Abstract:
A wound sealing system and method for closing a vascular access site. The method invisions suturing a single continuous Z-stitch into a skin area around a wound and wound tract while the catheter remains within the vessel; covering the wound and suture holes with a hemostatic powder; tightening and knotting the ends of the suture together in an X configuration, applying finger pressure against the hemostatic powder as the catheter is removed; and twisting the suture ends together to tension the Z-stitch, pulling the skin area into inversion. The wound sealing system includes a powder containment device (PCD) which surrounds wound and catheter and a suture twisting member configured with the PCD to tension the Z-stitch closing the wound and arresting blood flow. The hole in the PCD holds a quantity of the hemostatic agent sufficient to cover the wound and suture holes.

Description:
CROSS-REFERENCE TO RELATED APPLICATIONS 
       [0001]    Not applicable 
       STATEMENT REGARDING FEDERALLY SPONSORED RESEARCH OR DEVELOPMENT 
       [0002]    Not applicable 
       INCORPORATION-BY-REFERENCE OF MATERIAL SUBMITTED ON A COMPACT DISC 
       [0003]    Not applicable 
       BACKGROUND OF THE INVENTION 
       [0004]    1. Field of the Invention 
         [0005]    This invention relates generally to the field of vascular access procedures and more particularly to a suture tensioning concept for quickly arresting blood flow from a vascular access site. 
         [0006]    2. Description of Related Art 
         [0007]    Vascular access site closure has a long history of inventive strategies. The standard of care has always been simultaneous direct pressure on the vessel and the insertion site. This typically involves firm pressure over the access site at the skin surface and the vascular site at the surface of the artery or vein. Pressure is held for 10 to 30 minutes based on the blood chemistry and the blood&#39;s propensity to clot. During this time the patient typically experiences severe discomfort from the intense pressure. 
         [0008]    More recently, pluralities of closure devices have been invented to prevent bleeding at the vascular access site. Some deposit a dose of collagen inside the vascular vessel to prevent bleeding; some leave a mechanical device on the distal side of the access site; others implant a dissolvable “tampon-like” device into the tract between the insertion site and the access site which, upon swelling with blood, physically prevents bleeding from the access site. All of these closure devices can be characterized as having a direct effect on the access site. 
         [0009]    A composition for arresting the flow of blood or another protein containing blood fluids flowing from an open wound has been patented by Patterson et al. in U.S. Pat. No. 6,187,347 teaching a substantially anhydrous compound of a salt ferrate which will hydrate in the presence of blood and body fluid to produce Fe +++  promotes clotting when applied directly over a wound and forming a protective scab attached to the wound to enhance healing thereof. Oxygen is also produced during the reaction. 
         [0010]    One aspect of the present invention utilizes the heretofore unrealized virtues of the &#39;347 compound in conjunction with the installation of a catheter and other types of vascular access procedures both at the time of catheter insertion and at the time of removal of the catheter from the vein or artery and skin area of the patient. 
         [0011]    More recently, BIOSEAL ADVANCED hemostatic powder by Biolife, L.L.C. of Florida also called (the “powder” hereinafter), a combination of potassium ferrate and acidic cation exchange resin, has been used to form a seal of multi-valent cation-coagulated protein over the access site. This reduced the holding time, for example on arterial sites to 4 minutes, to achieve hemostasis. BIOSEAL ADVANCED is a bone-dry powder that absorbs blood liquid and rejects blood solids. The blood liquids dissolve the potassium ferrate and release a small amount of soluble Fe 3+ . The soluble iron coagulates the accumulating and rejected proteins to create a natural seal over the insertion site, independent of platelet count. The seal is semi-permeable and the powder continues to absorb blood liquids and reject solids. Eventually, the “filter cake” on the proximal side of the seal gets so thick that fluid flow ceases and bleeding stops. When bleeding has ceased, there are no flow events to disrupt the natural clotting at the vascular access site. The blood vessel clots as quickly as the patient&#39;s blood chemistry allows. The absorbed cations are replaced with protons from the acidic resin, lowering the pH at the skin/powder interface. 
         [0012]    BIOSEAL ADVANCED hemostatic agent significantly reduces the holding time for hemostasis but has no clinically proven effect on the TTA. Importantly, BIOSEAL ADVANCED seals over the insertion site by coagulating blood proteins in situ and then covering the site with a powder at pH 2. The seal acts as a microbial barrier, physically blocking colonizing microbes from infecting the host; the acidic environment adjacent to the seal inhibits microbial growth and kills most pathogens; the patient does not get infected. In a recently published retrospective study of BIOSEAL on PICC lines, the infection rate was reduced 40%. 
