US20070233163A1 - Anastomosis System with Cutting Element - Google Patents
Anastomosis System with Cutting Element Download PDFInfo
- Publication number
- US20070233163A1 US20070233163A1 US11/756,260 US75626007A US2007233163A1 US 20070233163 A1 US20070233163 A1 US 20070233163A1 US 75626007 A US75626007 A US 75626007A US 2007233163 A1 US2007233163 A1 US 2007233163A1
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- United States
- Prior art keywords
- target vessel
- anvil
- cutter
- vessel
- wall
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- Abandoned
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/11—Surgical instruments, devices or methods, e.g. tourniquets for performing anastomosis; Buttons for anastomosis
- A61B17/115—Staplers for performing anastomosis in a single operation
- A61B17/1152—Staplers for performing anastomosis in a single operation applying the staples on the outside of the lumen
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/04—Surgical instruments, devices or methods, e.g. tourniquets for suturing wounds; Holders or packages for needles or suture materials
- A61B17/0469—Suturing instruments for use in minimally invasive surgery, e.g. endoscopic surgery
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/068—Surgical staplers, e.g. containing multiple staples or clamps
- A61B17/072—Surgical staplers, e.g. containing multiple staples or clamps for applying a row of staples in a single action, e.g. the staples being applied simultaneously
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/12—Surgical instruments, devices or methods, e.g. tourniquets for ligaturing or otherwise compressing tubular parts of the body, e.g. blood vessels, umbilical cord
- A61B17/122—Clamps or clips, e.g. for the umbilical cord
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/00234—Surgical instruments, devices or methods, e.g. tourniquets for minimally invasive surgery
- A61B2017/00238—Type of minimally invasive operation
- A61B2017/00243—Type of minimally invasive operation cardiac
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/068—Surgical staplers, e.g. containing multiple staples or clamps
- A61B17/072—Surgical staplers, e.g. containing multiple staples or clamps for applying a row of staples in a single action, e.g. the staples being applied simultaneously
- A61B2017/07214—Stapler heads
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/068—Surgical staplers, e.g. containing multiple staples or clamps
- A61B17/072—Surgical staplers, e.g. containing multiple staples or clamps for applying a row of staples in a single action, e.g. the staples being applied simultaneously
- A61B2017/07214—Stapler heads
- A61B2017/07285—Stapler heads characterised by its cutter
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/11—Surgical instruments, devices or methods, e.g. tourniquets for performing anastomosis; Buttons for anastomosis
- A61B2017/1107—Surgical instruments, devices or methods, e.g. tourniquets for performing anastomosis; Buttons for anastomosis for blood vessels
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/11—Surgical instruments, devices or methods, e.g. tourniquets for performing anastomosis; Buttons for anastomosis
- A61B2017/1135—End-to-side connections, e.g. T- or Y-connections
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B90/00—Instruments, implements or accessories specially adapted for surgery or diagnosis and not covered by any of the groups A61B1/00 - A61B50/00, e.g. for luxation treatment or for protecting wound edges
- A61B90/03—Automatic limiting or abutting means, e.g. for safety
- A61B2090/037—Automatic limiting or abutting means, e.g. for safety with a frangible part, e.g. by reduced diameter
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61F—FILTERS IMPLANTABLE INTO BLOOD VESSELS; PROSTHESES; DEVICES PROVIDING PATENCY TO, OR PREVENTING COLLAPSING OF, TUBULAR STRUCTURES OF THE BODY, e.g. STENTS; ORTHOPAEDIC, NURSING OR CONTRACEPTIVE DEVICES; FOMENTATION; TREATMENT OR PROTECTION OF EYES OR EARS; BANDAGES, DRESSINGS OR ABSORBENT PADS; FIRST-AID KITS
- A61F2/00—Filters implantable into blood vessels; Prostheses, i.e. artificial substitutes or replacements for parts of the body; Appliances for connecting them with the body; Devices providing patency to, or preventing collapsing of, tubular structures of the body, e.g. stents
- A61F2/02—Prostheses implantable into the body
- A61F2/04—Hollow or tubular parts of organs, e.g. bladders, tracheae, bronchi or bile ducts
- A61F2/06—Blood vessels
- A61F2/064—Blood vessels with special features to facilitate anastomotic coupling
Definitions
- the invention relates to an apparatus and method for performing anastomosis.
- Anastomosis is a procedure by which two hollow tissue structures are joined together. More particularly, vascular anastomosis is a procedure by which two blood vessels within a patient are surgically joined together. vascular anastomosis is performed during treatment of a variety of conditions including coronary artery disease, diseases of the great and peripheral vessels, organ transplantation, and trauma.
- coronary artery disease CAD
- an occlusion or stenosis in a coronary artery interferes with blood flow to the heart muscle.
- Treatment of CAD involves the grafting of a vessel in the form of a prosthesis or harvested artery or vein to reroute blood flow around the occlusion and restore adequate blood flow to the heart muscle. This treatment is known as coronary artery bypass grafting (CABG).
- CABG coronary artery bypass grafting
- the suturing process is a time consuming and difficult procedure requiring a high level of surgical skill.
- a surgeon holds the edges of the incision in the target vessel with one handle and holds a needle in the other hand for suturing, or an assistant may hold the edges of the incision in the target vessel while a surgeon makes small stitches as close as possible to the edges of the incision.
- This suturing requires a high degree of precision and is quite time consuming.
- blood flow at the anastomosis site is stopped during suturing.
- a side clamp or other device may be used to isolate a portion of the wall of the aorta to which a graft vessel is sutured.
- the use of a side clamp or similar device can cause emboli to detach from the wall of the aorta and enter the bloodstream, which is undesirable.
- vascular anastomosis system that allows the tissue at the anastomosis site to be controlled during suturing or other connection of the graft and target vessels. It would also be desirable to provide a vascular anastomosis system that allows the connection of a graft vessel to a target vessel prior to making an incision in the target vessel which allows blood flow between the target vessel and the graft vessel.
- FIG. 1 is a perspective view of an anvil and a plurality of staples according to a first aspect of the present invention.
- FIG. 2 is a perspective view of the anvil of FIG. 1 being inserted into a target vessel.
- FIG. 3 is a perspective view of the anvil tenting a wall of a target vessel for an anastomosis procedure.
- FIG. 4 is a perspective view of a graft vessel placed adjacent an exterior of the tented target vessel for the anastomosis procedure.
- FIG. 5 is a perspective view of the staples being applied to the graft vessel and the target vessel during an anastomosis procedure.
- FIG. 6 is a perspective view of the completed anastomosis according to the first aspect of the present invention.
- FIG. 7 is a perspective view of a staple supported on a staple holding strip.
- FIG. 8 is a side view of the staple and staple holding strip of FIG. 7 when the ends of the staple have been bent by contact with an anvil.
- FIG. 9 is a perspective view of an anvil and staple according to another aspect of the present invention.
- FIGS. 10A and 10B are is a side views of a plurality of staples supported on two examples of expandable staple holding strips.
- FIG. 11 is a perspective view of a portion of an anvil having a movable cutting device.
- FIG. 12 is a side view of an anvil having an external cutting device.
- FIGS. 12A and 12B are side views of a portion of an anvil and two cutting devices that snap onto the anvil.
- FIG. 13 is a side view of a portion of an anvil with an extendable cutting device.
- FIG. 14 is a side view of the anvil of FIG. 13 with the cutting device extended.
- FIG. 15 is a side view of a portion of an anvil with an alternate extendable cutting device.
- FIG. 16 is a side view of the anvil of FIG. 15 with the cutting device extended.
- FIG. 17 is a perspective view of an anvil according to a second aspect of the invention being inserted into a target vessel.
- FIG. 18 is a perspective view of the anvil of FIG. 17 positioning inside a target vessel and a clamp being advanced to clamp the wall of the target vessel between the anvil and the clamp.
- FIG. 19 is a perspective view of a graft vessel being advanced to the target vessel with a continuous anastomosis staple while the anastomosis site on the target vessel is controlled by the anvil and clamp.
- FIGS. 20-22 are side cross sectional views of the steps of performing the anastomosis with the continuous anastomosis staple shown in FIG. 19 .
- FIG. 23 is a perspective view of the completed anastomosis performed as shown in FIGS. 19-22 .
- FIGS. 24-27 are perspective views of the steps of an alternative anvil and clamp system for controlling an anastomosis site and forming an incision through the clamped tissue of the target vessel.
- FIG. 28 is a perspective view of a system for controlling a tissue site and performing anastomosis according to the present invention.
- FIG. 29 is a cross sectional view taken along line C-C of FIG. 28 , showing a first step of the anastomosis procedure.
- FIG. 30 is a cross sectional view taken along line C-C of FIG. 28 , showing a second step of the anastomosis procedure.
- FIG. 31 is a cross sectional view taken along line C-C of FIG. 28 , showing a third step of the anastomosis procedure.
- FIG. 32 is a perspective view of an anvil according to another aspect of the present invention for use with sutures.
- FIG. 33 is a perspective view of the anvil of FIG. 32 positioned within a target vessel and used to locate a plurality of suture at an anastomosis site.
- FIG. 34 is a side cutaway view of a first embodiment of an anvil, a cutter and a staple holder, where the anvil and staple holder are spaced apart from each other.
- FIG. 35 is an end cross-section view of the anvil of FIG. 34 .
- FIG. 36 is a side cutaway view of a portion of the anvil inserted into the lumen of a target vessel.
- FIG. 37 is a side view of the cutter.
- FIG. 38 is a perspective view of the cutter of FIG. 37 .
- FIG. 39 is a side view of the distal end of a second embodiment of a cutter.
- FIG. 40 is a side view of the distal end of a third embodiment of a cutter.
- FIG. 41 is a side view of the distal end of a fourth embodiment of a cutter.
- FIG. 42 is a side view of a portion of a fifth embodiment of a cutter.
- FIG. 43 is a side view of the distal end of a sixth embodiment of a cutter.
- FIG. 44 is a side cutaway view of the anvil and staple holder of FIG. 34 , where the cutter is in a first position.
- FIG. 45 is a side cutaway view of the anvil and staple holder of FIG. 34 , where the cutter is in a second position.
- FIG. 46 is a side cutaway view of the anvil and staple holder of FIG. 34 , where the cutter is in a third position.
- FIG. 47 is a side cutaway view of the anvil and staple holder of FIG. 34 , where the cutter is in a fourth position.
- FIG. 48 is a side cutaway view of the anvil and staple holder of FIG. 34 , where the cutter is in a fifth position.
- FIG. 49 is a side cutaway view of a second embodiment of an anvil and a staple holder, where the anvil and staple holder are spaced apart from each other.
- FIG. 50 is a side cutaway view of the anvil and staple holder of FIG. 40 , where the cutter is in a first position.
- FIG. 51 is a side cutaway view of the anvil and staple holder of FIG. 40 , where the cutter is in a second position.
- FIG. 52 is a side cutaway view of the anvil and staple holder of FIG. 40 , where the cutter is in a third position.
- FIG. 53 is a side cutaway view of the anvil and staple holder of FIG. 40 , where the cutter is in a fourth position.
- FIG. 54 is a side cutaway view of the anvil and staple holder of FIG. 40 , where the cutter is in a fifth position.
- an anvil 10 includes a handle 12 and an anvil arm 14 extending from the handle 12 .
- the anvil arm 14 may be oriented substantially perpendicular to the handle 12 , or oriented at a different angle.
- the anvil arm 14 may be provided with one or more staple bending features 16 on opposite sides of the anvil arm 14 .
- the staple bending features 16 each include a plurality of recesses 20 which receive the ends of staples 22 and cause the staple ends to bend over. At least one of the staple bending features 16 may be configured differently or omitted, if desired.
- the staples 22 may be connected to a staple holding strip 24 .
- the staples 22 are U-shaped and are arranged in a spaced apart parallel configuration such that the staples 22 all lie in a single plane. Alternately, the staples 22 may be shaped differently, and/or lie in one or more different planes.
- An exemplary anvil arm 14 has a height and a width of about 2 mm or less, advantageously about 1 mm or less, and a length of about 2 to 15 mm, advantageously 5 to 12 mm.
- the length of the anvil will vary depending on the diameter of the graft vessel selected.
- the length to width ratio of the anvil arm 14 is substantially between 2:1 and 15:1. A different length to width ratio may be used, if desired.
- the staples 22 have widths of about 0.2-3 mm.
- the staples 22 have widths of substantially 2 mm or less.
- the leg lengths of the staples 22 are substantially 0.2-3 mm. Alternately, other leg lengths may be used.
- the anvil arm 14 has a sharp distal end 28 for puncturing the tissue of a target vessel to insert the anvil arm 14 into the target vessel.
- the anvil arm 14 is inserted into a pressurized or unpressurized target vessel 30 by puncturing the target vessel with the distal end 28 of the anvil arm 14 .
- the hole that is formed in the wall of the target vessel 30 by the anvil arm 14 is small enough to prevent significant bleeding through the puncture site.
- the hole is closed by hand suturing.
- the hole is closed with a biocompatible glue, adhesive or the like.
- the hole is closed with a clip, clamp, or other implantable device that remains on the target vessel.
- Such a device may be positioned on the outer surface and/or inner surface of the target vessel, and may extend into the hole.
- a device for closing the hole may be constructed from nitinol or other superelastic or pseudoelastic material, or from stainless steel or other material, where that device moves between a first configuration and a second configuration during deployment, and where the second configuration holds the hole closed.
- the hole is less than substantially 2 mm wide, and advantageously less than 1 mm wide.
- the anvil arm 14 has a blunt distal end 28 that is inserted through a hole created with a separate instrument, by a different instrument connected to the anvil arm 14 , or by a sharp member connected to the anvil arm 14 that can be retracted into the anvil arm 14 or otherwise blunted or concealed after puncturing or creating an incision in the wall of the target vessel.
- the anvil arm 14 may be pulled against an inner wall of the target vessel 30 , causing tenting of the thin tissue of the vessel wall as illustrated in FIG. 3 .
- This tenting of the vessel wall provides control over the anastomosis site during an anastomosis procedure that is described with respect to FIGS. 4-6 .
- tenting of the target vessel wall need not be tented in order to control the anastomosis site during the anastomosis procedure.
- a graft vessel 32 is advanced to the anastomosis site and an end 34 of the graft vessel 32 is positioned adjacent an exterior surface of the target vessel 30 at the anastomosis site.
- the tented portion of the target vessel 30 is positioned within the perimeter of the end 34 of the graft vessel 32 .
- a staple holder 38 is provided having two arms 40 which are pivotally connected to the handle 12 of the anvil 10 .
- the pivoting arms 40 of the staple holder 38 may be connected to the handle 12 in a different way, or may be connected to a separate or additional device.
- the arms 40 are spaced apart from one another across at least a part of their length.
- the graft vessel can be positioned between the arms 40 . That is, the arms 40 are positioned on substantially opposite sides of the graft vessel. In this way, each arm 40 may be positioned against a flap at an end of the graft vessel, as illustrated in FIGS. 29-31 .
- the arms 40 may be configured differently, if desired.
- the staple holder 38 may be used to hold individual staples 22 and/or staple holding strips 24 .
- each arm 40 of the staple holder 38 carries one row of staples 22 or one staple holding strip 24 , where the staples 22 are arranged in a substantially linear row.
- staples 22 or staple strips 24 may be arranged in two or more rows, parallel or otherwise, on one or more arms 40 .
- the staples 22 may be staggered on one or more arms, such that at least one row of staples 22 does not fall along a straight line.
- the staples 22 or staple strips 24 may be arranged or aligned in any manner on each arm 40 that results in a secure anastomosis between the graft vessel and the target vessel.
- the staples 22 are inserted through the flaps at the end of the graft vessel 32 , or another portion of the target vessel, and into the target vessel 30 by pivoting the arms 40 of the staple holder 38 towards the anvil arm 14 .
- the staple bending features 16 are positioned in a configuration corresponding to the configuration of the staples 22 , such that each staple 22 engages a corresponding staple bending feature 16 during deployment.
- the staple holder 38 is a connector deployer that deploys connectors other than or in addition to staples 22 .
- FIG. 6 illustrates a completed anastomosis between a target vessel 30 and a graft vessel 32 with a plurality of staples 22 .
- the spacing between the staples 22 is approximately 1 to 4 mm. This spacing is similar to the spacing between sutures in a conventional sutured anastomosis. A different spacing between the staples 22 may be used if desired.
- the anvil arm 14 is withdrawn from the target vessel 30 between adjacent staples 22 . The withdrawal of the anvil arm 14 leaves a gap that is approximately the same as the spacing between adjacent staples. Accordingly, substantially no blood leakage occurs at the location where the anvil arm has been withdrawn.
- FIGS. 7 and 8 illustrate one example of a staple 22 connected to a staple holding strip 24 .
- This staple 22 includes barbed staple ends 52 extending from the front portion of the staple 22 and a C-shaped portion 54 extending from a rear of the staple 22 for connecting the staple 22 to the staple holding strip 24 .
- the staple holding strip 24 includes a plurality of protrusions 56 for receiving the staples 22 .
- the C-shaped portion 54 of each staple 22 is received around one of the protrusions 56 and is secured in place at one or more locations, such as by welds 58 or by a frangible linkage or connection. Alternately, the C-shaped portion 54 of each staple 22 may be secured to the staple-holding strip 24 in a different way. As shown in FIG.
- the staple 22 may be detached from the staple holding strip 24 by the action of bending the barbed staple ends 52 such that the C-shaped portion 54 of the staple 22 splays outward and breaks apart from the corresponding protrusion 56 on the staple holding strip 24 , by bending a frangible connection between the staple holding strip and the staples to separate the staples, or any other known separation methods, such as melting of a connection between the staple and the staple holding strip.
- FIG. 9 illustrates an alternate staple 22 a having inwardly curved barbed staple ends 52 a .
- the staple ends 52 a are themselves curved, the corresponding staple bending feature or features 16 a need not be curved to bend the ends 52 a of the staples 22 a .
- the staple bending features 16 a on each side of the anvil arm 14 a may be formed as a single longitudinal groove along the anvil arm 14 a , where the staple bending feature 16 a has a substantially flat surface.
- the staple may be configured differently.
- two or more different kinds of staples are deployed by the staple holder 38 in order to form a single anastomosis.
- a plurality of staples 22 a are positioned on an expandable staple holding strip called an expandable backbone 66 .
- the expandable backbone 66 includes a plurality of elements 68 which are interconnected by one or more expanding members 70 .
- Each of the backbone elements 68 is provided with a connecting diamond member 72 that is connected to one of the staples 22 a .
- each staple 22 a is connected to the corresponding diamond member 72 by a thin connecting section 74 .
- the expandable backbone 66 allows the spacing between the staples 22 a to be adjusted for the particular anastomosis to be performed.
- the backbone 66 allows expansion of the distance between staples from a distance of approximately 0.1 mm to a distance of approximately 1 to 4 mm, i.e., expansion of up to 40 times the original spacing. Alternately, the backbone 66 allows a different amount of expansion.
- the expanding backbone 66 also includes two openings 76 at opposite ends which may be engaged by holding pins (not shown) on an anastomosis system or staple holder. The opening 76 allow the backbone 66 to be easily expanded by relative motion of the holding pins.
- the connecting diamond members 72 are configured to collapse inwardly toward the backbone when the staples 22 a engage the staple bending surface or surfaces 16 a of the anvil.
- each diamond member 72 forces the corresponding staple 22 a to separate from the diamond member 72 at a connecting section 74 .
