US20020095164A1 - Device and method for suturing tissue - Google Patents

Abstract

Systems for suturing a tissue layer having two sides with a suture by releasably retaining at least a portion of the suture in a stationary position on one side of the tissue layer. The portion of the suture is retrieved through the tissue layer from the opposite side whereby the suture is drawn from one side to the opposite side. Systems for suturing the wall of a tubular graft having two sides is also provided using a suture by releasably retaining at least a portion of the suture on one side of the wall. The portion of the length of suture is retrieved through the wall of the graft to the opposite side of the wall.

Description

RELATED APPLICATIONS
• The present invention repeats a substantial portion of application Ser. No. 07/989,611, filed Dec. 10, 1992, now issued as U.S. Pat. No. 5,417,699, which is relied on for priority by continuation-in part application Ser. No. 08/252,124, filed Jun. 1, 1994, now issued as U.S. Pat. No. 5,613,974, continuation-in-part and divisional application Ser. No. 08/259,410, filed Jun. 14, 1994, and continuation-in-part application Ser. No. 08/824,031 filed Mar. 26, 1997. The present application claims disclosure presented in the prior applications, as well as, adds and claims additional disclosure not presented in the prior applications. Since the present application names an inventor named in the prior application, it may constitute a continuation-in-part of the prior applications. These prior applications are incorporated fully herein by reference.[0001]
FIELD OF THE INVENTION
• The present invention relates generally to devices and methods for the suturing of tissue in various applications such as closure of arterial and venous puncture sites, suturing a graft anastomosis to an aperture in a vessel wall or other types of tissue, and the like. More particularly, the inventive devices and methods provide for suturing the tissue of a vessel even though the vessel may be under physiological flow and while preferably maintaining hemostasis.[0002]
BACKGROUND OF THE INVENTION
• A number of diagnostic and interventional vascular procedures are now performed transluminally, where a catheter is introduced to the vascular system at a convenient access location and guided through the vascular system to a target location using established techniques. Such procedures require vascular access which is usually established using the well known Seldinger technique, as described, for example, in William Grossman's “Cardiac Catheterization and Angiography,” 3rd Ed., Lea and Febiger, Philadelphia, 1986, incorporated herein by reference.[0003]
• When vascular access is no longer required, the introducer sheath must be removed and bleeding at the puncture site stopped. One common approach to attempt providing hemostasis (the cessation of bleeding) is to apply external force near and upstream from the puncture site, typically by manual or “digital” compression. This approach suffers from a number of disadvantages. It is time-consuming, frequently requiring one-half hour or more of compression before hemostasis is assured. This procedure is uncomfortable for the patient and frequently requires administering analgesics to be tolerable. Moreover, the application of excessive pressure can at times totally occlude the underlying blood vessel, resulting in ischemia and/or thrombosis. Following manual compression the patient is required to remain recumbent for at least six and at times as long as eighteen hours under close observation to assure continued hemostasis. During this time renewed bleeding may occur resulting in bleeding through the tract, hematoma and/or pseudoaneurism formation as well as arteriovenous fistula formation. These complications may require blood transfusion and/or surgical intervention. The incidence of these complications increases when the sheath size is increased and when the patient is anti-coagulated. It is clear that the standard technique for arterial closure can be risky, and is expensive and onerous to the patient. While the risk of such conditions can be reduced by using highly trained individuals, such use is both expensive and inefficient.[0004]
• To overcome the problems associated with manual compression, the use of bioabsorbable fasteners to stop bleeding has been proposed by several groups. Generally, these approaches rely on the placement of a thrombogenic and bioabsorbable material, such as collagen, at the superficial arterial wall over the puncture site. While potentially effective, this approach suffers from a number of problems. It can be difficult to properly locate the interface of the overlying tissue and the adventitial surface of the blood vessel, and locating the fastener too far from that surface can result in failure to provide hemostasis and subsequent hematoma and/or pseudo aneurism formation. Conversely, if the fastener intrudes into the arterial lumen, intravascular clots and/or collagen pieces with thrombus attached can form and embolize downstream causing vascular occlusion. Also, thrombus formation on the surface of a fastener protruding into the lumen can cause a stenosis which can obstruct normal blood flow. Other possible complications include infection as well as adverse reactions to the collagen implant.[0005]
• Catheters are also used to treat heart disease which is a major medical ailment wherein arteries become narrowed or blocked with a build-up of atherosclerotic plaque or clot which reduces flow to tissues downstream or “distal” to the blockage. When this flow reduction becomes significant, a patient's quality of life may be significantly reduced. In fact, heart disease patients often die when critical arteries, such as the coronary arteries, become significantly blocked.[0006]
• However, technology has been developed to open some blocked arteries in the treatment of heart disease. For example, balloon angioplasty has become a well accepted treatment wherein a balloon is inflated within the narrowed vessel to stretch or otherwise deform the blockage into a larger lumen. Alternatively, the blockage can even be removed, such as in a procedure known as atherectomy. In general, these treatments use percutaneous catheters which are inserted into the patients' vessels at a peripheral artery or vein puncture site and guided to the internal blockage site via x-ray visualization. The blockage is then treated remotely by use of hydraulic pressure in the case of balloon angioplasty, or by other actuating means to cause remote cutting or ablation of the blockage in the case of atherectomy.[0007]
CORONARY ARTERY BYPASS CRAFT SURGERY (“CABG”)
• In the alternative to using catheters to treat heart disease, or when such catheterizations are contraindicated, some blocked vessels can be treated with coronary artery bypass graft surgery (“CABG”). In conventional CABG techniques, a tubular graft is affixed to a port or aperture in an artery wall distally of the blockage. When the opposite end of the tube is in fluid communication with a pressurized arterial blood supply, such as the aorta, the tubular graft provides a conduit for flow into the vessel lumen distally of the blockage.[0008]
• Conventional CABG surgery is generally initiated by directly exposing the heart to the surgeon. This is accomplished by opening the patient's chest using known sternotomy and retraction techniques that cut the sternum and spread the rib cage open. Then, one or both lungs are usually deflated and the patient is connected to a respiratory assist machine.[0009]
• Once the heart is exposed, the patient is connected to a coronary bypass machine so that the blood supply circumvents the heart. In this way, the heart is depressurized so that apertures can be cut into the walls of the vessels for surgical graft attachment. The right atrium (or vena cava) and the aorta each is intubated with cannulas which are connected to an artificial pump and oxygenator. Once these major vessels are cannulated, cardioplegia is delivered to slow or stop the beating motion of the heart. The aorta is then clamped proximally of the aortic bypass cannula, thereby isolating the proximal aortic root from the blood that is being circulated by the bypass machine.[0010]
• After the heart is isolated from blood pressure, conventional bypass grafting is performed. The required grafts are implanted to feed the coronary arteries distal to the blockage, the clamp is removed from the aorta, the lungs are restored, and the patient is then taken off of the bypass pump.[0011]
• In one type of CABG method, the bypass grafting is achieved between the aorta and one of the three major coronary arteries or their sub-branches, the left anterior descending artery (LAD), the circumflex artery (CIRC), or the right coronary artery (RCA). In such a case, a saphenous vein is usually taken from the patient's leg and is transplanted as a “homograft” to connect these vessels in the same patient's chest. Artificial grafts have also been disclosed as providing potential utility for this purpose and are herein collectively included in the general discussion of “saphenous veins” as used in CABG procedures.[0012]
• An alternative CABG method uses the internal mammary artery (IMA) alone or in conjunction with the saphenous vein graft. The IMA is severed at a chosen location and is then connected to an aperture, in a coronary artery.[0013]
• In either case of using saphenous vein homografts or artificial grafts in CABG surgery, the proximal end of the graft is generally sutured or otherwise is affixed circumferentially to the tissue surrounding an aperture that is punched into the wall of the aorta. In this arrangement, the lumen of the graft communicates with the vessel through the aperture, wherein ideally the aperture approximates the inner diameter of the graft lumen. The opposite, distal end of the graft is sutured to an aperture formed in the wall of the coronary vessel distal to the blockage.[0014]
• The fluid connections between a graft and a vessel are herein referred to as “anastomoses.” In the instance of CABG, “proximal anastomoses” and “distal anastomoses” are terms used when referring to grafting to the aorta and the coronary artery, respectively. In most CABG procedures using saphenous vein grafts, the distal anastomosis is performed first, followed by the proximal anastomosis.[0015]
• For the CABG method using the IMA, only one distal anastomosis is formed distal to the arterial blockage. A proximal anastomosis to the aorta is not required as it is in a saphenous vein graft procedure because the IMA's natural arterial blood flow feeds the heart.[0016]
• In conventional CABG surgery methods such as those just summarized, the timing and technique of the anastomosis procedures are critical factors to procedural success. In fact, it is believed that three critical determinants which affect outcomes of CABG surgery are: (1) time the patient spends on bypass, (2) time the patient spends with a clamped aorta, and (3) the quality of the anastomoses. It is generally believed that a CABG patient's operative and peri-operative morbidity are directly related to how long the patient must be on heart bypass. In fact, it is generally understood that the risk of patient morbidity is believed to rise significantly after a threshold time of one hour on bypass. Perhaps the most prevalent complication arising from prolonged cardiac bypass is the high risk of distal thrombus created by the artificial plumbing. For example, such thrombi can embolize into the neurovasculature and potentially can cause a stroke. In analyzing the timing of individual CABG steps against the backdrop of a patient's critical time on bypass, the time spent anastomosing the grafts to vessels emerges as a controlling factor. The average time for suturing one anastomosis is approximately 7-10 minutes. Furthermore, it is believed that an average CABG procedure involves approximately five anastomoses: two saphenous vein grafts, each with a proximal and a distal anastomosis, and one internal mammary artery having only one distal anastomosis. Therefore, the average time for graft suturing ranges from 35 minutes to 50 minutes—in any case a significant portion of the 60 minute critical threshold to patient morbidity. Closely related to the time spent on bypass is a second CABG success factor related to the extent and time of aortic cross-clamping. It is believed that the inherent crushing force from a cross-clamp across the bridge of the muscular aortic arch may be associated with a high degree of tissue trauma and structural damage. Additionally, hemostasis formed at or adjacent to the cross clamp, perhaps in conjunction with the tissue trauma of clamping, may also be a source of unwanted thrombogenesis.[0017]
• In addition to the timing of anastomosing grafts and extent and duration of aortic cross-clamping, the quality of interface between the graft and vessel is also believed to be an indicator of procedural success. The accuracy, trauma, and repeatability of suturing, as well as the three-dimensional interface formed between the conduits at the anastomosis site, are significant variables in conventional manual surgical techniques. These variables are believed to significantly affect the short or long-term success of conventional CABG anastomosis procedures.[0018]
LIMITATIONS OF CONVENTIONAL CABG DEVICES & METHODS
• Both of the critical CABG success indicators summarized above—time on cardiac bypass and quality of anastomosis suturing—are directly affected by inherent limitations in the devices used in conventional CABG procedures. It is believed that improvements to these devices and related methods of use may provide for more rapid and reliable vessel-graft anastomosing. For example, conventional “surgical punches” are devices that cut or “punch” a plug in vessel wall tissue to form an aperture in the wall. In a CABG procedure, the tissue surrounding a punched-out aperture provides the substrate upon which a graft may be sutured to form an anastomosis. One procedural limitation in using conventional surgical punches is that hemostasis can not be maintained at a vessel wall after a plug of tissue is punched out and removed. Therefore, an aperture in an aortic wall during a saphenous vein graft procedure can only be made when that portion of the aorta is cross-clamped, bypassed, and depressurized. Otherwise, the high blood pressure and flow in the aorta would cause significant bleeding during the period from punching the aperture to forming the anastomosis. Because of this limitation in conventional surgical punches, the[0019]threshold 60 minute coronary bypass clock begins running before punching the aorta.