         [0013]    Once closure has been achieved with any of these devices, the patient has to rest until the physician is confident that he can get up and walk 100 feet. This time is called time to ambulation or TTA. A typical TTA for closure devices is 2-4 hours; for manual pressure, it is 4-6 hours. 
         [0014]    The U.S. vascular access industry is huge with more than 6 million arterial accesses per year (2008) splintered across many different service providers. The most common is a catheter lab or an IR lab in a hospital. Recently stand-alone clinics have become a lower cost alternative for routine vascular access procedures. In the U.S., these are regulated by POS11 (Point of Service 11). The gist of this regulation is that no more than 3 patients can be non-ambulatory at any one time. The practical result of POS11 is that procedures are initiated for the first 4 hours of a working day; the latter 4 hours are reserved for TTA and discharge. If the TTA could be reduced to 1 hour, then procedures could be scheduled for 6 hours of a working day, a 50% increase in revenue-generating potential. Thus there is a large economic incentive to reduce TTA. 
         [0015]    This driving force has led to the development of internal closure devices. There are, however, several problems with internal closure devices:
       1. These devices are safe and effective when the doctor is skilled and careful.
           a. There is a published 10-30% complication rate with these devices.   b. The devices are used only by the very skilled and shunned by the less skilled.   
           2. The devices are expensive.
           a. They range in price from $200-$250 per device.   
           3. Many dialysis patients visit the IR labs 2 to 4 times per year. Devices which are left in the patient take time for biological absorption, typically 90 days. During this interregnum, the vascular access site is not available. If the dialysis patient has to re-visit the IR lab in this time frame, the care the patient needs can be potentially compromised.   4. Many practicing physicians are ethically resistant to devices left inside the body for extended periods of time. This is not a universal concern as ˜33% of all arterial access procedures are closed with a closure device.       
 
         [0023]    There is a real need for a low-cost protocol to shorten TTA to 1 hour and not leave anything in the patient&#39;s body while simultaneously preventing external-sourced infections, hematomas and other complications. 
         [0024]    Sutures and staples are well known closure means to proximate two sides of a wound. Normal procedure is to make the stitch and pull it tight and then stitch again until the wound is closed. Many inventors have improved on the basic stitch by adding various tensioning means, such as Alghamdi, 20090281569 hereafter &#39;569, Weiss, U.S. Pat. No. 6,471,715 and Cosmetto et al U.S. Pat. No. 5,127,412. &#39;569 teaches a loop through the skin with a slipknot that is then pulled tight to provide tension. &#39;569 teaches this is particularly critical because excess tension can cause cosmetically unacceptable scaring. The key teaching of &#39;569 is direct tension on a suture to close a wound. Weiss and Cosmetto teach mechanical means to provide tension on a suture. One of them teaches a rotary device that converts circular motion into a linear force in-line with the suture. 
         [0025]    Shad et al, 2009/0082790, teaches a twist means to facilitate post-operative sternum closure. The suture is placed in a holding device and twisted to bring the internal sides together. 
         [0026]    Davis, U.S. Pat. No. 4,773,421, teaches a controlled linear tensioning device because excess tension of the suture can damage underlying skin. This is particularly important for sutures that remain in place for days. Davis points out that his device allows for tension adjustment as the healing process proceeds because frequent cleaning and inspection of the wound is required. Davis also teaches that the angle of the suture to the skin as the suture emerges from tissue is as close to a right angle to avoid the suture cutting into the skin. 
         [0027]    Taheri, U.S. Pat. No. 5,919,207, teaches a method of closing an artery by twisting wires in the artery to close the hole, then stapling the site together. The twisted wire is then removed and the artery heals. As an aside, Taheri teaches that the skin opening is approximated with a standard staple. With Taheri, there are two staples on the artery itself and at least one staple on the skin. 
         [0028]    Tiefenbrun, U.S. Pat. No. 6,331,182, teaches twisted sutures to close internal tissue. Lafontaine et al, U.S. Pat. No. 5,964,782, teaches that the time to complete the suturing function can result in significant blood loss, particularly on arterial interventions. He goes on to teach about other closure devices that may support clot formation and thrombosis. He goes on to teach that twisting the suture is an effective countermeasure. Like other inventors of closure devices, Lafontaine is dismissive of ways to achieve hemostasis at the access site. 
         [0029]    Gao et al, U.S. Pat. No. 6,752,810, teaches that adding tension to a suture is a successful way to approximate two sides of a wound. His device uses an external twister to generate linear tension. 