- the connecting section 74 is a frangible linkage connecting a staple 22 a to a corresponding diamond member 72 .
- FIG. 10B illustrates another example of staples 22 a detachably connected to a backbone 66 .
- the staples 22 a are each connected to the associated backbone elements 68 at two connecting sections 74 .
- the staples 22 a , backbone 66 , and associated components are substantially as described above with regard to FIG. 10A .
- FIG. 11 shows a portion of an anvil arm 14 with a movable cutting device 44 .
- the cutting device 44 includes a base 46 and a blade 48 .
- the base 46 of the cutting device 44 is positioned in a longitudinal groove 50 in the anvil arm 14 .
- the cutting device 44 may be moved longitudinally along the anvil arm 14 to form an incision in the target vessel.
- FIGS. 12, 12A , and 12 B illustrate external cutting devices that are advanced down onto the anvil arm 14 after the anastomosis procedure and cut an incision in the target vessel from an exterior of the target vessel as the anvil arm 14 is withdrawn.
- a knife 62 is positioned on a knife arm 64 that is movable along the handle 12 of the anvil. The knife 62 is moved downward in a direction substantially parallel to the longitudinal axis of the handle 12 until the knife 62 engages a recess 65 in the anvil arm 14 . The knife 62 is thereby positioned substantially at the anastomosis site.
- the end of the graft vessel is then placed substantially against the wall of the target vessel at the anastomosis site, over the knife 62 and knife arm 64 .
- the knife 62 forms an incision in the target vessel.
- the knife 62 and knife arm 64 exit the anastomosis site via the joint between the graft vessel and the target vessel.
- the withdrawal of the anvil arm 14 , knife 62 and knife arm 64 leaves a gap in the wall of the target vessel that is approximately the same as the spacing between adjacent staples to minimize or eliminate leakage through that gap.
- the knife 62 may be moveable relative to the handle 12 in at least one direction in addition to a direction substantially parallel to the longitudinal axis of the handle 12 .
- the knife 62 may be moveable in a direction substantially parallel to the wall of the target vessel to create an arteriotomy in the target vessel at the junction between the graft vessel and the target vessel.
- FIGS. 12A and 12B illustrate two alternate examples of the knife 62 which snap onto a corresponding engagement surface 65 of the anvil arm 14 so that the knife and anvil are secured together for formation of the incision during removal of the anvil arm 14 from the anastomosis site.
- FIGS. 13-16 illustrate two variations of extendable cutting devices for making an incision in the target vessel while withdrawing the anvil arm 14 from the target vessel.
- FIG. 13 illustrates an anvil arm 14 b having a blade 78 connected to a flexible blade support 80 .
- the blade support 80 is pulled in the direction of the arrow A with respect to the anvil arm 14 b , the blade 78 moves from a forwardly extending position shown in FIG. 13 to an upwardly extending position shown in FIG. 14 as a result of flexure of the blade support 80 .
- the blade 78 in the forwardly extending position may be used to form a small opening in the wall of the target vessel through which the anvil arm 14 is inserted into the target vessel.
- the blade 78 is moved to an upwardly angled or a vertical position in which the blade 78 is used to form an incision in the target vessel as the anvil arm 14 b is removed from the target vessel.
- FIGS. 15-16 illustrate an alternate example of an anvil arm 14 c having a blade 84 and a blade support 86 . While the anvil arm 14 c is inserted into the target vessel and during the anastomosis procedure, the blade 84 is positioned in a recess 88 in the anvil arm. The blade 84 may be moved from the position of FIG. 15 to the extended position of FIG. 16 by moving the blade support 86 in the direction of the arrow B with respect to the anvil arm. The blade 84 is flexible and stressed, such that freeing the blade 84 from the recess 88 causes the blade 84 to move to the extended position. Alternatively, the blade 84 may be extended automatically upon withdrawal of the anvil arm 14 when a blade tip 90 catches on an interior surface of the target vessel wall during withdrawal of the anvil arm.
- the extendable cutting devices shown in FIGS. 13-16 are merely shown as examples of the type of cutting devices which may be used for making the incision. Once these cutting devices or blades have been extended from the anvil arm, they may be fixed to perform cutting as the anvil arm is removed from the target vessel or the blades may be movable along the anvil arm to make an incision prior to removal of the anvil arm from the target vessel.
- anvil 10 also includes a cutter 200 that is moveable relative to the anvil 10 for making an incision in the wall of a target vessel.
- a tissue stop 220 is formed into or connected to the anvil 10 .
- the portion of the anvil 10 distal to the tissue stop 220 is configured to penetrate into the wall of a target vessel, and may be referred to as the anvil arm 14 .
- a channel 246 is defined within the anvil arm 14 , through which a cutter 200 is configured to move.
- the cutter 200 is narrower than the channel 246 , such that interior surfaces 202 on either side of the channel 246 may guide the translation of the cutter 200 relative to the anvil arm 14 .
- the term “translation” as used in regard to the cutter 200 refers to motion of the cutter 200 in the distal or proximal direction, whether or not the cutter 200 or a portion thereof moves upward or downward during that motion.
- the direction substantially perpendicular to the longitudinal centerline of the anvil arm 14 toward the wall of the target vessel may be referred to as “upward”, and the direction substantially perpendicular to the longitudinal centerline of the anvil arm 14 away from the wall of the target vessel may be referred to as “downward”.
- the positioning of the anvil arm 14 in use is not limited to an orientation in which these directions correspond to absolute directions measured relative to the ground.
- motion upward or downward may be referred to as “vertical” motion
- motion substantially parallel to the longitudinal centerline of the anvil arm 14 may be referred to as “horizontal” motion.
- the anvil arm 14 includes a contact surface 206 .
- the contact surface 206 of the anvil arm 14 is placed substantially against the inner surface 203 of a target vessel 201 .
- the contact surface 206 substantially defines a place that is substantially parallel to the longitudinal centerline of the anvil arm 14 .
- the contact surface 206 is contoured and/or oriented differently.
- An upper opening 248 extends along at least a portion of the contact surface 206 in a direction substantially parallel to the longitudinal centerline of the anvil arm 14 , and opens into the channel 246 .
- the upper opening 248 may divide the contact surface 206 into symmetrical or asymmetrical sections.
- the contact surface 206 may be formed by two substantially planar surfaces, by one substantially planar surface and a differently-shaped surface, or by another set of surfaces. Additionally, the contact surface 206 may be formed by two thin edges, each edge occurring at the intersection of a wall of the upper opening 248 and an outer surface of the anvil arm 14 .
- the upper opening 248 need not extend proximally any further than the tissue stop 220 . However, the upper opening 248 may extend proximal to the tissue stop 220 , if desired.
- a first lower opening 254 and a second lower opening 268 are defined through a lower surface 256 of the anvil arm 14 .
- the lower surface 256 of the anvil arm 14 may be substantially parallel to the contact surface 206 or may be oriented differently relative to the contact surface 206 .
- the first lower opening 254 and/or the second lower opening 268 do not extend completely through the anvil arm 14 , and instead are depressions extending along at least part of a bottom surface 266 of the channel 246
- the cutter 200 is a thin, rigid member, shaped such that it can be held within the channel 246 in the anvil arm 14 .
- the cutter 200 has a substantially constant width along its entire length. Alternately, the width of the cutter 20 may vary along its length.
- the cutter 200 may be made of metal, ceramic, plastic, or other material, or from a combination of different materials.
- a sharp projection 208 extends upward from the cutter 200 at or near its distal end.
- the projection 208 is substantially triangular, but may be shaped differently.
- the projection 208 may be smooth or serrated, or otherwise shaped or formed.
- a portion of the projection 208 may be ground or otherwise honed to a sharp edge to facilitate the motion of the projection 208 through the tissue of the wall of a target vessel, as described in greater detail below.
- the cutter 200 is composed of a material that can be sharpened adequately to cut tissue.
- the cutter 200 may be flexible, at least in part.
- the projection 208 may be located at a different position on the cutter 200 than at or near its distal end.
- An additional sharp point (not shown) may be provided at the distal end of the cutter 200 , extending in a distal direction, in order to create an initial puncture or incision in the wall of the target vessel. Such a point may be as described in U.S. patent application Ser. No. 10/134,081, which is herein incorporated by reference in its entirety.
- One or more additional projections 208 may be provided, if desired.
- two or more projections 208 may extend upward from the cutter 200 . Where multiple projections 208 are used, they may cooperate with one another to create an incision in the wall of the target vessel.
- a second projection 208 extends upward from the cutter 200 proximal to a first projection 208 .
- the projections 208 are both substantially the same triangular shape and the same size. However, the projections 208 may be shaped and sized differently.
- the projections 208 are both substantially planar, and are aligned such that both projections 208 lie in substantially the same plane.
- Each projection 208 may include at least one sharpened or beveled edge 209 oriented to engage and incise the wall of the target vessel when the cutter 200 is translated, as described below.
- at least two projections 208 extend upward from the cutter 200 .
- the projections 208 each have a barb 211 at the tip. However, the barb 211 may be omitted from some or all of the projections 208 .
- Under the barb 211 a sharpened or beveled edge 209 extends downward and proximally.
- the edge 209 may be straight or curved. The upper end of the edge 209 is distal to the lower, proximal end of the corresponding barb.
- each projection 208 is oriented to engage and incise the wall of the target vessel when the cutter 200 is translated.
- at least two projections 208 extend upward from the cutter 200 , at least one of which has a barb 211 at its tip.
- the edge 209 associated with each projection 208 is more curved than the edge 209 shown in FIG. 40 .
- the edge 209 is substantially straight, or gently curved, or positioned on a portion of a larger curved segment 213 extending downward from and proximal to the barb 211 .
- a number of projections 208 may be placed along a length of the cutter 200 .
- This length may be comparable to the desired length of the incision in the wall of the target vessel.
- These projections 208 may be substantially triangular as shown, or may be shaped differently. Where more than one projection 208 is used on the cutter 200 , the projections 208 need not have the same configuration. For example, projections 208 such as the exemplary projections 208 shown in FIGS. 39-41 may be mixed together on the same cutter 200 . Alternately, one or more of the projections 208 are moveable relative to the cutter 200 , such that one or more projections 208 can be moved upward or downward relative to the cutter 200 .
- the projections 208 extending upward from the cutter 200 each are substantially planar, and are aligned such that not all of the projections 208 lie in the same plane.
- the projections 208 may create a wider incision in the wall of the target vessel than would be created if the projections 208 were substantially aligned.
- one set of projections 208 may be aligned substantially in a first plane, and a second set of projections 208 may be aligned substantially in a second plane substantially parallel to the first plane.
- the second plane and the first plane may be oriented differently relative to one another, if desired.
- none of the projections 208 lie in a common plane with one or more other projections 208 .
- the cutter 200 need not be translated as far to make an incision in the wall of the target vessel as it would if only a single projection 208 were used, as described in greater detail below.
- an interior surface 202 is located on each side of the channel 246 .
- Each interior surface 202 may be substantially planar, curved, or may be shaped differently. Further, each interior surface 202 may be oriented at an angle to vertical or substantially vertical.
- the interior surfaces 202 may be formed such that the channel 246 is substantially bilaterally symmetrical, or may be formed to result in a channel 246 that is not bilaterally symmetrical.
- the interior surfaces 202 of the channel 246 within the anvil arm 14 may include raised features 204 that correspond to depressed staple bending features (not shown) on the outer surface of the anvil arm 14 .
- the depressed staple bending features result in corresponding raised features 204 on the interior surface 202 of the channel 246 .
- the raised features 204 do not interfere with the motion of the cutter 200 through the channel 246 . Alternately, the raised features 204 are not present on the interior surface 202 of the channel 246 .
- a safety feature 210 is connected to the underside of the anvil 10 and is biased toward the anvil 10 and the cutter 200 .
- the safety feature 210 may be biased into the channel 246 within the anvil 10 .
- the safety feature 210 is connected to a different location, such as the underside of the anvil arm 14 .
- the safety feature 210 may be flexible or rigid.
- the safety feature 210 includes a tip 212 that is oriented substantially transverse to the longitudinal centerline of the cutter 200 . Alternately, the tip 212 may be oriented in a different direction.
- the cutter 200 includes a safety recess 214 defined in it, corresponding to the tip 212 of the safety feature 210 .
- the tip 212 is shaped and sized such that it can engage the safety recess 214 .
- the tip 212 may be a bar or rod oriented substantially transverse to the direction of translation of the cutter 200 , or may be shaped or oriented differently.
- the staple holder 38 has not yet been moved into position to perform anastomosis.
- the tip 212 of the safety feature 210 is biased upward to engage the safety recess 214 .
- the engagement between the safety recess 214 and the tip 212 of the safety feature 210 substantially prevents translation of the cutter 200 within the channel 246 .
- the cutter 200 and the projection 208 are prevented from deploying until the staple holder 38 has been moved into the appropriate position relative to the anvil arm 14 , and inadvertent deployment of the cutter 200 is prevented.
- the cutter 200 includes an engagement member 216 extending upward from a location at or near its proximal end.
- the engagement member 216 instead may extend downward from the cutter 200 or to the side of the cutter 200 . Further, the engagement member 216 may be positioned at a location other than at or near the proximal end of the cutter 200 .
- the engagement member 216 is configured to engage at least a portion of a corresponding receiver 218 in the staple holder 38 . Thus, after engagement between the engagement member 216 and the receiver 218 , translation of the receiver 218 results in translation of the cutter 200 .
- the receiver 218 is a structure that is at least partially open on its underside and that includes at least one surface 219 configured to engage the engagement member 216 . As shown in FIG.
- the surface 219 is a partially-curved surface shaped to receive the curved upper end of the engagement member 216 .
- the receiver 218 may be a flat vertical surface, a curved surface, a structure such as an inverted cup that is open on its underside and that has a wall or walls encircling the engagement feature 216 , or any other structure or mechanism capable of engaging the engagement feature 216 and urging it distally.
- An anvil insert 222 is fixed to the anvil 10 .
- the anvil insert 222 is connected to and capable of motion relative to the anvil 10 .
- the anvil insert 222 may be connected to the proximal end of the anvil arm 14 , or another location on the anvil arm 14 .
- a cavity 228 is defined within the anvil insert 222 .
- An aperture 230 is defined through the distal end of the anvil insert 222 into the cavity 228 , connecting the channel 246 in the anvil arm 14 and anvil 10 to the cavity 228 .
- the cutter 200 extends through the aperture 230 , such that the distal end of the cutter 200 is positioned within the channel 246 and the proximal end of the cutter 200 is positioned within the cavity 228 .
- a cutter stop 236 may be formed into or connected to the anvil insert 222 .
- the cutter stop 236 may engage the proximal end of the cutter 200 if the cutter 200 is moved to a defined position within the cavity 228 , thereby restricting its proximal translation.
- a cavity 262 may be defined within the staple holder 38 or a separate component connected to the staple holder 38 .
- a post 258 is positioned at the upper end of the cavity 262 , where the post 258 is oriented downward.
- a biasing element 260 is connected at one end to the post 258 .
- the biasing element 260 may be a coil spring, a leaf spring, a different type of spring, an elastomer, a wire form, or other structure or mechanism capable of exerting a biasing force.
- the biasing element 260 is positioned within and protected by the cavity 262 , where the cavity 262 is used.
- the cavity 262 may be a cylindrical opening having a diameter substantially the same as the outer diameter of the biasing element 260 , such that the cavity 262 restricts the biasing element 260 to motion substantially along the axis of the cavity 262 and thus directs the force exerted by the biasing element 260 in a substantially downward direction, preventing bending or other undesirable motion of the biasing element 260 .
- the end of the biasing element 260 that is not connected to the post 258 contacts the cutter 200 .
- the biasing element 260 may be a compression spring that is compressed between the post 258 and the cutter 200 , resulting in a force on the cutter 200 that biases the cutter 200 downward.
- the cutter 200 is slidable relative to the biasing element 260 , such that the biasing element 260 exerts a downward force on the cutter 200 at different locations along its upper surface 252 as the cutter 200 translates.
- at least the distal end of the cutter 200 is biased downward throughout its translation along the anvil 10 .
- the entire cutter 200 may be biased downward, if desired.
- the post 258 is omitted, and the biasing element 260 is fixed to an upper surface of the cavity 260 .
- the biasing element 260 is omitted, and the cutter 200 is biased downward in another way.
- the cutter 200 may be constructed from an elastic or superelastic material that is formed in such a way as to produce a downward bias.
- the distal end of the anvil arm 14 initially is spaced apart from the staple holder 38 . While the distal end of the anvil arm 14 is spaced apart from the staple holder 38 , the anvil arm 14 is inserted through the wall of the target vessel, which is not shown for clarity.
- the anvil arm 14 has a cross-section small enough to allow it to enter the target vessel easily and to result in minimal or no leakage from the target vessel after the anvil arm 14 is removed.
- the distal tip of the anvil arm 14 may be sharp such that the anvil arm 14 itself penetrates the wall of the target vessel, resulting in an opening in the wall of the target vessel substantially the same size as the cross-section of the anvil arm 14 .
- a sharp retractable projection (not shown) is provided at the distal end of the anvil arm 14 .
- the retractable projection is extended to allow the distal end of the anvil arm 14 to penetrate the wall of the target vessel, then retracted into the anvil arm 14 .
- the retractable projection may be a wire, a blade, a substantially conical member, a screw or a screw-tipped rod, or any other sharp structure or mechanism capable of penetrating the wall of the target vessel.
- Such a retractable projection may be as described in U.S. patent application Ser. No. 10/134,081, which is herein incorporated by reference in its entirety.
- the cutter 200 includes a blade (not shown) at its distal end, where the blade is configured to swivel.
- the blade In a first position, the blade is configured to extend substantially distal to the distal end of the anvil arm 14 , such that the blade can penetrate the wall of the target vessel. Then, the blade is swiveled upward such that it can act as a protrusion 208 such as described in FIGS. 39-42 .
- a separate mechanism or structure is used to penetrate the wall of the target vessel, and the anvil arm 14 is later inserted through that penetration.
- the distal end of the anvil arm 14 enters the lumen of the target vessel.
- the anvil arm 14 is advanced into the target vessel until a tissue stop 220 on the anvil arm 14 encounters the edge of the penetration in the wall of the target vessel.
- the tissue stop 220 is substantially flat and/or blunt, and extends upward or in another direction relative to the anvil arm 14 to increase the height and/or width of the anvil arm 14 .
- the tissue stop 220 increases the cross-section of the anvil arm 14 such that the anvil arm 14 cannot easily move further into the penetration in the wall of the target vessel after the tissue stop 220 encounters the outer wall of the target vessel.
- the tissue stop 220 is blunt, it does not penetrate the wall of the target vessel or act to expand the size of the existing penetration. Thus, the distance between the distal end of the anvil arm 14 and the tissue stop 220 substantially determines how much of the anvil arm 14 is allowed into the lumen of the target vessel. After the anvil arm 14 has been inserted into the lumen of the target vessel, the contact surface 206 of the anvil arm 14 is substantially in contact with the inner surface of the wall of the target vessel.
- the staple holder 38 and the anvil 10 are rotated or otherwise moved closer to one another to a standby position.
- the staple holder 38 holds flaps at the end of the graft vessel, which are configured substantially as shown in FIGS. 29-31 , against the surface of the target vessel at the site of the anastomosis.
- the flaps are substantially fixed relative to the surface of the target vessel, such that the end of the graft vessel is substantially immobile relative to the wall of the target vessel.
- the position of the end of the graft vessel relative to the wall of the target vessel remains substantially unchanged throughout the duration of the anastomosis procedure.