• The prior art fails to disclose or fulfill the need which exists in the field of medical devices and methods for: suturing tissue by proximally drawing sutures through a tissue layer in the proximity of an aperture; suturing tissue by reversibly advancing needles from one side of a tissue layer to retrieve one or more sutures on the opposite side of the tissue layer; a medical device assembly and method that automatically and repeatably places suture thread through vessel wall tissue surrounding an aperture in the vessel wall in a suture pattern that is useful for anastomosing a tubular graft to the aperture; and a medical device assembly that deploys a suture with one end extending through the tissue that surrounds a aperture in a vessel wall and the opposite suture end extending radially through a tubular graft wall adjacent an open end of the graft, such that a vessel anastomosis may be rapidly and repeatably performed in a CABG procedure even while the vessel is under physiological flow.[0020]
SUMMARY OF THE INVENTION
• The present invention provides a device for suturing a tissue layer having two sides which includes a suture and means for releasably retaining at least a portion of the suture in a stationary position on one side of the tissue layer. The device also includes means for retrieving the portion of the suture through the tissue layer from the opposite side whereby the suture is drawn from one side to the opposite side.[0021]
• A device is also provided for suturing at least one tissue layer wherein each tissue layer has two sides. The device includes a fastener having at least a first and second portion. The first and second portions have means for securing the first and second portions together. The first and second portions have a base at one end to prevent the respective portion from passing completely through the tissue layer. The device includes means for releasably retaining the first portion in a stationary position on one side of the tissue layer and means for driving the second portion through the tissue layer from the opposite side and securely engaging the securing means of the first and second portions whereby the base of the first portion abuts one side of the tissue layer and the base of the second portion abuts the opposite side of the tissue layer.[0022]
• The present invention provides a device for suturing tissue in the proximity of an aperture in a tissue layer which include a shaft having a proximal and distal end and a foot attached to the distal end of the shaft. The foot is adapted for advancing through the aperture. At least one needle is carried above the distal end of the shaft. At least a portion of a suture is releasably retained on the foot in the proximity of the aperture. The device also includes means for reversibly advancing the needle through the tissue to retrieve and draw at least a portion of the suture through the tissue. The advancing means is integrally formed with the shaft.[0023]
• A device for suturing the wall of a tubular graft having two sides is also provided by the present invention. The device includes a suture, means for releasably retaining at least a portion of the suture on one side of the wall, and means for retrieving the portion of the length of suture through the wall of the graft to the opposite side of the wall.[0024]
• A graft anastomosis assembly is also provided for suturing a tubular graft about an aperture in a tissue wall. The assembly includes a suture, a tissue suturing and graft suturing devices. The tissue suturing device includes means for releasably retaining at least a portion of the suture in a stationary position on one side of the tissue layer and means for retrieving the portion of the suture through the tissue layer from the opposite side whereby the suture is drawn from one side to the opposite side. The graft suturing device includes means for releasably retaining at least a portion of the suture on one side of the graft and means for retrieving the portion of the length of suture through the wall of the graft to the opposite side of the graft.[0025]
• A graft assembly for anastomosing a tubular graft and vessel is also disclosed herein. The graft having a graft wall that defines a graft lumen with an open end. The graft wall has a plurality of ports spaced in a predetermined pattern near the open end. The assembly includes a plurality of sutures in the predetermined pattern. Each suture has a first suture portion extending through one of the plurality of ports in the graft wall. Each suture has a second suture portion extending along at least a portion of the graft lumen.[0026]
• A method for suturing a tissue layer having two sides is also provided by the present invention. The steps of the method include: releasably retaining at least a portion of a suture in a stationary position on one side of the tissue layer; and retrieving at least a portion of the suture through the tissue layer to the opposite side.[0027]
• Another method of the present invention sutures tissue in the proximity of an aperture in a tissue wall. The steps of the method include: forming a port from the proximal side of the tissue wall; passing at least a portion of a suture from the distal side of the tissue wall proximally through the port in the tissue wall in the proximity of the aperture; and forming a loop with the remaining portion of the suture to secure the suture.[0028]
• A further method for suturing an aperture in a vessel wall is provided herein. The steps of the method include: reversibly advancing a plurality of needles through the vessel wall to form ports in the proximity of the aperture; passing at least a portion of a suture proximally through the ports in the vessel wall disposed on opposite sides of the aperture from the interior of the vessel with the remaining portion of the suture passing out of the vessel; and securing the ends of the suture to close the aperture.[0029]
• Another method of the present invention sutures the wall of a tubular graft to define a graft lumen and an open graft end. The steps of the method include: releasably retaining at least a portion of a suture within the graft lumen and adjacent the graft open end; puncturing the tubular graft wall with the plurality of needles to form a plurality of ports in a circumferential pattern; and drawing the portion of suture outwardly from the graft lumen and through each of the plurality of ports and external of the graft wall.[0030]
BRIEF DESCRIPTION OF THE DRAWINGS
• In the drawings, which comprise a portion of this disclosure but are not to scale:[0031]
• FIG. 1 is a perspective view of an embodiment of a suturing device constructed in accordance with the principles of the present invention;[0032]
• FIG. 2A is a detail view of the distal end of the guide body of the suturing device of FIG. 1, shown with the needles retracted fully within the guide body;[0033]
• FIG. 2B is a view similar to FIG. 2A, except that the needles have been partially drawn back into the guide body;[0034]
• FIG. 3 is a cross-sectional view of the device of FIGS. 2A and 2B, taken along line[0035]3-3 of FIG. 2B;
• FIGS.[0036]4-7 illustrate the method of the present invention using the suturing device of FIG. 1;
• FIG. 8 illustrates the X-pattern of the tied suture applied by the suturing device;[0037]
• FIG. 9 is a perspective view of a tissue suturing device of the present invention inserted through a tissue layer;[0038]
• FIG. 10 is an isolated perspective view of the needle carrier and foot of the tissue suturing device in FIG. 9;[0039]
• FIG. 11 is a top view of the foot of the tissue suturing device in FIG. 9;[0040]
• FIG. 12 is a side view of the foot and shaft of the tissue suturing device in FIG. 9 inserted through a tissue layer;[0041]
• FIG. 13 is an isolated perspective view of an alternate embodiment of the shaft and foot of the tissue suturing device;[0042]
• FIG. 14A is a cross-sectional view of the foot along the[0043]lines14A-D in FIG. 13 illustrating an example of one cross-sectional shape for the foot;
• FIG. 14B is a cross-sectional view of the foot along the[0044]lines14A-D in FIG. 13 illustrating another example of one cross-sectional shape for the foot;
• FIG. 14C is a cross-sectional view of the foot along the[0045]lines14A-D in FIG. 13 illustrating another example of one cross-sectional shape for the foot;
• FIG. 14D is a cross-sectional view of the foot along the[0046]lines14A-D in FIG. 13 illustrating another example of one cross-sectional shape for the foot;
• FIG. 15 is a side view isolating the engagement of a needle and suture of the tissue suturing device illustrated in FIG. 9;[0047]
• FIG. 16 is a cross-sectional view of the needle and suture in FIG. 15 along the lines[0048]16-16 with the needle and suture in an engaged position;
• FIG. 17 is a top view of the needle and suture in FIG. 15 along the lines[0049]17-17 with the needle and suture in an engaged position;
• FIG. 18A is a side view of the suture end illustrating an example of a ball shape for the suture end;[0050]
• FIG. 18B is a side view of the suture end illustrating an example of a solid cuff shape for the suture end;[0051]
• FIG. 18C is a side view of the suture end illustrating an example of a ring shape for the suture end;[0052]
• FIG. 18D is a side view of the suture end illustrating an example of a serrated cuff shape having slits for the suture end;[0053]
• FIG. 18E is a side view of the suture end illustrating an example of a hook shape for the suture end;[0054]
• FIG. 19A is a side view of a serrated needle tip illustrating an example of a retrieving device of the present invention;[0055]
• FIG. 19B is a side view of a needle tip and tubing assembly illustrating an example of another retrieving device of the present invention;[0056]
• FIG. 19C is a side view of a needle tip with an indentation illustrating an example of another retrieving device of the present invention;[0057]
• FIG. 19D is a side view of a hook-shaped needle tip illustrating an example of another retrieving device of the present invention;[0058]
• FIG. 19E is a side view of a needle tip and tubing assembly illustrating an example of another retrieving device of the present invention;[0059]
• FIG. 20 is a cross-sectional view of two tissue layers being joined by the present invention using a multi-piece fastener in a tissue suturing device;[0060]
• FIG. 21 is a cross-sectional view of a tissue layer and suture being joined by the present invention using a multi-piece fastener in a tissue suturing device;[0061]
• FIG. 22 is a cross-sectional view of a suture cuff attached to two lengths of a suture for use with the present invention;[0062]
• FIG. 23 is a top view of an isolated section of tissue layer having a suture pattern therein formed by a continuous suture used with the present invention;[0063]
• FIG. 24 is a top view of an isolated section of tissue layer having a purse-string suture pattern therein formed by a single suture used with the present invention;[0064]
• FIG. 25 is a perspective view of another embodiment of a tissue suturing device of the present invention;[0065]
• FIG. 26 is an isolated top view of the foot of the tissue suturing device of FIG. 25;[0066]
• FIG. 27 is a cross-sectional view of an alternate button embodiment for retrieving a suture loop in the foot of the present invention;[0067]
• FIG. 28 is a top view of a tear shaped button embodiment for retrieving a suture loop in the foot of the present invention;[0068]
• FIG. 29 is a cross-sectional view of the button embodiment in FIG. 27 for retrieving a suture loop in the foot of the present invention;[0069]
• FIG. 30 is a diagrammatic side view of another embodiment of a tissue suturing device of the present invention utilizing a needle carrier and needle retrieval arrangement positioned at an obtuse angle to the longitudinal axis of the device;[0070]
• FIG. 31 is a perspective view of an anastomoses assembly of the present invention;[0071]
• FIG. 32 is an isolated perspective view of the graft suturing device from the assembly in FIG. 31;[0072]
• FIG. 33 is another embodiment of a graft suturing device of the present invention which retrieves sutures inwardly through a graft wall;[0073]
• FIG. 34 is another embodiment of a graft suturing device of the present invention which positions the graft through the needle carrier;[0074]
• FIG. 35 is a perspective view of another embodiment of the graft suturing device of the present invention which retrieves the sutures in an axial direction;[0075]
• FIG. 36 is a cross sectional view of a needle driving device for retrieving the sutures illustrated in FIG. 35;[0076]
• FIG. 37 is a side view of an alternate arrangement for driving the needles as illustrated in FIG. 36;[0077]
• Fig,[0078]38 is a cross-sectional view of a vessel illustrating the insertion of a foot of the inventive tissue suturing device from a remote access site;
• FIG. 39 is a cross-sectional view of a vessel illustrating the insertion of a foot of the inventive tissue suturing device from a remote access site; and[0079]
• FIG. 40 is a cross-sectional view of a vessel illustrating the insertion of another embodiment of a foot of the inventive tissue suturing device from a remote access site.[0080]
DETAILED DESCRIPTION OF THE INVENTION
• As used herein, the term “distal” is generally defined as in the direction of the patient, or away from a user of a device, or in a downstream direction relative to a forward flow of blood. In the context of a medical device intervention with or through a vessel wall, “distal” herein refers to the interior or the lumen side of the vessel wall.[0081]
• Conversely, “proximal” generally means away from the patient, or toward the user, or in an upstream direction relative to a forward flow of blood. In the context of a medical device intervention with or through a vessel wall, “proximal” herein refers to the exterior or outer side of the vessel wall.[0082]
• Additionally, “oblong” is herein intended to mean oval, elliptical, or otherwise having a generally rounded shape that is not perfectly circular. In particular, the term describes the shape of a tubular graft end cut at an acute angle relative to the plane perpendicular to the tissue walls defining the graft.[0083]