         [0030]    Sancoff et al, U.S. Pat. No. 7,081,124, teaches a suture at an arterial insertion site and then approximating the sides using a twist. 
         [0031]    Torque is different than tension. Tension is a linear force aligned with the suture. Torque (or twist) is the force at an angle to tension. Tension and torque together represent the in-line vector and the right-angle vector respectively with respect to the centerline of the suture. 
         [0032]    When torque is combined with sutured skin, the skin twists like an Archimedes Screw. Put a finger on the back of your other hand and then rotate 30° to see the Archimedes Screw effect on your skin. When the sutures and sutured skin are rotated clockwise (or counterclockwise) (looking down at the wound site), the lower skin is pulled up towards the torque-inducer. When a vein or artery (artery is used herein to mean either vein or artery) is embedded in the skin adjacent to the “screwed” skin, the arteriotomy is approximated. This is illustrated in Lafontaine &#39;782, FIG. 6c, in which a Y-shaped insertion pattern is twisted into a closed half-spiral. Thus twisting soft tissue to close it is well known. 
         [0033]    Doctors work hard to prevent over-tightening sutures because it increases scarring and the potential for skin damage, so that excess tension and especially excess tension and torque is not used in clinical practice. In addition, over-tightening elongates the hole and tends to prevent approximation at the distal end of the insertion site. An enlarged hole is a vector for infection, oozing and complications. 
         [0034]    Current best practices for extra-luminal closing of an arteriotomy involve manual pressure. With manual pressure, the nurse or doctor presses a finger on the artery upstream of the arteriotomy while simultaneously pressing on the insertion site. The best practitioners use semi-occlusive pressure such that the radius of the artery at the arteriotomy is little changed. Less skilled practitioners will use heavy pressure at the insertion site that transmits to the arteriotomy and changes the radius of the arteriotomy. Heavy pressure has a large complication rate compared to semi-occlusive pressure including intense pain for the patient. 
         [0035]    The prior art teaches:
       1. External pressure to close the insertion site, the tract and the vascular access site, or   2. An internal leave-behind unnatural device plus a suture, staple or manual pressure to stop bleeding at the access site, or   3. Manual pressure in combination with a haemostatic powder.       
 
         [0039]    An ideal solution would deliver the single step simplicity of external manual pressure, the short time to hemostasis and TTA of an internal closure device and the low complication rate of using a haemostatic powder plus manual pressure. 
         [0040]    The foregoing examples of the related art and limitations related therewith are intended to be illustrative and not exclusive. Other limitations of the related art will become apparent to those skilled in the art upon a reading of the specification and a study of the drawings. 
       BRIEF SUMMARY OF THE INVENTION 
       [0041]    This invention is directed to a wound sealing system and method for closing a vascular access site. The method invisions suturing a single continuous Z-stitch into a skin area around a wound and wound tract such that the submerged suture is perpendicular to the wound tract while the catheter remains within the vessel; covering the wound and suture holes with a hemostatic powder; tightening and knotting the ends of the suture together in an X configuration, applying finger pressure against the hemostatic powder as the catheter is removed; and twisting the suture ends together to tension the Z-stitch, pulling the skin area into inversion. The wound sealing system includes a powder containment device (PCD) which surrounds wound and catheter and a suture twisting member configured with the PCD to tension the Z-stitch closing the wound and arresting blood flow. The hole in the PCD holds a quantity of the hemostatic agent sufficient to cover the wound and suture holes. 
         [0042]    It is an object of the invention to eliminate the need for manual pressure, reduce TTA, reduce scarring and reduce complications. It is also an object of the invention to increase patient satisfaction. It is a further object that the closure means is an extra-luminal strategy with nothing left in the patient at discharge. It is a further object to lower cost. 
         [0043]    It is a further object to secure bodily tissue with a Z-stitch encompassing the area defined by the catheter insertion site, and the vascular access site distal to the blood vessel. The ends of the sutures are tied together to form an X. Twisting the external ends to create torque and excessive tension on the stitch further enhances the X. The tissue perpendicular to the subcutaneous stitch indents downward towards the tract and arterial access site and provides low-level continuous pressure on the wound. 
         [0044]    It is still a further object to seal the elongated suture holes to prevent oozing, bleeding and microbial colonization. 
         [0045]    The following embodiments and aspects thereof are described and illustrated in conjunction with systems, tools and methods which are meant to be exemplary and illustrative and not limiting in scope. In various embodiments one or more of the above-described problems have been reduced or eliminated while other embodiments are directed to other improvements. In addition to the exemplary aspects and embodiments described above, further aspects and embodiments will become apparent by reference to the drawings and by study of the following descriptions. 
