Abstract:
Tissue eversion apparatuses and methods suitable for use, as examples, with vascular closure devices. The tissue eversion apparatuses comprise a tissue engaging element, disposed within a delivery sheath. The delivery sheath protects the tissue engaging element and the surrounding tissue during use. The tissue engaging element can extend from the sheath and engage the tissue near an aperture in a tissue wall. Motion of the tissue engaging element away from the tissue can urge the tissue wall near the aperture to evert from the tissue wall, allowing, as examples, aperture closure apparatuses and methods to be conveniently employed.

Description:
CROSS-REFERENCE TO RELATED APPLICATIONS 
     This application claims priority to U.S. provisional application 60/711,279, filed Aug. 24, 2005, and to U.S. provisional application 60/726,985, filed Oct. 14, 2005, and is a continuation-in-part of U.S. utility application Ser. No. 11/316,775, filed Dec. 23, 2005 now abandoned, each of which is incorporated herein by reference. 
    
    
     FIELD OF THE INVENTION 
     The present invention relates to methods and apparatuses for closing punctures and apertures in human and animal tissue and to methods and apparatuses for inserting such an apparatus into such tissue to perform such closure functions. 
     BACKGROUND 
     During angiography and related procedures, catheters are inserted through an incision or puncture in the skin and underlying tissues to access an artery or vein, typically in the groin, neck, or subclavian areas of a patient. The catheter can be inserted through a puncture in the blood vessel and guided to the desired site to perform interventional procedures such as angiography, angioplasty, plaque removal, and infusion of a therapeutic substance. After the procedure is completed and the catheter is removed from the patient, the access hole must be closed to prevent massive hemorrhage. This is conventionally achieved by applying pressure over the blood vessel manually and then by applying a pressure bandage, compressive weight, or clamp device. With conventional methods, the rate of post-puncture hemorrhage is high, which causes considerable complications. This complication is exacerbated by the concomitant use of anticoagulant medications such as heparin or warfarin and by antiplatelet drugs, which are commonly used to treat vascular disease. 
     Sutures have been used to close access puncture wounds in blood vessels. U.S. 05,613,974 describes a device and method for applying sutures to a vascular puncture. US2004/0093027A1 describes barbed suture-like material that apposes the puncture site. US 2005/0121042 A1 describes a device and method for applying suture to a vascular puncture. Difficulties with these methods include the large number of steps necessary to deploy the needles, capture the suture, withdraw the suture, tie the knot, and cut the suture. In addition, the hole in the blood vessel is often widened by insertion of the instrument, and the suture remains intravascularly on the endothelial surface, and thus can be a nidus for thrombus or intravascular mural hyperplasia with later spontaneous and catastrophic closure of the vessel. 
     Extravascular plugs have also been proposed for closure of vascular punctures. U.S. Pat. No. 5,254,105 and U.S. Pat. No. 5,330,445 describe an extravascular plug which is slid down the external surface of the catheter or introducer and is placed into the puncture site in this manner. U.S. Pat. No. 5,643,318 relates to a similar device that has its own vessel locator device. US22022822A1 and US2004/0158287A1 describe an extravascular plug that is delivered with a specialized system. US24215232A1 describes an extravascular plug with an intravascular anchor set with a sheath with a detection port. US2005/0085855A1 describes an extravascular collagen plug, held in place with an intravascular anchor, and a device that locks over a piece of suture. U.S. Pat. No. 5,906,631 describes a plug made of hydrophilic material. U.S. Pat. No. 6,126,675 describes an intravascular anchor and a bioabsorble extravascular plug. U.S. Pat. No. 6,623,509 describes a bioabsorbable plug. U.S. Pat. No. 6,296,657 and U.S. Pat. No. 6,743,195 describe an inflatable balloon that puts pressure on the puncture site. U.S. Pat. No. 6,569,185 describes an injectable vascular plug. U.S. Pat. No. 6,663,655 describes a plug that screws in the puncture tract. US2004/0143290 A1 describes a combination of an intraluminal balloon and injectable sealant. Disadvantages to these methods are related to the high likelihood of thrombosis associated with the intravascular plug or anchor, and the presence of collagen or other bioabsorble materials which cause inflammation, activate the clotting cascade, and increase the likelihood of thrombosis, which, in an arterial system, is catastrophic. 