- the perimeter of the end of the graft vessel defines a closed area on the wall of the target vessel. Consequently, the location of a connection made between the end of the graft vessel and the wall of the target vessel is substantially registered with an opening made within the closed area in the wall of the target vessel, regardless of the order in which the connection and the opening are made. Further, the position of the end of the graft vessel relative to the wall of the target vessel substantially maintains position registration throughout the duration of the anastomosis procedure relative to the opening in the wall of the target vessel through which the anvil arm 14 is inserted. For clarity, the flaps and graft vessel are not shown in FIG. 44 .
- the staple holder 38 and anvil 10 may be actuated to move between the position shown in FIG.
- a cable (not shown) is connected to the anvil 10 at or near a shoulder 224 proximal to the tissue stop 220 .
- This connection may be made by soldering, welding, winding the cable tightly around the anvil 10 at the shoulder 224 , or in any other way that results in a secure connection between the cable and the anvil 10 .
- the cable is tensioned, causing the anvil 10 and/or the connected anvil insert 222 to rotate around a pivot point such as a pin 226 that pivotally connects the staple holder 38 to the anvil 10 .
- the pin 226 may be formed into or otherwise fixed to the staple holder 38 or anvil arm 14 , if desired.
- the anvil 10 and the staple holder 38 rotate relative to one another to the standby position.
- the engagement member 216 engages the receiver 218 . Further, the relative motion of the staple holder 38 and the anvil 10 causes the staple holder 38 to contact the safety feature 210 and urge it downward against its upward bias. Consequently, the tip 212 of the safety feature 210 is moved downward out of engagement with the safety recess 214 of the cutter 200 .
- another structure or mechanism is configured to engage the safety feature 210 when the staple holder 38 and anvil 10 are moved together, so as to urge the tip 212 out of the safety recess 214 .
- the cutter 200 is freed for translation along the channel 246
- an interface structure 238 may be connected to or formed into the staple holder 38 .
- the interface structure 238 engages the anvil 10 or a component associated with the anvil 10 as the staple holder 38 and the anvil 10 move to the standby position, such as by snapping onto a corresponding feature (not shown) on the anvil 10 .
- the interface structure 238 holds the staple holder 38 substantially fixed relative to the anvil 10 , in order to maintain registration between the target vessel, the graft vessel, the anvil 10 and the staple holder 38 .
- the interface structure 238 may be a tab, rail, bump, or any other feature that is capable of engaging a corresponding feature and holding the staple holder 38 substantially fixed relative to the anvil 10 .
- the interface structure 238 is formed into or connected to the anvil 10 and engages a corresponding feature on the staple holder 38 .
- the cutter 200 is urged distally relative to the anvil arm 14 .
- the staple holder 38 has stapled or otherwise connected the graft vessel to the target vessel before the cutter 200 is urged forward, such that the two vessels are connected before the cutter 200 makes an incision between them.
- the cutter 200 may be urged forward while the staple holder 38 is stapling or otherwise connecting the graft vessel to the target vessel, or before the staple holder 38 has stapled or otherwise connected the graft vessel to the target vessel.
- the cutter 200 is urged distally by the receiver 218 , which engages the engagement feature 216 of the cutter 200 .
- the receiver 218 is configured to travel along a guide structure 241 .
- the guide structure 241 is a rail or other structure along which the receiver 218 slide, and the receiver 218 interfaces with and translates along the rail.
- the guide structure 241 guides the translation of the receiver 218 .
- the guide structure 241 is a hollow channel defined within the staple holder 38 , such that the walls of the channel guide the translation of the receiver 218 .
- the guide structure 241 may be any other structure or mechanism capable of guiding the translation of the receiver 218 .
- the guide structure 241 is substantially aligned with the anvil arm 14 .
- the longitudinal centerline of the guide structure 241 is substantially parallel to the longitudinal centerline of the anvil arm 14 .
- motion of the receiver 218 along the guide structure 241 causes translation of the engagement feature 216 and therefore translation of the cutter 200 substantially parallel to the centerline of the anvil arm 14 .
- the receiver 218 may be actuated to translate along the guide structure 241 by an actuator (not shown).
- the actuator may directly transmit force from a human hand or the like to the cutter, such as via a cable (not shown).
- the cable may be the same cable described above that may be utilized to rotate the anvil 10 and staple holder 38 relative to one another, or may be a different cable. Alternately, the actuator may convert stored energy to force that is applied to the cutter.
- Such stored energy may be provided by a spring, battery, source of compressed gas, or other source.
- any mechanism, structure or method, using stored energy or not, may be used to translate the receiver 218 along the guide structure 241 .
- the particular mechanism, structure or method used to cause translation of the cutter 200 is not critical to the invention.
- a cavity 240 is provided in the staple holder 38 adjacent to the guide structure 241 to allow for motion of the receiver 218 along the guide structure 241 .
- the cavity 240 is sized to allow the receiver 218 to translate freely.
- the upper surface 252 of the cutter 200 is substantially planar proximal to the projection 208 .
- the biasing element 260 contacts the upper surface 252 of the cutter 200 and biases the cutter 200 downward.
- the cutter 200 includes a keel 264 that extends downward.
- the keel 264 may be formed into the cutter 200 , or may be a separate component connected to the cutter 200 .
- the keel 264 is substantially as wide as the adjacent portion of the cutter 200 . However, the keel 264 may be wider or narrower than the adjacent portion of the cutter 200 .
- the keel 264 is positioned at or near the distal end of the cutter 200 . Alternately, the keel 264 may be positioned at a different location on the cutter 200 .
- the keel 264 initially extends into the first lower opening 254 , which is defined through a lower surface 256 of the anvil 10 .
- the keel 264 may extend completely through the first lower opening 254 , such that its lowest point extends outside the anvil 10 .
- the keel 264 is biased downward into the first lower opening 254 as a result of the downward force exerted on the cutter 200 by the biasing element 260 .
- the projection 208 remains below the contact surface 206 of the anvil arm 14 . In this way, the projection 208 does not extend out of the anvil arm 14 while the anvil arm 14 is inserted into the wall of a target vessel.
- the first lower opening 254 extends along a fixed length of the lower surface 256 of the anvil 10 . As the cutter 200 translates distally, the keel 264 continues to remain at least partially within the first lower opening 254 , such that the projection 208 continues to remain below the contact surface 206 of the anvil arm 14 . Initially, the keel 264 may be positioned proximal to the distal end of the first lower opening 254 . The length of the first lower opening 254 is selected to cause the projection 208 to remain below the contact surface 206 of the anvil arm 14 across that distance.
- this distance is selected such that the projection 208 on the cutter 200 does not engage the wall of the target vessel until the projection 208 is positioned within the circumference of the graft vessel. That is, the connection between the graft vessel and the target vessel substantially defines a closed area, and the projection 208 is configured to engage the wall of the target vessel within that closed area. In this way, the projection 208 makes an incision completely within the connection between the graft vessel and the target vessel, completing the anastomosis between the two vessels and minimizing or eliminating leakage at the anastomosis site. While the projection 208 on the cutter 200 remains below the upper surface of the anvil arm 14 , it neither engages nor cuts the wall of the target vessel.
- the cutter 200 continues to advance distally as the receiver 218 continues to impel the engagement feature 216 distally. As described above, at least the distal end of the cutter 200 is biased downward. As the cutter 200 advances distally, the keel 264 encounters the distal end of the first lower opening 254 . This encounter, and the continued proximal translation of the cutter 200 , causes the keel 264 to move upward relative to the anvil arm 14 .
- the keel 264 and/or the distal end of the first lower opening 254 may be constructed to provide a smooth, gradual upward motion of the keel 264 , such as by providing a gradual slope on the keel 264 and/or the distal end of the first lower opening 254 .
- the keel 264 and/or the distal end of the first lower opening 254 may be constructed to allow or cause the keel 264 to move upward abruptly upon encountering the distal end of the first lower opening 254 .
- the upward motion of the keel 264 causes the distal end of the cutter 200 and the projection 208 to move upward.
- the size and position of the first lower opening 254 including the position of the distal end of the first lower opening 254 , control the motion of the cutter 200 and the projection 208 in the vertical direction.
- the projection 208 moves upward through the upper opening 248 in the anvil arm 14 .
- the contact surface 206 of the anvil arm 14 is substantially adjacent to the inner surface of the wall of the target vessel.
- upward motion of the projection 208 through the upper opening 248 and above the contact surface 206 of the anvil arm 14 causes the projection 208 to enter the wall of the target vessel.
- the cutter 200 continues to move distally, such that the keel 264 moves out of the first lower opening 254 completely and contacts the bottom surface 266 of the channel 246 of the anvil arm 14 .
- the projection 208 is sized such that the projection 208 completely penetrates the wall of the target vessel when the keel 264 has moved proximally to the first lower opening 254 and is in contact with the bottom surface 266 of the channel 246 . That is, at least a portion of the projection 208 passes through the wall of the target vessel and enters the lumen of the target vessel. This initial penetration of the wall of the target vessel defines the starting point of an arteriotomy performed on the target vessel by the projection 208 . The starting point of the arteriotomy is spaced apart from the location on the target vessel at which the anvil arm 14 is inserted, because the cutter 200 and the projection 208 have moved proximally a selected distance before penetrating or incising the wall of the target vessel.
- tissue bridge The portion of the wall of the target vessel between the arteriotomy and the insertion point of the anvil arm 14 may be referred to as a tissue bridge.
- the incision is referred to as an arteriotomy for convenience, and this terminology does not limit the type of anastomosis that may be performed.
- anastomosis may be performed between two tissue structures that are not blood vessels, such as bile ducts.
- the cutter 200 continues to advance distally as the receiver 218 continues to impel the engagement feature 216 distally.
- the lower surface of the keel 264 contacts the bottom surface 266 of the channel 246 during this translation.
- the contact between the keel 264 and the bottom surface 266 of the channel 246 counteracts the downward bias of the distal end of the cutter 200 .
- the projection 208 is maintained above the contact surface 206 of the anvil arm 14 .
- the projection 208 moves through the tissue of the wall of the target vessel in a direction substantially parallel to the longitudinal centerline of the anvil arm 14 , and incises the tissue of the wall of the target vessel to create an arteriotomy.
- the arteriotomy is performed from within the target vessel.
- the tip of the projection 208 may maintain substantially the same height relative to the contact surface 206 of the anvil arm 14 during translation of the cutter 200 , or may change its height relative to the contact surface 206 of the anvil arm, as long as the projection 208 continues to incise completely through the wall of the target vessel.
- a second lower opening 268 is defined through the lower surface 256 of the anvil arm 14 .
- the second lower opening 268 is distal to and substantially aligned with the first lower opening 254 .
- the cutter 200 continues to advance distally as the receiver 218 continues to impel the engagement feature 216 distally.
- the keel 264 encounters the proximal end of the second lower opening 268 . Because the distal end of the cutter 200 is biased downward, the keel 264 moves downward at least partially into the second lower opening 268 . The downward motion of the keel 264 causes the distal end of the cutter 200 and the projection 208 to move downward.
- the keel 264 and/or the proximal end of the second lower opening 268 may be constructed to provide a smooth, gradual downward motion of the keel 264 , such as by providing a gradual slope on the keel 264 and/or the proximal end of the second lower opening 268 .
- the keel 264 and/or the proximal end of the second lower opening 268 may be constructed to allow or cause the keel 264 to move downward abruptly upon encountering the proximal end of the second lower opening 268 .
- the downward motion of the distal end of the cutter 200 causes the projection 208 to retract into or completely through the upper opening 248 , such that the projection 208 no longer encounters the tissue of the wall of the target vessel.
- the projection 208 may be urged downward completely into the channel 246 , depending on the depth of the channel 246 and the height of the projection 208 . Alternately, the upper tip of the projection 208 may remain within the upper opening 248 .
- the cutter 200 may stop its distal translation at substantially the same time that the projection 208 retracts completely into the upper opening 248 , or may continue to translate distally within the channel 246 before coming to a stop.
- the second lower opening 268 is not provided, and only the first lower opening 254 extends through the lower surface 156 of the anvil arm 14 into the channel 246 .
- the cutter 200 is retracted in the proximal direction after the arteriotomy is formed, until the keel 264 moves downward into the first lower opening 254 and the projection 208 consequently retracts completely into the upper opening 248 .
- the distal end of the arteriotomy is defined, and the arteriotomy is complete.
- the distal end of the first lower opening 254 and the proximal end of the second lower opening 268 control the motion of the projection 208 and thereby control the penetration of the wall of the target vessel. That is, the distance between the distal end of the first lower opening 254 and the proximal end of the second lower opening 268 determines the length of the arteriotomy.
- the cutter 200 After performing the arteriotomy, the cutter 200 is in a distally-extended position. The cutter 200 remains in that position as the anvil arm 14 is removed from the target vessel. Thus, the projection 208 does not extend out of the upper opening 248 during removal of the anvil arm 14 from the target vessel.
- the anvil arm 14 is removed from the target vessel after the anastomosis between the graft vessel and the target vessel has been completed.
- the cutter 200 may be moved proximally within the channel 246 in the anvil arm 14 before removing the anvil arm 14 from the target vessel.
- the hole in the wall of the target vessel 30 through which the anvil arm 14 enters the target vessel is small enough to prevent significant bleeding through the puncture site.
- the hole is closed by hand suturing.
- the hole is closed with a biocompatible glue, adhesive or the like.
- the hole is closed with a clip, clamp, or other implantable device that remains on the target vessel.
- Such a device may be positioned on the outer surface and/or inner surface of the target vessel, and may extend into the hole.
- a device for closing the hole may be constructed from nitinol or other superelastic or pseudoelastic material, or from stainless steel or other material, where that device moves between a first configuration and a second configuration during deployment, and where the second configuration holds the hole closed.
- the hole is less than substantially 2 mm wide, and advantageously less than 1 mm wide.
- another embodiment of the anvil 10 also includes a cutter 200 moveable relative to the anvil 10 for making an incision in the wall of a target vessel.
- the anvil 10 , anvil arm 14 , staple holder 38 , and other components are substantially as described above with regard to FIGS. 34-38 and 44 - 49 .
- the anvil insert 222 is connected to the anvil 10 .
- An aperture 230 is defined through the distal end of the anvil insert 222 into the cavity 228 defined within the anvil insert 222 , connecting the channel 246 to the cavity 228 .
- the cutter 200 extends through the aperture 230 in the anvil insert 222 , such that the distal end of the cutter 200 is positioned within the channel 246 and the proximal end of the cutter 200 is positioned within the cavity 228 .
- a cam 232 is positioned within the cavity 228 above the aperture 230 . Alternately, the cam 232 may be positioned differently relative to the aperture 230 .
- the cam 232 is a structure used in controlling the motion of the cutter 200 , as is described in greater detail below.
- At least the distal end of the cutter 200 may be biased upward. This biasing may be performed by any appropriate structure or mechanism, such as by one or more springs (not shown). Such a spring or springs may act in compression to push the distal end of the cutter 200 upward, or may act in tension to pull the distal end of the cutter upward.
- the cutter 200 may be constructed from an elastic or superelastic material that is formed in such a way as to produce an upward bias. The entire cutter 200 may be biased upward, if desired. At least the distal end of the cutter 200 is biased upward during the translation of the cutter 200 along the anvil arm 14 . Alternately, the cutter 200 is not biased, either upward or downward. Instead, the cutter 200 is urged upward and downward at different locations during its translation by the interaction between at least one cam follower on the cutter 200 and at least the cam 232 .
- the distal end of the anvil arm 14 is spaced apart from the staple holder 38 .
- the anvil arm 14 is inserted through the wall of the target vessel, as described above, such that the contact surface 206 of the anvil arm 14 is in substantial contact with the inner wall of the target vessel.
- the staple holder 38 and anvil 10 are moved relative to one another into the standby position, as described above. In the standby position, the cutter 200 is freed for translation along the channel 246 , because the tip 212 of the safety feature 210 no longer engages the safety recess 214 of the cutter 200 .
- At least the distal end of the cutter 200 is biased upward, and the cam 232 limits the upward motion of the cutter 200 by contacting at least a portion of the upper surface 252 of the cutter 200 .
- the cam 232 controls the motion of the distal end of the cutter 200 in the vertical direction as the cutter 200 translates within the channel 246 . Because the projection 208 is fixed to the cutter 200 , the cam 232 also controls the motion of the projection 208 in the vertical direction, and thus controls the location at which the projection 208 encounters the wall of the target vessel.
- a first cam follower 242 is defined on the upper surface 252 of the cutter 200 .
- the first cam follower 242 is a raised structure formed into the upper surface 252 of the cutter 200 .
- the first cam follower 242 is a separate structure or mechanism constructed separately from the cutter 200 and later connected to the cutter 200 .
- the first cam follower 242 may be located on a surface of the cutter 200 in addition to or instead of its upper surface 252 , depending on the position and configuration of the cam 232 .
- the first cam follower 242 may be shaped as a trapezoid or similar shape, or may be shaped differently.
- the cam 232 is fixed, and the first cam follower 242 is raised relative to the upper surface 252 of the cutter 200 . At least the distal end of the cutter 200 is biased upward. Thus, as the cutter 200 translates distally, the cam 232 engages the first cam follower 242 and causes the cutter 200 to move downward.
- the cam 232 and the first cam follower 242 are shaped to smoothly engage each other. Alternately, the first cam follower 242 is shaped to induce the cutter 200 to abruptly move downward when the first cam follower 242 initially encounters the cam 232 .
- the height of the first cam follower 242 relative to the contact surface 206 of the anvil arm 14 determines the distance that the distal end of the cutter 200 is moved downward.
- the cutter 200 may include a keel 264 or similar projection extending downward. As the distal end of the cutter 200 moves downward, the keel 264 or other projection moves into the first lower opening 254 .
- the first lower opening 254 does not control the motion of the cutter 200 ; instead, it provides a space for the keel 264 to move downward without interfering with the vertical motion of the distal end of the cutter 200 . If the keel 264 is omitted, the first lower opening 254 and the second lower opening 268 may be omitted as well.
- the connection between the graft vessel and the target vessel substantially defines a closed area
- the projection 208 is configured to engage the wall of the target vessel within that closed area. That is, the end of the graft vessel has a perimeter that contacts the side of the target vessel, such that the perimeter of the end of the graft vessel defines a closed area on the wall of the target vessel.
- the projection 208 makes an incision completely within the connection between the graft vessel and the target vessel, completing the anastomosis between the two vessels and minimizing or eliminating leakage at the anastomosis site. While the projection 208 on the cutter 200 remains below the contact surface 206 of the anvil arm 14 , it neither engages nor cuts the wall of the target vessel.
- the first cam follower 242 is sized to translate the tip of the projection 208 below the contact surface 206 of the anvil arm 14 for a selected distance such that the projection 208 does not engage the tissue of the target vessel until the projection 208 is positioned to enter the closed area on the wall of the target vessel defined by the perimeter of the end of the graft vessel.
- the cutter 200 continues to advance distally as the receiver 218 continues to impel the engagement feature 216 distally.
- the first cam follower 242 of the cutter 200 advances distally relative to the cam 232 .
- at least the distal end of the cutter 200 is biased upward.
- the first cam follower 242 decreases in height at its proximal end.
- the first cam follower 242 is constructed to provide a smooth, gradual upward motion of the distal end of the cutter 200 and the projection 208 , such as by providing a gradual slope between an upper surface 250 of the first cam follower 242 and an upper surface 252 of the cutter 200 .