     
    
     
       BRIEF DESCRIPTION OF THE SEVERAL VIEWS OF THE DRAWING(S) 
         [0046]      FIG. 1  is a perspective view of the arterial access after the procedure is complete and closure has begun. 
           [0047]      FIGS. 1A to 1D  are top plan views of Z-stitch variations forming an inversion aligned with, and perpendicular to, the wound tract. 
           [0048]      FIG. 2  is a perspective view of  FIG. 1  showing the addition of a nylon powder containment ring (PCD). 
           [0049]      FIG. 3  is a perspective view of  FIG. 2  showing the addition of a hemostatic powder to the inside of the ring. 
           [0050]      FIG. 4  is a perspective view of  FIG. 3  showing the start of manual pressure as the sheath is removed. 
           [0051]      FIG. 5  is a perspective view of  FIG. 4  showing after the sheath is removed and the loose suture ends are tied off. 
           [0052]      FIG. 6  is a perspective view of  FIG. 5  after knotting the loose ends of the sutures around a twist bar and tied a second time. 
           [0053]      FIG. 6A  is a top plan view of  FIG. 6 . 
           [0054]      FIG. 6B  is a section view in the direction of arrows  6 B- 6 B in  FIG. 6A . 
           [0055]      FIG. 7A  is a section view in the direction of arrows  7 A- 7 A in  FIG. 6 . 
           [0056]      FIG. 7B  is a view of  FIG. 7A  showing the effect of twisting to pull up the 4 suture corners into inversion of the enclosed tissue. 
           [0057]      FIG. 7C  is a section view in the direction of arrows  7 C- 7 C in  FIG. 6  after the suture tightening step in  FIG. 7B . 
           [0058]      FIG. 7D  is a simplified top view of the suture insertion sites and the elongated suture holes after excess suture tension is applied. 
           [0059]      FIG. 8  is an exploded perspective view showing the removal of the parts and the removal of the suture just prior to ambulation. 
           [0060]      FIG. 9  is a perspective view of  FIG. 8  showing the addition of extra powder to seal the now-empty suture sites. 
           [0061]      FIG. 10  is a view of  FIG. 9  showing holding manual pressure for 15 seconds to seal the 5 puncture sites. 
           [0062]      FIG. 11  is a view of  FIG. 10  after the closing procedure is complete. 
           [0063]      FIGS. 12A to 12C  show alternate embodiments of the powder containment device (PCD). 
           [0064]      FIGS. 13A and 13B  are perspective broken views of alternate twist bars with jam slits to eliminate the need for the second knot. 
           [0065]      FIG. 14  is an exploded perspective view of a self-locking suture tensioner and PCD in combination. 
           [0066]      FIG. 15  is an exploded perspective view of another embodiment of a self-locking suture tensioner and PCD in combination. 
           [0067]      FIG. 16  is an exploded perspective view of the preferred embodiment of the self-locking suture tensioner and PCD in combination. 
           [0068]      FIG. 17  is another exploded perspective broken view of  FIG. 16 . 
           [0069]      FIGS. 18 and 19  are perspective views of yet another embodiment of the self-locking suture tensioner and PCD in combination. 
       
    
    
       [0070]    Exemplary embodiments are illustrated in reference figures of the drawings. It is intended that the embodiments and figures disclosed herein are to be considered to be illustrative rather than limiting. 
       DETAILED DESCRIPTION OF THE INVENTION 
       [0071]    A protocol has been developed for implementing the method of the present invention utilizing an anhydrous ferrate and cationic exchange resin composition (the powder) taught in U.S. Pat. No. 6,187,347, the entire teaching of which is incorporated herein by reference. 
         [0072]    Referring now to the drawings, and firstly to  FIG. 1  after an arteriogram or other vascular intervention within an artery of a leg is complete, while the catheter of the I.V. still remains in the artery and the wound tract, a suture  12  is placed into the skin at  14  adjacent the wound and under the skin and emerges at  16 . The suture  12  is then diagonally over the catheter and into the skin a second time at  18  to reemerge at a fourth corner  20 . Looking down and into the skin, the stitch pattern forms a “Z”, a typical stitch used to suture-close the stump after an appendectomy. 
         [0073]    Referring now to  FIGS. 1A , B, C, and D, there are four possible ways to configure the Z-stitch.  FIGS. 1B and 1D  create a skin inversion aligned with the access tract to create semi-occlusive pressure along the axis defined by the access site, the tract and the arteriotomy.  FIGS. 1B and 1D  are not preferred as the alignment may be off center. 