• The term “hemostasis” is herein used to mean the arrest of bleeding or substantially blocking flow of blood outwardly from a vessel lumen while the vessel lumen is pressurized or sustaining physiological blood flow. This amount of blockage or occlusion to flow is further defined such that the blood loss which is experienced is less than an amount which would affect procedural methods or outcomes according to a physician user of a device of ordinary skill in the art. In other words, “hemostasis” is not intended to mean only “total hemostasis” such that there is a total lack of blood loss. Rather, the term is used to also mean “procedural hemostasis” as a relative term in its use among physicians of ordinary skill.[0084]
• Similarly, “occlusion,” “occlude,” “blockage,” “block . . . plugging”, “block,” or variations thereof are all terms which are herein intended to have a procedurally relevant definition in the context of their use. For instance, an aperture is “occluded” although there is some measurable flow therethrough, but that flow is so low such that the intended procedural benefit of occlusion is at least partially achieved. Certainly, such terms also properly include within their scope a “total effect” definition, as well.[0085]
• The term “perfusion” is herein used to mean the flow of blood or other unit of perfusate (the fluid used for perfusion) per unit volume of tissue. Physiological perfusion refers to the amount of blood flow present when the body is functioning normally. For example, physiological perfusion usually prevents clinically significant ST elevations which is one of the most sensitive indicators of inadequate perfusion. Adequate perfusion refers to the amount of blood flow that avoids the clinical requirement of transfusing the patient or that is needed to prevent tissue necrosis distal to the aperture in the blood vessel.[0086]
• The term “suturing” is herein intended to include the process of joining two surfaces or edges together with a fastener so as to close an aperture, opening, or wound or join tissues. The fastener is usually a suture such as a thread of material (either polymeric or natural), gut, wire or the like. The term fastener as used herein also includes clamps, studs, hasps, catches, hooks, rivets, staples, snaps, stitches, VELCRO™, buttons, and other coupling members.[0087]
• Referring to FIGS.[0088]1-3, asuture applying device400 which is suitable for suturing and sealing of percutaneous vascular puncture site, particularly those made to the femoral artery in a patient's groin, will be described. It will be appreciated, however, that the device of the present invention can be readily adapted for use with punctures made to other hollow body organs and lumens, although it may be necessary to modify the dimensions and other particular aspects of the device to accommodate the different usage environment.
• The[0089]device400 comprises aguide body402 and aneedle shaft404. Theguide body402 includes aguide tip406 at its distal end, which guide tip includes a plurality ofguide channels408 which receive the proximal ends ofneedles410. An aligningarrow403 is mounted onhandle405 located at the proximal end of theguide body402. Amarker lumen bubble407 is located below the aligning arrow and serves to indicate when the distal end of the guide body has entered a blood vessel, as described in the embodiment below. Anindicator lumen411 which permits the flow of blood to themarker lumen bubble407 is illustrated in FIGS. 2A and 2B.
• The[0090]needles410 as illustrated comprise a sharpenedtip section412 and anelongate shank portion414, but may also be manufactured as an integral piece. Theshank portion414 will be sufficiently long so that the needles may be pushed from their butt end by asupport holster428 fixedly attached to theneedle shaft404 in order to advance the needles through the tissue to be sutured and fully through theguide body402 inserted together withsupport sheath440 in the associated tract so that no capture mechanism will be required.
• The[0091]guide body402 further includes a plurality ofneedle lumens420 which are axially aligned and spaced about the periphery of the guide body. As best seen in FIG. 2B, theneedles410 will enter the distal ends of thelumens420 as the needles are advanced proximally relative to the guide body.
• A[0092]flexible needle sheath426 will be attached to theguide tip406 ofguide body402. The central lumen of theneedle sheath426 receives asupport holster428 attached to the distal end of theneedle shaft404, as well as theneedles410. As with previous embodiments, the butts of theneedles410 are removably received within thesupport holster428. Thesheath426 will be sufficiently long to permit the needles to extend at least 5 cm beyond the distal end ofguide body402.
• Prior to use, the[0093]suture applying device400 will be in the configuration illustrated in FIGS. 1 and 2A. That is, theneedle shaft404 will be distally positioned within theguide body402 andneedle sheath426. In particular, the tips ofneedles412 will lie just at theguide tip406 so that they may be easily advanced through the arterial tissue surrounding the arteriotomy. That is, the tips of the needles will be generally retracted within theguide tip406. A length ofsuture422 is attached to theproximal tips412 of opposed pairs ofneedles410, with the connecting suture being stored inside lumens427 extending axially along the exterior of theneedle sheath426. As best observed in FIGS. 2A and 2B, thesuture422 extending between one pair of opposed needles is received in a first of theside lumens427, while the suture extending between the other pair of opposed needles is received in the second of the side lumens. While it would be possible to store thesuture422 in thelumens420 of the guide body402 (and thus eliminate the need for side lumens427), such storage is less preferred since it increases the risk that the suture will become entangled with theneedles410 as they are withdrawn proximally. The use ofside lumens427 greatly simplifies feeding of the suture as theneedles410 are withdrawn.
• After the[0094]guide tip406 has been passed through the puncture site to be sutured, the needles may then be drawn proximally forward through the tissue to be sutured by drawing proximally onhandle430 at the proximal end ofneedle shaft404. The method of the present invention will now be described in more detail with reference to FIGS.4-7.
• The situation following an interventional or other vascular procedure, where the attending physician is satisfied that the puncture site may be sealed, is illustrated in FIG. 4. A conventional introducer sheath is in place with a guidewire passing into the femoral artery. The conventional introducer sheath is withdrawn after assuring that an appropriate guidewire for the suturing process is in place. The device[0095]400 (including asupport sheath440 which initially covers the ports to the needle lumens420) will then be introduced over the guidewire, as illustrated in FIG. 4. Theneedles410 andsutures422 mostly encased byflexible needle sheath426, will be fully advanced into the femoral artery FA past the arterial puncturesite A. Handle441 onsupport sheath440 is then partially withdrawn proximally to expose the needle lumens420 (as shown in FIGS. 2A, 2B, and5). Handle430 will then be drawn proximally outward relative to theguide body402, causing theneedles410 to pass through the superficial wall of the femoral artery FA and into theneedle lumens420, as illustrated in FIGS. 2B and 5. Thehandle430 may continue to be drawn proximally (i.e., outward from the patient) in order to continue to pull theneedle shaft404 through theguide body402. Such movement of theneedle shaft404, in turn, continues to draw theneedles410 outward through thelumens420 of theguide body402 until the tips of the needles are exposed. The user may then grasp the needles and continue to draw them out until the suture is available to the user. Theguide body402 may then be withdrawn from thesupport sheath440, leaving a portion of theneedle sheath426 still in the puncture site A to maintain hemostasis. The suture can then be tied and the knot pushed back down through thesupport sheath440. The knot will then only be tightened when the needle sheath is finally withdrawn from the puncture site A.
• It can be seen that the[0096]guide tip406 deflects the needles radially outward so that the pattern of four needles engages the artery wall in an approximately square pattern about the arteriotomy A. After the sutures are tied and the knots advanced back through thesupport sheath440, the resulting pattern of tied suture will appear as in FIG. 8 when viewed towards adventitial surface of the femoral artery FA surrounding the arteriotomy A.
• [0097]Device400 has certain advantages over the previous embodiments. Since it is not necessary to capture the needles using an internal capture mechanism, the needles need not have barbs. Such barbless needles will minimize trauma to the arterial tissue around the puncture site A and simplify the procedure. Theguide body402 andguide tip406 are designed as an integral structure to assure that needles410 will be precisely centered around the puncture site A, and will very reliably enter theneedle lumens420 inguide body402. Also,tip406 will occlude the arteriotomy puncture during the performance of the procedure, providing hemostasis. Moreover, the entire procedure is simplified, with fewer discrete steps being performed. The user need only introduce the device over-the-wire and thereafter draw out the needle shaft to carry the needles through the tissue to be sutured and outward through the guide body, where the suture becomes accessible and may be tied in a conventional manner.
• The present invention also provides several devices which comprise a graft anastomosis assembly. One of the preferred embodiments of the graft anastomosis assembly and component devices depicted in the drawings is inserted through an aperture or hole in a tissue wall, such as the wall of the distal artery, an aorta, or other vascular tissue. The assembly mechanically places a predetermined pattern of sutures in the tissue wall. The aperture can then be enlarged manually or, optionally, by the assembly itself, such that the suture pattern is in close proximity to the circumference of the aperture. The assembly provides a graft to the tissue wall at the site of the aperture. Preferably, hemostasis is maintained during a substantial portion of the procedure. Furthermore, the graft anastomosis assembly and devices can maintain perfusion beyond the area of the device introduction through the vascular tissue.[0098]
• A preferred embodiment of one component for the graft anastomosis assembly is a[0099]tissue suturing device10 shown in FIGS.9-12 which reliably deploys a uniform suture pattern in atissue wall12 defining ablood vessel14. Thetissue suturing device10 is useable separately for suturing any type of tissue, whether or not as part of an anastomoses procedure. On the other hand, thetissue suturing device10 can be used to deploy sutures in either, or both, the blood vessel and graft in an anastomosis procedure. Optionally, thetissue suturing device10 can interlock with a graft suturing device, as will be discussed below, to provide alignment between the suture patterns in thetissue wall12 and a graft wall.
• The[0100]tissue suturing device10 includes anelongated body16 having adistal end18 andproximal end20. Referring specifically to FIG. 9, thetissue suturing device10 includes a hand grip22 partially nested within theelongated body16 and externally accessible to an operator. Thedevice10 also includes aneedle carrier24, afoot26 attached to ashaft28 which extends proximally into theelongated body16, and an actuating mechanism referred to generally as30. Supported within theelongated body16, theactuating mechanism30 attaches to the hand grip22 as illustrated by the cut-away portion.
• The[0101]actuating mechanism30 includes acam32 which is rotatably secured to theelongated body16 by afastener34. Thecam32 is integrally formed with the hand grip22 and pivots in the directions indicated byarrows36 using thefastener34 as the pivot point. Thecam32 includes aslot38 located between the hand grip22 and thefastener34 and extending through the cam itself. Thecam32 slidably connects to theproximal end40 of theneedle carrier24 by engaging apeg42 which is affixed to theneedle carrier24 and extends perpendicularly therefrom. Moving the hand grip22 in the direction of thearrows36, pivots thecam32 and slides thepeg42 along theslot38. As a result, theneedle carrier24 travels along theshaft28 within theelongated body16 and reversibly moves thedistal end44 of the needle carrier toward thefoot26.
• As specifically illustrated in FIG. 10, the[0102]distal end44 of the needle carrier includes an integrally formedcutting blade46 mounted on a surface approximating the size of the circumference of thefoot26. Oneend48 of the cutting blade is positioned near theshaft28 so as to meet the circumference of aninitial aperture52 formed in the tissue wall (as shown in FIG. 9). Preferably, thecutting blade end48 rides in a longitudinal groove54 (as shown in FIG. 11) formed in theshaft28 as thedistal end44 of the needle carrier and thefoot26 are squeezed together. Theopposite end50 of the cutting blade is positioned to enlarge theinitial aperture52 in the direction extending away from theshaft28. Thecutting blade46 preferably has a height profile which decreases from the oneend48 of the cutting blade near the shaft to theopposite end50 to form a decreasing gradient or slant. The decreasing gradient of thecutting blade46 allows theend48 of the cutting blade to first engage and cut thetissue wall12 near theshaft28. The cutting blade enlarges the incision toward theopposite end50 as thedistal end44 of the needle carrier andfoot26 are squeezed progressively together. The present invention also includes embodiments wherein thecutting blade46 has a uniform height across its length or a gradient which is increasing from thecutting blade end48 near the shaft to theopposite end50 of the cutting blade.
• Although one embodiment of the[0103]cutting blade46 and theactuating mechanism30 is illustrated, alternative embodiments are suitable for use with the present invention as may be apparent to one of ordinary skill in the art. A variety of suitable punch/cutting devices, such as circular blades, anvils, and the like, as well as actuating mechanisms, are disclosed in the following prior documents which are hereby incorporated in their entirety by reference thereto: U.S. Pat. Nos. 3,104,666; 3,776,237; 4,018,228; 4,216,776; and 5,192,294 and U.S. Des. Pat. No. 372,310.
