US 7662168 B2
An apparatus for closing an aperture comprising a horizontally extending member and elongated strand portions having extremity portions curving inwardly. The extremity portions have shape memory characteristics seeking to cause the extremity portions to curl to retain tissue engaged thereby when delivered from a delivery member. A central portion extends between the horizontally extending member and the elongated strand portions.
1. A surgical apparatus for closing a vessel aperture extending through a vessel wall of a patient comprising:
a. a horizontally extending member having first and second end portions and an intermediate portion, the horizontally extending member adapted to be positioned on a first side of the vessel aperture internal of the patient;
b. elongated strand portions having extremity portions curving inwardly adapted to be positioned on a second side of the vessel aperture internal of the patient, the extremity portions having shape memory characteristics seeking to cause said extremity portions to curl to retain tissue engaged thereby when delivered from a delivery member and in an unconstrained position, the extremity portions extend in a direction toward the horizontally extending member, each of the strand portions forming a loop; and
c. a central portion having an outer surface and adapted to extend through the vessel wall between the intermediate portion of the horizontally extending member and the elongated strand portions wherein the horizontally extending member extends a further lateral distance from a longitudinal axis of the central portion than a lateral distance the elongated strand portions extend from the longitudinal axis when delivered from the delivery member, the horizontally extending member configured to remain spaced from the strand portions on the first side of the aperture and extending along an axis transverse to the longitudinal axis of the central portion, the strand portions extending from the central portion and curling radially outwardly away from the outer surface of the central portion and curling back toward the outer surface of the central portion forming first and second loops alongside the central portion.
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This application is a continuation of U.S. application Ser. No. 10/269,899, filed Oct. 11, 2002 now U.S. Pat. No. 6,749,622 which is a continuation of application Ser. No. 09/659,648, filed Sep. 12, 2000 now abandoned which claims priority from provisional application No. 60/153,736, filed Sep. 13, 1999.
1. Field of the Invention
This invention relates to methods and apparatus for closing apertures in human and animal tissue and to methods and apparatus for inserting apparatus into such tissue to perform such closure functions.
2. Description of the Prior Art
During certain types of vascular surgery, catheters are inserted through an incision in the skin and underlying tissue to access the femoral artery in the patient's leg. The catheter is then inserted through the access opening made in the wall of the femoral artery and guided through the artery to the desired site to perform surgical procedures such as angioplasty or plaque removal. After the surgical procedure is completed and the catheter is removed from the patient, the access hole must be closed. This is quite difficult not only because of the high blood flow from the artery, but also because there are many layers of tissue that must be penetrated to reach the femoral artery.
Several approaches have used to close femoral access holes. Typically, manual compression by hand over the puncture site can be augmented by a sandbag or weight until the blood coagulates. With this approach it can take up to six hours for the vessel hole to close and for the patient to be able to ambulate. This increases time for the surgical procedure as well as overall cost of the procedure since the hospital staff must physically hold pressure and the patient's discharge is delayed because of the inability to ambulate. This is not an efficient use of either the patient's or staff's time. After some procedures, to close the vessel puncture site a clamp is attached to the operating table and the patient's leg; The clamp applies pressure to the vessel opening. The patient must be monitored to ensure the blood is coagulating, requiring additional time of the hospital staff and increasing cost of the procedure.
To avoid the foregoing disadvantages of manual pressure approaches, suturing devices have been developed. One such suturing device, referred to as “The Closer” and sold by Perclose, advances needles adjacent the vessel wall opening and pulls suture material outwardly through the wall adjacent the opening. The surgeon then ties a knot in the suture, closing the opening. One difficulty with this procedure involves the number of steps required by the surgeon to deploy the needles, capture the suture, withdraw the suture, and tie the knot, and cut the suture. Moreover, the surgeon cannot easily visualize the suture because of the depth of the femoral artery (relative to the skin) and essentially ties the suture knot blindly or blindly slips a pre-fabricated knot into position. Additionally, the ability to tie the knot varies among surgeons; therefore success and accuracy of the hole closure can be dependent on the skill of the surgeon. Yet another disadvantage of this suturing instrument is that the vessel opening is widened for insertion of the instrument, thus creating a bigger opening to close in the case of failure to deliver the closure system.