     Vascular patches have also been used for repairing blood vessels, but usually only for large areas of damage. U.S. Pat. No. 5,100,422 describes a vascular patch that is sutured to the external surface of the damaged blood vessel. U.S. Pat. No. 5,100,422 describes a vascular patch achieved by instilled adhesives and the device for doing such. These are generally impractical for catheter-based methods. U.S. Pat. No. 6,248,124 and U.S. Pat. No. 5,507,744 describe devices and methods that use electrocautery for sealing vascular punctures. This also requires a complicated device, and perforation and thrombosis are very real possibilities. 
     Vascular clips or staples delivered through a catheter device have also been proposed. These devices have penetrating members that bring the edges of the tissue together. U.S. Pat. No. 6,695,867 describes a clip or staple that is delivered by a specialized device. U.S. Pat. No. 6,749,622 describes a number of different clips with sharpened barbs or ends that include both intra- and extravascular portions, made of metal with memory characteristics. U.S. Pat. No. 5,861,005 describes an arterial staple that is delivered with a specialized device. U.S. Pat. No. 5,919,207 describes a stapling system based on long hooked wires that appose the surfaces, with a small staple gun to close the lesion. U.S. Pat. No. 6,022,372 describes a similar staple gun. U.S. Pat. No. 6,296,657, U.S. Pat. No. 6,663,655, and U.S. Pat. No. 6,749,621 describe a clip that is external to the vessel, but clips the two sides of the puncture together, and a device for achieving such. U.S. Pat. No. 5,782,861 and U.S. Pat. No. 5,964,782 describe clip devices composed of two or more prongs or hooks that, depending on the direction of the prongs, can clip together the puncture site from the intra- or extravascular position, through the use of a collar which forces the prongs together or other mechanisms. These clip devices are composed of thick semi-rigid material, and can be placed only with a specialized instruments, and because of the rigidity have great potential to injure or cut the blood vessel. Disadvantages of these clip devices in general include difficulty in retrieving the device if misplaced, excessive manipulation required, the thickness of the clip material which tends to cut or shear the blood vessel, the large forces that must be used to curve the staples and fix the clips, the increased possibility of tearing the blood vessel, and the general lack of control of the forces being applied to the blood vessel. 
     Accordingly, there is a need for methods and apparatuses that are suitable for closure of vascular punctures or other openings, and that do not suffer from the drawbacks of conventional approaches. 
     SUMMARY OF THE INVENTION 
     The present invention provides methods and apparatuses that are suitable for closure of vascular punctures or other openings, and that do not suffer from the drawbacks of conventional approaches. 
     An apparatus according to the present invention comprises a tool that can be inserted through a puncture wound in a blood vessel, opens within the blood vessel by the extension of multiple members, the members engage and/or penetrate the vessel wall from the intralumenal side of the blood vessel, the members bring the vessel wall into apposition by the combination of traction and the geometric shape of the members, the member can the blood vessel so that a closure device can be inserted over the apposition/eversion device, and a closure device (which could be an external suture or external clip) placed on the outside of the blood vessel where it seizes and engages the everted edges of the puncture wound as the members prevent the blood vessel wound edges from moving, and finally, removing the wound eversion device or detaching the wound eversion device leaving the closure device proximal to everted wound edges. 
     The present invention also comprises methods of using devices according to the present invention, and methods for bring aperture edges into apposition using devices such as those described herein. 