         [0074]      FIGS. 1A and 1C  create a skin inversion perpendicular to the tract defined by the access site, the tract and the arteriotomy and this pressure is not applied along the entire length of the wound.  FIGS. 1A and 1C  are preferred because they assure that pressure is applied across the entire vessel. 
         [0075]    In  FIG. 2 , a substantially incompressible powder containment device (PCD)  30  is placed around the catheter and the Z stitch  12   b . The PCD  30  is formed preferably of substantially incompressible resilient plastic material having a thickness of approximately 0.08″ to 0.40″ having an overall diameter of approximately 2″ with a central hole  32  having a diameter of 1.25″. The diagonal slot  34  is formed through this flat ring-shaped PCD  30  as a clearance to pass over the catheter into the position shown. 
         [0076]    In  FIG. 3 , a quantity of potassium ferrate/strong acid cationic exchange resin mixture as an anhydrous ferrate compound  36 , is poured into the PCD to fill it. In  FIG. 4 , finger pressure is applied over the powder  36  with gentle pressure while the I.V. with catheter is withdrawn in the direction of arrow C. The ferrate compound is a hemostatic agent which includes an effective amount of a salt ferrate combined with an effective amount of an insoluble cation exchange material, the salt ferrate combining with blood or blood serum to form a trivalent Fe +++  ion which promotes blood clotting and produces oxygen to reduce the bacteria level at the wound site W. The cation exchange material also forms a protective cover over the wound site as the trivalent Fe +++  ion is formed. In  FIG. 5 , both ends  12   a  and  12   c  of the suture  12  are then pulled tight in the direction of arrows D at the suture entry points  14 ,  16 ,  18  and  20 . The suture ends  12   a  and  12   c  are then knotted at  40  over the site. Hemostasis is immediate. 
         [0077]    In  FIG. 6 , a saline syringe is disassembled and the elongated barrel  42  recovered and used as a twist bar or windlass. The loose ends  12   a  and  12   c  of the suture  12  distal to the knot  40  over the insertion site are wrapped around the barrel  42  and a second knot is tied at  44 , thus forming a “Spanish Windlass”. The barrel  42  is turned clockwise creating a braid  12   e  of the two ends of the suture  12 . As seen in  FIGS. 6A and 6B , the twisted suture forms a braid  12   e  which shortens between knots  40  and  44  thus drawing the barrel  42  against the exposed surface of the PCD  30  and pressing the PCD  30  against the skin. When this shortening-by-twisting effect reduces the distance sufficiently between knots  40  and  44 , the barrel  42  becomes parked or wedged into the slot  34  which acts as a detent to keep the barrel  42  and the braid  12   e  from unwinding. 
         [0078]    In  FIGS. 7A and 7C , as the barrel  42  is turned, the twisted braid  12   e  winds to shorten the linear distance between the barrel  42  and the wound, creating almost-right-angle tension on the embedded portions of the suture  12 . As best seen in  FIG. 7B , the right-angle-tension pulls the corners inward and pushes the center down (inversion) towards the artery and along the tract and insertion site. The twisted suture also pulls the barrel  42  and the PCD  30  down toward the skin, creating a physical seal between the PCD  30  and the skin which keeps loose powder  36  from falling out. 
         [0079]    In another embodiment, there is an encircling plastic “washer” through which the free ends of the suture are threaded and then the washer is placed over the insertion site. The washer has a detent to bind the windlass means in place after torque has been applied. The barrel can be of any rotatable shape and any material with sufficient strength to withstand the torque. 
         [0080]    In a preferred embodiment, the  FIG. 4  step is eliminated by pulling the catheter after the  FIG. 7  twisting process. This embodiment is preferred because it eliminates a potential weakness, i.e., the time gap between pulling the catheter and achieving inversion. This time gap makes it vulnerable to a hemostasis. Moving  FIG. 4  step after inversion eliminates the potential for hemostasis. 
       Wound Eversion 
       [0081]    According to MacKay-Wiggan et al in Suturing Techniques, May 1, 2009 (Web MD): “The choice of suture technique depends on the type and anatomic location of the wound, the thickness of the skin, the degree of tension, and the desired cosmetic result. The proper placement of sutures enhances the precise approximation of the wound edges which helps minimize and redistribute skin tension. Wound eversion is essential to maximize the likelihood of good epidermal approximation. Eversion is desirable to minimize the risk of scar depression secondary to tissue contraction during healing. Usually, inversion is not desirable and probably does not decrease the risk of hypertrophic scarring in an individual with a propensity for hypertrophic scars.” 