• The[0104]distal end44 of the needle carrier includes a plurality ofneedles56 attached thereto and extending in a generally perpendicular direction. Theneedles56 are arranged in a predetermined pattern which matches a desired corresponding suture pattern58 (as seen in FIG. 12). Theneedles56 are positioned at approximately uniform intervals around the circumference of theinitial aperture52 which is enlarged to accommodate a graft (not shown). The height of each of theneedles56 from the surface of thedistal end44 of the needle carrier to its tip is slightly higher than the height of thecutting blade46 so that theneedles56 engage thetissue wall12 just as, or slightly before, thecutting blade46 engages thetissue wall12. Having theneedles56 engage thetissue wall12 before, or simultaneously with, thecutting blade46, allows thetissue wall12 to be captured and retained in position to form the desiredsuture pattern58 even after thecutting blade46 enlarges theinitial aperture52. The circumference of the enlarged aperture is retained in apposition as thecutting blade46 completes the incision.
• The[0105]foot26 has atop surface60 and an opposingbottom surface62 as seen in FIG. 11. Thetop surface60 faces thedistal end44 of the needle carrier and has agroove64 which corresponds in position to thecutting blade46 on thedistal end44 of the needle carrier. Thegroove64 is of sufficient size to accommodate a portion of thecutting blade46 below the plane of thetop surface60 to facilitate the making of the incision. Thegroove64 has the same depth profile from oneend66 of the groove near theshaft28 to theopposite end68 as the height profile of thecutting blade46. Located near thecircumference70 of thetop surface60 is a plurality ofsuture channels72 extending through the depth of thefoot26 to thebottom surface62. The pattern of thesuture channels72 on thetop surface60 corresponds to the pattern ofneedles56 on thedistal end44 of the needle carrier (as seen in FIG. 10). As thedistal end44 of the needle carrier travels toward thetop surface60 of the foot, theneedles56 have sufficient height relative to the length of travel by theneedle carrier24 to slightly penetrate thesuture channels72.
• Each of the[0106]suture channels72 in the foot are sized to releasably retain asuture74 having a suture body orlength78 terminating at oneend76. Preferably, theend76 of the suture is releasably retained in one of thesuture channels72. As illustrated in FIG. 10, a plurality of thesutures lengths78 extend downward through alumen80 in theshaft28 emerging through adistal shaft aperture82. As eachsuture length78 emerges from the shaft, it is positioned within one of a plurality ofsuture grooves84 within thebottom surface62 of the foot. Eachsuture groove84 extends at least partially from thedistal shaft aperture82 to arespective suture channel72. The depth of eachsuture groove84 is sufficient to accommodate the width of thesuture length78 to provide a flush profile to thebottom surface62. The end of eachsuture76 extends to therespective channel72 where it is releasably retained near thetop surface60 of the foot. Although it is preferred to position thesuture end76 approximately flush with thetop surface60 of the foot, it is suitable for thesuture end76 to be in any position where it can be retrieved or engaged by the correspondingneedle56 or other retrieving device or means when theactuating mechanism30 squeezes thefoot26 and thedistal end44 of the needle carrier together.
• Although a plurality of[0107]needles56 are illustrated on theneedle carrier24 in a one-to-one correspondence with thesuture channels72 on thefoot26, the present invention also provides other embodiments. For example, a single needle or a subset of needles less than the number of suture channels can be used on the needle carrier. The single needle or subset of needles engages a corresponding number of suture channels with a first stroke bringing the foot and needle carrier together. Upon retrieving a corresponding number of sutures, the single needle or needle subset is rotated to a new position after each stroke bringing the foot and needle carrier together along theshaft28. Rather than having the needles deploy simultaneously with a single stroke, a multi-stroke, successive deployment is used.
• Referring to FIG. 9, the[0108]suture lengths78 extend toward theproximal end20 of the elongated body. Thesuture lengths78 exit from thelumen80 and pass through a longitudinal slot86 (also illustrated in FIG. 10) which extends along the length of theshaft28 and thedistal end44 of the needle carrier. Optionally, thesuture lengths78 extend from thelongitudinal slot86 to aguide88 which organizes the sutures. Theguide88 is located on the external surface of the elongated body near the distal end. Thesuture lengths78 extend through asecond guide90 to asuture holder92. Thesecond guide90 is located near theproximal end20 of the elongated body. Thesuture holder92 releasably retains the opposite ends94 of the suture lengths so they may be individually identified as to their position in thesuture pattern58 and retrieved by the operator.
• The[0109]longitudinal slot86 allows the removal of thefoot26 from the aperture completed52 in thetissue wall12 and the subsequent removal of thesuture lengths78 so that each end,76 and94, of the sutures can be fastened together. In an alternate embodiment, thesuture lengths78 extend internally along the length of theelongated body16 toward theproximal end20. Aseam98 along the length of theelongated body16 connects to the end of thelongitudinal slot86 so that the elongated body can be split open to remove thesuture lengths78 once thesuture pattern58 has been completed. Thelongitudinal slot86 itself can also be replaced with a seam to similarly split theshaft28,foot26, andneedle carrier24 to remove thesuture lengths78 from thelumen80.
• Preferably, the[0110]suture pattern58 is a uniform distance from the perimeter of the completedaperture52 in the tissue wall. Usually, theinitial aperture52 is a simple longitudinal incision. Preferably, the present invention adjusts for the distance which thetissue wall12 surrounding theshaft28 is offset. As illustrated in FIGS. 10 and 11, thefoot26 is partially defined by opposingside walls100 and end walls which define aheel102 andtoe104 for the foot. Theside walls100 bulge slightly outward in the vicinity of theshaft28. Specifically, the distance between the circumference of the shaft and theside walls100 is the same as the distance from thecutting blade groove64 or longitudinal axis of thefoot26 to theside walls100 along the remainder of the foot. Like the remainingsuture channels72, the suture channels in the vicinity of the bulge, like106 and108, are located at the circumference of theside walls100 which offsetssuture channels106,108 in thesuture pattern58. The offsetsuture channels106,108 provide a uniform amount of tissue wall capture around the entire perimeter of the completedaperture52 by adjusting the position of thesuture pattern58 for the offset of thetissue wall12 on each side of theshaft28. Usually, thetissue wall12 is negligibly offset by theshaft28 in the direction of theheel end wall102 because the shaft is positioned toward or at theheel end wall102 of the incision creating theinitial aperture52. To further minimize the offset of thetissue wall12 caused by theshaft28, it is preferred that the shaft have an oval shape to its cross-section as specifically illustrated in FIG. 11.
• The[0111]needles56 on the surface of thedistal end44 of the needle carrier which correspond to the offsetsuture channels106,108 on the foot are similarly offset. The surface of thedistal end44 of the needle carrier in the vicinity of theshaft28 is offset or bulges in a similar pattern as the opposingside walls100 of the foot.
• FIG. 12 illustrates a side view of the[0112]foot26 upon insertion through theinitial aperture52 in thetissue wall12. Preferably, thetoe end wall104 is inserted first and moved forward. The shaft has a cut-awayportion110 near its distal end to allow forward movement of the foot assisting the insertion of theheel end wall102 through thetissue wall12. Theheel end wall102 is then moved back slightly to abut one end of theinitial aperture52. Thetop surface60 of thefoot26 abuts thedistal side112 of the tissue wall promoting uniform tissue capture when the needles engage thetop surface60 of the foot. As thefoot26 passes through thetissue wall12, the dilated tissue around theaperture52 usually responds elastically and compresses onto theshaft28, thereby maintaining hemostasis. Once in position, thetop surface60 of the foot lies adjacent thedistal side112 of the tissue wall, allowing adequate perfusion beneath thebottom surface62 of the foot and thevessel wall intima114. When the assembly is used on vascular tissue, the perimeter of the shaft is preferably about equal to the perimeter of the incision. For example, using thetissue suturing device10 to perform an anastomosis on the distal artery places the diameter of the shaft in a preferred range of about 1.5 mm to about 2 mm which is the generally accepted diameter of the distal artery.
• In those operations where the[0113]initial aperture52 is formed by incising thetissue wall12 or punching a hole of a size approximating the diameter of theshaft28 in the tissue wall, there is significantly less offset of the tissue wall in the vicinity of the shaft. As a result, a nearlyuniform suture pattern58 is formed without thefoot26 having offset suture channels. As illustrated in FIG. 13, the present invention includes an embodiment of thefoot26 which does not have an offset or bulge in theside walls100 in the vicinity of theshaft28. The same reference numerals are used for like components illustrated in the other figures. FIG. 13 also illustrates theshaft28 having a more round cross-section shape. Thefoot26 can be formed in many other shapes and sizes while employing the inventive concepts described herein to a particular surgical procedure, suture pattern, specific tissue, etc.
• As illustrated in FIG. 14A, one preferred embodiment of the[0114]foot26 has a rounded shape to the corners and edges of the top60 and bottom62 surfaces to provide for an atraumatic entry through the tissue wall and to guard against traumatizing the tissue wall intima opposite theaperture52 upon advancing thefoot26 into the lumen of theblood vessel14 as previously seen in FIG. 12. Another example illustrated in FIG. 14B emphasizes an even more roundedbottom surface62 than FIG. 14A to guard against traumatizing thevessel wall intima114 opposite theinitial aperture52.
• The[0115]foot26 can also have several cross-sectional configurations as illustrated in FIGS. 14C and 14D for example, which provide apassageway115 along the longitudinal axis of the foot for perfusion when the foot has been inserted through thetissue wall12 into a vessel14 (as seen in FIG. 12). FIG. 14C provides thelongitudinal passageway115 along the length of thefoot26 from theheel end wall102 to thetoe end wall104. FIG. 14D provides an example of alongitudinal passageway115 to ensure perfusion being used in combination with a curvedtop surface60 to the foot to minimize distortion of the proximal side of thetissue wall12. Arounded bottom surface62 prevents traumatizing thevessel wall intima114 opposite theaperture52. Thesuture channels72 are positioned at an angle to thetop surface60 of the foot so that they are still perpendicular to theneedles56 on a corresponding needle carrier24 (as seen in FIG. 10).
• Other examples of perfusion passageways include pathways which have a baffled or tortuous path. A coiled path is another example of a non-straight perfusion passageway.[0116]
• Turning now to FIGS.[0117]15-17, the relationship between thesutures74 and needles56 is described in more detail. Oneend76 of each of the sutures preferably terminates with acuff116 attached to thesuture length78 along abottom exterior wall118. Thecuff116 has a generally cup-shapeinterior space120 defined by a sideinterior wall122 and a bottominterior wall124. Theinterior space120 is sized to accommodate one of theneedles56 in a press-fit engagement. Thedistal end126 of each needle has an arrowhead shape with atip128 and one ormore barbs130. The arrowhead is mounted on aneedle shaft132 which has a taperedsection134 near the arrowhead.
• As specifically illustrated by FIGS. 16 and 17, when the[0118]needle56 engages theinterior space120 of the cuff, the diameter of thearrowhead barb130 is sized to be slightly larger than the interior diameter of the cuffinterior space120. As a result, thecuff side wall122 deflects slightly as thearrowhead barb130 is inserted into the interior space. The deflectedside wall122 is biased against thebarb130 to provide a retaining force. Thetip128 of the arrowhead continues until theinterior side124 of the bottom wall is engaged as a backstop to prevent further insertion of thearrowhead tip128. Penetration of thetip128 into theinterior bottom wall124 is not required to provide an engaging force between theneedle56 and thesuture74.
• For the sake of example, and not to be limited thereby, the preferred dimensions of the[0119]needle56 are in a range of about a 0.01 inch to about a 0.02inch needle shaft132 diameter which decreases to a diameter of about 0.005 inch in atapered section134. The length of the taperedsection134 at the narrowest diameter is about 0.005 inch with an overall length of about 0.013 inch. The diameter of thearrowhead barb130 is in the range of about 0.007 to about 0.008 inch. The height of thearrowhead barb130 is in the range of about 0.010 inch to about 0.014 inch. The height of the interior side of theside wall122 is about 0.02 inch with thecuff116 having an overall height of about 0.03 inch. The diameter of theinterior space120 from the interior side of theside wall122 is about 0.005 inch. The thickness of theside wall122 is about 0.0025 inch and thebottom wall118 is about 0.01 inch. The dimensions of eachsuture channel72 in thefoot26 for this particular example have an interior diameter at thetop surface60 of the foot of about 0.011 inch.
• The[0120]suture cuff116 is preferably welded to thesuture length78 or molded as one-piece from polypropylene. Thecuff116 can be made from other medical polymers or malleable metals with a preferred hardness to provide the retaining force by allowing thearrowhead barb130 of aneedle56 to deflect and bias theside wall122 of the cuff against itself and/or allow thebarbs130 of a needle to penetrate theside wall122 of the cuff.