It would therefore be advantageous to provide an instrument which quickly and accurately closes holes in vessel walls. Such instrument would advantageously avoid the aforementioned time and expense of manual pressure, simplify the steps required to close the opening, and avoid widening of the opening.
The present invention overcomes the disadvantages and deficiencies of the prior art by, in one of its aspects, providing clip apparatus for closing a lumen aperture, particularly a vascular aperture, resulting from insertion of a surgical implement subsequent to completion of an invasive therapeutic procedure and withdrawal of the implement from the aperture where the apparatus includes an elongated strand comprising a central portion together with extremity portions extending from the central portion. The apparatus further involves tips of the extremity portions remote from the central portion being shaped to retain aperture peripheral tissue encountered thereby with the extremity portions having memory characteristics seeking to cause the extremity portions to curl towards and over one another about the central portion when the strand is in an unconstrained disposition, free of externally applied stress. Preferably, the apparatus is deployed in a two stage operation whereby the clip apparatus is initially deployed partially from a delivery apparatus with tips of the extremity portion contacting and the penetrating the interior surface of tissue of the vessel and acts to draw the aperture closed. In a second step the apparatus is fully dispensed from the delivery portion; tips of extremity portion of the apparatus do not penetrate the vessel tissue in the region about the aperture to be closed but act to draw the subcutaneous fascia on top of the outside aspect of the aperture. The two stage deployment of the closure apparatus results in a ratchet-type action by the deployment apparatus thereby providing extreme tactile sensitivity for the physician or other health professional handling the apparatus with resulting high sensitivity to the location of the apparatus and greater safety for the patient than otherwise possible.
In another of its aspects, this invention provides clip apparatus for closing a aperture, particularly a vascular aperture resulting from insertion of a surgical implement, into subsequent to completion of an invasive therapeutic procedure and withdrawal of the implement from the resulting aperture. In this aspect of the invention, the apparatus includes a plurality of elongated strands with each strand including a central portion and extremity portions extending from the central portion. Tips of the extremity portions remote from the central portion are shaped to retain aperture peripheral tissue encountered thereby. The extremity portions have memory characteristics seeking to cause the extremity portions to curl towards and about the central portion when the strand is in an unconstrained disposition, free of externally applied stress.
The clip apparatus may further include a band circumferentially enveloping the strands proximate the longitudinal midpoints of the strands for retaining the strand midpoints in close proximity to one another as the tip portions curl towards and about the midpoints. The band is preferably bonded to the strands.
The clip apparatus may further include a longitudinally elongated member extending from the central portions of grouped strands substantially in the longitudinal direction with respect thereto for facilitating gripping and guiding the strand portions of the clip member. The longitudinally elongated member is preferably rigid relative to the strand members.
In yet another of its aspects this invention provides a clip formed from a one piece integral strand, serving to close a lumen aperture such as a vascular aperture resulting from the insertion of a surgical instrument, where the clip includes an elongated strand of ribbon-like configuration having a central portion and extremity portions extending in opposite directions from the central portion. The central portion assumes a linear configuration and the extremity portions extending from the central portion assume configurations in which first parts of the extremity portions proximate the central portion curve towards one another and towards the central portion and second parts of the extremity portions relatively more remote from the central portion curve away from one another and from the central portion to position arcuate tips of the extremity portion sufficiently skew to the central portion that tissue around the periphery of the aperture which is punctured by the extremity portions is retained between the tip portions as the clip relaxes.
In yet another of its aspects this invention provides apparatus for closing an aperture such as a vascular aperture resulting from insertion of a surgical instrument into where the apparatus includes a telescoping tubular housing and clip apparatus resident within the housing for closing the aperture. In this aspect of the invention, the clip apparatus preferably includes a plurality of elongated strands with each strand having a central portion and extremity portions extending from the central portion. Tips of the extremity portions remote from the central portion are shaped to retain aperture peripheral tissue encountered thereby. The extremity portions have memory characteristics seeking to cause the extremity portions to curl towards and about the central portion of a respective strand when the strand is in an unconstrained disposition, free of externally applied stress.