         [0082]    The inversion-induced force is on the insertion site, the wound tract and the wound or insertion site. The induced pressure is gentle but consistent and hemostasis is achieved along the entire wound. The barrel  42  is left in place one hour to allow clotting to go to completion. Prior art teaches that right angle tension is undesirable, and it is for extended time, but not for one hour. However, the induced force over the entire site is detrimental to the suture entry sites as they are elongated as seen in  FIG. 7D  and the open surface area is increased. The hemostatic powder  36  mitigates this issue by sealing the enlarged raw surface area and protects against bleeding and infection. What is key is that the suture sites are elongated for only an hour, much less than the time for complete healing. There is no scarring. 
         [0083]    After the hour, the stitches are removed as shown in  FIG. 8  as follows:
       1. The suture  12  is cut from around the barrel  42 ;   2. The barrel  42  is removed and the PCD is then removed;   3. The suture  12  is cut one to four times below the knot  40 ;   4. The one to four suture fragments are pulled out of the skin;   5. Residual hemostatic powder is poured on the suture holes  14 ,  16 ,  18  and  20  as shown in  FIG. 9  and finger pressure is held to form a seal as seen in  FIG. 10 .   6. The wound is not bandaged as seen in  FIG. 11  because the seal is sufficient.       
 
       Alternate PCD Embodiments 
       [0090]    Other embodiments of the PCD facilitate this same methodology. In  FIGS. 12   a ,  12   b  &amp;  12   c , different configurations of the PCD are illustrated at  50 ,  60  and  70 . The PCD  50  includes an oval-shaped hole  52  along with a slot  54  serving as a detent for the twisted-tight barrel  42  as previously described. The PCD  60  includes a racetrack-shaped central hole  62  and the detent slot  64 , which, again, facilitates fitting of this PCD around the catheter while still inserted into the vascular leg area. The PCD  70  also includes a central racetrack-shaped hole  72  and a slit  74  which may be resiliently opened for access around the catheter. 
         [0091]    In  FIGS. 13A  and B, dedicated twist bars  80  and  80   a  each have a jam-fit groove  82  or  82   a  cut into the cylindrical shape. The physician takes the ends  12  &amp;  12   a  and jams them into the groove  82  or  82   a  and then starts twisting. The jam-fit eliminates the need for a second knot. 
         [0092]    In  FIG. 13C , the twist bar  84  is a “rolling pin-like structure” in which the major diameter  86  is greater than the detent slot  54  or  64  and the minor diameter  88  is less than the detent slot  54  or  64 . This way, after inversion is achieved, the minor diameter  88  nests completely in the detent slot  54  or  64  and cannot “unwind” during the TTA. 
       Combination PCD and Suture Twister 
       [0093]    Referring now to  FIG. 14 , a vascular access wound sealing system as a combination powder containment device and suture twister is there shown generally at numeral  90  and includes a cup-shaped powder containment device  92  and a suture tensioner  94 . The PCD  92  includes a central hole  96  and an access slot  100  which function as previously described. The PCD  92  also includes an upright outer wall having inwardly facing internal teeth  98  extending entirely therearound. These teeth  98  mesh with outwardly facing teeth  102  formed around the perimeter of the suture tensioner  94 . When the suture tensioner  94  is inserted into teeth meshing engagement with the PCD  92 , the suture tensioner  94  is rotatable in only one direction, that being clockwise in the direction of the arrow F. 
         [0094]    The suture tensioner  94  also includes an upright finger turning blade  112  connected to a top surface therefore which facilitates the tensioning of the suture  12 . The suture ends  12   a  and  12   c  are fed from knot  40  into locking notches  104  and  106 , respectively, as the suture twister  94  is lowered into tooth engagement with the PCD  92 . Thereafter, one of the suture ends  12   a  is fed through a central locking notch  118  and then through one of the side locking notches  114  or  116  formed through blade  112 , while the other suture end  12   c  is fed firstly through the central locking notch  118  and then through the alternate side-locking notch  116  or  114 . Once the suture ends  12   a  and  12   c  are lockingly engaged as described and shown, rotation by manual grasping of the finger blade  112  is effected in the direction of arrow G to properly tension the suture  12  as previously described. 