• Other means of attaching the[0121]suture length78 to thecuff116 are also suitable for use in the present invention such as attaching the cuff to the suture length with a conventional adhesive like cyanoacrylate or by forming the cuff with an indentation in theexterior side118 of the bottom wall and crimping the suture length therein. In another embodiment, thebottom wall124 of the cuff can be made of the same, or different, polymer which exhibits a surface hardness sufficient to resist penetration of thetip128 and provide a backstop preventing excessive penetration. Thecuff116 may also be initially molded as a solid block and subsequently bore aninterior space120 into the solid block to complete the cuff.
• Preferably, the[0122]suture length78 is a single strand or monofilament. Although a multi-stranded, covered, twisted, or braided suture length is also suitable for use with the present invention. Thecuff116 is also preferably removable from thesuture length78. A suitable rupture strength of the cuff and suture length attachment is about 2 ounces to about 10 ounces so that the two may be separated with the application of a sharp tug.
• The present invention provides other configurations for the[0123]suture end76. Illustrated for the sake of example, and not for limitation, FIGS.18A-E are suture ends76 which can be retrieved or fetched by a retrieving device. Thesuture end76 in FIG. 18A includes asuture length78 having a ball-shapedend136 which is made of a soft material. Similarly, thesuture end76 in FIG. 18B includes asuture length78 attached to asolid cuff138 made of a soft material.
• The[0124]suture end76 of FIG. 18C includes thesuture length78 attached in a perpendicular manner to one side of aring140. Made of deformable material, thering140 compresses in the suture channel (not shown) as the larger diameter arrowhead barb is inserted entirely through thehole142 so that the ring is positioned above the barbs in the tapered section of the needle shaft. As the compressed material relaxes, thering140 is retained in the tapered section as the needle is withdrawn through the tissue wall. Oneend144 of the ring is preferably tapered to allow for easy passage through the tissue layer. Another example of a retrieving device for use with thering140 is a hook as described further below.
• The[0125]suture end76 of FIG. 18D includes thesuture length78 attached to acuff146 defined by aserrated side wall148 providingslits150 therein. The barbs of the needle previously discussed easily deform theside wall148 and at least partially fill into one or more of theslits150 to provide a solid engagement therebetween.
• The[0126]suture end76 of FIG. 18E includes thesuture length78 which terminates in a hook-shapedend152 made of a material sufficiently hard to resist flexing as it is pulled through the tissue layer. Configurations of the suture end like the hook-shapedend152 can be engaged by a retrieving device like, for example, a similarly shaped hook or by passing the hook-shaped end through the center of a retrieving device having a ring shape.
• Other configurations of the retrieving device provided by the present invention are illustrated for example, and not limitation, in FIGS.[0127]19A-E. Preferably, the retrieving device of the present invention generally includes means for forming a port in the tissue layer through which a suture, or other fastener, is retrieved or introduced. The suture or fastener usually remains within the port.
• Specifically, another configuration suitable for impaling the suture end is illustrated in FIG. 19A as a[0128]serrated needle tip154 effectively using a plurality of barbs like156,158 at various positions and elevations along theshaft132 of the needle to engage the suture end.
• FIG. 19B retrieves the[0129]suture length78 with amultiple piece assembly160 having theneedle shaft132 with atapered section134 near thetip128. A separate piece oftubing162 in the taperedsection134 is initially retracted towards theupper portion164 of the tapered section until thesuture length78 is biased into anindentation166 in thebottom168 of the tapered section. As theneedle shaft132 is withdrawn, thetubing162 slides downward to thebottom168 of the tapered section and over thesuture length78 to retain it in place. Thetubing162 can further be configured to have an offset170 at its bottom end to accommodate the thickness of thesuture length78 while simultaneously covering the portion of the suture resting in theindentation166. Optionally, theneedle shaft132 having the taperedsection134 can be used without thetubing162.
• FIG. 19C shows the[0130]suture length78 retained within anindentation172 of the otherwisebarbless needle shaft132 with the aid of asuture loop174 formed in the shape of a noose with aclasp176. In place of theclasp176, the noose can also be formed by tying a knot in thesuture loop174.
• Another example of a retrieving device is illustrated in FIG. 19D with the[0131]needle shaft132 having a hook-shapedend178 with atip180 suitable for piercing the tissue layer. Optionally, the hook-shapedend178 can further include an inwardly facingbarb182 for assistance in retaining the suture end within the bight of the hook-shaped end. Examples of a suture end suitable for use with the hook-shapedend178 are shown in FIGS. 18C and 18E.
• FIG. 19E illustrates another retrieving device having a cannula with a lumen or[0132]tube184 with a removable piercing element such as aneedle186 located within the interior of the tube. Theneedle186 is initially used to form a port in the tissue layer to atraumatically introduce thetube184 through the tissue within the proximity of the suture end. Theneedle186 is subsequently removed and the interior of thetube184 is placed under a vacuum sufficient to draw the suture end to theend188 of the tube. Thetube184 engaged to the suture end is then drawn through the tissue layer. Examples of a suture end suitable for use with thetube184 are shown in FIGS. 18A and 18B.
• The present invention provides other means for engaging a portion of a fastener through a tissue layer from the side opposite means for retaining another portion of the fastener in a stationary position. The present invention provides for using a variety of fasteners to form different types of suture patterns. Other examples of the engaging means for a fastener are illustrated in FIGS. 20 and 21.[0133]
• In FIG. 20 a[0134]first tissue layer200 andsecond tissue layer202 are joined by releasably retaining a first portion of afastener204 in a stationary position on one side of the first tissue layer. As previously described, thefirst portion204 can be releasably retained in thefoot26 of a tissue suturing device. A second portion of thefastener206 is releasably retained in thedistal end44 of the needle carrier of the tissue device. Thesecond portion206 includes aneedle tip208 on aneedle shaft210 for piercing and forming aport212 in the first and second tissue layers. Thesecond portion206 also includes abase214 for abutting thesecond tissue layer202 and abarb216 on the needle shaft for engaging and being retained in anindentation218 formed in thefirst fastener portion204. Thefirst fastener portion204 includes aface220 for abutting thefirst tissue layer200. As thedistal end44 of the needle carrier is squeezed toward thefoot26, theneedle tip208 engages theindentation218 and the first and second portions of thefastener204,206 are retained together. As a result, the first and second tissue layers200 and202 are held in apposition.
• FIG. 21 illustrates a[0135]tissue layer222 and asuture224 are joined by releasably retaining a first portion of afastener204 in a stationary position on one side of thetissue layer222. As previously described, thefirst portion204 can be releasably retained in thefoot26 of a tissue suturing device. A second portion of thefastener206 is releasably retained in thedistal end44 of the needle carrier of the tissue device. Thesecond portion206 includes aneedle tip208 on aneedle shaft210 for piercing and forming aport212 in thetissue layer222. Thesecond portion206 also includes abase214 for abutting thetissue layer222 and a portion of thesuture224. Abarb216 on the needle shaft passes through an aperture226 in thefirst fastener portion204 and is retained therein. Thefirst fastener portion204 includes aface220 for abutting the opposite side of thetissue layer222. As thedistal end44 of the needle carrier is squeezed toward thefoot26, theneedle tip208 passes through the aperture226 and the first and second portions of thefastener204,206 are retained together. As a result, the first and second portions of the fastener secure thesuture224 therebetween.
• The present invention is not limited to retrieving a suture only at its end. As illustrated in FIG. 22, another embodiment of the[0136]cuff116 attaches directly to asuture length78 and not theterminal end76 of the suture forming twolengths230,232 of the suture extending from theexterior bottom wall118 of the cuff. Although thecuff116 can be integrally formed as one-piece with thesuture length78, the cuff can be attached to the suture length with a conventional adhesive. Thesuture length78 can be one of a plurality of sutures that are deployed to form the suture pattern.
• The suture length-cuff attachment illustrated in FIG. 22 can be used to form a[0137]suture pattern58 in proximity to theaperture52 in the tissue layer as illustrated in FIGS. 23 and 24 using either a single or a continuous suture. Usingsuture cuffs116 periodically attached along the length of acontinuous suture234 as described in FIG. 22, thecuffs116 are releasably retained in thesuture channels72 of thefoot26 as previously described. Theneedles56 penetrate thetissue wall12 forming aport236 to engage eachcuff116, and pull each cuff through the tissue wall. Eachcuff116 is removed from the attached two ends230,232 of the suture length to form asuture loop238 which proximally extends through and returns distally through the tissue wall at eachport236. Eachsuture loop238 is exposed on theproximal side240 of the tissue wall can be utilized in several ways such as by attaching one or more separate sutures like242, fasteners, or anchors on theproximal side240 of the tissue wall in order to attach a graft (not shown) or to close theaperture52. For example, a corresponding plurality of separate sutures such as242 attached at one end to a graft can be passed through each of the exposedsuture loops238. Eachseparate suture242 can also accommodate an anchor therethrough so that as thelengths230 and232 of the suture are pulled to draw each of thesuture loops238 approximately flush with theproximal side240 of the tissue wall. Theseparate sutures242 can also be tightened to bring the graft in apposition with theproximal side240 of the tissue wall. Theseparate sutures242 can then be tied off.
• As illustrated in FIG. 24, a purse-[0138]string suture pattern246 in proximity to the aperture in the tissue layer uses asingle suture248 having free ends250. To prevent drawing thesuture loops238 completely through the tissue layer, aconventional anchor244 is positioned underneath eachsuture loop238 at eachport236 and pulling the free ends250 of the suture to draw the pattern closed. Thissuture pattern246 would be useful, for example, to close a puncture site oraperture52.
• Another embodiment of the inventive[0139]tissue suturing device310 is shown in FIGS.25-26. Thetissue suturing device310 includes anelongated body316 having a distal318 and proximal320 end. An actuating mechanism (not shown for clarity) operates afoot326 in a reversible motion against thedistal end344 of aneedle carrier324 using ashaft328. Thedistal end344 of the needle carrier optionally includes integrally formed cutting blades like346 on each side of the shaft mounted on a surface approximating the size of the circumference of thefoot326. Thedistal end344 of the needle carrier includes a plurality ofneedles356 attached thereto and extending in a generally perpendicular direction. Theneedles356 are arranged in a predetermined pattern which matches a correspondingsuture pattern358. Theneedles356 are positioned at approximately uniform intervals around the circumference of the completed aperture which is being enlarged or slit to accommodate a graft (not shown). The height of each of theneedles356 from the surface of thedistal end344 of the needle carrier to its tip is higher than the thickness of the tissue layer theneedles356 are anticipated to penetrate.
• The[0140]foot326 has atop surface360 facing thedistal end344 of the needle carrier and an opposingbottom surface362. Located on thetop surface360 is a plurality ofsuture channels372 extending at least partially into the depth of the foot. The pattern of thesuture channels372 on the top surface corresponds to the pattern ofneedles356 on thedistal end344 of the needle carrier. As thedistal end344 of the needle carrier slides along theshaft328 towards the foot, theneedles356 on the distal end have sufficient height relative to the length of travel by theneedle carrier324 to penetrate thesuture channels372.
• Each of the[0141]suture channels372 in the foot are sized to allow insertion by thetip380 of the needles. Thetop surface360 releasably retains the sutures, preferablyloops382 formed by one or more of the sutures. A plurality ofsuture lengths378 extend downward throughgrooves384 in the shaft emerging along thetop surface360 of the foot to be positioned within one of a plurality ofsuture grooves386 within the top surface of the foot. Eachsuture groove386 extends at least partially from the grooves on the shaft to arespective channel372. The depth of eachsuture groove386 is sufficient to accommodate the width of the suture to provide an approximately flush profile to thetop surface360. Eachsuture length378 extends to therespective channel372 where it is releasably retained near thetop surface360 of the foot. Although it is preferred to position thesuture length378 approximately flush with thetop surface360 of the foot, it is suitable for thesuture length378 to be in any position where it can be retrieved by the correspondingneedle356 when the actuating mechanism squeezes thefoot326 anddistal end344 of the needle carrier together.
