Abstract:
The present disclosure relates to a vascular closure device adapted for use in closing a puncture in a blood vessel after e.g. a percutaneous interventional procedure. The disclosure also relates to a method for vascular closure using such a vascular closure device.

Description:
RELATED PATENT APPLICATIONS 
       [0001]    This patent application is a continuation of U.S. patent application Ser. No. 15/277,542, filed Sep. 27, 2016, naming Thomas Larzon, Robert G. Whirley, Daniel Karlsson, Henrik Nyman, Joseph Humphrey and Cecilia Larzon as inventors, entitled VASCULAR CLOSURE DEVICE, which claims the benefit of Swedish Patent Application No. 1551238-7, filed Sep. 28, 2015, naming Thomas Larzon as inventor and entitled VASCULAR CLOSURE DEVICE, and Swedish Patent Application No. 1551441-7, filed Nov. 6, 2015, naming Thomas Larzon as inventor, entitled VASCULAR CLOSURE DEVICE, all of which are incorporated by reference herein in their entirety, including all text and drawings. 
     
    
     TECHNICAL FIELD 
       [0002]    The present disclosure relates to a vascular closure device adapted for use in closing a puncture in the artery after e.g. a percutaneous interventional procedure. The disclosure also relates to a method for vascular closure using such a vascular closure device. 
       BACKGROUND OF THE DISCLOSURE 
       [0003]    In most cardiovascular procedures, a catheter is inserted into an artery, such as the femoral artery, either directly or through a percutaneous vascular access. The catheter may be inserted, typically over a guidewire, directly into an artery (a “bareback” procedure), or the catheter may be inserted through a vascular introducer. When the procedure is complete, the physician removes the catheter and then removes the introducer from the vessel (if one was used). The physician then must prevent or limit the amount of blood that leaks through the vascular access. Physicians currently use a number of methods to close the vascular access, such as localized external compression, suture-mediated closure devices, plugs, gels, foams and similar materials. 
         [0004]    However, such closure procedures may be time consuming, and may consume a significant portion of the time of the procedure. In addition, existing methods are associated with complications such as hematoma or thromboses. Still further, some of such procedures, particularly suture-mediated closure devices, are known to have high failure rates in the presence of common vascular disease such as atherosclerosis and calcification. 
         [0005]    EP 2095774 B1 tries to overcome the above-mentioned problems by introducing a semi-automated closure apparatus. The suggested closure apparatus is provided for delivering a closure element into engagement with tissue adjacent an opening into a body lumen. The apparatus includes a sheath including a lumen extending between its proximal and distal ends, and a locator member disposed within the sheath, the locator member having a distal portion extending distally beyond the distal end of the sheath. One or more positioning elements are provided on the distal portion of the locator member, the positioning elements being selectively expandable between a substantially axial collapsed configuration and a substantially transverse expanded configuration. 
         [0006]    Even though EP 2095774 B1 provides some relief for the patient by reducing the time necessary for performing a vascular closure, there appears to be room for further improvement in regards to rapid vascular closure, specifically in regards to a device that is easy to use. 
       SUMMARY 
       [0007]    In view of above-mentioned and other drawbacks of the prior art, there is in accordance to the first aspect of the present disclosure therefore provided a vascular closure device for closing a passage through tissue proximate to a blood vessel, the vascular closure device comprising an elongated housing having a proximal end and a distal end, the distal end adapted to be proximate the tissue, a first and a second engagement member releasably arranged with the elongated housing, a deployment member arranged with the elongated housing and adapted to deploy the first and the second engagement member at a distance from each other in engaged contact with said tissue, without engaging a wall portion of the blood vessel, and a retraction member arranged with the elongated housing and adapted to reduce the distance between the first and the second engagement member to close said passage. 