In this aspect of the invention, the clip preferably further includes a band circumferentially enveloping the strands proximate the longitudinal midpoints thereof for retaining the strand midpoints in close proximity to one another as the tip portions curl towards and about the midpoints. In this aspect of the invention, the clip preferably further includes a longitudinally elongated member extending from the central portions of the strands substantially in the longitudinal direction with respect thereto and serving to facilitate gripping and guiding of the strand portions of the clip member. The strands, the band and the longitudinally elongated member are preferably bonded together integrally and reside in a housing. The housing is operable to dispense the clip from one end upon relative movement between telescoping sections of the housing.
In another aspect of the invention the housing may be tubular but not telescoping.
When the housing is telescoping, the housing may include at least two (2) telescoping sections and may operate to dispense the clip in a two (2) stage operation in which first relative movement between the telescoping sections results in a first portion of the clip being dispensed from the housing and additional relative movement between the telescoping section results in the remaining portion of the clip being dispensed from the housing.
In this aspect of the invention, the clip may further include a filament, positioned within the housing, connecting the clip to the housing with the filament preferably being connected to a longitudinal member portion of the clip. The filament is preferably flexible.
In this aspect of the invention, the longitudinal member portion of the clip preferably includes a loop formed therein thereby presenting a transverse passageway through the longitudinal member.
The housing preferably further includes a safety member for precluding second telescoping movement of the telescoping sections of the housing after the first telescoping movement until a safety member has been released.
In yet another of its aspects, this invention embraces a method for closing a vascular or other aperture resulting from, for example, insertion of the surgical implement thereinto subsequent to the completion of invasive therapeutic procedure and withdrawal of the implement from the aperture. The method includes providing an elongated strand comprising a central portion and extremity portions extending from the central portion with tips of the extremity portions remote from the central portion being shaped to retain aperture peripheral tissue encountered thereby with the extremity portions having memory characteristics seeking to cause the extremity portions to curl towards and over one another about the central portions when the strand is in an unconstrained disposition, free of externally applied stress.
The method further embraces dispensing the elongated strand from a tubular housing partially into the lumen aperture sufficiently far for the dispensed portion, consisting of the strand from an extremity to a central portion, to curl about and towards the strand central portion thereby to encounter tissue positioned immediately about the periphery of the aperture and to draw the aperture peripheral tissue radially inwardly relative to a longitudinal axis of the strand. In this aspect of the invention the method further embraces dispensing the remaining portion of the strand from a housing thereby permitting the remaining portion of the strand, from the central portion to a second strand extremity, to curl about and towards the central to of the vessel and drawing surrounding subcutaneous fascia radially inwardly relative to the longitudinal axis of the strand thereby substantially augmenting closure of the vessel, puncture site of the vessel external compression.
In yet another of its aspects this invention in a preferred embodiment provides clip apparatus for closing an aperture in tissue where the apparatus includes a first portion forming an arc, a second portion extending transversely from the first portion relative to the arc and a third portion extending from the second portion remotely from the first portion, with the third portion curving progressively relative to the second portion initially towards the first portion and then towards the second portion with a tip of the third portion being adapted for piercing and retaining tissue encountered thereby. In this aspect the invention further preferably includes at least two third portions extending from the second portion at a common position with the third portions curving progressively first towards the first portion and then towards the second portion and each other.
In this aspect the invention may further embrace clip apparatus having a pair of second portions respectively connected to parts of the first portion separated by the arc and extending transversely to the arc in a common direction relative thereto with a pair of third portions extending from respective ones of the second portions, curving progressively first towards the first portion and then simultaneously towards the second portion and each other.
In this aspect of the invention extremities of the third portions desirably contact the second portions, the second portions are preferably linear and the curved segments of the third portions are preferably separated by linear segments.
In this aspect of the invention the first portion is preferably configured as a figure eight.
In this aspect of the invention the second portion preferably extends away from the first portion perpendicularly to a plane of the arc.
When the first portion is configured as a figure eight the second portion preferably extends away from the center of the figure eight configuration.
In this aspect of the invention the first portion further preferably has at least two arcs separated by a straight segment. Further, at least one of the arcs preferably subtends an angle of greater than one hundred eighty degrees.