     Devices according to the present invention can utilize a contractible or expandable material, for example with memory characteristics, that allow the members of the device to open and engaed spontaneously on a puncture wound of a blood vessel. Members of such devices can have textured gripping surfaces, tissue hooks, or penetrators, to seize the vessel wall and stabilize the device. Such devices can use the spontaneous opening and closing characteristics to seize the edges of the puncture site, and close them, resulting in a complete vascular closure. Such devices can be kept in a contracted or expanded state (high energy state of a memory material) by a delivery sheath and assume its functional, closing form (low energy state of a memory material) when pushed off a delivery sheath. 
    
    
     
       BRIEF DESCRIPTION OF THE FIGURES 
       The invention is explained by using embodiment examples and corresponding drawings, which are incorporated into and form part of the specification. 
         FIGS. 1   a - d  are schematic illustrations of a puncture wound eversion-retraction device according to the present invention. 
         FIGS. 2   a - c  are schematic illustrations of a puncture wound eversion-retraction according to the present invention. 
         FIGS. 3   a - d  are schematic illustrations of a puncture wound eversion-retraction according to the present invention. 
         FIGS. 4   a - g  is are schematic illustrations of a puncture wound eversion-retraction according to the present invention. 
         FIG. 5  ( a,b ) is a schematic illustration of a puncture wound eversion-retraction according to the present invention. 
         FIG. 6  ( a,b ) is a schematic illustration of a puncture wound eversion-retraction according to the present invention. 
         FIG. 7  ( a,b ) is a schematic illustration of eversion and retraction of the edges of a tissue opening using a device according to the present invention. 
         FIG. 8  ( a,b,c,d ) is a schematic illustration of steps in a method of closing a tissue opening according to the present invention. 
         FIG. 9  ( a,b ) is a schematic illustration of steps in a method of closing a tissue opening according to the present invention. 
         FIG. 10  ( a,b,c,d ) is a schematic illustration of an example puncture wound everter device. 
         FIG. 11  ( a,b,c,d ) is a schematic illustration of an example puncture wound everter device. 
         FIG. 12  ( a,b,c,d ) is a schematic illustration of an example puncture wound everter device. 
         FIG. 13  ( a,b,c,d,e ) is a schematic illustration of an example puncture wound everter device. 
         FIG. 14  ( a,b,c,d ) is a view of another example embodiment of a gripper device with a residing memory gripper being used. 
     
    
    
     DETAILED DESCRIPTION 
     The present invention provides apparatuses and methods for closing a vascular puncture wound or any tissue aperture, for example those resulting from the insertion of a vascular catheter or surgical instrument, trauma or disease. The present invention embraces both apparatuses and methods for closing tissue openings such as vascular punctures. Devices according to the present invention can be inserted in a vascular sheath, the sheath removed or pulled back, a closure device placed over the everter device, the everted device activated by extending the graspers within the blood vessel, the graspers pulled up against and penetrate the vascular vessel wall, the wound edges everted, apposed, and brought up into the closure device, and finally the everted wound edges closed distal to the graspers by the means of an extravascular clip, extravascular suture, extravascular glue or patch, extravascular heat coagulation, or by staples or sutures that are placed through the lips of the everted wound edges. This behavior can be provided by forming at least a portion of the grasping device of a memory metal or material. The stress free state corresponds to the state at which the apparatus has closed upon the everted edges of a puncture wound of a blood vessel, and the stressed state is when the device is open and seated on the delivery sheath. Example embodiments of tissue closure apposition devices according to the present invention are shown in  FIGS. 1 ,  2 ,  3 , and  4 . The descriptions may refer to “vessels” for convenience; the present invention is applicable to facilitate closure of various types of tissue openings. 