         [0008]    According to the present disclosure, the vascular closure device may be used percutaneously at a vascular access site used for a diagnostic or therapeutic intervention. A vascular access site may in some embodiments correspond to the expression “the passage through tissue proximate to a blood vessel”. Engagement members may then be placed and released through the vascular closure device and may attach to the tissue proximate to the blood vessel, however without engaging a wall portion of the blood vessel. The engagement members are subsequently released out from the vascular closure device using the deployment member, for example using pusher rods arranged in independent lumens comprised with the vascular closure device. In an embodiment, a pusher assembly may for example be arranged in a common lumen that simultaneously deploys all engagement members, through a spring-loaded mechanism or by means of similar functionality. The engagement members may preferably be connected with an elongate flexible tension element such as a suture. The suture may be routed through each of the engagement members in sequence, or individually connected to each engagement member. The tissue in proximity to the blood vessel may then be pulled together with the suture(s) connected to the engagement members. When pulled together, the distance between the initial positions where the engagement members have been positioned to engage with the tissue will be reduced, thereby closing the passage, e.g. the mentioned vascular access site. The tightening accordingly creates a tissue lock thereby closing the passage in the tissue proximate to the blood vessel and indirectly closing the passage in the blood vessel/artery. 
         [0009]    Advantages with the present disclosure include the possibility of closing large passages, such as a large bore access site, post-procedure, and that no preparation of the access site for percutaneous closure is necessary prior to the time of closure, being of high importance e.g. during acute cases. The present disclosure is however not limited to large bore holes, also small passages/holes can be closed with the present vascular closure device. 
         [0010]    In addition to the above, it should specifically be understood that the blood vessel is not engaged directly and thus not included when closing the passage in the tissue proximate the blood vessel, rather, only the tissue proximate to the blood vessel is used for closing the passage. This may typically avoid complications involved with diseased vessels, such as dissection of the intimal layer that can occur and that might cause thrombosis, or such calcified plaques may be present and prevent penetration of the arterial wall. Furthermore, the proposed vascular closure device replaces an established invasive, manual surgical procedure with an automatized, minimally invasive, and easy to learn closure method. 
         [0011]    The terms “proximal” and “distal” are used herein with reference to a clinician manipulating the vascular closure device. The term “proximal end” referring to the portion closest to the clinician and the term “distal end” referring to the portion located away from the clinician. It will be further appreciated that, for convenience and clarity, spatial terms such as “vertical”, “horizontal”, “up”, and “down” may be used herein with respect to the drawings. However, the vascular closure device may be used in many orientations and positions, and these terms are not intended to be limiting and/or absolute. 
         [0012]    It is in some embodiments possible to adapt the engagement member to mechanically engage (or anchor into) the tissue, possibly at a predetermined distance from the distal end of the vascular closure device. The predetermined distance may in one embodiment be as small as only a few millimeters. 
         [0013]    In one embodiment, the first and the second engagement members are adapted to engage with a fascia membrane of said tissue. The fascia membrane is made up of fibrous connective tissue containing closely packed bundles of collagen fibers oriented in a wavy pattern. The fascia membrane is consequently flexible and able to resist great unidirectional tension forces until the wavy pattern of fibers has been straightened out by the pulling force. Adapting the vascular closure device such that the first and the second engagement members are adapted to engage with the fascia membrane of said tissue is thus, in some embodiments, considered suitable for further enhancing the closure of the passage to the blood vessel. The structure of the fascia membrane may additionally allow for the distance reduction, as mentioned above, to be performed without risking that the first and the second engagement members dislocate/disengage from the tissue. 
         [0014]    In an embodiment of the present disclosure, the vascular closure device further comprises an anvil member to be used for determining a location of the anterior wall of the blood vessel/artery, and thereby to be used for providing a reference point in relation to the blood vessel. By means of such an implementation, it may be possible to allow the first and the second engagement members to successfully engage with said tissue at a predetermined distance from anvil member. In a possible embodiment, the distal end of the elongated housing may be positioned e.g. a few millimeters above the fascia membrane, typically not in contact with the fascia membrane or the wall position of the blood vessel. 