         [0095]    Referring to  FIG. 15 , the preferred embodiment of the PCD  122  and suture tensioner  124  combination of this wound sealing system is shown generally at numeral  120 . The PCD  122  is formed having a U-shaped upwardly opening channel  132  formed along the perimeter thereof having upwardly facing teeth  128  formed at the bottom of this channel  132 . The inner wall  126  defines a hole or opening for access to the wound and sutures as previously described, along with notch  130  which provides access around the in-place catheter. 
         [0096]    The suture tensioner  124  has downwardly facing teeth  134  which matably engage into teeth  128  of the PCD  122  when the suture tensioner  124  is downwardly positioned into the U-shaped channel  132 . The suture tensioner  124  further includes V-shaped notches  138  and  142  having locking ends  140  which secure the suture ends as previously described in  FIG. 14 . An upright finger blade  144  connected to, and upwardly extending from the upper surface of the suture twister  124 , include central and side upright V-shaped locking notches  150 ,  146  and  148 , respectively, for locking interengagement with the suture ends as described with respect to  FIG. 14 . Rotation in the direction of arrow H tensions the suture  12 . 
         [0097]    A surface adhering device may also be used to pull the skin from around the access site together while pushing down in the center to create an inversion in the skin and tissue therebeneath. This inversion puts pressure over the hole in the vessel to stop the bleeding from that vessel. This device can be used with or without the hemostatic powder. The device an attach by means of a surface adhesive, mechanical hooks, or the like. The hooks can be designed to barely penetrate the surface of the skin or to penetrate into the tissue beneath. Depth of penetration may be used to control the degree of inversion of the tissue beneath. The device can also be turned, twisting the skin and tissue beneath creating a tortuous track to reduce oozing from said tract. 
         [0098]    In the  FIGS. 15 and 16 , a preferred embodiment of the wound sealing system  160  is used to exert low-level continuous pressure similar to the device showed in  FIGS. 14 and 15 . The  FIG. 14  device was found to have a critical defect in that the suture ends slipped in the device  120  and did not retain the required torque. It was also determined that the elapsed time from pulling the sheath (sheath could be any tubular device inserted into the skin) to tying the first knot predicted the frequency of hematomas. A further objective was to eliminate any time lag between application of tension and pulling the sheath. 
         [0099]    The FIG.  16 / 17  wound sealing system  160  works this way:
       1. BioSeal Advanced hemostatic powder is improved with the addition of a powderous substance that is attracted to a magnet such as Magnetite, making the entire powder  36   a  magnetic.   2. The vascular access procedure ends normally and the catheter is still in the tract. There is no bleeding.   3. The Z stitch is placed at the distal side of the insertion site and the proximal side of the access site.   4. Beneath the twist device  160  is a low power magnet  196  used to hold the powder in place within cavity  172 . The magnet  196  is covered by a soft foam  194 .   5. Magnetic BioSeal Advanced powder  36   a  is poured into the inverted device  160 .   6. The magnet  196  holds the powder  36   a  in place as it is turned right side up and slid over the catheter and the suture ends. The device  160  is pressed down against the skin and the powder  36   a  is compressed over the wound site and in intimate contact with the wound.   7. The interfacial pH drops to 2 as the powder absorbs cation-rich blood liquid.   8. The two ends of the Z-stitch suture are pulled tight.   9. The suture ends are tied around the twist device  164  in the device  160  and knotted.   10. The twist device  164  is rotated one to two revolutions until skin inversion occurs, congruent with removing the catheter.   11. Hemostasis is immediate; time to ambulation is 60 minutes.       
 
         [0111]    Device  160  is the preferred embodiment because it eliminates any time lag between pulling the catheter (or sheath) and creating skin inversion. This tensioner  160  also simplifies the procedure because there is only one knot, not two and eliminates any messiness potential with the powder  36   a  as the powder  36   a  is held in place magnetically. 
         [0112]    The suture tensioner  160  includes a PCD  162  and a suture tensioner  164  which are preassembled together so, to the practioner, it is a one piece device, not two. The suture tensioner  164  pulls the sutures through a central slot  176 / 178  and holds tension on the sutures for the entire length of patient recovery. This can be accomplished by wrapping the suture around a cylindrical surface  170  of the PCD  162  after the suture ends have been locked into locking notches  192 , followed by manual rotation of the suture tensioner  164  by finger blades  186 . 
         [0113]    The PCD  162  is formed having upwardly facing teeth  168  which lockingly mesh with the downwardly facing teeth  184  formed on the suture tensioner  164 . An access notch  174  is formed radially inwardly from the perimeter of the body  166  of the PCD  162  for providing access around the in-place catheter. A clearance notch  188  in the perimeter of body  180 . By making the powder  36   a  magnetic by the addition of magnetized powder such as Magnetite, and by providing a magnet  196  positioned at the top of cavity  172  covered by a compressible foam layer  194 , all of the magnetic hemostatic powder  36   a  is held within the cavity  172  as the device  160  is positioned over the in-place sutures around the wound and wound tract as previously described. 