- the first cam follower 242 may be constructed to allow the distal end of the cutter 200 and the projection 208 to abruptly snap upward as the first cam follower 242 moves distal to the cam 232 .
- the projection 208 moves upward through the upper opening 248 in the anvil arm 14 .
- the contact surface 206 of the anvil arm 14 is adjacent to the inner surface of the wall of the target vessel.
- upward motion of the projection 208 through the upper opening 248 causes the projection 208 to enter the wall of the target vessel.
- the projection 208 is sized, and the first cam follower 242 and cam 232 are shaped, such that the upward motion of the projection 208 after the first cam follower 242 has moved distal to the cam 232 causes the projection 208 to completely penetrate through the wall of the target vessel. That is, at least a portion of the projection 208 passes through the wall of the target vessel and enters the lumen.
- This initial penetration of the wall of the target vessel defines the starting point of an arteriotomy performed on the target vessel by the projection 208 .
- the starting point of the arteriotomy is spaced apart from the location on the target vessel at which the anvil arm 14 is inserted, resulting in a tissue bridge therebetween.
- the cutter 200 continues to advance distally as the receiver 218 continues to impel the engagement feature 216 distally.
- the upper surface 252 of the cutter 200 may contact the cam 232 during this motion, because the distal end of the cutter 200 continues to be biased upward.
- the projection 208 moves through the tissue of the wall of the target vessel in a direction substantially parallel to the longitudinal centerline of the anvil arm 14 . In this way, the projection 208 incises the tissue of the wall of the target vessel to create an arteriotomy.
- the tip of the projection 208 may maintain substantially the same height relative to the contact surface 206 of the anvil arm 14 during its distal translation, or may change its height relative to the contact surface 206 of the anvil arm 14 , as long as the tip of the projection 208 remains in the lumen of the target vessel during that translation.
- a second cam follower 244 is defined on the upper surface 252 of the cutter 200 , proximal to and spaced apart from the first cam follower 242 .
- a single cam follower is defined on the upper surface 252 of the cutter 200 , where that single cam follower includes a feature corresponding to the first cam follower 242 , a feature corresponding to the second cam follower 244 , and a section of reduced height between them corresponding to the upper surface 252 of the cutter 200 .
- the cutter 200 continues to advance distally as the receiver 218 continues to impel the engagement feature 216 distally. As a result of this motion, the second cam follower 244 contacts the cam 232 .
- the shape and size of the second cam follower 244 and cam 232 are selected such that the distal end of the cutter 200 is pushed downward far enough to cause the projection 208 to retract into the upper opening 248 .
- the projection 208 may be urged downward completely into the channel 246 , depending on the depth of the channel 246 and the height of the projection 208 . Alternately, the upper tip of the projection 208 may remain within the upper opening 248 .
- the cutter 200 may stop its distal translation at substantially the same time that the projection 208 retracts completely into the upper opening 248 , or may continue to translate distally within the channel 246 before coming to a stop.
- each cam follower 242 , 244 includes a location thereon having a height relative to the upper surface 252 of the cutter 200 sufficient to cause the projection 208 to be pushed out of contact with the wall of the target vessel. The distance between these locations defines the length of the arteriotomy.
- the cam followers 242 , 244 control the motion of the projection 208 and control the penetration of the wall of the target vessel.
- the cutter 200 After performing the arteriotomy, the cutter 200 is in a distally-extended position. The cutter 200 remains in that position as the anvil arm 14 is removed from the target vessel. The anvil arm 14 is removed from the target vessel after the anastomosis between the graft vessel and the target vessel has been completed. Alternately, after performing the arteriotomy, the cutter 200 may be moved proximally within the channel 246 before removing the anvil arm 14 from the target vessel. The hole at the puncture site and its closure are substantially as described above.
- the cutter 200 is initially in a distally-extended position, and retracted proximally in order to make an incision in the wall of the target vessel.
- the structures and mechanisms are as described above, but operated in substantially the reverse order as described above.
- the cutter 200 and the projection 208 may be moved in a different way in order to incise the tissue of the wall of the target vessel.
- each projection 208 is able to form a portion of the incision during translation of the cutter 200 .
- the distance that the cutter 200 is translated to form the incision is related to the distance between the projections 208 . That is, because each projection 208 forms a portion of the incision, no single projection 208 need be translated along the entire length of the incision.
- the projections 208 may be inserted into the wall of the target vessel, after which energy is applied to the projections 208 via the cutter 200 or directly in order to create an incision in the wall of the target vessel.
- an energy source (not shown) is connected to the cutter 200 .
- an ultrasound generator (not shown) may be connected to the cutter 200 and to the energy source.
- the ultrasound generator may be a piezoelectric crystal, as is standard, or a different structure or mechanism. Electrical energy may be applied to the ultrasound generator from the energy source, thereby causing the ultrasound generator to vibrate the projections 208 .
- FIGS. 17-23 illustrate an alternate anvil 100 that is used with a clamp 102 for controlling an incision site during an anastomosis procedure.
- the anvil 100 includes an anvil arm 104 and a handle 106 .
- the clamp 102 is slidable on the handle 106 to clamp the tissue of the target vessel 30 between the clamp 102 and the anvil arm 104 .
- the anvil arm 104 includes two rows of staple bending features 108 in the form of recesses positioned in two parallel rows along a top surface of the anvil arm 104 .
- the clamp 102 has a central opening 110 .
- a continuous anastomosis staple device 114 may be used to connect the graft vessel 32 to the target vessel 30 at the anastomosis site.
- the staple device 114 as shown in FIG. 19 includes a plurality of linkages forming a tubular configuration and a plurality of staple ends extending from the linkages.
- FIGS. 20-22 illustrate how the staple ends 116 of the staple device 114 are positioned in the end of the graft vessel 32 and are inserted through the incision 118 in the target vessel and bent over by contact with the staple bending features 108 of the anvil. As shown in FIG. 22 , the opposite ends 120 of the staple device 114 are folded over to complete the anastomosis.
- FIG. 23 illustrates a completed anastomosis performed according to the steps illustrated in FIGS. 19-22 .
- FIGS. 24-27 illustrate an alternate example of an anvil arm 14 d having a cutting wire 124 for forming the incision in the wall of the target vessel 30 .
- the cutting wire 124 may be used to form an incision before, during or after performing an end-to-side anastomosis procedure.
- a clamp 126 is used to trap the tissue at the anastomosis site between the clamp 126 and the anvil arm 14 d prior to performing the incision.
- the incision is spaced apart from the entry point of the anvil arm 14 d into the target vessel, creating a tissue bridge between the incision made in the wall of the target vessel and the entry point of the anvil arm 14 d into the target vessel.
- a portion of the contact between the anastomosed graft vessel and target vessel extends across the tissue bridge, such that the incision is located within the closed area defined by the contact between the perimeter of the end of the graft vessel and the wall of the target vessel.
- FIG. 28 shows a system 140 for controlling a tissue site and performing anastomosis.
- the system 140 includes an anvil arm 142 , a cutter 144 , and a graft vessel holder 146 all mounted on a handle 148 .
- the anvil arm 142 is mounted on the handle 148 and connected to a first actuator 150 that allows the anvil to be moved downward against the bias of a spring inside the handle.
- the cutter 144 may be spring biased or fixed and is positioned on the handle 148 directly above the anvil arm 142 .
- the graft vessel holder 146 includes two fixed arms 152 and two movable arms 154 .
- the two movable arms 154 are connected to a second actuator 156 on the handle 148 . Depression of the second actuator 156 against the bias of a spring within the handle causes the movable arms 154 to be moved downward away from the fixed arms to receive portions of a graft vessel between the movable and fixed arms.
- FIG. 29 The operation of the system 140 of FIG. 28 is shown in the cross sectional views of FIGS. 29-31 .
- an end of a graft vessel 32 is split so that each half of the graft vessel 32 can be held between a fixed arm 152 and a movable arm 154 .
- the first actuator 150 and the second actuator 156 are depressed to move the anvil arm 142 and the movable arms 154 downward.
- the split graft vessel 32 is then inserted between the fixed and movable arms 152 , 154 and the second actuator 156 is released to trap the ends of the graft vessel 32 , as shown in FIG. 30 .
- the anvil arm 142 is then inserted into the target vessel 30 in the same or similar manner as described above.
- FIG. 31 illustrates the tented target vessel 30 positioned adjacent the split and trapped graft vessel 32 in a position for performing anastomosis.
- the staple holders 38 are then advanced in the direction of the arrows D toward opposite sides of the anvil to staple the graft vessel and target vessel together.
- the staple holders 38 may hold a staple strip with an expandable backbone as shown in FIGS. 10A and 10B , or may instead or additionally hold different types of staples not connected to a backbone.
- the staple holders 38 may be provided with movable pins which allow the spacing between the staples to be adjusted depending on a size of the graft vessel used.
- staple bending features are provided on the anvil and staples are provided at an exterior of the tissue.
- the staples and/or staple holding strips may be positioned on the anvil and an exterior member with staple bending features may be moved toward the anvil to bend the ends of the staples and secure the graft and target vessels together.
- FIGS. 32-33 illustrate the use of an alternate anvil 130 for controlling the tissue at an anastomosis site.
- the anvil 130 includes a longitudinal opening 132 extending through the anvil 130 for application of a plurality of conventional sutures at the anastomosis site.
- the anvil 130 is inserted into the target vessel 30 and pulled against the interior wall of the target vessel 30 , tenting the target vessel as shown in FIG. 33 .
- Sutures 134 are then passed through the opening 132 in the anvil 130 and through the tissue of the target vessel wall on opposite sides of the anvil 130 . Once the sutures 134 are placed as shown in FIG. 33 , an incision is made in the target vessel along a center of the anvil 130 .
- each of the sutures 34 is then pulled out through the incision in the target vessel and cut so that an even row of sutures is provided along each of the sides of the incision.
- This system eliminates the tedious procedure of placing each individual suture very close to the edge of the incision in the very thin and flexible target vessel wall.
- Each of the sutures 134 is connected to a graft vessel in a conventional manner completing the anastomosis.
- the anvil as shown in FIGS. 32-33 allows quick and easy placement of a plurality of sutures in a very even manner close to the edge of the incision.
- the sutures of a conventional anastomosis are generally within about one millimeter of the edge of the incision and are advantageously within 0.5 millimeters of the edge of the incision.
- the cutter 200 does not include one or more projections 208 .
- the cutter 200 includes or is connected directly or indirectly to an energy source (not shown), which is used to create an opening in the wall of the target vessel.
- an energy source (not shown), which is used to create an opening in the wall of the target vessel.
- an emitter of laser or RF energy may be connected to the cutter 200 and to the energy source.
- the emitter of laser or RF energy is selectively actuated to transmit energy into the wall of the target vessel during translation of the cutter 200 , thereby creating an opening therein.
- the energy source may transmit a first type of energy to the emitter or other mechanism, which is converted by the emitter into a second type of energy delivered into the wall of the target vessel.
- the cutter 200 may include a projection 208 and additionally be connected to an energy source that is selectively actuated in order to assist in creating an opening in the wall of the target vessel.
- the cutter 200 does not translate through the anvil arm 14 . Instead, the cutter 200 is spatially removed from the anvil arm 14 , and creates an opening in the wall of the target vessel before or after the anvil arm 14 is inserted into the target vessel.
- the anvil arm 14 is inserted into a hole in the wall of the target vessel and the staple holder 38 deploys staples or other connectors to connect the graft vessel to the target vessel, as described above.
- the anvil arm 14 is removed, and an independent cutter 200 is then introduced through the hole in the wall of the target vessel.
- the cutter 200 may be configured as described above, including a projection 208 extending therefrom, or may be configured differently.
- the cutter 200 is manipulated relative to the connection between the target vessel and the graft vessel to create an opening at the junction therebetween. That is, registration is maintained between the cutter 200 and the junction between the end of the graft vessel and the wall of the target vessel.
- an imaging device (not shown) or other device may be connected to the cutter 200 or utilized in conjunction with the cutter 200 .
- a standard intravascular ultrasound unit may be connected to or used in conjunction with the cutter 200 .
- the intravascular ultrasound unit is connected to a display device (not shown) visible to the operator.
- the operator controls the intravascular ultrasound unit to visualize the interior of the target vessel and the surrounding area, thereby locating the junction between the target vessel and the graft vessel and allowing the cutter 200 to be controlled to incise an opening in the wall of the target vessel within the closed area on the wall of the target vessel defined by the perimeter of the end of the graft vessel, thereby allowing blood to flow through the opening into the target vessel.
- a different visualization device or devices may be inserted into or positioned outside of the target vessel to locate the junction with the graft vessel.
- the cutter 200 and any visualization device present in the lumen of the target vessel are then removed from the lumen of the target vessel, and the opening in the wall of the target vessel through which they were removed is sealed.
- the anvil arm 14 is inserted into a hole in the wall of the target vessel and the staple holder 38 deploys staples or other connectors to connect the graft vessel to the target vessel, as described above.
- the anvil arm 14 is removed, and the hole in the wall of the target vessel is removed.
- a cannula (not shown) is inserted into the lumen of the graft vessel through the free end of the graft vessel, and a stylet (not shown) is inserted through the lumen of the cannula.
- the cannula and the stylet are surgical instruments that are well known in the art.
- the stylet has a distal end configured to penetrate the wall of the target vessel.
- a sharp point, blade, or other penetrating member may be formed into or connected to the distal end of the stylet.
- the cannula may be inserted into the lumen of the graft vessel such that its distal end contacts the outer wall of the target vessel.
- a force is exerted on the stylet to cause its distal end to penetrate the wall of the target vessel. Consequently, an opening is created between the graft vessel and the target vessel within the circumference of the end of the graft vessel.
- the cannula and stylet are then removed from the lumen of the graft vessel through its free end.
- the anvil arm 14 is inserted into a hole in the wall of the target vessel and the staple holder 38 deploys staples or other connectors to connect the graft vessel to the target vessel, as described above.
- the anvil arm 14 is removed, and the hole in the wall of the target vessel is closed.
- An independent cutter 200 is then introduced through the wall of the graft vessel.
- the cutter 200 itself may create an opening in the wall of the graft vessel through which it can enter, or a separate implement may be used to create an opening in the wall of the graft vessel.
- the cutter 200 may be configured as described above, including a projection 208 extending therefrom, or may be configured differently.
- the cutter 200 may be J-shaped or L-shaped to facilitate creation of the opening between the graft vessel and the target vessel through the wall of the graft vessel.
- the cutter 200 is manipulated relative to the connection between the target vessel and the graft vessel to create an opening in the wall of the target vessel at the junction therebetween. That is, registration is maintained between the cutter 200 and the junction between the end of the graft vessel and the wall of the target vessel.
- the cutter 200 is then removed through the wall of the graft vessel, and the opening in the wall of the graft vessel is sealed.
Abstract
A surgical tool for performing anastomosis between a graft vessel and a target vessel may include an anvil; a cutting element connected to the anvil; and an energy source connected to the cutting element, wherein the energy source is configured to deliver energy to the cutting element. A method for performing anastomosis with that tool may include placing an end of the graft vessel against a side of the target vessel; creating an opening in the wall of the target vessel at a first location; inserting an anvil through the opening from outside the wall of the target vessel into the lumen of the target vessel; creating an incision in the wall of the target vessel spaced apart from the first location; and connecting the graft vessel to the target vessel.
Description
- This application is a divisional of U.S. patent application Ser. No. 10/151,441, filed on May 20, 2002, which in turn is a continuation-in-part of U.S. patent application Ser. No. 09/363,255, filed on Jul. 28, 1999, now U.S. Pat. No. 6,391,038, each of which is herein incorporated by reference in its entirety.
- The invention relates to an apparatus and method for performing anastomosis.
- Anastomosis is a procedure by which two hollow tissue structures are joined together. More particularly, vascular anastomosis is a procedure by which two blood vessels within a patient are surgically joined together. Vascular anastomosis is performed during treatment of a variety of conditions including coronary artery disease, diseases of the great and peripheral vessels, organ transplantation, and trauma. In coronary artery disease (CAD) an occlusion or stenosis in a coronary artery interferes with blood flow to the heart muscle. Treatment of CAD involves the grafting of a vessel in the form of a prosthesis or harvested artery or vein to reroute blood flow around the occlusion and restore adequate blood flow to the heart muscle. This treatment is known as coronary artery bypass grafting (CABG).
- In the conventional CABG, a large incision is made in the chest and the sternum is sawed in half to allow access to the heart. In addition, a heart-lung machine is used to circulate the patient's blood so that the heart can be stopped and the anastomosis can be performed. In order to minimize the trauma to the patient induced by conventional CABG, less invasive techniques have been developed in which the surgery is performed through small incisions in the patient's chest with the aid of visualizing scopes. In both conventional and less invasive CABG procedures, the surgeon has to suture one end of the graft vessel to the coronary artery and the other end of the graft vessel to a blood-supplying artery, such as the aorta. The suturing process is a time consuming and difficult procedure requiring a high level of surgical skill. In order to perform the suturing of the graft to a target vessel such as the coronary artery or the blood supplying artery, a surgeon holds the edges of the incision in the target vessel with one handle and holds a needle in the other hand for suturing, or an assistant may hold the edges of the incision in the target vessel while a surgeon makes small stitches as close as possible to the edges of the incision. This suturing requires a high degree of precision and is quite time consuming. In addition, during conventional CABG procedures blood flow at the anastomosis site is stopped during suturing. This prevents bleeding from the incision site but also prevents blood from reaching a portion of the heart muscle served by the vessel. Further, during off-pump CABG procedures a side clamp or other device may be used to isolate a portion of the wall of the aorta to which a graft vessel is sutured. The use of a side clamp or similar device can cause emboli to detach from the wall of the aorta and enter the bloodstream, which is undesirable.
- Accordingly, it would be desirable to provide a vascular anastomosis system that allows the tissue at the anastomosis site to be controlled during suturing or other connection of the graft and target vessels. It would also be desirable to provide a vascular anastomosis system that allows the connection of a graft vessel to a target vessel prior to making an incision in the target vessel which allows blood flow between the target vessel and the graft vessel.