         [0015]    In addition to providing a reference point to the engagement members, the anvil member may additionally be used for controlling bleeding during the procedure. However, it should be understood that it of course may be possible to include a further hemostasis member adapted to block blood flow through the passage in the fascia, blood vessel or both, where the hemostasis member is positioned within the blood vessel prior to deploying the first and the second engagement member. 
         [0016]    As mentioned above, the anvil member may provide an orientation in relation to the blood vessel, possibly in a two-dimensional orientation (x-y) in relation to the blood vessel. This may further allow for the first and the second engagement member to mechanically capture or otherwise be secured to the tissue with a predetermined pattern in relation to the blood vessel. 
         [0017]    The anvil member may for example comprise one of a balloon, a deployable disk, a deployable positioning feature or an anchoring plate, depending on the selected implementation of the vascular closure device. Similar anvil members are of course possible. In addition, it is in accordance with the present disclosure possible to remove the anvil member from blood vessel in completing the procedure involving the vascular closure device, leaving nothing behind in the artery. The anvil member may for example be arranged to form part of the elongated housing. 
         [0018]    As an alternative to using the anvil member for providing a reference point in relation to the blood vessel, it could be possible to adapt the vascular closure device to instead comprise a small port on the distal end of the device, which communicates with a lumen that extends an external port near the proximal end of the device. The operator of the vascular closure device may then determine the reference point by inserting the vascular closure device until blood is seen coming from the proximal port, thereby indicating that the distal port is just inside the blood vessel and blood pressure is forcing blood through the vascular closure device. 
         [0019]    The vascular closure device may additionally further comprise a device-positioning member to be aligned with a longitudinal axis of the blood vessel prior to deploying the first and the second engagement member. Such a device positioning member may for example be implemented using an extendable portion of the housing, where the device positioning member is to be aligned e.g. with a limb (e.g. leg or arm) where the passage is located. 
         [0020]    As mentioned above, it is possible to allow a suture to be connected to the first and the second engagement member, wherein the retraction member is adapted to retract the suture to reduce the distance between the first and the second engagement member. A single suture may be used connect to all of the engagement members, or alternatively the suture and a corresponding further suture may be individually connected to the first and the second engagement member, respectively. It should be understood that it may be possible, and within the scope of the present disclosure, to include e.g. a third and a fourth (or even further) engagement members, where a single or a plurality of sutures may be connected to the engagement members in a similar manner as mentioned. Alternatively, a separate suture may be attached to each engagement member and routed into a lumen through the distal aspect of the device such that applying tension to the sutures serves to pull the fascia attachments toward the vascular closure device, reduce the distance between the engagement members and thereby close the passage. 
         [0021]    In some embodiments, it may be suitable to form the suture/sutures from a biodegradable or bio-absorbable material, such as a bio-absorbable polymer. In addition, also the engagement member may be formed from a similar biodegradable or bio-absorbable material. This will allow post handling of the closure site to be simplified as no further engagement is needed for removing the engagement members/suture(s). 
         [0022]    In an embodiment of the present disclosure, the vascular closure device is further adapted to comprise a suture restraint or a locking member arranged with the elongated housing and adapted to maintain the suture in a retracted state, thereby creating the above mentioned tissue lock. In addition, the locking member may be formed from a similar biodegradable and bio-absorbable material. The locking arrangement may for example be formed from a wire or similar encircling a bundle of collected sutures, in case of using individual sutures for each of the engagement members or in case of a suture looped by the plurality of engagement members, thus forming two end portions of the suture to be bundled together. In addition, in one embodiment it may be possible to form the locking member from a preloaded coil arranged to clench and secure the tightened suture relative to each other in the retracted state. 
