US 20080287967 A1
Systems for suturing a tissue layer having two sides with a suture be 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.
1. A device for closing an opening in tissue, the device comprising:
an elongated body having a proximal end and a distal end, a flexible sheath extending from the distal end of the elongated body and carrying a length of suture, with a cuff molded on an end of the length of suture, to close the opening in the tissue, the length of suture being deployable to penetrate the tissue wall, the elongated body being advanceable toward the opening along a guidewire to position the length of suture substantially adjacent the opening, and further comprising at least one needle advanceable through tissue surrounding the opening to deploy the length of suture through the tissue wall, the cuff having an inner space adapted to receive a tip of one needle of the at least one needle following advancement of the at least one needle through the tissue.
2. The device of
3. The device of
4. The device of
5. The device of
6. A device for closing an opening in tissue, the device comprising:
a shaft having a proximal end and a distal end;
a foot near the distal end of the shaft;
a length of suture having an end and a cuff molded on the end of the suture, the cuff being releasably retained in the foot; and
at least one needle arranged on the device to be advanceable through the tissue surrounding the opening, the needle having a barbed end for insertion through the cuff to attach the needle to the suture to draw the suture through the tissue, the cuff having an inner space adapted to receive a tip of one needle of the at least one needle following advancement of the at least one needle through the tissue.
7. The device of
8. The device of
9. The device of
10. The device of
11. A method for closing an opening in tissue, the method comprising:
advancing an elongated body, the elongated body having a proximal end, a distal end, at least one needle, and a flexible sheath extending from the distal end of the elongated body and carrying a length of suture with a cuff molded on an end of the length of suture, along a guidewire to position the length of suture substantially adjacent the opening,
advancing the at least one needle through tissue surrounding the opening; and
deploying the length of suture through the tissue wall, the cuff having an inner space adapted to receive a tip of one needle of the at least one needle following advancement of the at least one needle through the tissue through the opening.
12. The method of
13. The method of
14. The method of
15. The method of
16. A method for closing an opening in tissue, the method comprising:
providing a suturing device having a shaft, the shaft having a distal end;
advancing at least a portion the shaft through the opening;
positioning a length of suture on a distal side of the tissue, the suture having an end and a molded cuff on the end of the suture;
advancing a needle through the tissue adjacent the opening and through the cuff to attach the needle to the length of suture; and
withdrawing the needle and the suture through the tissue.
17. The method of
18. The method of
19. The method of
20. The method of
21. A method for closing an opening in tissue, the method comprising:
inserting a guidewire through the opening in the tissue;
providing a closing device adapted to penetrate the tissue and permit closing of the opening carrying an implant with a cuff molded on an end of the implant;
using the guidewire to guide a portion of the closing device to a position substantially adjacent the opening; and
penetrating the tissue to at least partially close the opening.
22. The method of
23. The method of
24. The method of
25. The method of
positioning a portion of the suture on a distal side of the tissue, the molded cuff releasably retained on the closing device;
advancing the needle through the tissue adjacent the opening and through the cuff to attach the needle to the length of suture; and
withdrawing the needle and the suture through the tissue.
This application is a continuation of U.S. patent application Ser. No. 10/737,668, filed Dec. 16, 2003, which is a continuation of U.S. patent application Ser. No. 10/033,689, filed Dec. 28, 2001, which is a continuation of U.S. patent application Ser. No. 08/883,246, filed Jun. 26, 1997, now U.S. Pat. No. 6,355,050, which is a continuation-in-part of U.S. patent application Ser. No. 08/824,031, filed Mar. 26, 1997, now U.S. Pat. No. 6,036,699, which is a continuation-in-part of U.S. patent application Ser. No. 08/259,410, filed Jun. 14, 1994, now U.S. Pat. No. 5,779,719, which is a divisional and a continuation-in-part of U.S. application Ser. No. 07/989,611, filed Dec. 10, 1992, now U.S. Pat. No. 5,417,699. The disclosures of these prior applications are hereby incorporated by reference in their entirety.
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.
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.
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.
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.
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.
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. Attentively, 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.
Coronary Artery Bypass Graft 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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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 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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
In the drawings, which comprise a portion of this disclosure but are not to scale:
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.
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.
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.
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.