Still further, the arcs preferably each have straight segments adjoining the ends of the arcs and connecting with the second portions. In this aspect of the invention both of the arcs preferably subtend an angle of greater than one hundred eighty degrees. The second portions are preferably straight and the linear segments of the third portions are preferably straight.
In another aspect this invention provides apparatus for closing an aperture in tissue where the apparatus includes an elongated unitary strand having a central portion and extremity portions extending from the central portion. Tips of the extremity portions remote from the central portion are preferably pointed to engage and retain tissue encountered thereby. The strand is preferably configured so that the tips are at ends of respective curved portions and face towards one another when the clip is in an unconstrained state, free of internal stresses. The strand preferably has a memory characteristic causing the clip, when unconstrained, to seek to return to an unstressed state with the tips seeking to draw together sufficiently to retain tissue engaged by the tips for closing the aperture and retaining the subcutaneous tissue at the exterior surface of the aperture causing external compression by the tips.
In this aspect of the invention the strand preferably further includes a pair of mid-portions intermediate the tips and the central portion with the central portion disposed in a first plane and the mid-portion disposed in a plane transverse to the first plane. The mid-portion preferably has a linear part connected to the central portion and extending transversely therefrom.
Preferably, the central portion is configured to have at least one loop subtending an angle of at least about 180 degrees.
In this aspect of the invention the loop is preferably closed by overlap of the strand upon itself, the central portion preferably lies in a plane, the extremity portions are preferably in a plane transverse to the plane of the central portion and the tips are preferably at ends of the curved portions of the strand, with the tips being closer to the central portion than to the curved portions of the strand supporting the tips.
In this aspect of the invention an upper portion of the apparatus is preferably configured as a figure eight. This apparatus aspect of the invention further has the strand preferably having a mid-portion intermediate the tips and the central portion, extending transversely to the central portion with the tips facingly opposing one another on either side of the mid-portion and pointing away from the central portion in a common direction. The mid-portion is preferably perpendicular to the central portion; the central portion preferably includes a plurality of loops.
In this aspect of the invention the strand is preferably metal and is most preferably a filament. The strand may include at least two filaments.
In this apparatus aspect of the invention the central portion may include at least two preferably co-planar loops.
In another aspect, this invention provides apparatus for inserting a surgical clip which is housed therewithin into tissue to close an aperture in the tissue where the apparatus includes a first handle portion housing a tubular member and having a hand grip extending transversely therefrom where the tubular member is connected to the handle portion and extends generally longitudinally from the handle portion. Surgical clip positioning means are preferably provided at a distal end of the tubular member remote from the handle. A clip loading wire is preferably provided looping around the clip, residing at least partially within the tubular member at a distal end thereof, extending along the length of the tubular member and exiting from the handle portion at a proximate end of the tubular member. The apparatus preferably further includes a clip pusher member movable axially within the tubular member through a range of motion from a first through an intermediate to a second position for displacing the clip from within the tubular member in two stages. The clip is housed within the apparatus and is ready for insertion into the lumen when the pusher member is at the first position. The clip extends partially from the tubular member when the pusher member is at the intermediate position; the clip is separated from the apparatus and presumably within the tissue of interest closing the targeted aperture when the pusher member is at the second position.
In this aspect of the invention the surgical clip insertion apparatus preferably further includes a ring connected to the wire with the ring being detachably mounted on the handle portion at the proximate end of the tubular member. The ring facilitates hand powered movement of the loading wire to draw the clip at least partially into the tubular member.
Preferably in this aspect of the invention the clip positioning means serves to position the clip angularly within the tubular member; most desirably the clip positioning means are slots formed in the tubular member with the slots communicating with the distal end of the tube. Most desirably the slots correspond in number to the number of tissue penetrating points of the surgical clip housed within the apparatus. Further desirably the clip positioning means served to position the surgical clip longitudinally within the tubular member.