         [0023]    Accordingly, in the case of providing individual sutures to each of the engagement members (or using the mentioned two end portions of a looped single suture), the plurality of sutures (or suture end portions) may be routed into the center of a lumen that protrudes distally from the main housing of the vascular closure device. The locking member, such as the suture retention coil, may in such an embodiment initially be placed over the outer diameter of this lumen, and to be preloaded or pre-stretched such that the coil collapses to a smaller diameter when it is displaced off the distal tip of the lumen and contracts onto the sutures and thereby serves to prevent relative motion of the two or more sutures. The suture retention coil may be deployed, at the appropriate time, by distally sliding another tube that is external to the lumen on which the suture retention coil is preloaded such that the outer tube pushes the coil off the inner tube and enables it to contract onto the plurality of sutures. The suture retention coil may consist of two or more coil windings; in another embodiment three to four coil windings, in a helical configuration. In a possible embodiment, the wire used to construct the coil may not be of round cross section and may have edges or angles to increase friction with the suture. 
         [0024]    Furthermore, the engagement member (such as the first and the second and further engagement members) may be formed in a structure corresponding to one of a barb, a hook, a needle, an anchor and a spear to mechanically capture the tissue, possibly including the fascia membrane, to provide a suitable connection point for allowing the retraction member to subsequently reduce the distance between the engagement members. 
         [0025]    The engagement members may alternatively comprise an anchor (or be formed in a manner providing a corresponding functionality), where the anchor may be arranged as a flexible structure. Still further, the anchor may be adapted to rotate, pivot or expand once in engaged connection with said tissue, possibly including the fascia membrane, thereby further enhancing mechanical capturing of such an anchor within the tissue in some cases. In an alternative embodiment, it is possible to adapt the anchor to expand after being pushed into the fascia membrane. 
         [0026]    For example, the anchor may be adapted to have an umbrella like shape in the collapsed position as it passes through the fascia membrane, and then either a stored spring force or tension on the suture could cause it to expand into a reverse-conical configuration, similar to an open umbrella, so that it presents much more surface area to the fascia than did the anchor in the original configuration, and thereby provides increased retention strength in the fascia. In addition, the engagement members may also comprise a hypotube section having an inclined end portion, as will be further discussed below in relation to the detailed description of the present disclosure. 
         [0027]    According to a further aspect of the present disclosure, there is provided a method of closing a passage through tissue communicating with a blood vessel, the method comprising providing a vascular closure device, the vascular closure device comprising an elongated housing having a proximal end and a distal end, a first and a second engagement member releasably arranged with the elongated housing, a deployment member arranged with the elongated housing, and a retraction member arranged with the elongated housing. Once provided, the distal end of the vascular closure device is positioned proximate to the tissue, deploying, using the deployment member, the first and the second engagement member from the vascular closure device to engage with said tissue at a distance from each other, without engaging a wall portion of the blood vessel, applying a predetermined retraction force, using the retraction member, to reduce the distance between the first and the second engagement member to close said passage. This aspect of the present disclosure provides similar advantages as discussed above in relation to the previous aspect of the present disclosure. 
         [0028]    Some embodiments of a vascular closure device for treating a passage in a blood vessel by closing a passage through tissue proximate to a blood vessel, may include an elongated housing having a proximal end, a distal end, and a distal section and a plurality of engagement members which are each adapted to be secured to tissue upon deployment into tissue. A plurality of deployment members may be adapted to extend from the distal section of the elongated housing in a distal and radially outward direction, with each of the deployment members being adapted to deploy at least one of the engagement members into the tissue proximate to the blood vessel such that the engagement members are secured to the tissue proximate to the blood vessel and disposed at a distance from each other in engaged contact with said tissue, without engaging a wall portion of the blood vessel. Each of a plurality of elongate flexible tension elements may be secured to at least one engagement member. A retraction member is coupled in operative arrangement with the tension elements and adapted to apply axial tension to the tension elements and reduce the distance between the engagement members to a radially retracted state to close the passage in the tissue proximate to the blood vessel. 