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.
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.
The term “suturing” is herein intended to include the process of joining two surfaces or edges together with a fasten r 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, VELCROC, buttons, and other coupling members.
The device 400 comprises a guide body 402 and a needle shaft 404. The guide body 402 includes a guide tip 406 at its distal end, which guide tip includes a plurality of guide channels 408 which receive the proximal ends of needles 410. An aligning arrow 403 is mounted on handle 405 located at the proximal end of the guide body 402. A marker lumen bubble 407 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. An indicator lumen 411 which permits the flow of blood to the marker lumen bubble 407 is illustrated in
The needles 410 as illustrated comprise a sharpened tip section 412 and an elongate shank portion 414, but may also be manufactured as an integral piece. The shank portion 414 will be sufficiently long so that the needles may be pushed from their butt end by a support holster 428 fixedly attached to the needle shaft 404 in order to advance the needles through the tissue to be sutured and fully through the guide body 402 inserted together with support sheath 440 in the associated tract so that no capture mechanism will be required.
The guide body 402 further includes a plurality of needle lumens 420 which are axially aligned and spaced about the periphery of the guide body. As best seen in
A flexible needle sheath 426 will be attached to the guide tip 406 of guide body 402. The central lumen of the needle sheath 426 receives a support holster 428 attached to the distal end of the needle shaft 404, as well as the needles 410. As with previous embodiments, the butts of the needles 410 are removably received within the support holster 428. The sheath 426 will be sufficiently long to permit the needles to extend at least 5 cm beyond the distal end of guide body 402.
Prior to use, the suture applying device 400 will be in the configuration illustrated in
After the guide tip 406 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 on handle 430 at the proximal end of needle shaft 404. The method of the present invention will now be described in more detail with reference to
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
It can be seen that the guide tip 406 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 the support sheath 440, the resulting pattern of tied suture will appear as in
Device 400 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. The guide body 402 and guide tip 406 are designed as an integral structure to assure that needles 410 will be precisely centered around the puncture site A, and will very reliably enter the needle lumens 420 in guide body 402. Also, tip 406 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.
A preferred embodiment of one component for the graft anastomosis assembly is a tissue suturing device 10 shown in
The tissue suturing device 10 includes an elongated body 16 having a distal end 18 and proximal end 20. Referring specifically to
The actuating mechanism 30 includes a cam 32 which is rotatably secured to the elongated body 16 by a fastener 34. The cam 32 is integrally formed with the hand grip 22 and pivots in the directions indicated by arrows 36 using the fastener 34 as the pivot point. The cam 32 includes a slot 38 located between the hand grip 22 and the fastener 34 and extending through the cam itself. The cam 32 slidably connects to the proximal end 40 of the needle carrier 24 by engaging a peg 42 which is affixed to the needle carrier 24 and extends perpendicularly therefrom. Moving the hand grip 22 in the direction of the arrows 36, pivots the cam 32 and slides the peg 42 along the slot 38. As a result, the needle carrier 24 travels along the shaft 28 within the elongated body 16 and reversibly moves the distal end 44 of the needle carrier toward the foot 26.
As specifically illustrated in
Although one embodiment of the cutting blade 46 and the actuating mechanism 30 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 distal end 44 of the needle carrier includes a plurality of needles 56 attached thereto and extending in a generally perpendicular direction. The needles 56 are arranged in a predetermined pattern which matches a desired corresponding suture pattern 58 (as seen in
The foot 26 has a top surface 60 and an opposing bottom surface 62 as seen in
Each of the suture channels 72 in the foot are sized to releasably retain a suture 74 having a suture body or length 78 terminating at one end 76. Preferably, the end 76 of the suture is releasably retained in one of the suture channels 72. As illustrated in
Although a plurality of needles 56 are illustrated on the needle carrier 24 in a one-to-one correspondence with the suture channels 72 on the foot 26, 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 the shaft 28. Rather than having the needles deploy simultaneously with a single stroke, a multi-stroke, successive deployment is used.