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FIG. 1 is a perspective view of an anvil and a plurality of staples according to a first aspect of the present invention. -
FIG. 2 is a perspective view of the anvil ofFIG. 1 being inserted into a target vessel. -
FIG. 3 is a perspective view of the anvil tenting a wall of a target vessel for an anastomosis procedure. -
FIG. 4 is a perspective view of a graft vessel placed adjacent an exterior of the tented target vessel for the anastomosis procedure. -
FIG. 5 is a perspective view of the staples being applied to the graft vessel and the target vessel during an anastomosis procedure. -
FIG. 6 is a perspective view of the completed anastomosis according to the first aspect of the present invention. -
FIG. 7 is a perspective view of a staple supported on a staple holding strip. -
FIG. 8 is a side view of the staple and staple holding strip ofFIG. 7 when the ends of the staple have been bent by contact with an anvil. -
FIG. 9 is a perspective view of an anvil and staple according to another aspect of the present invention. -
FIGS. 10A and 10B are is a side views of a plurality of staples supported on two examples of expandable staple holding strips. -
FIG. 11 is a perspective view of a portion of an anvil having a movable cutting device. -
FIG. 12 is a side view of an anvil having an external cutting device. -
FIGS. 12A and 12B are side views of a portion of an anvil and two cutting devices that snap onto the anvil. -
FIG. 13 is a side view of a portion of an anvil with an extendable cutting device. -
FIG. 14 is a side view of the anvil ofFIG. 13 with the cutting device extended. -
FIG. 15 is a side view of a portion of an anvil with an alternate extendable cutting device. -
FIG. 16 is a side view of the anvil ofFIG. 15 with the cutting device extended. -
FIG. 17 is a perspective view of an anvil according to a second aspect of the invention being inserted into a target vessel. -
FIG. 18 is a perspective view of the anvil ofFIG. 17 positioning inside a target vessel and a clamp being advanced to clamp the wall of the target vessel between the anvil and the clamp. -
FIG. 19 is a perspective view of a graft vessel being advanced to the target vessel with a continuous anastomosis staple while the anastomosis site on the target vessel is controlled by the anvil and clamp. -
FIGS. 20-22 are side cross sectional views of the steps of performing the anastomosis with the continuous anastomosis staple shown inFIG. 19 . -
FIG. 23 is a perspective view of the completed anastomosis performed as shown inFIGS. 19-22 . -
FIGS. 24-27 are perspective views of the steps of an alternative anvil and clamp system for controlling an anastomosis site and forming an incision through the clamped tissue of the target vessel. -
FIG. 28 is a perspective view of a system for controlling a tissue site and performing anastomosis according to the present invention. -
FIG. 29 is a cross sectional view taken along line C-C ofFIG. 28 , showing a first step of the anastomosis procedure. -
FIG. 30 is a cross sectional view taken along line C-C ofFIG. 28 , showing a second step of the anastomosis procedure. -
FIG. 31 is a cross sectional view taken along line C-C ofFIG. 28 , showing a third step of the anastomosis procedure. -
FIG. 32 is a perspective view of an anvil according to another aspect of the present invention for use with sutures. -
FIG. 33 is a perspective view of the anvil ofFIG. 32 positioned within a target vessel and used to locate a plurality of suture at an anastomosis site. -
FIG. 34 is a side cutaway view of a first embodiment of an anvil, a cutter and a staple holder, where the anvil and staple holder are spaced apart from each other. -
FIG. 35 is an end cross-section view of the anvil ofFIG. 34 . -
FIG. 36 is a side cutaway view of a portion of the anvil inserted into the lumen of a target vessel. -
FIG. 37 is a side view of the cutter. -
FIG. 38 is a perspective view of the cutter ofFIG. 37 . -
FIG. 39 is a side view of the distal end of a second embodiment of a cutter. -
FIG. 40 is a side view of the distal end of a third embodiment of a cutter. -
FIG. 41 is a side view of the distal end of a fourth embodiment of a cutter. -
FIG. 42 is a side view of a portion of a fifth embodiment of a cutter. -
FIG. 43 is a side view of the distal end of a sixth embodiment of a cutter. -
FIG. 44 is a side cutaway view of the anvil and staple holder ofFIG. 34 , where the cutter is in a first position. -
FIG. 45 is a side cutaway view of the anvil and staple holder ofFIG. 34 , where the cutter is in a second position. -
FIG. 46 is a side cutaway view of the anvil and staple holder ofFIG. 34 , where the cutter is in a third position. -
FIG. 47 is a side cutaway view of the anvil and staple holder ofFIG. 34 , where the cutter is in a fourth position. -
FIG. 48 is a side cutaway view of the anvil and staple holder ofFIG. 34 , where the cutter is in a fifth position. -
FIG. 49 is a side cutaway view of a second embodiment of an anvil and a staple holder, where the anvil and staple holder are spaced apart from each other. -
FIG. 50 is a side cutaway view of the anvil and staple holder ofFIG. 40 , where the cutter is in a first position. -
FIG. 51 is a side cutaway view of the anvil and staple holder ofFIG. 40 , where the cutter is in a second position. -
FIG. 52 is a side cutaway view of the anvil and staple holder ofFIG. 40 , where the cutter is in a third position. -
FIG. 53 is a side cutaway view of the anvil and staple holder ofFIG. 40 , where the cutter is in a fourth position. -
FIG. 54 is a side cutaway view of the anvil and staple holder ofFIG. 40 , where the cutter is in a fifth position. - The use of the same reference symbols in different figures indicates similar or identical items.
- As shown in
FIG. 1 , one embodiment of ananvil 10 includes ahandle 12 and ananvil arm 14 extending from thehandle 12. Theanvil arm 14 may be oriented substantially perpendicular to thehandle 12, or oriented at a different angle. Theanvil arm 14 may be provided with one or more staple bending features 16 on opposite sides of theanvil arm 14. In theanvil 10 shown inFIG. 1 , the staple bending features 16 each include a plurality ofrecesses 20 which receive the ends ofstaples 22 and cause the staple ends to bend over. At least one of the staple bending features 16 may be configured differently or omitted, if desired. Thestaples 22 may be connected to astaple holding strip 24. Thestaples 22 are U-shaped and are arranged in a spaced apart parallel configuration such that thestaples 22 all lie in a single plane. Alternately, thestaples 22 may be shaped differently, and/or lie in one or more different planes. Anexemplary anvil arm 14 has a height and a width of about 2 mm or less, advantageously about 1 mm or less, and a length of about 2 to 15 mm, advantageously 5 to 12 mm. The length of the anvil will vary depending on the diameter of the graft vessel selected. The length to width ratio of theanvil arm 14 is substantially between 2:1 and 15:1. A different length to width ratio may be used, if desired. As one example, thestaples 22 have widths of about 0.2-3 mm. Advantageously, thestaples 22 have widths of substantially 2 mm or less. The leg lengths of thestaples 22 are substantially 0.2-3 mm. Alternately, other leg lengths may be used. - The
anvil arm 14 has a sharpdistal end 28 for puncturing the tissue of a target vessel to insert theanvil arm 14 into the target vessel. As illustrated inFIG. 2 , theanvil arm 14 is inserted into a pressurized orunpressurized target vessel 30 by puncturing the target vessel with thedistal end 28 of theanvil arm 14. The hole that is formed in the wall of thetarget vessel 30 by theanvil arm 14 is small enough to prevent significant bleeding through the puncture site. Alternately, the hole is closed by hand suturing. Alternately, the hole is closed with a biocompatible glue, adhesive or the like. Alternately, the hole is closed with a clip, clamp, or other implantable device that remains on the target vessel. Such a device may be positioned on the outer surface and/or inner surface of the target vessel, and may extend into the hole. A device for closing the hole may be constructed from nitinol or other superelastic or pseudoelastic material, or from stainless steel or other material, where that device moves between a first configuration and a second configuration during deployment, and where the second configuration holds the hole closed. The hole is less than substantially 2 mm wide, and advantageously less than 1 mm wide. Alternately, theanvil arm 14 has a bluntdistal end 28 that is inserted through a hole created with a separate instrument, by a different instrument connected to theanvil arm 14, or by a sharp member connected to theanvil arm 14 that can be retracted into theanvil arm 14 or otherwise blunted or concealed after puncturing or creating an incision in the wall of the target vessel. - Once the
anvil arm 14 has been inserted into thetarget vessel 30, theanvil arm 14 may be pulled against an inner wall of thetarget vessel 30, causing tenting of the thin tissue of the vessel wall as illustrated inFIG. 3 . This tenting of the vessel wall provides control over the anastomosis site during an anastomosis procedure that is described with respect toFIGS. 4-6 . However, tenting of the target vessel wall need not be tented in order to control the anastomosis site during the anastomosis procedure. - As shown in
FIG. 4 , agraft vessel 32 is advanced to the anastomosis site and anend 34 of thegraft vessel 32 is positioned adjacent an exterior surface of thetarget vessel 30 at the anastomosis site. The tented portion of thetarget vessel 30 is positioned within the perimeter of theend 34 of thegraft vessel 32. As shown inFIG. 5 , astaple holder 38 is provided having twoarms 40 which are pivotally connected to thehandle 12 of theanvil 10. Alternatively, the pivotingarms 40 of thestaple holder 38 may be connected to thehandle 12 in a different way, or may be connected to a separate or additional device. Thearms 40 are spaced apart from one another across at least a part of their length. Thus, the graft vessel can be positioned between thearms 40. That is, thearms 40 are positioned on substantially opposite sides of the graft vessel. In this way, eacharm 40 may be positioned against a flap at an end of the graft vessel, as illustrated inFIGS. 29-31 . Thearms 40 may be configured differently, if desired. - Referring also to
FIG. 1 , thestaple holder 38 may be used to holdindividual staples 22 and/or staple holding strips 24. In one embodiment, eacharm 40 of thestaple holder 38 carries one row ofstaples 22 or onestaple holding strip 24, where thestaples 22 are arranged in a substantially linear row. Alternately,staples 22 or staple strips 24 may be arranged in two or more rows, parallel or otherwise, on one ormore arms 40. Alternately, thestaples 22 may be staggered on one or more arms, such that at least one row ofstaples 22 does not fall along a straight line. Thestaples 22 or staple strips 24 may be arranged or aligned in any manner on eacharm 40 that results in a secure anastomosis between the graft vessel and the target vessel. Thestaples 22 are inserted through the flaps at the end of thegraft vessel 32, or another portion of the target vessel, and into thetarget vessel 30 by pivoting thearms 40 of thestaple holder 38 towards theanvil arm 14. The staple bending features 16 are positioned in a configuration corresponding to the configuration of thestaples 22, such that each staple 22 engages a correspondingstaple bending feature 16 during deployment. When the ends of thestaples 22 engage the staple bending features 16 on theanvil arm 14, the ends of thestaples 22 are bent over, securing thegraft vessel 32 andtarget vessel 30 together. Once the staple ends are bent over, thestaples 22 are released from thestaple holding strip 24 or thestaple holder 38, resulting in spaced apartstaples 22 securing thegraft vessel 32 and thetarget vessel 30 together as shown inFIG. 6 . Alternately, thestaple holder 38 is a connector deployer that deploys connectors other than or in addition tostaples 22. - After stapling is complete, an incision is formed in the wall of the
target vessel 30 to allow blood flow between the target vessel and thegraft vessel 32. Some examples of methods and devices for forming the incision will be described in further detail below.FIG. 6 illustrates a completed anastomosis between atarget vessel 30 and agraft vessel 32 with a plurality ofstaples 22. The spacing between thestaples 22 is approximately 1 to 4 mm. This spacing is similar to the spacing between sutures in a conventional sutured anastomosis. A different spacing between thestaples 22 may be used if desired. After completion of the anastomosis, theanvil arm 14 is withdrawn from thetarget vessel 30 betweenadjacent staples 22. The withdrawal of theanvil arm 14 leaves a gap that is approximately the same as the spacing between adjacent staples. Accordingly, substantially no blood leakage occurs at the location where the anvil arm has been withdrawn. -
FIGS. 7 and 8 illustrate one example of a staple 22 connected to astaple holding strip 24. Thisstaple 22 includes barbed staple ends 52 extending from the front portion of the staple 22 and a C-shapedportion 54 extending from a rear of the staple 22 for connecting the staple 22 to thestaple holding strip 24. Thestaple holding strip 24 includes a plurality ofprotrusions 56 for receiving thestaples 22. The C-shapedportion 54 of each staple 22 is received around one of theprotrusions 56 and is secured in place at one or more locations, such as bywelds 58 or by a frangible linkage or connection. Alternately, the C-shapedportion 54 of each staple 22 may be secured to the staple-holdingstrip 24 in a different way. As shown inFIG. 8 , when thestaple holding strip 24 is advanced toward theanvil arm 14, the barbed staple ends 52 are received in therecesses 20 in theanvil arm 14. Contact between eachstaple end 52 and thecorresponding recess 20 generates a moment that causes the barbed staple ends 52 to bend towards one another. At the same time that the barbed staple ends 52 bend over, or after the bending of the staple ends 52, thestaple 22 is detached from thestaple holding strip 24. The staple 22 may be detached from thestaple holding strip 24 by the action of bending the barbed staple ends 52 such that the C-shapedportion 54 of the staple 22 splays outward and breaks apart from the correspondingprotrusion 56 on thestaple holding strip 24, by bending a frangible connection between the staple holding strip and the staples to separate the staples, or any other known separation methods, such as melting of a connection between the staple and the staple holding strip. -
FIG. 9 illustrates an alternate staple 22 a having inwardly curved barbed staple ends 52 a. Because the staple ends 52 a are themselves curved, the corresponding staple bending feature or features 16 a need not be curved to bend the ends 52 a of the staples 22 a. As shown inFIG. 9 , the staple bending features 16 a on each side of the anvil arm 14 a may be formed as a single longitudinal groove along the anvil arm 14 a, where the staple bending feature 16 a has a substantially flat surface. When the curved ends 52 a of the staple 22 a are received in the groove 16 a of the anvil arm 14 a, the ends bend inward to secure the tissue with the staple. Alternately, the staple may be configured differently. Alternately, two or more different kinds of staples are deployed by thestaple holder 38 in order to form a single anastomosis. - Referring also to
FIG. 10A , a plurality of staples 22 a are positioned on an expandable staple holding strip called anexpandable backbone 66. Theexpandable backbone 66 includes a plurality ofelements 68 which are interconnected by one or more expandingmembers 70. Each of thebackbone elements 68 is provided with a connectingdiamond member 72 that is connected to one of the staples 22 a. As shown inFIG. 10A , each staple 22 a is connected to thecorresponding diamond member 72 by a thin connectingsection 74. Theexpandable backbone 66 allows the spacing between the staples 22 a to be adjusted for the particular anastomosis to be performed. Thebackbone 66 allows expansion of the distance between staples from a distance of approximately 0.1 mm to a distance of approximately 1 to 4 mm, i.e., expansion of up to 40 times the original spacing. Alternately, thebackbone 66 allows a different amount of expansion. The expandingbackbone 66 also includes twoopenings 76 at opposite ends which may be engaged by holding pins (not shown) on an anastomosis system or staple holder. Theopening 76 allow thebackbone 66 to be easily expanded by relative motion of the holding pins. The connectingdiamond members 72 are configured to collapse inwardly toward the backbone when the staples 22 a engage the staple bending surface or surfaces 16 a of the anvil. The collapsing of eachdiamond member 72 forces the corresponding staple 22 a to separate from thediamond member 72 at a connectingsection 74. The connectingsection 74 is a frangible linkage connecting a staple 22 a to acorresponding diamond member 72. -
FIG. 10B illustrates another example of staples 22 a detachably connected to abackbone 66. The staples 22 a are each connected to the associatedbackbone elements 68 at two connectingsections 74. The staples 22 a,backbone 66, and associated components are substantially as described above with regard toFIG. 10A . -
FIG. 11 shows a portion of ananvil arm 14 with amovable cutting device 44. The cuttingdevice 44 includes abase 46 and ablade 48. Thebase 46 of the cuttingdevice 44 is positioned in alongitudinal groove 50 in theanvil arm 14. After theanvil arm 14 has been inserted into the target vessel, the cuttingdevice 44 may be moved longitudinally along theanvil arm 14 to form an incision in the target vessel. -
FIGS. 12, 12A , and 12B illustrate external cutting devices that are advanced down onto theanvil arm 14 after the anastomosis procedure and cut an incision in the target vessel from an exterior of the target vessel as theanvil arm 14 is withdrawn. As shown inFIG. 12 , aknife 62 is positioned on aknife arm 64 that is movable along thehandle 12 of the anvil. Theknife 62 is moved downward in a direction substantially parallel to the longitudinal axis of thehandle 12 until theknife 62 engages arecess 65 in theanvil arm 14. Theknife 62 is thereby positioned substantially at the anastomosis site. The end of the graft vessel is then placed substantially against the wall of the target vessel at the anastomosis site, over theknife 62 andknife arm 64. As theanvil arm 14 is withdrawn from the anastomosis site, theknife 62 forms an incision in the target vessel. Theknife 62 andknife arm 64 exit the anastomosis site via the joint between the graft vessel and the target vessel. The withdrawal of theanvil arm 14,knife 62 andknife arm 64 leaves a gap in the wall of the target vessel that is approximately the same as the spacing between adjacent staples to minimize or eliminate leakage through that gap. Alternately, theknife 62 may be moveable relative to thehandle 12 in at least one direction in addition to a direction substantially parallel to the longitudinal axis of thehandle 12. For example, theknife 62 may be moveable in a direction substantially parallel to the wall of the target vessel to create an arteriotomy in the target vessel at the junction between the graft vessel and the target vessel. -
FIGS. 12A and 12B illustrate two alternate examples of theknife 62 which snap onto acorresponding engagement surface 65 of theanvil arm 14 so that the knife and anvil are secured together for formation of the incision during removal of theanvil arm 14 from the anastomosis site. -
FIGS. 13-16 illustrate two variations of extendable cutting devices for making an incision in the target vessel while withdrawing theanvil arm 14 from the target vessel.FIG. 13 illustrates ananvil arm 14 b having ablade 78 connected to aflexible blade support 80. When theblade support 80 is pulled in the direction of the arrow A with respect to theanvil arm 14 b, theblade 78 moves from a forwardly extending position shown inFIG. 13 to an upwardly extending position shown inFIG. 14 as a result of flexure of theblade support 80. Theblade 78 in the forwardly extending position may be used to form a small opening in the wall of the target vessel through which theanvil arm 14 is inserted into the target vessel. After an anastomosis has been performed, or while an anastomosis is performed, theblade 78 is moved to an upwardly angled or a vertical position in which theblade 78 is used to form an incision in the target vessel as theanvil arm 14 b is removed from the target vessel. -
FIGS. 15-16 illustrate an alternate example of ananvil arm 14 c having ablade 84 and ablade support 86. While theanvil arm 14 c is inserted into the target vessel and during the anastomosis procedure, theblade 84 is positioned in arecess 88 in the anvil arm. Theblade 84 may be moved from the position ofFIG. 15 to the extended position ofFIG. 16 by moving theblade support 86 in the direction of the arrow B with respect to the anvil arm. Theblade 84 is flexible and stressed, such that freeing theblade 84 from therecess 88 causes theblade 84 to move to the extended position. Alternatively, theblade 84 may be extended automatically upon withdrawal of theanvil arm 14 when ablade tip 90 catches on an interior surface of the target vessel wall during withdrawal of the anvil arm. - The extendable cutting devices shown in
FIGS. 13-16 are merely shown as examples of the type of cutting devices which may be used for making the incision. Once these cutting devices or blades have been extended from the anvil arm, they may be fixed to perform cutting as the anvil arm is removed from the target vessel or the blades may be movable along the anvil arm to make an incision prior to removal of the anvil arm from the target vessel. - Another embodiment of the
anvil 10 also includes acutter 200 that is moveable relative to theanvil 10 for making an incision in the wall of a target vessel. Referring toFIGS. 34 and 35 , atissue stop 220 is formed into or connected to theanvil 10. The portion of theanvil 10 distal to thetissue stop 220 is configured to penetrate into the wall of a target vessel, and may be referred to as theanvil arm 14. Achannel 246 is defined within theanvil arm 14, through which acutter 200 is configured to move. Thecutter 200 is narrower than thechannel 246, such thatinterior surfaces 202 on either side of thechannel 246 may guide the translation of thecutter 200 relative to theanvil arm 14. As used in this document, the term “translation” as used in regard to thecutter 200 refers to motion of thecutter 200 in the distal or proximal direction, whether or not thecutter 200 or a portion thereof moves upward or downward during that motion. For convenience, the direction substantially perpendicular to the longitudinal centerline of theanvil arm 14 toward the wall of the target vessel may be referred to as “upward”, and the direction substantially perpendicular to the longitudinal centerline of theanvil arm 14 away from the wall of the target vessel may be referred to as “downward”. However, the positioning of theanvil arm 14 in use is not limited to an orientation in which these directions correspond to absolute directions measured relative to the ground. Similarly, for convenience, motion upward or downward may be referred to as “vertical” motion, and motion substantially parallel to the longitudinal centerline of theanvil arm 14 may be referred to as “horizontal” motion. - The