         [0029]    Further features of, and advantages with, the present disclosure will become apparent when studying the appended claims and the following description. The skilled addressee will realize that different features of the present disclosure may be combined to create embodiments other than those described in the following, without departing from the scope of the present disclosure. 
     
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         [0030]    The various aspects of the disclosure, including its particular features and advantages, will be readily understood from the following detailed description and the accompanying drawings, in which: 
           [0031]      FIG. 1  schematically exemplifies a first embodiment of a vascular closure device according to a possible embodiment of the present disclosure; 
           [0032]      FIGS. 2A and 2B  show a detailed view of the creation of a tissue lock using the vascular closure device; 
           [0033]      FIGS. 2C and 2D  illustrate a closure sequence for treatment of an unwanted passage through a wall of a blood vessel. 
           [0034]      FIGS. 3A and 3B  conceptually illustrate an engagement member, exemplified as an anchor element; 
           [0035]      FIGS. 4A and 4B  illustrate the operation of an anvil member that functions as a deployable positioning feature; 
           [0036]      FIGS. 5A-5I  show a sequence for operating an embodiment of the vascular closure device; 
           [0037]      FIGS. 6A-6F  illustrate a perspective view of operating the vascular closure device as shown in  FIGS. 5A-5I ; 
           [0038]      FIGS. 7A-7C  conceptually illustrate the application of a locking member, provided in the form of a preloaded coil arranged to clench the suture; 
           [0039]      FIGS. 8A-8C  illustrate the operation of a further engagement member embodiment, provided as a cut hypotube; 
           [0040]      FIGS. 9A-9C  illustrate a cross section of a further embodiment of a vascular closure; and 
           [0041]      FIG. 10  is a flow chart showing the method steps for operating the vascular closure device according to the present disclosure. 
       
    
    
     DETAILED DESCRIPTION 
       [0042]    The present disclosure will now be described more fully hereinafter with reference to the accompanying drawings, in which embodiments of the disclosure are shown. The present disclosure may, however, be embodied in many different forms and should not be construed as limited to the embodiments set forth herein; rather, these embodiments are provided for thoroughness and completeness, and fully convey the scope of the present disclosure to the skilled person. Like reference characters refer to like elements throughout. 
         [0043]    Turning now to the drawings and to  FIG. 1  in particular, the vascular closure device  100  is introduced percutaneously over a guide wire  8  into the blood vessel/artery  5 , through the skin  1  and the fascia lata  2  of a patient. An optional anvil member  9  is arranged inside the blood vessel  5  to create a reference point to the engagement members  11  and/or for controlling bleeding. The engagement members  11  may then be placed and released through the vascular closure device  100  and may attach to tissue proximate to the blood vessel  5  and may involve the fascia membrane  3  (fascia iliacus), but not a wall of the blood vessel  5 . The engagement members  11  may for example be pushed out of the vascular closure device  100  and into the fascia membrane  3  using deployment members provided as pusher rods  12  arranged in independent lumens provided with the vascular closure device  100 , for example through a pusher assembly in a common lumen that simultaneously deploys all engagement members  11 , through a spring-loaded mechanism or similar. The engagement members  11  are preferably connected with a single or a plurality of sutures as will be further elaborated below. In  FIG. 1  there is further shown a femoral vein  4 , a femoral nerve  6  and adjacent/interstitial tissues  7 . 
         [0044]    With further reference to  FIGS. 2A and 2B , the above-mentioned suture  13  may for example be routed through each of the engagement members  11  in sequence. In particular, one suture  13  may be looped through each of the engagement members  11  in sequence, or a separate suture  13  may be attached to each engagement member  11 . The tissue, e.g. fascia membrane  3 , is then pulled together with the suture  13  connected to the engagement members  11 . When pulled together, the tissue/fascia membrane  3  is tightened towards the center and creates a tissue lock, thereby indirectly closing the artery  5 . That is, a distance between the initial position of the engagement members  11  and a distance between the engagement members once the engagement members  11  have been moved towards each other is thereby reduced. When tightening the fascia membrane  3  the anvil member  9  may be removed from the artery  5 . 