       FIG. 1(   a,b,c,d ) is a schematic illustration of an puncture wound everter device.  FIG. 1   a  is a lateral view cutawary of a puncture wound everter device in the closed state (high energy state). A plurality of grasping members  101  (generally a minimum of two members, or otherwise grasping tissue at at least two locations) in the retracted state, and a sheath  102  contains grasping members. This sheath can accommodate a guidewire, or in another embodiment can be inserted through a sheath or a closure device and used like a guidewire.  FIG. 1   b  is a lateral view of the same device in the extended or opened state (low energy state), where the grasping members  103  are extended, and curl up and engage and/or pierce the blood vessel wall.  FIG. 1   c  is a lateral view of the everting device in the retracted state with a plunger mechanism  104  to extend the grasping members and finger flanges or rests  105  to control the device.  FIG. 1   d  is the same device with the grasping members extended by pushing a plunger mechanism  106 . 
     In  FIG. 1  the everter device can be placed into the puncture wound by means of a guidewire that can be accommodated within the sheath  102  in which cases the everter device is placed over the guidewire and pushed through the puncture wound into the blood vessel. The closure device is then placed over the everter device and the terminal end brought up against the exterior blood vessel wall. The everter members are then extended and the device pulled up against the blood vessel wall, and the everted wound edges retracted within and held within the closure device, after which the guidewire is removed, the closure mechanism applied by the closure device causing the wound edges to be closed distally to the everting members. At this point the everter members are retracted and both the closure device and everter device removed, leaving the closure mechanism in place on the external surface of the blood vessel. 
     Alternatively, in  FIG. 1  the everter device can be placed into the puncture wound by means of a sheath that can accomodate the everter device internally. The everter device sheath  102  is placed within the operating sheath and pushed through the existing sheath into the puncture wound and into the internal lumen of the blood vessel. The operator sheath is then removed and the closure device is then placed over the everter device with the everter device sheath being used as a guidewire. The terminal end of the closure device is brought up against the exterior blood vessel wall. The everter members of the everter device are then extended, the device pulled up against the blood vessel wall, the everter members penetrating and seizing the blood vessel wall, the everted device being partially retracted, and the everted wound edges being retracted within and held within the closure device. The closure mechanism is then applied by the closure device causing the everted wound edges to be closed distally to the everting grasping members. At this point the everter members are retracted and both the closure device and everter device removed, leaving the closure mechanism in place on the external surface of the blood vessel. 
       FIG. 1  presents for illustration purposes  2  active members; the device can comprise as few as two active members (or one, if it grasps the tissue at multiple locations), but can include any plurality, and as many as are practical within applicable design considerations. The tissue engagement features, shown as sharp hook-like portions of the active members in the figure, can comprise textured portions or attachments, mating portions with apposing feet, penetrating devices, hooks, teeth, or other adaptations to allow firm grip of the tissue. The members can comprise memory materials to fit within the delivery sheath, to assume a lower profile when delivered, and expanded and engage the vessel wall when extended. 
       FIG. 2(   a, b, c ) demonstrates an example of how a puncture wound everter device according to the present invention can be used.  FIG. 2   a  is a lateral cutaway view of the everter device after insertion into the blood vessel where  FIG. 2   a - 1  is the everter device sheath,  FIG. 2   a - 2  is the retracted (high energy state) grasping member,  FIG. 2   a - 3  is the proximal vessel wall;  FIG. 2   a - 4  is the guidewire, and  FIG. 2   a - 5  is the distal vessel wall.  FIG. 2   b  demonstrates the everter device with the grasping members extended where  FIG. 2   b - 6  is the extended grasping member, and  FIG. 2   b - 7  is the grasping member penetrating the proximal vessel wall.  FIG. 2   c  show the everter device with traction, where  FIG. 2   c - 8  is the everter device pulled proximately towards the operator, which enlongates, everts, apposes and hold the vessel wall  FIG. 2   c - 9 , so that a closure device can be placed on the neck of the everted wound margins  FIG. 2   c - 10 . 