         [0114]    The device  160  holds constant pressure over the wound in the vessel while in use with no outside assistance from a clinician. The pressure is created by gathering the tissue from the area around the insertion site, pulling it together while maintaining or creating a force over the skin to create an inversion in the tissue. This inversion in the tissue pushes down on the vessel stopping the bleeding. The sutures penetrate the skin on either side of the wound in the vessel, pulling the sides of the vessel upwards and inwards, creating a deep inversion that pushes down over the wound in the vessel as previously described. 
         [0115]    Referring now to  FIGS. 18 and 19 , a linear self-locking, one piece wound sealing device is there shown generally at numeral  200  and includes a PCD  202  and a suture tensioner  204  which are interengaged along mating linear grooves  212  and rails  224  so that the suture tensioner  204  is movable in the direction of the arrow with respect to the PCD  202 . 
         [0116]    The PCD  202  includes a cylindrical body  206  having a catheter clearance notch  208  formed radially inwardly from the perimeter to the center of the body  206  and also has a suture clearance hole  214  centrally therethrough. Upwardly facing teeth  210  of the PCD  202  interlock with the downwardly facing teeth  222  of the linear tract  220  of the suture tensioner  204 . The suture ends upwardly extend from the central aperture  214  and lockingly engage within locking grooves  226   a  and  228   a  of locking members  226  and  228 , respectively. Thereafter, linear movement of the suture tensioner  204  in the direction of the arrow applies tension in linear response to that movement to tension the Z-stitch positioned beneath the hemostatic powder cavity  216  in a fashion previously described. 
       Clinical Trials 
       [0117]    Clinical trials were conducted on randomly selected patients&#39; legs, comparing the methodology of this disclosure to subcombinations thereof:
       1. The first leg was subjected to a vascular procedure after which manual pressure only was applied.
           a. Time to hemostasis=20-30 minutes depending on blood chemistry   b. Time to ambulate (TTA)=4-6 hours   c. Complications=2%   
           2. The second leg was also subjected to the vascular procedure after which manual pressure and hemostatic powder were applied.
           a. Time to hemostasis=5-7 minutes   b. TTA=2-4 hours   c. Complications=2%   
           3. The third leg underwent the vascular procedure followed by application of the twisted suture procedure described hereinabove and hemostatic powder.
           a. Time to hemostasis=0 minutes   b. TTA=1 hour   c. Complications=0.1%   
           4. The trial is a random, prospective, multi-center trial using 7 doctors and four sites.
           a. Each doctor did 30 procedures of each leg.   
           5. Blood ACT&lt;250       
 
       Test Results 
       [0133]    The results for the three conditions tested were: 
         [0134]    Pressure only:
       TTA=4.5 hr; Complications=2%; Patient rating=5       
 
         [0136]    Pressure+BIOSEAL:
       TTA=2.5 hr; Complications=2%; Patient rating=7       
 
         [0138]    Suture Twist+BIOSEAL:
       TTA=1.3 hr; Complications=0.5%; Patient rating=9       
 
         [0140]    In a second experiment, the windlass was used without the haemostatic powder. Closure was achieved without manual pressure and the TTA was 1.5 hours; there was a 1% complication rate from infection; bandage changes were required to soak up oozing. 
       Economic Data 
       [0141]    The clinical trial also collected economic data and analyzed the economic impact of the three legs both as to cost and also as to revenue. The revenue analysis continued after the test period. The Twist+BIOSEAL significantly reduced the overall cost of the procedure. 
         [0142]    The one-hour TTA was independent of the platelet count of the patient. Closure devices previously were used on about 30% of the cases; this skews by doctor. Some doctors used a closure device frequently (33% of all arterial accesses use closure devices), particularly when the patient had a low platelet count or other clotting compromise. Most doctors used closure devices infrequently. The most significant economic difference was the ability to schedule one additional case per day without overtime, a revenue increase of $2,000 per day per clinic. The increase in cost was $50/day for the suture twist kit 10. 
         [0143]    While a number of exemplary aspects and embodiments have been discussed above, those of skill in the art will recognize certain modifications, permeations and additions and subcombinations thereof. It is therefore intended that the following appended claims and claims hereinafter introduced are interpreted to include all such modifications, permeations, additions and subcombinations that are within their true spirit and scope.