In yet another aspect the invention provides apparatus for inserting a surgical clip into tissue to close an aperture in tissue where the apparatus includes a first handle portion, a tubular member connected to the handle portion and extending generally transversely therefrom, a clip loading member pivotally connected to the tubular member and moveable between positions at which the clip is loaded into the apparatus and at which the clip is housed within the apparatus and ready for insertion into the tissue and a clip trigger member which is moveably axially within the tubular member through a range of motion from a first through an intermediate to a second position for displacing the clip from the tubular member in two stages. The clip is desirably housed within the apparatus and ready for insertion into tissue when the trigger is at the first position. The clip preferably extends partially from the tubular member when the trigger is at the second position. The clip is preferably separated from the apparatus and presumably inserted into tissue and closing the aperture of interest when the trigger is at the third position.
This invention provides apparatus and methods for closing a tissue aperture, particularly a vascular or vessel (the two terms being used interchangeably herein) aperture, resulting from insertion of a surgical implement or from accidental trauma or from disease. The invention embraces both apparatus and method aspects of devices for closing a vascular aperture and apparatus and method aspects of second devices for delivering the closure apparatus into the aperture being closed. The closure apparatus preferably has at least a portion formed of a memory material, preferably metal, which, when deformed from its stress-free state, seeks to return to the stress-free state. The stress-free state corresponds to the state at which the apparatus has closed an aperture in a vessel. In conjunction with the delivery apparatus of the invention, the closure apparatus provides a two-step, ratchet-like action closing the aperture of interest while acting to draw a subcutaneous tissue exterior to the vessel towards the aperture simulating manual compression.
In the drawings tissue closure clips in accordance with the invention are designated generally 10. Four different embodiments of the invention are respectively identified 10-1, 10-2, 10-3 and 10-4 in the drawings. The embodiment of the tissue closure clip identified as 10-1 in
In the first embodiment in which the clip is designated generally 10-1 a central portion 14 leads into a pair of upper horizontally extending side arms 30 and into two lower elongated strand portions 12 that function to at least contact and preferably pierce the vessel wall and close the aperture.
In the drawings and particularly in
Clip 10-1 is preferably formed from a single strand of material and hence includes two third portions 206 formed at respective ends of the strand. Each third portion 206 includes a transition portion 24, a central segment 26, a transition portion 28 and a tip 18, all as illustrated in
Still referring to the same drawing figures and particularly to
Clip 10-1 is preferably memory metal and has an unstrained conformation illustrated in
Central portion 14 is coincident with a central vertical axis designated A and drawn in
Preferably, angular expansion of horizontally extending side arms 30 from the central midpoint within the
As is apparent from
Lateral extremities of upper half 64 preferably are about 0.037 inches below the center of upper half 64, namely crossover junctures 36, as indicated by dimensional indicator E in
Lower half 66 includes a part of central portions 14-1 extending leading into elongated portions of strand 12-1 which define third portion 26-1 and function to pierce the tissue of vessel 11, closing the aperture. Referring to
Transition junctures 22 lead to straight segments 23 which in turn lead to the beginning of outwardly curved portions 32 of horizontally extending side arms 30, all being a part of first portion 200. Two outwardly curved portions 32 preferably extend horizontally and hence transversely with respect to preferably vertical central portion 14 to define horizontally extending side arms 30 wherein transition portions 34 define the radial outward extremities of curved portions 32.
As illustrated in
A front end 52 of a suitable clip delivery member 20 is depicted in
In the event the physician or other attending health professional wishes to reposition clip 10-1 in the midst of the procedure, the physician or other attending health professional may draw clip 10-1 back into tube 55 in the direction indicated by arrow B in
Grooves 58 in front end 52 of clip delivery member 20 guide third portions 206, which normally extend horizontally when clip 10-1 is deployed and has relieved itself of internal stresses, when the clip is loaded into delivery member 20. Movement of clip 10-1 is depicted by an arrow within ejection chamber 56 denoting the downward direction of ejection of clip 10-1 from ejection chamber 56.
An enlarged view of front end 52 of clip delivery member 20 shown in
Deployment of clip 10-1 from within ejection chamber 56 into a vessel is depicted in
As apparent from
Tips 18 may penetrate exterior surface tissue 13 of a vessel 11 without passing entirely through the tissue of vessel 11. Alternatively, tips 18 may penetrate entirely through vessel 11 or other tissue in which an aperture is to be closed with the tips extending out of the exterior of the vessel or other tissue in which an aperture is to be closed. As yet another alternative, tips 18 may be dull and serve only to press against the surface of tissue surrounding an aperture to be closed, with 18 tips serving to draw the tissue together without penetration of the tissue by tips 18. The clip may be provided with tips 18 sharpened or dull depending upon the clinical used for the particular clip of interest.