       FIG. 3(   a, b, c, d ) demonstrates how an everter device according to the present invention can be used to apply an extravascular clip or stable.  FIG. 3   a  is a lateral cutaway view, where  3   a - 1  is expulsion portion of the closure devices,  3   a - 2  is the extravascular clip or staple, and  3   a - 3  is the extravascular clip or staple delivery sheath.  FIG. 3   b  is a view of the clip  3   b - 4  being delivered onto the neck of the everted wound edges, closing the wound  3   b - 5 .  FIG. 3   c  demonstrates the everter device  3   c - 7  with the members retracted, leaving the clip or staple closed over the guidewire  3   c - 8 .  FIG. 3   d  demonstrates the clip or staple left in situ, with the clip  3   d - 9  left in place, completely closing the puncture wound edges  3   d - 10 . 
       FIG. 4(   a,b,c,d,e,f,g ) is a demonstration of a method to insert a closure device, in this case an extravascular suture.  FIG. 4   a  is a lateral view where the gripper sheath  4   a - 1  is placed over the guidewire  4   a - 4 , so that the distal edge of the sheath has been pushed internally relative to the proximal blood vessel war  4   a - 3 . The gripper members  4   a - 2  have not been extended. In  FIG. 4   b  the gripper tines  4   b - 6  are extended penetrating or gripping the proximal blood vessel wall  4   b - 97 . In  FIG. 4   c  traction is then placed on the gripper sheath and members  4   c - 8 , which pull and evert the wound edges  4   c - 9 . In  FIG. 4   d  the suture introducer sheath  4   d - 10  is the placed over the gripper sheath, and the suture  4   d - 11  is tightened by pulling on the suture drawstring contained in  4   d - 12 .  FIG. 4   e  the suture is then completely closed around the guidewire  4   d - 14 , closing the puncture. In  FIG. 4   f  the gripper members  4   f - 15  are retracted within the everter gripper sheath, and the suture loop  4   f - 16  is cut. In  FIG. 4   g , if there is no bleeding, the guidewire is removed leaving  4   g - 17  an external suture closure of the blood vessel puncture wound. 
       FIG. 5(   a,b ) is another schematic illustration of a puncture wound everter device, similar to that of  FIG. 1 .  FIG. 5   a  is a lateral view cutawary of a puncture wound everter device in the closed state (high energy state).  FIG. 5   a - 1  are the plurality of grasping members (comprising a minimum of two members) in the retracted state; these are constrained within internal lumen  FIG. 5   a - 2 , which are held within the everter device sheath.  FIG. 5   a - 3  is the sheath that contains grasping members. This sheath can accommodate a guidewire, or in another embodiment can be inserted through a sheath or a closure device and used like a guidewire.  FIG. 5   b  is a lateral view of the same device in the extended or opened state (low energy state), where the grasping members  5   b - 4  are extended, and curl up and engage and/or pierce the blood vessel wall. This device would otherwise be inserted, operated, and used identically to the embodiment in  FIG. 1 .  FIG. 5  presents for illustration purposes two active members; the device can comprise as few as two active members, but can include any plurality, and as many as are practical within applicable design considerations. The tissue engagement features, shown as sharp hook-like portions of the active members in the figure, can comprise textured portions or attachments, mating portions with apposing feet, penetrating devices, hooks, teeth, or other adaptations to allow firm grip of the tissue. The members can comprise memory materials to fit within the delivery sheath, to assume a lower profile when delivered, and expanded and engage the vessel wall when extended. 