The longitudinal slot 86 allows the removal of the foot 26 from the aperture completed 52 in the tissue wall 12 and the subsequent removal of the suture lengths 78 so that each end, 76 and 94, of the sutures can be fastened together. In an alternate embodiment, the suture lengths 78 extend internally along the length of the elongated body 16 toward the proximal end 20. A seam 98 along the length of the elongated body 16 connects to the end of the longitudinal slot 86 so that the elongated body can be split open to remove the suture lengths 78 once the suture pattern 58 has been completed. The longitudinal slot 86 itself can also be replaced with a seam to similarly split the shaft 28, foot 26, and needle carrier 24 to remove the suture lengths 78 from the lumen 80.
Preferably, the suture pattern 58 is a uniform distance from the perimeter of the completed aperture 52 in the tissue wall. Usually, the initial aperture 52 is a simple longitudinal incision. Preferably, the present invention adjusts for the distance which the tissue wall 12 surrounding the shaft 28 is offset. As illustrated in
The needles 56 on the surface of the distal end 44 of the needle carrier which correspond to the offset suture channels 106, 108 on the foot are similarly offset. The surface of the distal end 44 of the needle carrier in the vicinity of the shaft 28 is offset or bulges in a similar pattern as the opposing side walls 100 of the foot.
In those operations where the initial aperture 52 is formed by incising the tissue wall 12 or punching a hole of a size approximating the diameter of the shaft 28 in the tissue wall, there is significantly less offset of the tissue wall in the vicinity of the shaft. As a result, a nearly uniform suture pattern 58 is formed without the foot 26 having offset suture channels. As illustrated in
As illustrated in
The foot 26 can also have several cross-sectional configurations as illustrated in
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.
Turning now to
As specifically illustrated by
For the sake of example, and not to be limited thereby, the preferred dimensions of the needle 56 are in a range of about a 0.01 inch to about a 0.02 inch needle shaft 132 diameter which decreases to a diameter of about 0.005 inch in a tapered section 134. The length of the tapered section 134 at the narrowest diameter is about 0.005 inch with an overall length of about 0.013 inch. The diameter of the arrowhead barb 130 is in the range of about 0.007 to about 0.008 inch. The height of the arrowhead barb 130 is in the range of about 0.010 inch to about 0.014 inch. The height of the interior side of the side wall 122 is about 0.02 inch with the cuff 116 having an overall height of about 0.03 inch. The diameter of the interior space 120 from the interior side of the side wall 122 is about 0.005 inch. The thickness of the side wall 122 is about 0.0025 inch and the bottom wall 118 is about 0.01 inch. The dimensions of each suture channel 72 in the foot 26 for this particular example have an interior diameter at the top surface 60 of the foot of about 0.011 inch.
The suture cuff 116 is preferably welded to the suture length 78 or molded as one-piece from polypropylene. The cuff 116 can be made from other medical polymers or malleable metals with a preferred hardness to provide the retaining force by allowing the arrowhead barb 130 of a needle 56 to deflect and bias the side wall 122 of the cuff against itself and/or allow the barbs 130 of a needle to penetrate the side wall 122 of the cuff.
Other means of attaching the suture length 78 to the cuff 116 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 the exterior side 118 of the bottom wall and crimping the suture length therein. In another embodiment, the bottom wall 124 of the cuff can be made of the same, or different, polymer which exhibits a surface hardness sufficient to resist penetration of the tip 128 and provide a backstop preventing excessive penetration. The cuff 116 may also be initially molded as a solid block and subsequently bore an interior space 120 into the solid block to complete the cuff.
Preferably, the suture length 78 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. The cuff 116 is also preferably removable from the suture length 78. 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 suture end 76. Illustrated for the sake of example, and not for limitation,
The suture end 76 of
The suture end 76 of
The suture end 76 of
Other configurations of the retrieving device provided by the present invention are illustrated for example, and not limitation, in
Specifically, another configuration suitable for impaling the suture-end is illustrated in
Another example of a retrieving device is illustrated in
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
The present invention is not limited to retrieving a suture only at its end. As illustrated in
The suture length-cuff attachment illustrated in
As illustrated in
Another embodiment of the inventive tissue suturing device 310 is shown in
The foot 326 has a top surface 360 facing the distal end 344 of the needle carrier and an opposing bottom surface 362. Located on the top surface 360 is a plurality of suture channels 372 extending at least partially into the depth of the foot. The pattern of the suture channels 372 on the top surface corresponds to the pattern of needles 356 on the distal end 344 of the needle carrier. As the distal end 344 of the needle carrier slides along the shaft 328 towards the foot, the needles 356 on the distal end have sufficient height relative to the length of travel by the needle carrier 324 to penetrate the suture channels 372.