• As specifically shown in FIG. 26, each[0142]suture length378 extends from thegroove386 in the top surface of the foot and forms thesuture loop382 in a stationary position around therespective suture channel372. Therespective needle356 travels in a perpendicular direction into thesuture channel372. The suture loop is tensioned or biased towards theneedle356, preferably by being positioned to slightly overlap the path of travel expected for theneedle356. As theneedle356 is inserted into thesuture channel372, thesuture loop382 is positioned to engage the side ofneedle shaft388 near theneedle tip380. As theneedle356 continues its downward insertion, thesuture loop382 is pushed slightly to one side until theneedle356 has been inserted sufficiently deep for theindentation390 in the side of theneedle shaft388 to reach thesuture loop382. The tension on thesuture loop382 biases it toward theneedle shaft388 so the suture loop slides into theindentation390 in the needle shaft given the opportunity for the suture loop to return to its initial position. It is not necessary to move thesuture loop382 toward theneedle shaft388 to engage theindentation390. Proper position of thesuture loop382 relative to the side of theneedle shaft388 creates the desired bias to have the suture loop return to its starting position when theindentation390 is adjacent the suture. Subsequently removing theneedle356 from thesuture channel372 back through the tissue layer pulls the suture loop along and passes it through the tissue layer.
• Other embodiments of retaining the[0143]suture length378 in thesuture channel372 are shown in FIGS.27-29. Thesuture channel372 in thetop surface360 of the foot retains abutton392 made of deformable material in a press-fit. Alternately or in combination therewith, thebutton392 is supported from the inside of the foot by an elastic tube orspring394 which is positioned between the button and thebottom362 of the foot.
• As specifically shown in FIG. 28, the[0144]button392 has a preferred tear-drop shape so that thesuture loop382 fits between the bottom and the edge of thesuture channel372. Thesuture loop382 is tensioned or biased against thebutton392 as previously discussed. Thebutton392 includes an outer surface having anindentation396 accessible to theneedle356 from the exterior side of thetop surface360 of the foot as seen in FIG. 27. As theneedle tip380 is inserted into theouter surface indentation396, thebutton392 is not depressed by theneedle356 until theindentation390 or barb of the needle shaft is about even with the outer surface of button to align thesuture382 with the barb orneedle indentation390. As seen in FIG. 29, theneedle356 further depresses thebutton392 which releases thesuture loop382 which slides into the barb orneedle indentation390. Theneedle356 is withdrawn and pulls thesuture loop382 back through thesuture channel372 and, subsequently, through the tissue layer.
• Although the embodiments of the tissue suturing device discussed above show the[0145]needles358 penetrating the tissue layer from a perpendicular direction into a foot having a flat or planartop surface360, the present invention is not so limited. Anotherembodiment510 of the inventive tissue suturing device is shown in FIG. 30. Thetissue suturing device510 includes anelongated body516 having a distal end. An actuating mechanism (not shown for clarity) operates thefoot526 in a reversible motion against thedistal end544 of a needle carrier using theshaft528. Thedistal end544 of the needle carrier optionally includes integrally formed cuttingblades546. Thedistal end544 of the needle carrier includes a plurality ofneedles556 attached thereto. Theneedles556 are positioned near the circumference of thedistal end544 of the needle carrier and extend downward toward thefoot526 and inward toward theshaft528 forming an obtuse angle relative to the side surface of theelongated body516.
• The[0146]foot526 has a curvedtop surface560 facing thedistal end544 of the needle carrier and a curved opposingbottom surface562. Located on thetop surface560 is a plurality ofsuture channels572 extending at least partially into the depth of thefoot526. The pattern of thesuture channels572 on thetop surface560 corresponds to the pattern of needles on thedistal end544 of the needle carrier. As thedistal end544 of the needle carrier slides along theshaft528 allowing thefoot526 to travel towards the distal end, theneedles556 on the distal end have sufficient height relative to the length of travel by the foot to penetrate the suture channels.
• Each of the[0147]channels572 in the foot are sized to allow insertion by thetip580 of the needles. A plurality ofsuture lengths578 extend downward throughgrooves584 in the shaft emerging along thetop surface560 of the foot to be positioned within one of a plurality of suture grooves within the top surface of the foot. Eachsuture length578 is positioned where it can be retrieved by the correspondingneedle556 when the actuating mechanism squeezes the foot and distal end of the elongate body together in the manner described above.
• Another preferred embodiment of a[0148]tissue suturing device610 is illustrated in FIG. 31. Theactuating mechanism630 includes amotor682 secured to theelongated body616. Themotor682 rotatably connects at one end to aworm gear684 which connects to theproximal end640 of the needle carrier. Thehand grip622 includes aswitch686 connected to themotor682 to control the direction and number of revolutions by theworm gear684. Activating theswitch686 energizes themotor682 to turn theworm gear684 and advance theneedle carrier624 along theshaft628 within theelongated body616. Once theneedle carrier624 has advanced to retrieve the sutures in thefoot626, themotor682 is stopped by manually deactivating theswitch686 or by using an automatic cut-off. Theswitch686 can then be activated to have themotor682 turn theworm gear684 in the opposite direction and reverse the travel of theneedle carrier624 to pass the sutures proximally through the tissue. Apower source688 for themotor682 is included within theelongated body616 although an external power source can also be used.
• FIG. 31 also illustrates a graft anastomoses assembly[0149]700 which includes agraft suturing device710 as a second component. A preferred embodiment of thegraft suturing device710 is illustrated in FIGS. 31 and 32. Thegraft suturing device710 reliably deploys a uniform graft suture pattern in a graft wall. Thegraft suturing device710 is useable separately for suturing any type of graft, whether or not as part of an anastomoses procedure. Optionally, thegraft suturing device710 can interlock with a tissue suturing device like610 to provide alignment between the suture patterns in the tissue wall and a graft wall. Thegraft suturing device710 includes agraft needle carrier724, agraft foot726 attached to ashaft728 which extends into theelongated body616 of thetissue suturing device610, and theactuating mechanism630 which can be the same as used by thetissue suturing device610.
• The[0150]graft needle carrier724 includes adistal end744 having a mounting surface with anintegral cutting blade746 thereon. Thecutting blade746 has a circular shape. Thedistal end744 of the needle carrier includes a plurality of graft needles756 attached thereto and extending in a generally perpendicular direction. The graft needles756 are arranged in a predetermined pattern which matches a correspondinggraft suture pattern758. The graft needles756 are positioned at approximately uniform intervals around the circumference of the wall of the graft end782 (as seen in FIG. 32). The height of each of the graft needles756 from the surface of thedistal end744 of the graft needle carrier to itstip780 is slightly higher than the height of the graft cutting blade so that the needles engage the graft wall just as, or slightly before, the edge of thecutting blade746 engages the wall near thegraft end782. Having theneedles756 engage the wall near thegraft end782 before, or simultaneously with, thecutting blade746 allows the wall of thegraft end782 to be captured and retained in position to form the desiredsuture pattern758 even after the edge of thecutting blade746 cuts the wall near thegraft end782.
• Another suitable embodiment of the[0151]cutting blade746 preferably has a decreasing depth profile forming a decreasing gradient or slant from the one side of thegraft needle carrier724. The decreasing gradient allows the end of the cutting blade edge to engage and cut thegraft end782 in an oblong shape. The edge of the cutting blade makes the cut as thedistal end744 andgraft foot726 are squeezed progressively together. The present invention also includes embodiments wherein thecutting blade746 has a uniform height across its length. An oblong shape or other desired shape can still be formed with acutting blade746 of uniform height by changing the circular shape of the cutting blade on the surface of thedistal end744 to the desired shape.
• Referring specifically to FIG. 31, the[0152]graft foot726 has atop surface760 facing thedistal end744 of the graft needle carrier and an opposing bottom surface. Thetop surface760 has a graft groove which corresponds in position to the graft cutting blade on thedistal end744 of the graft needle carrier. The graft groove is of sufficient size to accommodate a portion of the edge of the graft cutting blade below the plane of the top surface to facilitate the making of the cut. Located near the circumference of the top surface is a plurality ofsuture channels772 extending through the depth of the graft foot to the bottom surface. The pattern of thesuture channels772 on the top surface corresponds to the pattern of graft needles on thedistal end744 of the graft needle carrier. As thedistal end744 of the graft needle carrier travels toward the top surface of the graft foot, the graft needles756 have sufficient height relative to the length of travel by thegraft needle carrier724 to penetrate thechannels772.
• Each of the[0153]suture channels772 in the graft foot are sized to releasably retain asuture length778, preferably theend776 of the suture as previously described. Although it is preferred to position thesuture end776 approximately flush with the top surface of the foot, it is suitable for the suture end to be in any position where it can be retrieved or engaged by the correspondinggraft needle756 or other retrieving device or means when the actuating mechanism squeezes the foot and the needle carrier together. Thesuture lengths778 extend within alumen780 in thegraft shaft728 to the surface of thedistal end744 of the graft needle carrier where a slot in the cutting blade allows thesuture lengths778 to extend to the external side of theelongated body616 as previously described with regard to thetissue suturing device610. Thegraft shaft728 extends to connect to theshaft628 of the tissue suturing device or can be integrally made as a one-piece member.
• The[0154]actuating mechanism630 connects to thegraft needle carrier724 in the same manner as between the actuating mechanism and theneedle carrier624 of thetissue suturing device610 in any of the embodiments previously described. FIG. 31 illustrates one such embodiment wherein the actuating mechanism includes themotor682 secured to the elongated body. Themotor682 rotatably connects on the opposite end to asecond worm gear784 which connects to theproximal end740 of the graft needle carrier. Thehand grip622 includes aswitch686 connected to the motor to control the direction and number of revolutions by the worm gear. Activating the switch energizes the motor to turn the worm gear and advance the needle carrier along the shaft within the elongated body. Once thegraft needle carrier724 has advanced to retrieve the suture ends776 in thefoot726, the motor is stopped by manually deactivating the switch or by using an automatic cut-off. Theswitch686 can then be activated to have the motor turn thesecond worm gear784 in the opposite direction and reverse the travel of the needle carrier to pass the sutures proximally through the tissue. Although one embodiment of the cutting blade and the actuating mechanism is illustrated, alternative embodiments are suitable for use with the present invention as may be apparent to one of ordinary skill in the art.
• Two other embodiments of a[0155]graft suturing devices810 are shown in FIGS.33-34 wherein the needles and suture channels are positioned on the opposite components of the device compared to the previously described embodiments. Thegraft suturing devices810 integrally mounts thefoot826 on theproximal end820 of theelongated body816. Ashaft828 extends from theproximal end820 of theelongated body816 to connect to theneedle carrier824 and to an actuating mechanism (not shown). Agraft800 is pulled over theneedle carrier824 and extends toward thefoot826. Thefoot826 includessuture channels872 which releasably retainsutures874 and are in alignment withneedles856 on the needle carrier. As previously described, theneedles856 move axially to engage thesutures874 and retrieve the sutures through thegraft800.
• Specifically, FIG. 33 ties one[0156]end802 of the graft to theshaft828 with atie804. Acutting blade846 is located inwardly of theneedles856 toward theshaft828. As a result, when thefoot826 andneedle carrier824 are drawn together, thesutures874 will be drawn through thegraft800 from theexternal wall806 to theinternal wall808. Thesutures874 can then be pulled out through theopen end802 of the graft once the graft is removed from theneedle carrier824.
• In FIG. 34, the[0157]graft800 is positioned over theshaft828 and pulled through theneedles carrier824. Thegraft800 is further positioned over thetop surface860 of the foot to provide thecutting blade846 with proper alignment to cut the graft in the proximity of theend802. Since thegraft800 extends through theneedle carrier824, anindexing device830 provides the proper alignment for theneedles856 to engage thesutures874 and for thecutting blade846 to cut thegraft end802. Optionally, theneedle carrier824 may be detachable from the remainder of thegraft suturing device810.
• Another embodiment of a[0158]graft suturing device910 is shown in FIGS.35-37 which includes agraft needle carrier924, agraft foot926 attached to ashaft928. Optionally, thegraft shaft928 may extend into the graft anastomosis assembly. Agraft900 is positioned coaxially about thegraft foot926 and held in position with a tie909. Thegraft foot926 containssuture channels972 for releasably retainingsutures974. Thesutures974 extend from the graft foot throughsuture grooves984. Thesuture channels972 are positioned in an axial position relative to the longitudinal axis along thegraft shaft928. As a result, theneedles956 carried by theneedle carrier924 must also retrieve thesutures972 in an axial position. Theneedles956 are deployed radially inwardly through thegraft900 in a regularly spaced pattern of penetration sites or ports in the graft.