       FIG. 6(   a,b ) is another schematic illustration of a puncture wound everter device, similar to that of  FIG. 1 .  FIG. 6   a  is a lateral view cutaway of a puncture wound everter device in the closed state (high energy state).  FIG. 6   a - 1  are the plurality of grasping members (comprising a minimum of two members) in the retracted state; these are constrained within internal lumen  FIG. 6   a - 2  (or not), which are held within the everter device sheath  FIG. 6   a - 3  is the sheath that contains grasping members. In this case the members are extended in a cross-wise function across the sheath, the purpose being that the wound edges are more efficiently and mechanically brought into apposition by the method of retraction. The sheath can accommodate a guidewire, or in another embodiment can be inserted through a sheath or a closure device and used like a guidewire.  FIG. 6   b  is a lateral view of the same device in the extended or opened state (low energy state), where the grasping members  6   b - 4  are extended, and curl up and engage and/or pierce the blood vessel wall. This device would otherwise be inserted, operated, and used identically to the embodiment in  FIG. 1 .  FIG. 6  presents for illustration purposes two active members; the device can comprise as few as two active members, but can include any plurality, and as many as are practical within applicable design considerations. The tissue engagement features, shown as sharp hook-like portions of the active members in the figure, can comprise textured portions or attachments, mating portions with apposing feet, penetrating devices, hooks, teeth, or other adaptations to allow firm grip of the tissue. The members can comprise memory materials to fit within the delivery sheath, to assume a lower profile when delivered, and expanded and engage the vessel wall when extended. 
       FIG. 7(   a,b ) is another schematic illustration of an puncture wound everter device, similar to that of  FIG. 1 .  FIG. 7   a  is a lateral view cutaway of a puncture wound everter device in the closed state (high energy state).  FIG. 7   a - 1  are the plurality of grasping members (comprising a minimum of two members) in the retracted state; these are constrained within internal lumen  FIG. 7   a - 2  (or not), which are held within the everter device sheath  FIG. 7   a - 3  is the sheath that contains grasping members. In this case the members are comprised at a sharp geometric angle. The sheath can accommodate a guidewire, or in another embodiment can be inserted through a sheath or a closure device and used like a guidewire.  FIG. 7   b  is a lateral view of the same device in the extended or opened state (low energy state), where the grasping members  7   b - 4  are extended, and curl up and engage and/or pierce the blood vessel wall. This device would otherwise be inserted, operated, and used identically to the embodiment in  FIG. 1 .  FIG. 7  presents for illustration purposes two active members; the device can comprise as few as two active members, but can include any plurality, and as many as are practical within applicable design considerations. The tissue engagement features, shown as sharp hook-like portions of the active members in the figure, can comprise textured portions or attachments, mating portions with apposing feet, penetrating devices, hooks, teeth, or other adaptations to allow firm grip of the tissue. The members can comprise memory materials to fit within the delivery sheath, to assume a lower profile when delivered, and expanded and engage the vessel wall when extended. 
       FIG. 8(   a,b,c,d ) is a schematic illustration of an puncture wound everter device.  FIG. 8   a  is a lateral view cutaway of a puncture wound everter device in the closed state (high energy state).  FIG. 8   a - 1  are the plurality of grasping members (comprising a minimum of two members) in the retracted state; in this case, the members are flexed back within the sheath; and  FIG. 8   a - 2  is the sheath that contains grasping members. This sheath can accommodate a guidewire, or in another embodiment can be inserted through a sheath or a closure device and used like a guidewire.  FIG. 8   b  is a lateral view of the same device in the retracted or closed states state (low energy state), where the grasping members  8   b - 3  flexed forward.  FIG. 8   c  is a lateral view of the same device in the extended or opened state (low energy state), where the grasping members  8   b - 4  are extended, and flex up and engage and/or pierce the blood vessel wall which represents the extended form of the devices shown in  FIG. 8   a  and  FIG. 8   b .  FIG. 8   d  is a lateral view of the same device in the retracted or closed state (high energy state), where the grasping members  8   d - 5  are retracted, and flexed down which represents the retracted form of the devices shown in  FIG. 8   a  and  FIG. 8   b.    