anvil arm 14 includes acontact surface 206. Referring also toFIG. 36 , in use, thecontact surface 206 of theanvil arm 14 is placed substantially against theinner surface 203 of atarget vessel 201. Thecontact surface 206 substantially defines a place that is substantially parallel to the longitudinal centerline of theanvil arm 14. Alternately, thecontact surface 206 is contoured and/or oriented differently. Anupper opening 248 extends along at least a portion of thecontact surface 206 in a direction substantially parallel to the longitudinal centerline of theanvil arm 14, and opens into thechannel 246. Theupper opening 248 may divide thecontact surface 206 into symmetrical or asymmetrical sections. Further, thecontact surface 206 may be formed by two substantially planar surfaces, by one substantially planar surface and a differently-shaped surface, or by another set of surfaces. Additionally, thecontact surface 206 may be formed by two thin edges, each edge occurring at the intersection of a wall of theupper opening 248 and an outer surface of theanvil arm 14. Theupper opening 248 need not extend proximally any further than thetissue stop 220. However, theupper opening 248 may extend proximal to thetissue stop 220, if desired. A firstlower opening 254 and a secondlower opening 268 are defined through alower surface 256 of theanvil arm 14. Thelower surface 256 of theanvil arm 14 may be substantially parallel to thecontact surface 206 or may be oriented differently relative to thecontact surface 206. Alternately, the firstlower opening 254 and/or the secondlower opening 268 do not extend completely through theanvil arm 14, and instead are depressions extending along at least part of abottom surface 266 of thechannel 246 - Referring also to
FIGS. 37-38 , thecutter 200 is a thin, rigid member, shaped such that it can be held within thechannel 246 in theanvil arm 14. Thecutter 200 has a substantially constant width along its entire length. Alternately, the width of thecutter 20 may vary along its length. Thecutter 200 may be made of metal, ceramic, plastic, or other material, or from a combination of different materials. Asharp projection 208 extends upward from thecutter 200 at or near its distal end. Theprojection 208 is substantially triangular, but may be shaped differently. Theprojection 208 may be smooth or serrated, or otherwise shaped or formed. A portion of theprojection 208 may be ground or otherwise honed to a sharp edge to facilitate the motion of theprojection 208 through the tissue of the wall of a target vessel, as described in greater detail below. If so, thecutter 200 is composed of a material that can be sharpened adequately to cut tissue. Alternately, thecutter 200 may be flexible, at least in part. Further, theprojection 208 may be located at a different position on thecutter 200 than at or near its distal end. An additional sharp point (not shown) may be provided at the distal end of thecutter 200, extending in a distal direction, in order to create an initial puncture or incision in the wall of the target vessel. Such a point may be as described in U.S. patent application Ser. No. 10/134,081, which is herein incorporated by reference in its entirety. - One or more
additional projections 208 may be provided, if desired. For example, two ormore projections 208 may extend upward from thecutter 200. Wheremultiple projections 208 are used, they may cooperate with one another to create an incision in the wall of the target vessel. Referring also toFIG. 39 , asecond projection 208 extends upward from thecutter 200 proximal to afirst projection 208. Theprojections 208 are both substantially the same triangular shape and the same size. However, theprojections 208 may be shaped and sized differently. Theprojections 208 are both substantially planar, and are aligned such that bothprojections 208 lie in substantially the same plane. Eachprojection 208 may include at least one sharpened orbeveled edge 209 oriented to engage and incise the wall of the target vessel when thecutter 200 is translated, as described below. Referring toFIG. 40 , at least twoprojections 208 extend upward from thecutter 200. Theprojections 208 each have abarb 211 at the tip. However, thebarb 211 may be omitted from some or all of theprojections 208. Under thebarb 211, a sharpened orbeveled edge 209 extends downward and proximally. Theedge 209 may be straight or curved. The upper end of theedge 209 is distal to the lower, proximal end of the corresponding barb. Theedge 209 of eachprojection 208 is oriented to engage and incise the wall of the target vessel when thecutter 200 is translated. Referring toFIG. 41 , at least twoprojections 208 extend upward from thecutter 200, at least one of which has abarb 211 at its tip. Theedge 209 associated with eachprojection 208 is more curved than theedge 209 shown inFIG. 40 . Alternately, theedge 209 is substantially straight, or gently curved, or positioned on a portion of a largercurved segment 213 extending downward from and proximal to thebarb 211. Referring toFIG. 42 , a number ofprojections 208 may be placed along a length of thecutter 200. This length may be comparable to the desired length of the incision in the wall of the target vessel. Theseprojections 208 may be substantially triangular as shown, or may be shaped differently. Where more than oneprojection 208 is used on thecutter 200, theprojections 208 need not have the same configuration. For example,projections 208 such as theexemplary projections 208 shown inFIGS. 39-41 may be mixed together on thesame cutter 200. Alternately, one or more of theprojections 208 are moveable relative to thecutter 200, such that one ormore projections 208 can be moved upward or downward relative to thecutter 200. - As another example of a configuration of the
projections 208, referring toFIG. 43 , theprojections 208 extending upward from thecutter 200 each are substantially planar, and are aligned such that not all of theprojections 208 lie in the same plane. In such a configuration, theprojections 208 may create a wider incision in the wall of the target vessel than would be created if theprojections 208 were substantially aligned. For example, one set ofprojections 208 may be aligned substantially in a first plane, and a second set ofprojections 208 may be aligned substantially in a second plane substantially parallel to the first plane. The second plane and the first plane may be oriented differently relative to one another, if desired. As another example, none of theprojections 208 lie in a common plane with one or moreother projections 208. Referring toFIGS. 39-42 , by using multiple projections, thecutter 200 need not be translated as far to make an incision in the wall of the target vessel as it would if only asingle projection 208 were used, as described in greater detail below. - Referring back to
FIGS. 34-35 , aninterior surface 202 is located on each side of thechannel 246. Eachinterior surface 202 may be substantially planar, curved, or may be shaped differently. Further, eachinterior surface 202 may be oriented at an angle to vertical or substantially vertical. The interior surfaces 202 may be formed such that thechannel 246 is substantially bilaterally symmetrical, or may be formed to result in achannel 246 that is not bilaterally symmetrical. The interior surfaces 202 of thechannel 246 within theanvil arm 14 may include raisedfeatures 204 that correspond to depressed staple bending features (not shown) on the outer surface of theanvil arm 14. That is, if the staple bending features are stamped into theanvil arm 14, or formed in another way that causes deformation of theanvil arm 14, the depressed staple bending features result in corresponding raised features 204 on theinterior surface 202 of thechannel 246. The raised features 204 do not interfere with the motion of thecutter 200 through thechannel 246. Alternately, the raised features 204 are not present on theinterior surface 202 of thechannel 246. - A
safety feature 210 is connected to the underside of theanvil 10 and is biased toward theanvil 10 and thecutter 200. Thesafety feature 210 may be biased into thechannel 246 within theanvil 10. Alternately, thesafety feature 210 is connected to a different location, such as the underside of theanvil arm 14. Thesafety feature 210 may be flexible or rigid. Thesafety feature 210 includes atip 212 that is oriented substantially transverse to the longitudinal centerline of thecutter 200. Alternately, thetip 212 may be oriented in a different direction. Thecutter 200 includes asafety recess 214 defined in it, corresponding to thetip 212 of thesafety feature 210. Thetip 212 is shaped and sized such that it can engage thesafety recess 214. Thetip 212 may be a bar or rod oriented substantially transverse to the direction of translation of thecutter 200, or may be shaped or oriented differently. InFIG. 34 , thestaple holder 38 has not yet been moved into position to perform anastomosis. In this position, thetip 212 of thesafety feature 210 is biased upward to engage thesafety recess 214. The engagement between thesafety recess 214 and thetip 212 of thesafety feature 210 substantially prevents translation of thecutter 200 within thechannel 246. Thus, thecutter 200 and theprojection 208 are prevented from deploying until thestaple holder 38 has been moved into the appropriate position relative to theanvil arm 14, and inadvertent deployment of thecutter 200 is prevented. - The
cutter 200 includes anengagement member 216 extending upward from a location at or near its proximal end. Theengagement member 216 instead may extend downward from thecutter 200 or to the side of thecutter 200. Further, theengagement member 216 may be positioned at a location other than at or near the proximal end of thecutter 200. Theengagement member 216 is configured to engage at least a portion of acorresponding receiver 218 in thestaple holder 38. Thus, after engagement between theengagement member 216 and thereceiver 218, translation of thereceiver 218 results in translation of thecutter 200. Thereceiver 218 is a structure that is at least partially open on its underside and that includes at least onesurface 219 configured to engage theengagement member 216. As shown inFIG. 34 , thesurface 219 is a partially-curved surface shaped to receive the curved upper end of theengagement member 216. However, thereceiver 218 may be a flat vertical surface, a curved surface, a structure such as an inverted cup that is open on its underside and that has a wall or walls encircling theengagement feature 216, or any other structure or mechanism capable of engaging theengagement feature 216 and urging it distally. - An
anvil insert 222 is fixed to theanvil 10. Alternately, theanvil insert 222 is connected to and capable of motion relative to theanvil 10. Further, theanvil insert 222 may be connected to the proximal end of theanvil arm 14, or another location on theanvil arm 14. Acavity 228 is defined within theanvil insert 222. Anaperture 230 is defined through the distal end of theanvil insert 222 into thecavity 228, connecting thechannel 246 in theanvil arm 14 andanvil 10 to thecavity 228. Thecutter 200 extends through theaperture 230, such that the distal end of thecutter 200 is positioned within thechannel 246 and the proximal end of thecutter 200 is positioned within thecavity 228. - A
cutter stop 236 may be formed into or connected to theanvil insert 222. Thecutter stop 236 may engage the proximal end of thecutter 200 if thecutter 200 is moved to a defined position within thecavity 228, thereby restricting its proximal translation. Acavity 262 may be defined within thestaple holder 38 or a separate component connected to thestaple holder 38. Apost 258 is positioned at the upper end of thecavity 262, where thepost 258 is oriented downward. A biasingelement 260 is connected at one end to thepost 258. The biasingelement 260 may be a coil spring, a leaf spring, a different type of spring, an elastomer, a wire form, or other structure or mechanism capable of exerting a biasing force. The biasingelement 260 is positioned within and protected by thecavity 262, where thecavity 262 is used. Thecavity 262 may be a cylindrical opening having a diameter substantially the same as the outer diameter of the biasingelement 260, such that thecavity 262 restricts the biasingelement 260 to motion substantially along the axis of thecavity 262 and thus directs the force exerted by the biasingelement 260 in a substantially downward direction, preventing bending or other undesirable motion of the biasingelement 260. The end of the biasingelement 260 that is not connected to thepost 258 contacts thecutter 200. As an example, the biasingelement 260 may be a compression spring that is compressed between thepost 258 and thecutter 200, resulting in a force on thecutter 200 that biases thecutter 200 downward. Thecutter 200 is slidable relative to the biasingelement 260, such that the biasingelement 260 exerts a downward force on thecutter 200 at different locations along itsupper surface 252 as thecutter 200 translates. Thus, at least the distal end of thecutter 200 is biased downward throughout its translation along theanvil 10. Theentire cutter 200 may be biased downward, if desired. Alternately, thepost 258 is omitted, and the biasingelement 260 is fixed to an upper surface of thecavity 260. Alternately, the biasingelement 260 is omitted, and thecutter 200 is biased downward in another way. For example, thecutter 200 may be constructed from an elastic or superelastic material that is formed in such a way as to produce a downward bias. - As shown in
FIG. 34 , the distal end of theanvil arm 14 initially is spaced apart from thestaple holder 38. While the distal end of theanvil arm 14 is spaced apart from thestaple holder 38, theanvil arm 14 is inserted through the wall of the target vessel, which is not shown for clarity. Advantageously, theanvil arm 14 has a cross-section small enough to allow it to enter the target vessel easily and to result in minimal or no leakage from the target vessel after theanvil arm 14 is removed. The distal tip of theanvil arm 14 may be sharp such that theanvil arm 14 itself penetrates the wall of the target vessel, resulting in an opening in the wall of the target vessel substantially the same size as the cross-section of theanvil arm 14. Alternately, a sharp retractable projection (not shown) is provided at the distal end of theanvil arm 14. The retractable projection is extended to allow the distal end of theanvil arm 14 to penetrate the wall of the target vessel, then retracted into theanvil arm 14. The retractable projection may be a wire, a blade, a substantially conical member, a screw or a screw-tipped rod, or any other sharp structure or mechanism capable of penetrating the wall of the target vessel. Such a retractable projection may be as described in U.S. patent application Ser. No. 10/134,081, which is herein incorporated by reference in its entirety. Alternately, thecutter 200 includes a blade (not shown) at its distal end, where the blade is configured to swivel. In a first position, the blade is configured to extend substantially distal to the distal end of theanvil arm 14, such that the blade can penetrate the wall of the target vessel. Then, the blade is swiveled upward such that it can act as aprotrusion 208 such as described inFIGS. 39-42 . Alternately, a separate mechanism or structure is used to penetrate the wall of the target vessel, and theanvil arm 14 is later inserted through that penetration. - Referring also to
FIG. 36 , after insertion, the distal end of theanvil arm 14 enters the lumen of the target vessel. Theanvil arm 14 is advanced into the target vessel until atissue stop 220 on theanvil arm 14 encounters the edge of the penetration in the wall of the target vessel. Thetissue stop 220 is substantially flat and/or blunt, and extends upward or in another direction relative to theanvil arm 14 to increase the height and/or width of theanvil arm 14. Thetissue stop 220 increases the cross-section of theanvil arm 14 such that theanvil arm 14 cannot easily move further into the penetration in the wall of the target vessel after the tissue stop 220 encounters the outer wall of the target vessel. Because thetissue stop 220 is blunt, it does not penetrate the wall of the target vessel or act to expand the size of the existing penetration. Thus, the distance between the distal end of theanvil arm 14 and the tissue stop 220 substantially determines how much of theanvil arm 14 is allowed into the lumen of the target vessel. After theanvil arm 14 has been inserted into the lumen of the target vessel, thecontact surface 206 of theanvil arm 14 is substantially in contact with the inner surface of the wall of the target vessel. - Next, referring also to
FIG. 44 , thestaple holder 38 and theanvil 10 are rotated or otherwise moved closer to one another to a standby position. As thestaple holder 38 andanvil 10 move closer together, thestaple holder 38 holds flaps at the end of the graft vessel, which are configured substantially as shown inFIGS. 29-31 , against the surface of the target vessel at the site of the anastomosis. The flaps are substantially fixed relative to the surface of the target vessel, such that the end of the graft vessel is substantially immobile relative to the wall of the target vessel. Thus, the position of the end of the graft vessel relative to the wall of the target vessel remains substantially unchanged throughout the duration of the anastomosis procedure. The perimeter of the end of the graft vessel defines a closed area on the wall of the target vessel. Consequently, the location of a connection made between the end of the graft vessel and the wall of the target vessel is substantially registered with an opening made within the closed area in the wall of the target vessel, regardless of the order in which the connection and the opening are made. Further, the position of the end of the graft vessel relative to the wall of the target vessel substantially maintains position registration throughout the duration of the anastomosis procedure relative to the opening in the wall of the target vessel through which theanvil arm 14 is inserted. For clarity, the flaps and graft vessel are not shown inFIG. 44 . Thestaple holder 38 andanvil 10 may be actuated to move between the position shown inFIG. 34 and the position shown inFIG. 44 by any structure, mechanism or method. As one example, a cable (not shown) is connected to theanvil 10 at or near ashoulder 224 proximal to thetissue stop 220. This connection may be made by soldering, welding, winding the cable tightly around theanvil 10 at theshoulder 224, or in any other way that results in a secure connection between the cable and theanvil 10. To move theanvil 10 and thestaple holder 38 relative to one another, the cable is tensioned, causing theanvil 10 and/or the connectedanvil insert 222 to rotate around a pivot point such as apin 226 that pivotally connects thestaple holder 38 to theanvil 10. Thepin 226 may be formed into or otherwise fixed to thestaple holder 38 oranvil arm 14, if desired. Thus, theanvil 10 and thestaple holder 38 rotate relative to one another to the standby position. - As the
staple holder 38 andanvil 10 move together, theengagement member 216 engages thereceiver 218. Further, the relative motion of thestaple holder 38 and theanvil 10 causes thestaple holder 38 to contact thesafety feature 210 and urge it downward against its upward bias. Consequently, thetip 212 of thesafety feature 210 is moved downward out of engagement with thesafety recess 214 of thecutter 200. Alternately, another structure or mechanism is configured to engage thesafety feature 210 when thestaple holder 38 andanvil 10 are moved together, so as to urge thetip 212 out of thesafety recess 214. Thus, in the standby position, thecutter 200 is freed for translation along thechannel 246 - Optionally, an
interface structure 238 may be connected to or formed into thestaple holder 38. Theinterface structure 238 engages theanvil 10 or a component associated with theanvil 10 as thestaple holder 38 and theanvil 10 move to the standby position, such as by snapping onto a corresponding feature (not shown) on theanvil 10. By doing so, theinterface structure 238 holds thestaple holder 38 substantially fixed relative to theanvil 10, in order to maintain registration between the target vessel, the graft vessel, theanvil 10 and thestaple holder 38. Theinterface structure 238 may be a tab, rail, bump, or any other feature that is capable of engaging a corresponding feature and holding thestaple holder 38 substantially fixed relative to theanvil 10. Alternately, theinterface structure 238 is formed into or connected to theanvil 10 and engages a corresponding feature on thestaple holder 38. - Referring also to
FIG. 45 , after thecutter 200 has been freed for translation, thecutter 200 is urged distally relative to theanvil arm 14. Advantageously, thestaple holder 38 has stapled or otherwise connected the graft vessel to the target vessel before thecutter 200 is urged forward, such that the two vessels are connected before thecutter 200 makes an incision between them. Alternately, thecutter 200 may be urged forward while thestaple holder 38 is stapling or otherwise connecting the graft vessel to the target vessel, or before thestaple holder 38 has stapled or otherwise connected the graft vessel to the target vessel. - The
cutter 200 is urged distally by thereceiver 218, which engages theengagement feature 216 of thecutter 200. Thereceiver 218 is configured to travel along aguide structure 241. Theguide structure 241 is a rail or other structure along which thereceiver 218 slide, and thereceiver 218 interfaces with and translates along the rail. Thus, theguide structure 241 guides the translation of thereceiver 218. Alternately, theguide structure 241 is a hollow channel defined within thestaple holder 38, such that the walls of the channel guide the translation of thereceiver 218. Alternately, theguide structure 241 may be any other structure or mechanism capable of guiding the translation of thereceiver 218. Theguide structure 241 is substantially aligned with theanvil arm 14. That is, the longitudinal centerline of theguide structure 241 is substantially parallel to the longitudinal centerline of theanvil arm 14. Thus, motion of thereceiver 218 along theguide structure 241 causes translation of theengagement feature 216 and therefore translation of thecutter 200 substantially parallel to the centerline of theanvil arm 14. Thereceiver 218 may be actuated to translate along theguide structure 241 by an actuator (not shown). The actuator may directly transmit force from a human hand or the like to the cutter, such as via a cable (not shown). The cable may be the same cable described above that may be utilized to rotate theanvil 10 andstaple holder 38 relative to one another, or may be a different cable. Alternately, the actuator may convert stored energy to force that is applied to the cutter. Such stored energy may be provided by a spring, battery, source of compressed gas, or other source. Alternately, any mechanism, structure or method, using stored energy or not, may be used to translate thereceiver 218 along theguide structure 241. The particular mechanism, structure or method used to cause translation of thecutter 200 is not critical to the invention. Acavity 240 is provided in thestaple holder 38 adjacent to theguide structure 241 to allow for motion of thereceiver 218 along theguide structure 241. Thecavity 240 is sized to allow thereceiver 218 to translate freely. - The