• FIG. 36 specifically illustrates the details of the graft suturing device that permits an inward radial deployment of the[0159]needles956. Thegraft suturing device910 further includes anouter cam902 which deploys as a sleeve around theneedle carrier924 and needles956. Thecam902 includesridges904 andtroughs906 along asurface908 of the interior circumference of the cam. Thecam902 is rotated about the longitudinal axis along thegraft shaft928 in either a clockwise or counterclockwise direction as indicated byarrows988. Each of theneedles956 includes atail990 which abuts and slides along theinterior surface908. The rotation of thecam902 moves each of theneedles956 in either an inward or outward direction as thetail990 encounters either theridges904 ortroughs906 respectively. Theneedles956 are driven inwardly through thegraft900 to engage thesutures974. Then the direction of the needles' movement is reversed and theneedles956 move outwardly from thegraft900 with thesutures974 in tow. The return of theneedles956 to their initial position is assisted by aspring992 coiled around the needles shaft. Subsequently, thesutures974 can be released from theneedles956 and thegraft900 can be removed from thecam902 andgraft foot926.
• As illustrated in FIG. 36, the[0160]needles956 move simultaneously inward. In another embodiment, the needles can move inward successively by changing the position of theridges904 andtroughs906 relative to each one another.
• Other embodiments of the[0161]cam902 provide means for moving theneedles956 outwardly without using a spring-like member. For example, FIG. 37 illustrates using arail994 to which thetail990 of one of the needles is rotatably secured. As thecam902 rotates in the direction of thearrows988 and slides along therail994, theneedle956 is moved inward and then is positively moved outward as the cam advanced. In a similar example, theinterior surface908 can include the rail to which thetail990 of the needle is slidably attached. As thecam902 is rotated, thetail990 slides along the rail fromtrough906 toridge904 and vice versa. Since thetail990 is positively attached to theinterior surface908, the needle moves outward without the assistance of a spring-like member.
• Referring to FIG. 31, the[0162]graft suturing device710 and thetissue suturing device610 can be used solely independent (one without the other) or operating together simultaneously or successively. The inventivetissue suturing device610 and inventivegraft suturing device710 described herein can also be used solely independent with other devices or methods (conventional or not) to perform the other device's function in anastomosis assembly and method. For example, thegraft suturing device710 described in the related applications can be readily adapted to interlock with thetissue suturing device610 herein.
• Preferably, the graft suturing device can be loaded with the graft prior to the insertion and operation of the tissue suturing device. The two devices are then combined into one assembly to provide proper orientation of the graft to the deployed suture pattern in the vessel wall. This results in a two-stroke method being used wherein one needle passes the suture through the graft and a second needle passes the suture through the vessel wall.[0163]
• In another embodiment, a one-stroke method can be used with the present invention. For example, using only the vessel suturing device, the needles can first pass the suture through the proximal side of the graft before they are attached to the distal end of the vessel suturing device. Then, as described above, the vessel suturing device is inserted through the vessel wall. The suture can then be passed through the distal side of the vessel wall to complete the loop.[0164]
• The present invention also provides a tissue suturing device and an anastomosis assembly which inserts a portion of the tissue suturing device from a remote access site other than the site of the tissue suturing or anastomosis. Several embodiments of the tissue suturing and/or graft anastomosis assembly which uses a remote access site are illustrated in FIGS.[0165]38-40.
• FIGS. 38 and 40 illustrate a[0166]remote access site1000 in thetissue wall1012 of ablood vessel1014. Aremote foot1026 is introduced into theblood vessel1014 through theremote access site1000. Theremote foot1026 is attached near itsheel end wall1002 to aguide wire1004 which is controlled at the other end by anactuating mechanism1030.
• The[0167]remote foot1026 has atop surface1060 with agroove1064 thereon for facing the distal end of a needle carrier and corresponding to the position of a cutting blade as discussed herein. Located near the circumference1070 of thetop surface1060 is a plurality ofsuture channels1072 extending into thefoot1026. The pattern of thesuture channels1072 on thetop surface1060 corresponds to the pattern of needles on the distal end of the needle carrier that will be attached to theremote foot1026 at the site where the suture pattern is desired. Each of thesuture channels1072 in the remote foot are sized to releasably retain a suture1074 having a suture body orlength1078 terminating at oneend1076. Preferably, theend1076 of the suture is releasably retained in one of thesuture channels1072.
• The[0168]sutures lengths1078 extend across thetop surface1060 of the remote foot and to terminate at the bottom of aplug1006. Theplug1006 releasably retains theends1094 of the sutures1074 opposite the suture ends1076 retained in thesuture channels1072 so the suture ends1094 may be individually identified as to their position in the suture pattern and retrieved by the operator. Theplug1006 is detachable from the remote foot by theactuating mechanism1030. Once theremote foot1026 has been guided to the desired cite of the suture pattern, theplug1006 is released from the remote foot by theactuating mechanism1030 and driven through thetissue wall1012 of the blood vessel by a releasable connection to asecond wire1009 associated with theguide wires1004 as seen in FIG. 39. To assist in making aninitial aperture1052 through thetissue layer1012 for theplug1006 to pass through, adilating blade1008 is preferably mounted on the top surface of the plug. Thesuture lengths1078 have an excess amount of length sufficient to allow theplug1006 to be pulled free of theblood vessel1014. The excess amount of length is coiled within theremote foot1026 beneath the bottom surface of theplug1006 before the plug is released. After theplug1006 has passed through thetissue wall1012, the opposite suture ends1094 can be released.
• With the release of the[0169]plug1006, adepression1098 corresponding to the shape of the plug is left in thetop surface1060 of the remote foot. This depression is adapted to securely receive the distal end of a shaft of a tissue suturing device (not shown) as previously described herein. The shaft is advanced through theinitial aperture1052 into thedepression1098. Attachment of the shaft of the tissue suturing device to theremote foot1026 provides proper alignment of the needle carrier and needles of the tissue suturing device with thesuture channels1072 of the remote foot.
• Optionally, the[0170]plug1006 can be another embodiment of the graft foot previously discussed herein. Referring to FIG. 39, theplug1006 includessuture channels1096 for releasably retaining the opposite suture ends1094. Thesuture channels1096 are illustrated in an axial position relative to the longitudinal axis. Theplug1006 can then be attached to the shaft or other positioning device on a graft suturing device as previously described herein specifically with regard to FIG. 35.
• An alternate embodiment of the[0171]plug1006 positions thesuture channels1096 along the longitudinal axis so thatsuture channels1072 are flush with the top surface of theplug1006. With this configuration ofsuture channels1072, the plug can be attached to the shaft of a graft suturing device as previously described herein specifically with regard to FIG. 31.
• Another embodiment of a tissue suturing device and an anastomosis assembly which inserts a portion of the tissue suturing device from a remote access site other than the site of the tissue suturing or anastomosis is illustrated in FIG. 40. The[0172]tissue suturing device1110 in this embodiment uses aneedle carrier1124, ashaft1128, and aremote foot1126 as previously described with regard to the embodiments of the non-remote tissue suturing device. Theremote foot1126, however, is attached to arigid extension1102 which connects at the other end to theshaft1128. Similarly, theneedle carrier1124 is attached to arigid extension1104 which connects at the other end to theshaft1128. Theextensions1102 and1104 allow theremote foot1126 to be inserted through thetissue layer1112 into ablood vessel1114 at aremote access site1100. As previously described with regard to the various embodiments of the tissue suturing devices, theneedle carrier1124 has a shape corresponding to theremote foot1126 so that theneedles1156 are aligned with thesuture channels1172.
• The[0173]suture channels1172 releasably retainsutures1174 at one of theends1176 while thesuture lengths1178 extend across thetop surface1160 of the remote foot throughsuture grooves1184 near the perimeter of the remote foot. The opposite ends1194 of the sutures terminate in aplug1106 which is releasably retained flush with thetop surface1160 of the remote foot. One of the needles like1157 on the needle carrier is aligned to retrieve theplug1106 and draw it through thetissue layer1112. After theplug1106 has been drawn through thetissue layer1112, the opposite ends1194 of the sutures can be freed from the plug.
• The[0174]tissue suturing device1110 demonstrates that a suture pattern can be deployed at adeployment site1108 other than the remote access site. Furthermore, thetissue suturing device1110 does not need an initial aperture at thesuture deployment site1108 in order to deploy the suture pattern. The alignment between theneedles1156 and thesuture channels1172 is provided by theextensions1102 and1104 without a shaft extending through an aperture at thedeployment site1108.
• Optionally, a[0175]cutting blade1146 can be mounted on theneedle carrier1124 and is positioned to make an incision at thedeployment site1108 to form an anastomosis site different from theremote access site1100 and not simply enlarge an initial insertion site. Thecutting blade1146 is preferably aligned with thegroove1164 on thetop surface1160 of the remote foot and avoids contact with thesuture lengths1178. Rather than drawing theplug1106 through a separate port in thetissue layer1112, theplug1106 can be drawn through the incision made by thecutting blade1146.
• With the various inventive embodiments, alternate means of fastening the two ends of the suture body together are suitable. For example and not for limitation, the two ends of the suture body can be simply tied in a knot manually or, optionally, with a knot device as is described in copending application U.S. Ser. No. 08/552,211 filed Nov. 2, 1995.[0176]
• Even though the suture devices are illustrated herein with regard to vascular tissue, it should be understood that the present invention is not limited to any particular type of tissue. Generally, the devices of the present invention can be used for suturing all types of tissue in many applications. More specifically, the present invention can close apertures in tissue or bind layers of tissue together such as in anastomoses. For example, and not for limitation, the present invention can be used to close apertures in the septum of the heart such as with a atrial septal defect or a patent foramen ovale. The present invention can deploy sutures around the annulus of a valve for the heart or other organs and around the proximity of a prosthesis.[0177]
• The present invention can be used in anastomoses to provide a direct or indirect communication between two blood vessels, lymphatics, hollow viscera, or other tubular structures. Although the anastomoses between an aperture in a vessel wall and the end of a graft is specifically illustrated, the present invention can also be used to anastomose tubular structures in other configurations such end-to-end, end-to-side, in continuity, conjoined, or closed-end. Examples of specific applications include the CABG methods described herein using vessels and tubular grafts such as the aorta, veins, the internal mammary artery, or superficial temporal artery. An example of an anastomosis involving an organ instead of a blood vessel is a Roux-en-Y operation which implants the distal end of the divided jejunum with the proximal end into the side of the jejunum at a suitable distance below the first to form a Y-shape pattern.[0178]
• The suturing devices described herein, particularly the tissue suturing devices, can be used on grafts which do not have an open end. In some instances, the open end of a graft is closed off by a clamp or other closure means. An incision is made in the graft to allow penetration of the foot of the tissue suturing device of the present invention into the side of the graft. The tissue suturing device deploys the desired suture pattern and is withdrawn from the graft. The suture pattern is available for attachment to a corresponding suture pattern or other fastener arrangement. In an anastomoses procedure, the corresponding suture pattern is deployed on the selected vessel.[0179]
• The present invention can be used with catheter-based surgical techniques wherein one of the elements of the devices described herein is delivered to the suture site through a remote or alternate access location. For example, the vessel suturing device described herein can be introduced to the aorta through the femoral artery to the site where the sutures are deployed. The present invention allows indirect visualization of the desired deployment site via marker ports, crystals or the like.[0180]
• While particular embodiments of the invention have been herein described in detail, it is to be appreciated that the present invention encompasses variations and combinations thereof, as may be apparent to one of ordinary skill from this disclosure. It is therefore to be understood that within the scope of the appended claims, the invention may be practiced otherwise than as specifically described herein.[0181]