Each of the suture channels 372 in the foot are sized to allow insertion by the tip 380 of the needles. The top surface 360 releasably retains the sutures, preferably loops 382 formed by one or more of the sutures. A plurality of suture lengths 378 extend downward through grooves 384 in the shaft emerging along the top surface 360 of the foot to be positioned within one of a plurality of suture grooves 386 within the top surface of the foot. Each suture groove 386 extends at least partially from the grooves on the shaft to a respective channel 372. The depth of each suture groove 386 is sufficient to accommodate the width of the suture to provide an approximately flush profile to the top surface 360. Each suture length 378 extends to the respective channel 372 where it is releasably retained near the top surface 360 of the foot. Although it is preferred to position the suture length 378 approximately flush with the top surface 360 of the foot, it is suitable for the suture length 378 to be in any position where it can be retrieved by the corresponding needle 356 when the actuating mechanism squeezes the foot 326 and distal end 344 of the needle carrier together.
As specifically shown in
Other embodiments of retaining the suture length 378 in the suture channel 372 are shown in
As specifically shown in
Although the embodiments of the tissue suturing device discussed above show the needles 358 penetrating the tissue layer from a perpendicular direction into a foot having a flat or planar top surface 360, the present invention is not so limited. Another embodiment 510 of the inventive tissue suturing device is shown in
The foot 526 has a curved top surface 560 facing the distal end 544 of the needle carrier and a curved opposing bottom surface 562. Located on the top surface 560 is a plurality of suture channels 572 extending at least partially into the depth of the foot 526. The pattern of the suture channels 572 on the top surface 560 corresponds to the pattern of needles on the distal end 544 of the needle carrier. As the distal end 544 of the needle carrier slides along the shaft 528 allowing the foot 526 to travel towards the distal end, the needles 556 on the distal end have sufficient height relative to the length of travel by the foot to penetrate the suture channels.
Each of the channels 572 in the foot are sized to allow insertion by the tip 580 of the needles. A plurality of suture lengths 578 extend downward through grooves 584 in the shaft emerging along the top surface 560 of the foot to be positioned within one of a plurality of suture grooves within the top surface of the foot. Each suture length 578 is positioned where it can be retrieved by the corresponding needle 556 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 tissue suturing device 610 is illustrated in
The graft needle carrier 724 includes a distal end 744 having a mounting surface with an integral cutting blade 746 thereon. The cutting blade 746 has a circular shape. The distal end 744 of the needle carrier includes a plurality of graft needles 756 attached thereto and extending in a generally perpendicular direction. The graft needles 756 are arranged in a predetermined pattern which matches a corresponding graft suture pattern 758. The graft needles 756 are positioned at approximately uniform intervals around the circumference of the wall of the graft end 782 (as seen in
Another suitable embodiment of the cutting blade 746 preferably has a decreasing depth profile forming a decreasing gradient or slant from the one side of the graft needle carrier 724. The decreasing gradient allows the end of the cutting blade edge to engage and cut the graft end 782 in an oblong shape. The edge of the cutting blade makes the cut as the distal end 744 and graft foot 726 are squeezed progressively together. The present invention also includes embodiments wherein the cutting blade 746 has a uniform height across its length. An oblong shape or other desired shape can still be formed with a cutting blade 746 of uniform height by changing the circular shape of the cutting blade on the surface of the distal end 744 to the desired shape.
Referring specifically to
Each of the suture channels 772 in the graft foot are sized to releasably retain a suture length 778, preferably the end 776 of the suture as previously described. Although it is preferred to position the suture end 776 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 corresponding graft needle 756 or other retrieving device or means when the actuating mechanism squeezes the foot and the needle carrier together. The suture lengths 778 extend within a lumen 780 in the graft shaft 728 to the surface of the distal end 744 of the graft needle carrier where a slot in the cutting blade allows the suture lengths 778 to extend to the external side of the elongated body 616 as previously described with regard to the tissue suturing device 610. The graft shaft 728 extends to connect to the shaft 628 of the tissue suturing device or can be integrally made as a one-piece member.