Referring again to
Still referring to
An upper end of base portion 78 transitions to mid-stem support piece 82 through juncture 80. Mid-stem support piece 82 transitions to top stem closure piece 86 through juncture 84. Stem 76 is the anchor for extending portions 89. Generally, each of four curved extending portions 89 extend in a linear upwardly direction out of piece 90 and are coincident with each other at a position of tangency 91.
Areas of transition 94 define transition from upwardly and outwardly curved portions 92 to peak central portions 96 wherein peak central portions 96 define the parts of curved extending portions farthest from exterior surface of curved saddle portion 75. Peak central portions 96 transition into outwardly and downwardly curved portions 98 which in turn transition to outwardly curved portions 100 defining the portion farthest from piece 90. Outwardly curved portions 100 transition into inwardly curved portions 102 thereby transitioning to front end portions 104 terminating in tips 106. Preferably tips 106 comprise a sharp point to pierce tissue surrounding the aperture to be closed. Exterior surface 120 of saddle 75 meets juncture segment 74 defining commencement of stem 76.
Saddle portion 75 has a circular periphery and a configuration in which two opposing sides curve downwardly with transition portions 116 being lower than transition portions 118.
Preferably, to form the saddle configuration the sides of saddle portion 75 curve downwardly to transition portions 116, continue therethrough to upwardly curved portions 115 and then to transition portions 118.
As apparent from
Elongated strands 12-3 preferably extend upwardly and downwardly from central region 19-3; band 21-3 retains central portion 14-3 of elongated strands 12-3. Elongated strands 12-3 curve outwardly from central portion 14-3.
A longitudinally extending load wire loop 210 preferably extends from within central region 19-3 and is constrained by band 21-3. Loading wire 54 loops through loop 210 to draw medical clip 10-3 into ejection chamber 56-3.
Referring now to
Preferably, side arms 50 extend outwardly, perpendicular to longitudinally extending chamber 38, facilitating manual “firing” of clip 10 and manual aim of clip delivery member 20. Side arms 50 may be grasped by an operator, using the fingers while the thumb may be used to “fire” push rod 44 with firing button 48.
An expanded view of an optionally configured front end 52 of clip delivery member 20 illustrated in
Push rod 44 ejects clip 10-1 by urging the upper portion 64 of clip 10-1 downwardly out of ejection chamber 56.
Clip 10-1 facilitates rapid closure of a tissue aperture. Preferably, clip 10-1 is constructed of memory metal and when unconstrained assumes the configuration illustrated in
In another aspect of the invention an optional front end 52 of a preferred embodiment of clip delivery member 12 is depicted in
Side chambers 128 contain strips 130 of memory metal that may extend through apertures 126 located on opposite sides of tube 55 equidistant from each other within front end 52 of clip delivery member 12.
Ejection of clip 10 may be accomplished with or without loops 140.
In operation, medical clip 10 returns to the unconstrained configuration rapidly to seal the aperture with minimal discomfort to the patient.
Clip 10-4 is further preferably fabricated with the radii of the arcs defining transition portion 24-4 between second portion 202-4 and forming the transition thereof into third portion 206-4 is formed preferably having a radius of about 0.048 inches as indicated by arrow CC in
Clip 104 illustrated in
Clip 104 is further preferably fabricated such that clip 10-4 has an overall height of about 0.206 inches as indicated by dimensional indicator FF in FIG. 28. Clip 10-4 is further preferably fabricated having a distance from the underlying surface of first portion 200 to a locale of transition between central portion 14 and third portion 206 as indicated by dimensional indicator GG in
While the invention has been described with respect to closing apertures and vessels, the invention is not limited to this. Specifically, the invention has applicability to closing laparoscopic portals, to pistula which are leaks in the bowel to closing holes in the heart to dealing with froamen ovals, congenital holes, ventricular central defects, arterial central defects and other apertures in the aorta and associated pulmonary arteries and veins.
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