upper surface 252 of thecutter 200 is substantially planar proximal to theprojection 208. The biasingelement 260 contacts theupper surface 252 of thecutter 200 and biases thecutter 200 downward. Thecutter 200 includes akeel 264 that extends downward. Thekeel 264 may be formed into thecutter 200, or may be a separate component connected to thecutter 200. Thekeel 264 is substantially as wide as the adjacent portion of thecutter 200. However, thekeel 264 may be wider or narrower than the adjacent portion of thecutter 200. Thekeel 264 is positioned at or near the distal end of thecutter 200. Alternately, thekeel 264 may be positioned at a different location on thecutter 200. - As shown in
FIG. 45 , thekeel 264 initially extends into the firstlower opening 254, which is defined through alower surface 256 of theanvil 10. Thekeel 264 may extend completely through the firstlower opening 254, such that its lowest point extends outside theanvil 10. Thekeel 264 is biased downward into the firstlower opening 254 as a result of the downward force exerted on thecutter 200 by the biasingelement 260. While thekeel 264 is biased into the firstlower opening 254, theprojection 208 remains below thecontact surface 206 of theanvil arm 14. In this way, theprojection 208 does not extend out of theanvil arm 14 while theanvil arm 14 is inserted into the wall of a target vessel. The firstlower opening 254 extends along a fixed length of thelower surface 256 of theanvil 10. As thecutter 200 translates distally, thekeel 264 continues to remain at least partially within the firstlower opening 254, such that theprojection 208 continues to remain below thecontact surface 206 of theanvil arm 14. Initially, thekeel 264 may be positioned proximal to the distal end of the firstlower opening 254. The length of the firstlower opening 254 is selected to cause theprojection 208 to remain below thecontact surface 206 of theanvil arm 14 across that distance. That is, this distance is selected such that theprojection 208 on thecutter 200 does not engage the wall of the target vessel until theprojection 208 is positioned within the circumference of the graft vessel. That is, the connection between the graft vessel and the target vessel substantially defines a closed area, and theprojection 208 is configured to engage the wall of the target vessel within that closed area. In this way, theprojection 208 makes an incision completely within the connection between the graft vessel and the target vessel, completing the anastomosis between the two vessels and minimizing or eliminating leakage at the anastomosis site. While theprojection 208 on thecutter 200 remains below the upper surface of theanvil arm 14, it neither engages nor cuts the wall of the target vessel. - Referring also to
FIG. 46 , thecutter 200 continues to advance distally as thereceiver 218 continues to impel theengagement feature 216 distally. As described above, at least the distal end of thecutter 200 is biased downward. As thecutter 200 advances distally, thekeel 264 encounters the distal end of the firstlower opening 254. This encounter, and the continued proximal translation of thecutter 200, causes thekeel 264 to move upward relative to theanvil arm 14. Thekeel 264 and/or the distal end of the firstlower opening 254 may be constructed to provide a smooth, gradual upward motion of thekeel 264, such as by providing a gradual slope on thekeel 264 and/or the distal end of the firstlower opening 254. Alternately, thekeel 264 and/or the distal end of the firstlower opening 254 may be constructed to allow or cause thekeel 264 to move upward abruptly upon encountering the distal end of the firstlower opening 254. The upward motion of thekeel 264 causes the distal end of thecutter 200 and theprojection 208 to move upward. Thus, the size and position of the firstlower opening 254, including the position of the distal end of the firstlower opening 254, control the motion of thecutter 200 and theprojection 208 in the vertical direction. - As the distal end of the
cutter 200 moves upward, theprojection 208 moves upward through theupper opening 248 in theanvil arm 14. Thecontact surface 206 of theanvil arm 14 is substantially adjacent to the inner surface of the wall of the target vessel. Thus, upward motion of theprojection 208 through theupper opening 248 and above thecontact surface 206 of theanvil arm 14 causes theprojection 208 to enter the wall of the target vessel. Thecutter 200 continues to move distally, such that thekeel 264 moves out of the firstlower opening 254 completely and contacts thebottom surface 266 of thechannel 246 of theanvil arm 14. Theprojection 208 is sized such that theprojection 208 completely penetrates the wall of the target vessel when thekeel 264 has moved proximally to the firstlower opening 254 and is in contact with thebottom surface 266 of thechannel 246. That is, at least a portion of theprojection 208 passes through the wall of the target vessel and enters the lumen of the target vessel. This initial penetration of the wall of the target vessel defines the starting point of an arteriotomy performed on the target vessel by theprojection 208. The starting point of the arteriotomy is spaced apart from the location on the target vessel at which theanvil arm 14 is inserted, because thecutter 200 and theprojection 208 have moved proximally a selected distance before penetrating or incising the wall of the target vessel. The portion of the wall of the target vessel between the arteriotomy and the insertion point of theanvil arm 14 may be referred to as a tissue bridge. The incision is referred to as an arteriotomy for convenience, and this terminology does not limit the type of anastomosis that may be performed. For example, anastomosis may be performed between two tissue structures that are not blood vessels, such as bile ducts. - Referring also to
FIG. 47 , thecutter 200 continues to advance distally as thereceiver 218 continues to impel theengagement feature 216 distally. The lower surface of thekeel 264 contacts thebottom surface 266 of thechannel 246 during this translation. The contact between thekeel 264 and thebottom surface 266 of thechannel 246 counteracts the downward bias of the distal end of thecutter 200. In this way, theprojection 208 is maintained above thecontact surface 206 of theanvil arm 14. As thecutter 200 continues to translate distally, theprojection 208 moves through the tissue of the wall of the target vessel in a direction substantially parallel to the longitudinal centerline of theanvil arm 14, and incises the tissue of the wall of the target vessel to create an arteriotomy. Because theprojection 208 is connected to and translated by thecutter 200, which is within the target vessel, the arteriotomy is performed from within the target vessel. The tip of theprojection 208 may maintain substantially the same height relative to thecontact surface 206 of theanvil arm 14 during translation of thecutter 200, or may change its height relative to thecontact surface 206 of the anvil arm, as long as theprojection 208 continues to incise completely through the wall of the target vessel. - Referring also to
FIG. 48 , a secondlower opening 268 is defined through thelower surface 256 of theanvil arm 14. The secondlower opening 268 is distal to and substantially aligned with the firstlower opening 254. Thecutter 200 continues to advance distally as thereceiver 218 continues to impel theengagement feature 216 distally. As a result of this translation, thekeel 264 encounters the proximal end of the secondlower opening 268. Because the distal end of thecutter 200 is biased downward, thekeel 264 moves downward at least partially into the secondlower opening 268. The downward motion of thekeel 264 causes the distal end of thecutter 200 and theprojection 208 to move downward. Thekeel 264 and/or the proximal end of the secondlower opening 268 may be constructed to provide a smooth, gradual downward motion of thekeel 264, such as by providing a gradual slope on thekeel 264 and/or the proximal end of the secondlower opening 268. Alternately, thekeel 264 and/or the proximal end of the secondlower opening 268 may be constructed to allow or cause thekeel 264 to move downward abruptly upon encountering the proximal end of the secondlower opening 268. The downward motion of the distal end of thecutter 200 causes theprojection 208 to retract into or completely through theupper opening 248, such that theprojection 208 no longer encounters the tissue of the wall of the target vessel. Theprojection 208 may be urged downward completely into thechannel 246, depending on the depth of thechannel 246 and the height of theprojection 208. Alternately, the upper tip of theprojection 208 may remain within theupper opening 248. Thecutter 200 may stop its distal translation at substantially the same time that theprojection 208 retracts completely into theupper opening 248, or may continue to translate distally within thechannel 246 before coming to a stop. Alternately, the secondlower opening 268 is not provided, and only the firstlower opening 254 extends through thelower surface 156 of theanvil arm 14 into thechannel 246. In such a configuration, thecutter 200 is retracted in the proximal direction after the arteriotomy is formed, until thekeel 264 moves downward into the firstlower opening 254 and theprojection 208 consequently retracts completely into theupper opening 248. - When the
projection 208 is retracted out of the tissue of the wall of the target vessel, the distal end of the arteriotomy is defined, and the arteriotomy is complete. The distal end of the firstlower opening 254 and the proximal end of the secondlower opening 268 control the motion of theprojection 208 and thereby control the penetration of the wall of the target vessel. That is, the distance between the distal end of the firstlower opening 254 and the proximal end of the secondlower opening 268 determines the length of the arteriotomy. - After performing the arteriotomy, the
cutter 200 is in a distally-extended position. Thecutter 200 remains in that position as theanvil arm 14 is removed from the target vessel. Thus, theprojection 208 does not extend out of theupper opening 248 during removal of theanvil arm 14 from the target vessel. Theanvil arm 14 is removed from the target vessel after the anastomosis between the graft vessel and the target vessel has been completed. Alternately, after performing the arteriotomy, thecutter 200 may be moved proximally within thechannel 246 in theanvil arm 14 before removing theanvil arm 14 from the target vessel. The hole in the wall of thetarget vessel 30 through which theanvil arm 14 enters the target vessel is small enough to prevent significant bleeding through the puncture site. Alternately, the hole is closed by hand suturing. Alternately, the hole is closed with a biocompatible glue, adhesive or the like. Alternately, the hole is closed with a clip, clamp, or other implantable device that remains on the target vessel. Such a device may be positioned on the outer surface and/or inner surface of the target vessel, and may extend into the hole. A device for closing the hole may be constructed from nitinol or other superelastic or pseudoelastic material, or from stainless steel or other material, where that device moves between a first configuration and a second configuration during deployment, and where the second configuration holds the hole closed. The hole is less than substantially 2 mm wide, and advantageously less than 1 mm wide. - Referring to
FIG. 49 , another embodiment of theanvil 10 also includes acutter 200 moveable relative to theanvil 10 for making an incision in the wall of a target vessel. Theanvil 10,anvil arm 14,staple holder 38, and other components are substantially as described above with regard toFIGS. 34-38 and 44-49. Referring toFIGS. 35 and 49 , theanvil insert 222 is connected to theanvil 10. Anaperture 230 is defined through the distal end of theanvil insert 222 into thecavity 228 defined within theanvil insert 222, connecting thechannel 246 to thecavity 228. Thecutter 200 extends through theaperture 230 in theanvil insert 222, such that the distal end of thecutter 200 is positioned within thechannel 246 and the proximal end of thecutter 200 is positioned within thecavity 228. Acam 232 is positioned within thecavity 228 above theaperture 230. Alternately, thecam 232 may be positioned differently relative to theaperture 230. Thecam 232 is a structure used in controlling the motion of thecutter 200, as is described in greater detail below. - At least the distal end of the
cutter 200 may be biased upward. This biasing may be performed by any appropriate structure or mechanism, such as by one or more springs (not shown). Such a spring or springs may act in compression to push the distal end of thecutter 200 upward, or may act in tension to pull the distal end of the cutter upward. As another example, thecutter 200 may be constructed from an elastic or superelastic material that is formed in such a way as to produce an upward bias. Theentire cutter 200 may be biased upward, if desired. At least the distal end of thecutter 200 is biased upward during the translation of thecutter 200 along theanvil arm 14. Alternately, thecutter 200 is not biased, either upward or downward. Instead, thecutter 200 is urged upward and downward at different locations during its translation by the interaction between at least one cam follower on thecutter 200 and at least thecam 232. - As shown in
FIG. 49 , the distal end of theanvil arm 14 is spaced apart from thestaple holder 38. Theanvil arm 14 is inserted through the wall of the target vessel, as described above, such that thecontact surface 206 of theanvil arm 14 is in substantial contact with the inner wall of the target vessel. Next, referring toFIG. 50 , thestaple holder 38 andanvil 10 are moved relative to one another into the standby position, as described above. In the standby position, thecutter 200 is freed for translation along thechannel 246, because thetip 212 of thesafety feature 210 no longer engages thesafety recess 214 of thecutter 200. At least the distal end of thecutter 200 is biased upward, and thecam 232 limits the upward motion of thecutter 200 by contacting at least a portion of theupper surface 252 of thecutter 200. Thecam 232 controls the motion of the distal end of thecutter 200 in the vertical direction as thecutter 200 translates within thechannel 246. Because theprojection 208 is fixed to thecutter 200, thecam 232 also controls the motion of theprojection 208 in the vertical direction, and thus controls the location at which theprojection 208 encounters the wall of the target vessel. - Referring also to
FIG. 51 , after thecutter 200 has been freed for translation, it is urged distally by thereceiver 218 as described above. Afirst cam follower 242 is defined on theupper surface 252 of thecutter 200. Thefirst cam follower 242 is a raised structure formed into theupper surface 252 of thecutter 200. Alternately, thefirst cam follower 242 is a separate structure or mechanism constructed separately from thecutter 200 and later connected to thecutter 200. Alternately, thefirst cam follower 242 may be located on a surface of thecutter 200 in addition to or instead of itsupper surface 252, depending on the position and configuration of thecam 232. Thefirst cam follower 242 may be shaped as a trapezoid or similar shape, or may be shaped differently. - The
cam 232 is fixed, and thefirst cam follower 242 is raised relative to theupper surface 252 of thecutter 200. At least the distal end of thecutter 200 is biased upward. Thus, as thecutter 200 translates distally, thecam 232 engages thefirst cam follower 242 and causes thecutter 200 to move downward. Thecam 232 and thefirst cam follower 242 are shaped to smoothly engage each other. Alternately, thefirst cam follower 242 is shaped to induce thecutter 200 to abruptly move downward when thefirst cam follower 242 initially encounters thecam 232. The height of thefirst cam follower 242 relative to thecontact surface 206 of theanvil arm 14 determines the distance that the distal end of thecutter 200 is moved downward. As described above, thecutter 200 may include akeel 264 or similar projection extending downward. As the distal end of thecutter 200 moves downward, thekeel 264 or other projection moves into the firstlower opening 254. In this embodiment, the firstlower opening 254 does not control the motion of thecutter 200; instead, it provides a space for thekeel 264 to move downward without interfering with the vertical motion of the distal end of thecutter 200. If thekeel 264 is omitted, the firstlower opening 254 and the secondlower opening 268 may be omitted as well. - The connection between the graft vessel and the target vessel substantially defines a closed area, and the
projection 208 is configured to engage the wall of the target vessel within that closed area. That is, the end of the graft vessel has a perimeter that contacts the side of the target vessel, such that the perimeter of the end of the graft vessel defines a closed area on the wall of the target vessel. In this way, theprojection 208 makes an incision completely within the connection between the graft vessel and the target vessel, completing the anastomosis between the two vessels and minimizing or eliminating leakage at the anastomosis site. While theprojection 208 on thecutter 200 remains below thecontact surface 206 of theanvil arm 14, it neither engages nor cuts the wall of the target vessel. Thus, thefirst cam follower 242 is sized to translate the tip of theprojection 208 below thecontact surface 206 of theanvil arm 14 for a selected distance such that theprojection 208 does not engage the tissue of the target vessel until theprojection 208 is positioned to enter the closed area on the wall of the target vessel defined by the perimeter of the end of the graft vessel. - Referring also to
FIG. 52 , thecutter 200 continues to advance distally as thereceiver 218 continues to impel theengagement feature 216 distally. Thus, thefirst cam follower 242 of thecutter 200 advances distally relative to thecam 232. As described above, at least the distal end of thecutter 200 is biased upward. Thefirst cam follower 242 decreases in height at its proximal end. Thus, as the upwardly-biasedfirst cam follower 242 moves distally relative to thecam 232, thecam 232 and thefirst cam follower 242 gradually disengage, causing both the distal end of thecutter 200 and theprojection 208 to move upward. Thefirst cam follower 242 is constructed to provide a smooth, gradual upward motion of the distal end of thecutter 200 and theprojection 208, such as by providing a gradual slope between anupper surface 250 of thefirst cam follower 242 and anupper surface 252 of thecutter 200. Alternately, thefirst cam follower 242 may be constructed to allow the distal end of thecutter 200 and theprojection 208 to abruptly snap upward as thefirst cam follower 242 moves distal to thecam 232. - As the distal end of the
cutter 200 moves upward, theprojection 208 moves upward through theupper opening 248 in theanvil arm 14. Thecontact surface 206 of theanvil arm 14 is adjacent to the inner surface of the wall of the target vessel. Thus, upward motion of theprojection 208 through theupper opening 248 causes theprojection 208 to enter the wall of the target vessel. Theprojection 208 is sized, and thefirst cam follower 242 andcam 232 are shaped, such that the upward motion of theprojection 208 after thefirst cam follower 242 has moved distal to thecam 232 causes theprojection 208 to completely penetrate through the wall of the target vessel. That is, at least a portion of theprojection 208 passes through the wall of the target vessel and enters the lumen. This initial penetration of the wall of the target vessel defines the starting point of an arteriotomy performed on the target vessel by theprojection 208. The starting point of the arteriotomy is spaced apart from the location on the target vessel at which theanvil arm 14 is inserted, resulting in a tissue bridge therebetween. - Referring also to
FIG. 53 , thecutter 200 continues to advance distally as thereceiver 218 continues to impel theengagement feature 216 distally. Theupper surface 252 of thecutter 200 may contact thecam 232 during this motion, because the distal end of thecutter 200 continues to be biased upward. As thecutter 200 translates, theprojection 208 moves through the tissue of the wall of the target vessel in a direction substantially parallel to the longitudinal centerline of theanvil arm 14. In this way, theprojection 208 incises the tissue of the wall of the target vessel to create an arteriotomy. The tip of theprojection 208 may maintain substantially the same height relative to thecontact surface 206 of theanvil arm 14 during its distal translation, or may change its height relative to thecontact surface 206 of theanvil arm 14, as long as the tip of theprojection 208 remains in the lumen of the target vessel during that translation. - Referring also to
FIG. 54 , asecond cam follower 244 is defined on theupper surface 252 of thecutter 200, proximal to and spaced apart from thefirst cam follower 242. Alternately, a single cam follower is defined on theupper surface 252 of thecutter 200, where that single cam follower includes a feature corresponding to thefirst cam follower 242, a feature corresponding to thesecond cam follower 244, and a section of reduced height between them corresponding to theupper surface 252 of thecutter 200. Thecutter 200 continues to advance distally as thereceiver 218 continues to impel theengagement feature 216 distally. As a result of this motion, thesecond cam follower 244 contacts thecam 232. Engagement between thesecond cam follower 244 and thecam 232 pushes the distal end of thecutter 200 downward. The shape and size of thesecond cam follower 244 andcam 232 are selected such that the distal end of thecutter 200 is pushed downward far enough to cause theprojection 208 to retract into theupper opening 248. Theprojection 208 may be urged downward completely into thechannel 246, depending on the depth of thechannel 246 and the height of theprojection 208. Alternately, the upper tip of theprojection 208 may remain within theupper opening 248. Thecutter 200 may stop its distal translation at substantially the same time that theprojection 208 retracts completely into theupper opening 248, or may continue to translate distally within thechannel 246 before coming to a stop. - When the
projection 208 is retracted out of the tissue of the wall of the target vessel, the distal end of the arteriotomy is defined, and the arteriotomy is complete. The distance between thefirst cam follower 242 and thesecond cam follower 244, and the shape of thecam followers cam follower upper surface 252 of thecutter 200 sufficient to cause theprojection 208 to be pushed out of contact with the wall of the target vessel. The distance between these locations defines the length of the arteriotomy. Thus, thecam followers projection 208 and control the penetration of the wall of the target vessel. - After performing the arteriotomy, the