The actuating mechanism 630 connects to the graft needle carrier 724 in the same manner as between the actuating mechanism and the needle carrier 624 of the tissue suturing device 610 in any of the embodiments previously described.
Two other embodiments of a graft suturing devices 810 are shown in
Another embodiment of a graft suturing device 910 is shown in
As illustrated in
Other embodiments of the cam 902 provide means for moving the needles 956 outwardly without using a spring-like member. For example,
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.
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 Mend 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.
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
The remote foot 1026 has a top surface 1060 with a groove 1064 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 circumference 1070 of the top surface 1060 is a plurality of suture channels 1072 extending into the foot 1026. The pattern of the suture channels 1072 on the top surface 1060 corresponds to the pattern of needles on the distal end of the needle carrier that will be attached to the remote foot 1026 at the site where the suture pattern is desired. Each of the suture channels 1072 in the remote foot are sized to releasably retain a suture 1074 having a suture body or length 1078 terminating at one end 1076. Preferably, the end 1076 of the suture is releasably retained in one of the suture channels 1072.
The sutures lengths 1078 extend across the top surface 1060 of the remote foot and to terminate at the bottom of a plug 1006. The plug 1006 releasably retains the ends 1094 of the sutures 1074 opposite the suture ends 1076 retained in the suture channels 1072 so the suture ends 1094 may be individually identified as to their position in the suture pattern and retrieved by the operator. The plug 1006 is detachable from the remote foot by the actuating mechanism 1030. Once the remote foot 1026 has been guided to the desired cite of the suture pattern, the plug 1006 is released from the remote foot by the actuating mechanism 1030 and driven through the tissue wall 1012 of the blood vessel by a releasable connection to a second wire 1009 associated with the guide wires 1004 as seen in
With the release of the plug 1006, a depression 1098 corresponding to the shape of the plug is left in the top surface 1060 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 the initial aperture 1052 into the depression 1098. Attachment of the shaft of the tissue suturing device to the remote foot 1026 provides proper alignment of the needle carrier and needles of the tissue suturing device with the suture channels 1072 of the remote foot.
Optionally, the plug 1006 can be another embodiment of the graft foot previously discussed herein. Referring to
An alternate embodiment of the plug 1006 positions the suture channels 1096 along the longitudinal axis so that suture channels 1072 are flush with the top surface of the plug 1006. With this configuration of suture channels 1072, the plug can be attached to the shaft of a graft suturing device as previously described herein specifically with regard to
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
The suture channels 1172 releasably retain sutures 1174 at one of the ends 1176 while the suture lengths 1178 extend across the top surface 1160 of the remote foot through suture grooves 1184 near the perimeter of the remote foot. The opposite ends 1194 of the sutures terminate in a plug 1106 which is releasably retained flush with the top surface 1160 of the remote foot. One of the needles like 1157 on the needle carrier is aligned to retrieve the plug 1106 and draw it through the tissue layer 1112. After the plug 1106 has been drawn through the tissue layer 1112, the opposite ends 1194 of the sutures can be freed from the plug.
The tissue suturing device 1110 demonstrates that a suture pattern can be deployed at a deployment site 1108 other than the remote access site. Furthermore, the tissue suturing device 1110 does not need an initial aperture at the suture deployment site 1108 in order to deploy the suture pattern. The alignment between the needles 1156 and the suture channels 1172 is provided by the extensions 1102 and 1104 without a shaft extending through an aperture at the deployment site 1108.
Optionally, a cutting blade 1146 can be mounted on the needle carrier 1124 and is positioned to make an incision at the deployment site 1108 to form an anastomosis site different from the remote access site 1100 and not simply enlarge an initial insertion site. The cutting blade 1146 is preferably aligned with the groove 1164 on the top surface 1160 of the remote foot and avoids contact with the suture lengths 1178. Rather than drawing the plug 1106 through a separate port in the tissue layer 1112, the plug 1106 can be drawn through the incision made by the cutting blade 1146.
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.
Even though the suture devices are illustrated herein with regard to vascular tissue, it should be understood that the present invention is riot 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.
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.
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,
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.
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.