the liver alone, if that makes best sense from a medical/surgical standpoint.
The subject invention is also useful for effecting the sealing of percutaneous incisions or punctures in the heart, such as could result from a wound. In this connection, as shown in Figure 7, a wound penetrating the left lung and left ventricle may be sealed by introducing the insertion device 20 with a closure 100/200 therein through the wound, through the puncture in the lung, and into the puncture in the left ventricle. The closure 100/200 is then ejected so that its holding portion 106 is located within the left ventricle, while its sealing portion 102 extends through the puncture in the left ventricle wall and through the puncture in the left lung. In such applications, it is preferred that the closure member 100/200 be configured so that its sealing portion 102 is of a substantial length to extend not only through the puncture in the left ventricle, but also the puncture in the lung and through the wound in the skin to some exterior point closely adjacent the skin. Thus, the closure 100/200 acts as a tamponade.
In order to accelerate hemostasis the natural forming the closures of this invention may include conventional clotting agents, such as tissue throboplastin.
As should be appreciated by those skilled in the art, the device of this invention can be used to seal a puncture in any body tissue or organ to prevent the flow of fluid through that puncture or incision from one body portion to another.
Without further elaboration the foregoing will so fully illustrate my invention that others may, by applying current or future knowledge, adopt the same for use under various conditions of service.