       FIG. 9(   a,b ) is another schematic illustration of an puncture wound everter device, similar to that of  FIG. 1 .  FIG. 9   a  is a lateral view cutaway of a puncture wound everter device in the partially opened state (half-way to low energy state).  FIG. 9   a - 1  are the plurality of grasping members (comprising a minimum of two members) in the partially extended state.  FIG. 9   b  is a lateral view of the same device in the fully extended or opened state (low energy state), where the grasping members  9   b - 2  are extended, and curl towards each other after then have engaged and/or pierced the blood vessel wall. In this case the members when fully extended move towards the midline of the sheath, the purpose being that the wound edges are more efficiently and mechanically brought into apposition during extension and retraction. This device would otherwise be inserted, operated, and used identically to the embodiments in the prior examples.  FIG. 9  presents for illustration purposes two active members; the device can comprise as few as two active members, but can include any plurality, and as many as are practical within applicable design considerations. The tissue engagement features, shown as sharp hook-like portions of the active members in the figure, can comprise textured portions or attachments, mating portions with apposing feet, penetrating devices, hooks, teeth, or other adaptations to allow firm grip of the tissue. The members can comprise memory materials to fit within the delivery sheath, to assume a lower profile when delivered, and expanded and engage the vessel wall when extended. 
       FIG. 10(   a,b,c,d ) is a schematic illustration of an example puncture wound everter device.  FIG. 10   a  is a lateral view cutaway of a puncture wound everter device in the closed state (high energy state).  FIG. 10   a - 1  are the plurality of grasping members (comprising a minimum of two members) in the retracted state; in this case, the members are closed within an internal lumen  10   a - 2  and/or with the sheath  10   a - 3 . The grasping members are attached to a solid member  6   a - 4  which can be a solid or hollow columnar device with an internal lumen for a guidewire, or can be a wire in itself. This sheath can accommodate a guidewire, or in another embodiment can be inserted through a sheath or a closure device and used like a guidewire.  FIG. 10   b  is a lateral view of the same device in the extended or open state (low energy state), where the grasping members  6   b - 5  are extended into their grasping or extended position.  FIG. 10   c  is a lateral view of the everting device in the retracted state with a plunger mechanism  FIG. 10   c - 6  to extend the grasping members and finger flanges or rests  FIG. 10   c - 7  to control the device.  FIG. 10   d  is the same device with the grasping members extended by pushing the plunger mechanism  FIG. 10   d - 7 . 
       FIG. 11(   a,b,c,d ) is a schematic illustration of an example puncture wound everter device.  FIG. 11   a  is a lateral view cutaway of a puncture wound everter device in the closed state (high energy state).  FIG. 11   a - 1  are a plurality of grasping members (comprising a minimum of two members) in the retracted state; in this case, the members can rotate from internally to externally upon each upon an axis moved by a mechanical mechanism  11   a - 2  (which could be a flywheel mechanism or gear and groove axel mechanism) all which are closed within an internal lumen  11   a - 3  and/or with the sheath  11   a - 3 .  FIG. 11   b  is a lateral view of the same device in the extended or open state, where the grasping members  11   b - 4  are extended into their grasping or extended position.  FIG. 11   c  is a lateral view of the everting device in the retracted state with a plunger mechanism  FIG. 11   c - 5  to extend the grasping members, and finger flanges or rests  FIG. 11   c - 6  to control the device.  FIG. 11   d  is the same device with the grasping members extended by pushing the plunger mechanism  FIG. 11   d - 6 . 
       FIG. 12(   a,b,c,d ) is a schematic illustration of an example puncture wound everter device.  FIG. 12   a  is a lateral view cutaway of a puncture wound everter device in the closed state (high energy state) that is placed through a puncture wound within the blood vessel.  FIG. 12   a - 1  are internal lumina for the plurality of grasping members  12   a - 2  (comprising a minimum of two members) in the retracted state; at least two parallel locator members are also present  12   a - 3  in their lumina within the everter device sheath  12   a - 4 .  FIG. 12   b  demonstrates that the grasping members  12   b - 5  have not been extended, while the locator members  12   b - 6  have been extended. As can be seen, these do not have penetrating surfaces. The locator members are pulled up against the internal edges of the puncture wound, locating the wound margins. In  FIG. 12   c , once the wound margins have been located the grasping members are extended  12   c - 7 , and these penetrate and grasp the proximal vessel wall. In  FIG. 12   d  once the vessel is grasped by the grasping members  12   d - 8 , the locator members are re-retracted, and the device is then used identically to the other examples. 