Claims (23)

1. A method for suturing tissue in the proximity of an aperture in a tissue wall, comprising:

forming a port from the proximal side of the tissue wall;

passing at least a portion of a suture from the distal side of the tissue wall proximally through the port in the tissue wall in the proximity of the aperture; and

forming a loop with the remaining portion of the suture to secure the suture.

2. The method ofclaim 1, wherein forming a port comprises:

advancing a needle from the proximal side to the distal side of the tissue wall to form the port; and

wherein passing at least a portion of a suture comprises:

engaging the suture with the needle; and

withdrawing the needle and suture through the port.

3. The method ofclaim 1, further comprising:

introducing a fastener over the portions of the suture.

4. The method ofclaim 1, further comprising:

passing the remaining portion of the suture through the wall of a graft.

5. The method inclaim 1, wherein passing at least a portion of a suture comprises advancing a shaft through the aperture so that a pair of needles having a length of suture therebetween engage suture ports on opposite sides of the aperture, drawing the suture outwardly to guide the needles through the suture port into the tissue tract, and removing the ends of the suture from the needles.

6. The method inclaim 1, wherein passing at least a portion of a suture comprises advancing a shaft through the aperture so that at least one needle having a portion of suture engages the port, engaging the suture portion with the needle, drawing the suture portion through the tissue and retracting the needle from the port.

7. The method inclaim 1, further comprising:

passing the remaining portion of the suture through the aperture before the step of passing the suture portion through the tissue wall.

8. A method for suturing an aperture in a vessel wall, comprising:

reversibly advancing a plurality of needles through the vessel wall to form ports in the proximity of the aperture;

passing at least a portion of a suture proximally through the ports in the vessel wall disposed on opposite sides of the aperture from the interior of the vessel with the remaining portion of the suture passing out of the vessel; and

securing the ends of the suture to close the aperture.

9. The method as inclaim 8, further comprising:

passing the suture portion through the ports as a continuous loop with two ends.

10. The method as inclaim 8, further comprising:

passing the suture portion through the ports by passing at least a portion of a pair of needles therethrough while carrying the suture portion therebetween.

11. The method as inclaim 10, further comprising:

carrying the suture portion between the pair of needles as a continuous length.

12. The method as inclaim 8, further comprising:

passing the needles from the exterior of the vessel, through the ports in the vascular tissue, and external of the vessel so that at least a portion of the suture is external to the vessel.

13. The method as inclaim 8, further comprising:

removing the suture portion from the needles after removing the needles from the vessel.

14. The method as inclaim 8, wherein the portions of the suture are secured over the wall of the vessel to close an aperture.

15. The method as inclaim 8, wherein the portions of the suture are secured to contact the vessel wall with a graft in an anastomosis procedure.

16. A method of suturing an opening in a vessel wall, comprising:

positioning opposite ends of a length of suture within the vessel;

puncturing holes through the vessel wall with a pair of needles; and

pulling the opposite ends of the length of suture through the vessel wall, wherein each needle pulls an end of the length of suture in a proximal direction through the holes in the vessel wall.

17. The method ofclaim 16, further comprising:

tying the opposite ends of the length of suture to close an opening in the vessel wall.

18. The method ofclaim 16, wherein the opposite ends of the suture loop are positioned within the vessel by:

supporting the opposite ends of the length of suture on a distal end of an elongated member; and

advancing the elongated member through the opening in the vessel wall such that the distal end of the elongated member is positioned within the vessel.

19. The method ofclaim 18, wherein each of the pair of needles moves in a path which is radially angled to the elongated member as the needles pass through the vessel wall.

20. The method ofclaim 18, wherein the ends of the needles move radially outwardly from the elongated member prior to passing through the vessel wall.

21. The method ofclaim 16, wherein each needle has a barbed tip.

22. The method ofclaim 16, wherein the holes are disposed longitudinally along the length of the vessel wall.

23. The method ofclaim 16, wherein the holes are disposed transversely across the width of the vessel wall.

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