cutter 200 is in a distally-extended position. Thecutter 200 remains in that position as theanvil arm 14 is removed from the target vessel. Theanvil arm 14 is removed from the target vessel after the anastomosis between the graft vessel and the target vessel has been completed. Alternately, after performing the arteriotomy, thecutter 200 may be moved proximally within thechannel 246 before removing theanvil arm 14 from the target vessel. The hole at the puncture site and its closure are substantially as described above. - Alternately, in the embodiment of
FIGS. 34-35 and 44-49, or the embodiment ofFIGS. 50-54 , thecutter 200 is initially in a distally-extended position, and retracted proximally in order to make an incision in the wall of the target vessel. The structures and mechanisms are as described above, but operated in substantially the reverse order as described above. Alternately, thecutter 200 and theprojection 208 may be moved in a different way in order to incise the tissue of the wall of the target vessel. - Where
multiple projections 208 are provided on thecutter 200 as shown inFIGS. 39-43 , thecutter 200 need not be translated as far to make an incision in the wall of the target vessel as it would if only a single projection were used. Because theprojections 208 are spaced apart from each other along the direction of translation of thecutter 200, eachprojection 208 is able to form a portion of the incision during translation of thecutter 200. Thus, by translating eachprojection 208 across a distance less then the intended length of the entire incision, the complete incision can be formed. The distance that thecutter 200 is translated to form the incision is related to the distance between theprojections 208. That is, because eachprojection 208 forms a portion of the incision, nosingle projection 208 need be translated along the entire length of the incision. - Alternately, where
multiple projections 208 are utilized, theprojections 208 may be inserted into the wall of the target vessel, after which energy is applied to theprojections 208 via thecutter 200 or directly in order to create an incision in the wall of the target vessel. In such an embodiment, an energy source (not shown) is connected to thecutter 200. For example, an ultrasound generator (not shown) may be connected to thecutter 200 and to the energy source. The ultrasound generator may be a piezoelectric crystal, as is standard, or a different structure or mechanism. Electrical energy may be applied to the ultrasound generator from the energy source, thereby causing the ultrasound generator to vibrate theprojections 208. Thus, energy may be applied from the energy source to the ultrasound generator after theprojections 208 have been inserted into the wall of the target vessel, causing theprojections 208 to move and thereby create an incision. Advantageously, a plurality ofprojections 208 spaced relatively close to one another are utilized. Other methods may be used to vibrate, move or oscillate theprojections 208.FIGS. 17-23 illustrate analternate anvil 100 that is used with aclamp 102 for controlling an incision site during an anastomosis procedure. As shown inFIGS. 17 and 18 , theanvil 100 includes ananvil arm 104 and ahandle 106. Theclamp 102 is slidable on thehandle 106 to clamp the tissue of thetarget vessel 30 between theclamp 102 and theanvil arm 104. As with theanvil arm 104 described above, theanvil arm 104 includes two rows of staple bending features 108 in the form of recesses positioned in two parallel rows along a top surface of theanvil arm 104. Theclamp 102 has acentral opening 110. Once the tissue of the target vessel wall has been trapped between theclamp 102 and theanvil arm 104, an incision may be made through the target vessel wall and the edges of the incision are controlled by the combination of theanvil arm 104 and theclamp 102. - As shown in
FIG. 19 , a continuous anastomosisstaple device 114 may be used to connect thegraft vessel 32 to thetarget vessel 30 at the anastomosis site. Thestaple device 114 as shown inFIG. 19 includes a plurality of linkages forming a tubular configuration and a plurality of staple ends extending from the linkages.FIGS. 20-22 illustrate how the staple ends 116 of thestaple device 114 are positioned in the end of thegraft vessel 32 and are inserted through theincision 118 in the target vessel and bent over by contact with the staple bending features 108 of the anvil. As shown inFIG. 22 , the opposite ends 120 of thestaple device 114 are folded over to complete the anastomosis.FIG. 23 illustrates a completed anastomosis performed according to the steps illustrated inFIGS. 19-22 . -
FIGS. 24-27 illustrate an alternate example of ananvil arm 14 d having acutting wire 124 for forming the incision in the wall of thetarget vessel 30. Thecutting wire 124 may be used to form an incision before, during or after performing an end-to-side anastomosis procedure. Referring particularly toFIGS. 26-27 , for forming the incision after the anastomosis procedure, aclamp 126 is used to trap the tissue at the anastomosis site between theclamp 126 and theanvil arm 14 d prior to performing the incision. The incision is spaced apart from the entry point of theanvil arm 14 d into the target vessel, creating a tissue bridge between the incision made in the wall of the target vessel and the entry point of theanvil arm 14 d into the target vessel. A portion of the contact between the anastomosed graft vessel and target vessel extends across the tissue bridge, such that the incision is located within the closed area defined by the contact between the perimeter of the end of the graft vessel and the wall of the target vessel. -
FIG. 28 shows asystem 140 for controlling a tissue site and performing anastomosis. For purposes of clarity, the staple holder and staples have been omitted fromFIG. 28 . Thesystem 140 includes ananvil arm 142, acutter 144, and agraft vessel holder 146 all mounted on ahandle 148. Theanvil arm 142 is mounted on thehandle 148 and connected to afirst actuator 150 that allows the anvil to be moved downward against the bias of a spring inside the handle. Thecutter 144 may be spring biased or fixed and is positioned on thehandle 148 directly above theanvil arm 142. Thegraft vessel holder 146 includes two fixedarms 152 and twomovable arms 154. The twomovable arms 154 are connected to asecond actuator 156 on thehandle 148. Depression of thesecond actuator 156 against the bias of a spring within the handle causes themovable arms 154 to be moved downward away from the fixed arms to receive portions of a graft vessel between the movable and fixed arms. - The operation of the
system 140 ofFIG. 28 is shown in the cross sectional views ofFIGS. 29-31 . As shown inFIG. 29 , an end of agraft vessel 32 is split so that each half of thegraft vessel 32 can be held between afixed arm 152 and amovable arm 154. In order to load thegraft vessel 32 into thesystem 140, thefirst actuator 150 and thesecond actuator 156 are depressed to move theanvil arm 142 and themovable arms 154 downward. Thesplit graft vessel 32 is then inserted between the fixed andmovable arms second actuator 156 is released to trap the ends of thegraft vessel 32, as shown inFIG. 30 . Theanvil arm 142 is then inserted into thetarget vessel 30 in the same or similar manner as described above. - Once the anvil has been inserted in the
target vessel 30 as shown inFIG. 30 , thefirst actuator 150 is released to allow the anvil to move upward to tent the wall of the target vessel.FIG. 31 illustrates thetented target vessel 30 positioned adjacent the split and trappedgraft vessel 32 in a position for performing anastomosis. Thestaple holders 38 are then advanced in the direction of the arrows D toward opposite sides of the anvil to staple the graft vessel and target vessel together. Thestaple holders 38 may hold a staple strip with an expandable backbone as shown inFIGS. 10A and 10B , or may instead or additionally hold different types of staples not connected to a backbone. Thestaple holders 38 may be provided with movable pins which allow the spacing between the staples to be adjusted depending on a size of the graft vessel used. Once the staples have been placed, theanvil arm 142 is removed and thecutter 144 makes an incision in the target vessel before or during removal of the anvil. - As described above, staple bending features are provided on the anvil and staples are provided at an exterior of the tissue. Alternately, the staples and/or staple holding strips may be positioned on the anvil and an exterior member with staple bending features may be moved toward the anvil to bend the ends of the staples and secure the graft and target vessels together.
-
FIGS. 32-33 illustrate the use of analternate anvil 130 for controlling the tissue at an anastomosis site. Theanvil 130 includes alongitudinal opening 132 extending through theanvil 130 for application of a plurality of conventional sutures at the anastomosis site. According to this method, theanvil 130 is inserted into thetarget vessel 30 and pulled against the interior wall of thetarget vessel 30, tenting the target vessel as shown inFIG. 33 .Sutures 134 are then passed through theopening 132 in theanvil 130 and through the tissue of the target vessel wall on opposite sides of theanvil 130. Once thesutures 134 are placed as shown inFIG. 33 , an incision is made in the target vessel along a center of theanvil 130. A center portion of each of thesutures 34 is then pulled out through the incision in the target vessel and cut so that an even row of sutures is provided along each of the sides of the incision. This system eliminates the tedious procedure of placing each individual suture very close to the edge of the incision in the very thin and flexible target vessel wall. Each of thesutures 134 is connected to a graft vessel in a conventional manner completing the anastomosis. The anvil as shown inFIGS. 32-33 allows quick and easy placement of a plurality of sutures in a very even manner close to the edge of the incision. For example, the sutures of a conventional anastomosis are generally within about one millimeter of the edge of the incision and are advantageously within 0.5 millimeters of the edge of the incision. - In an alternate embodiment, the
cutter 200 does not include one ormore projections 208. Instead, thecutter 200 includes or is connected directly or indirectly to an energy source (not shown), which is used to create an opening in the wall of the target vessel. For example, an emitter of laser or RF energy, or another type of energy, may be connected to thecutter 200 and to the energy source. As thecutter 200 translates along theanvil arm 14, it translates the emitter of laser or RF energy relative to the wall of the target vessel. The emitter of laser or RF energy is selectively actuated to transmit energy into the wall of the target vessel during translation of thecutter 200, thereby creating an opening therein. The energy source may transmit a first type of energy to the emitter or other mechanism, which is converted by the emitter into a second type of energy delivered into the wall of the target vessel. Alternately, thecutter 200 may include aprojection 208 and additionally be connected to an energy source that is selectively actuated in order to assist in creating an opening in the wall of the target vessel. - In an alternate embodiment, the
cutter 200 does not translate through theanvil arm 14. Instead, thecutter 200 is spatially removed from theanvil arm 14, and creates an opening in the wall of the target vessel before or after theanvil arm 14 is inserted into the target vessel. In one example of such an embodiment, theanvil arm 14 is inserted into a hole in the wall of the target vessel and thestaple holder 38 deploys staples or other connectors to connect the graft vessel to the target vessel, as described above. Theanvil arm 14 is removed, and anindependent cutter 200 is then introduced through the hole in the wall of the target vessel. Thecutter 200 may be configured as described above, including aprojection 208 extending therefrom, or may be configured differently. Thecutter 200 is manipulated relative to the connection between the target vessel and the graft vessel to create an opening at the junction therebetween. That is, registration is maintained between thecutter 200 and the junction between the end of the graft vessel and the wall of the target vessel. In order to position and manipulate thecutter 200 to create an opening at the location of the junction between the target vessel and the graft vessel, an imaging device (not shown) or other device may be connected to thecutter 200 or utilized in conjunction with thecutter 200. For example, a standard intravascular ultrasound unit may be connected to or used in conjunction with thecutter 200. The intravascular ultrasound unit is connected to a display device (not shown) visible to the operator. The operator controls the intravascular ultrasound unit to visualize the interior of the target vessel and the surrounding area, thereby locating the junction between the target vessel and the graft vessel and allowing thecutter 200 to be controlled to incise an opening in the wall of the target vessel within the closed area on the wall of the target vessel defined by the perimeter of the end of the graft vessel, thereby allowing blood to flow through the opening into the target vessel. A different visualization device or devices may be inserted into or positioned outside of the target vessel to locate the junction with the graft vessel. Thecutter 200 and any visualization device present in the lumen of the target vessel are then removed from the lumen of the target vessel, and the opening in the wall of the target vessel through which they were removed is sealed. - In another example of such an embodiment, the
anvil arm 14 is inserted into a hole in the wall of the target vessel and thestaple holder 38 deploys staples or other connectors to connect the graft vessel to the target vessel, as described above. Theanvil arm 14 is removed, and the hole in the wall of the target vessel is removed. A cannula (not shown) is inserted into the lumen of the graft vessel through the free end of the graft vessel, and a stylet (not shown) is inserted through the lumen of the cannula. The cannula and the stylet are surgical instruments that are well known in the art. The stylet has a distal end configured to penetrate the wall of the target vessel. Thus, a sharp point, blade, or other penetrating member may be formed into or connected to the distal end of the stylet. The cannula may be inserted into the lumen of the graft vessel such that its distal end contacts the outer wall of the target vessel. After the stylet has been inserted into the cannula, a force is exerted on the stylet to cause its distal end to penetrate the wall of the target vessel. Consequently, an opening is created between the graft vessel and the target vessel within the circumference of the end of the graft vessel. The cannula and stylet are then removed from the lumen of the graft vessel through its free end. - In another example of such an embodiment, the
anvil arm 14 is inserted into a hole in the wall of the target vessel and thestaple holder 38 deploys staples or other connectors to connect the graft vessel to the target vessel, as described above. Theanvil arm 14 is removed, and the hole in the wall of the target vessel is closed. Anindependent cutter 200 is then introduced through the wall of the graft vessel. Thecutter 200 itself may create an opening in the wall of the graft vessel through which it can enter, or a separate implement may be used to create an opening in the wall of the graft vessel. Thecutter 200 may be configured as described above, including aprojection 208 extending therefrom, or may be configured differently. For example, thecutter 200 may be J-shaped or L-shaped to facilitate creation of the opening between the graft vessel and the target vessel through the wall of the graft vessel. Thecutter 200 is manipulated relative to the connection between the target vessel and the graft vessel to create an opening in the wall of the target vessel at the junction therebetween. That is, registration is maintained between thecutter 200 and the junction between the end of the graft vessel and the wall of the target vessel. Thecutter 200 is then removed through the wall of the graft vessel, and the opening in the wall of the graft vessel is sealed. - While the invention has been described in detail, it will be apparent to one skilled in the art that various changes and modifications can be made and equivalents employed, without departing from the present invention. It is to be understood that the invention is not limited to the details of construction, the arrangements of components, and/or the steps of performing anastomosis set forth in the above description or illustrated in the drawings. Therefore, the invention is not to be restricted or limited except in accordance with the following claims and their legal equivalents.
Claims (21)
1. A surgical tool for performing anastomosis between a graft vessel and a target vessel, comprising:
an anvil;
a cutting element connected to said anvil; and
an energy source connected to said cutting element, wherein said energy source is configured to deliver energy to said cutting element.
2. The surgical tool of claim 1 , wherein said cutting element is configured to vibrate upon delivery of energy thereto.
3. The surgical tool of claim 1 , wherein said cutting element further comprises an emitter connected to said energy source.
4. The surgical tool of claim 3 , wherein said emitter is configured to emit laser energy upon delivery of energy thereto.
5. The surgical tool of claim 3 , wherein said emitter is configured to emit radio frequency energy upon delivery of energy thereto.
6. The surgical tool of claim 1 , wherein said cutting element is movably connected to said anvil.
7. The surgical tool of claim 6 , wherein said anvil includes a channel defined therein, wherein said cutting element is movable within and along said channel.
8. The surgical tool of claim 7 , wherein said cutting element includes at least one projection extending generally upward.
9. The surgical tool of claim 8 , wherein at least one said projection is movable upward, then along, then downward relative to said channel.
10. A method for performing anastomosis between a graft vessel and a target vessel, each vessel having a lumen therein, comprising:
placing an end of the graft vessel against a side of the target vessel;
creating an opening in the wall of the target vessel at a first location;
inserting an anvil through the opening from outside the wall of the target vessel into the lumen of the target vessel;
creating an incision in the wall of the target vessel, the incision spaced apart from the first location; and
connecting the graft vessel to the target vessel.
11. The method of claim 10 , wherein said creating an incision is performed by translating a cutting element relative to said anvil.
12. The method of claim 11 , wherein said placing an end of the graft vessel against a side of the target vessel defines a closed area on the side of the target vessel, and said incising is performed by controlling said cutting element to position said incision entirely within the closed area.
13. The method of claim 12 , wherein said controlling is performed by biasing said cutting element upward and providing at least one control element on the upper surface of said cutting element.
14. The method of claim 12 , wherein said controlling is performed by biasing said cutting element downward and providing at least one control element on the lower surface of said cutting element.
15. The method of claim 11 , wherein said anvil includes a channel defined therein, and wherein at least part of said translating comprises translating at least part of said cutting element within and along said channel.
16. The method of claim 15 , wherein said cutting element includes at least one projection extending generally upward; further comprises moving said projection to a position completely within said channel after said creating an incision.
17. The method of claim 10 , wherein said creating an incision is performed outward from the lumen of the target vessel through the wall of the target vessel.
18. The method of claim 10 , wherein said creating an incision is performed by delivering energy from said cutting element to the wall of the target vessel.
19. The method of claim 18 , wherein said delivering energy comprises delivering ultrasonic energy.
20. The method of claim 18 , wherein said delivering energy comprises delivering laser energy.
21. The method of claim 18 , wherein said delivering energy comprises delivering radio frequency energy.
Priority Applications (2)
Application Number | Priority Date | Filing Date | Title |
---|---|---|---|
US11/756,260 US20070233163A1 (en) | 1999-07-28 | 2007-05-31 | Anastomosis System with Cutting Element |
US12/715,268 US20100155453A1 (en) | 1999-07-28 | 2010-03-01 | Surgical Staples Frangibly Connected to Staple Holding Strip |
Applications Claiming Priority (3)
Application Number | Priority Date | Filing Date | Title |
---|---|---|---|
US09/363,255 US6391038B2 (en) | 1999-07-28 | 1999-07-28 | Anastomosis system and method for controlling a tissue site |
US10/151,441 US7285131B1 (en) | 1999-07-28 | 2002-05-20 | System for performing anastomosis |
US11/756,260 US20070233163A1 (en) | 1999-07-28 | 2007-05-31 | Anastomosis System with Cutting Element |
Related Parent Applications (1)
Application Number | Title | Priority Date | Filing Date |
---|---|---|---|
US10/151,441 Division US7285131B1 (en) | 1999-07-28 | 2002-05-20 | System for performing anastomosis |
Related Child Applications (1)
Application Number | Title | Priority Date | Filing Date |
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US12/715,268 Continuation US20100155453A1 (en) | 1999-07-28 | 2010-03-01 | Surgical Staples Frangibly Connected to Staple Holding Strip |
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Publication Number | Publication Date |
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US20070233163A1 true US20070233163A1 (en) | 2007-10-04 |
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US10/151,441 Expired - Fee Related US7285131B1 (en) | 1999-07-28 | 2002-05-20 | System for performing anastomosis |
US11/756,260 Abandoned US20070233163A1 (en) | 1999-07-28 | 2007-05-31 | Anastomosis System with Cutting Element |
US12/715,268 Abandoned US20100155453A1 (en) | 1999-07-28 | 2010-03-01 | Surgical Staples Frangibly Connected to Staple Holding Strip |
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Application Number | Title | Priority Date | Filing Date |
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US10/151,441 Expired - Fee Related US7285131B1 (en) | 1999-07-28 | 2002-05-20 | System for performing anastomosis |
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US12/715,268 Abandoned US20100155453A1 (en) | 1999-07-28 | 2010-03-01 | Surgical Staples Frangibly Connected to Staple Holding Strip |
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US (3) | US7285131B1 (en) |
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