       FIG. 13(   a,b,c,d,e ) is a schematic illustration of an example puncture wound everter device.  FIG. 13   a  is a lateral view cutaway of a puncture wound everter device in the closed state (high energy state) that is placed through a puncture wound within a blood vessel.  FIG. 13   a - 1  shows the plurality of grasping members (comprising a minimum of two members) in the retracted state within an internal lumen  13   a - 2  within the everter device sheath  13   a - 3 . The grasping members  13   a - 1  are attached to an internal columnar structure  13   a - 4 .  FIG. 13   b  illustrates the grasping members  13   b - 5  extended, by action of the internal columnar structure  13   a - 6  being extended.  FIG. 13   c  illsutrates the grasping members  13   c - 8  detached from the columnar structure at the mating area  13   c - 7  and expelled independently.  FIG. 13   d  is a lateral view of the everting device in the retracted state with a plunger mechanism  13   d - 10  to extend the grasping members and finger flanges or rests  FIG. 13   d - 9  to control the device.  FIG. 13   d  is the same device with the grasping members extended by pushing the plunger mechanism  13   d - 11 . 
       FIG. 14(   a, b, c, d ) is a view of another example embodiment of a gripper device with a residing memory gripper being used. In  FIG. 14   a  the gripper device sheath  14   a - 1  with the residing gripper  14   a - 2  with columnar connecter is introduced into the blood vessel  14   a - 3  over the guidewire  14   a - 4 . In  FIG. 14   b  after introduction, the gripper  14   b - 6  is expelled from the sheath, and the gripping members then penetrate and grip  14   b - 7  the proximal tissue surrounding the puncture wound. In  FIG. 14   c  traction (pulling) is placed on the  14   c - 8  gripper sheath and gripper members on the columnar base, everting the wound edges  14   c - 9 . In  FIG. 14   d  a closure device  14   d - 10  is placed over the gripper device and closed on the neck of the everted wound edges, closing the wound edges  14   d - 11 . The gripping device  14   d - 12  is detached from the columnar holder and is held in place and prevented from migrating internally by the closure device  14   d - 10  and the closure device is prevented from migrating externally by the gripping device  14 - d   12 . Thus, this is a combination of a clip and a suture. 
     Any part of an apparatus according to the present invention can be made from any of a number of suitable materials, or combinations thereof. In some applications, it can be desirable for members to be of radioopaque materials or be coated to be made radioopaque. Members can be made from bioabsorbable polymers or compounds, non-absorbable alloys and compounds including stainless steel, MP35, Nitinol, Nickel-Titanium alloy, Kevlar, nylon polyester acrylic, gold, platinum, tantalum, niobium, molybdenum, rhodium, palladium silver, hafnium, tungsten, iridium. Materials with memory can be useful, where the memory property can provide force for activation of the active members from the open to the closed state. Members can be made in the form of wires, fibers, filaments, small beams, and other extruded, woven, or formed shapes. Examples of suitable materials include piano wire, super elastic memory wire, chromium allows, alloys of titanium and nickel, and other elastic memory materials. A suitable fabric or coating can be made from a number of suitable materials; in some applications it can be desirable to use flexible polymeric materials with elastomeric properties including polyurethane, polyethylene, polyestenurethane, polyimide, olyethreimide, polycarbonate, polysiloxane, polyvinyls, hydroxyethylmethacrylate, related polymers, co-polymers of these or other polymers, or drug-embedded or drug-eluting polymers to prevent coagulation or intimal hyperplasia (such as Taxol), which can be made radioopaque by markers to addition of appropriate radiopaque materials. 
     The particular sizes and equipment discussed above are cited merely to illustrate particular embodiments of the invention. It is contemplated that the use of the invention may involve components having different sizes and characteristics. It is intended that the scope of the invention be defined by the claims appended hereto.