         [0045]    Referring to  FIGS. 2C and 2D , an embodiment of a closure sequence is shown whereby a passage through a wall of a vessel such as the blood vessel shown is treated such that leakage of blood from the interior volume of the blood vessel (not shown) is slowed or stopped to a clinically acceptable degree. As seen in  FIG. 2C , a passage in the wall of the blood vessel, specifically, the femoral artery  5 , is disposed in general alignment with a passage through the tissue layer disposed proximate to an outer surface of the femoral artery  5 . For this particular exemplary embodiment, the tissue layer disposed outside of and proximate to the outer surface of the femoral artery  5  is the fascia iliacus  3 . For purposes of this general discussion, the phrase “in general alignment” as applied to the respective passages may mean at least that an appropriately sized elongate device such as a catheter or sheath may pass through both passages without significant relative lateral displacement between the tissue  3  and artery  5 . In addition, in some cases, the tissue layer  3  may be disposed sufficiently proximate the outside surface of the blood vessel  5  such that gathering and approximation of the tissue  3  which is disposed about the passage through the tissue  3  so as to close the passage through the tissue/fascia membrane  3  and form a tissue lock is sufficient to tighten and displace the closed gathered tissue/fascia membrane  3  against the outer surface of the artery  5  which is adjacent the passage through the artery  5  as shown in  FIG. 2D . When the gathered tissue  3  has been displaced and deflected so as to be disposed against the passage of the artery  5  and wall of the artery  5  disposed about the passage in the artery  5 , this mechanical approximation will typically be sufficient in order to achieve a clinically sufficient slowing or stoppage of blood leakage from the passage in the artery  5  in order to permit closure of an access site through the patient&#39;s skin  1  adjacent the passages. In some instances, an inner surface of the tissue layer  3  disposed proximate to the outer surface of the blood vessel  5  may be separated from the outer surface of the blood vessel in the region of the respective passages therethrough by a distance of up to about 10 mm, more specifically, up to about 5 mm. 
         [0046]    With further reference to  FIGS. 3A and 3B , there is conceptually illustrated an engagement member, exemplified as an anchor element  300 . In  FIG. 3A , the anchor element  300  is shown as initially deployed, so that it slides easily in the direction away from a deployment point. Note that the deployment point may optionally be deflected toward the tissue/fascia membrane  3  to promote engagement.  FIG. 3B  shows the anchor element  300  after motion has been reversed toward the deployment point, and the anchor element  300  has embedded into the tissue/fascia membrane  3 . That is, a tip  302  of the anchors element  300  is in one embodiment hook-shaped, so that it easily slides outward without engaging the tissue/fascia membrane  3 . However, once the anchor element  300  is retracted, at least the tip  302  of the anchor element  300  is adapted to mechanically engage with the tissue/fascia membrane  3 . 
         [0047]      FIGS. 4A and 4B  conceptually illustrate the operation of an anvil member exemplified as a deployable positioning feature  400 . In  FIG. 4A , deployable positioning feature  400  is inserted through the wall  402  and into the interior volume of the blood vessel, such as the femoral artery  5 . The deployable positioning feature  400  is structured similar to an umbrella (using a mesh material), where the deployable positioning feature  400  in a radially collapsed form may be inserted into the artery  5 . Once within the artery  5 , with further reference to  FIG. 4B , the deployable positioning feature  400  may be “unfolded” and radially expanded from the collapsed form such that a total surface area proximate to the longitudinal axis of the deployable positioning feature  400  is increased and thus may be retracted towards the interior wall of the artery  5 . Accordingly, a reference point may be thereby established for further operation of the vascular closure device. 
         [0048]      FIGS. 5A-5I , in conjunction with  FIG. 10 , describe, in step-by-step fashion, the use of a vascular closure device  500  according to a second embodiment of the present disclosure. The first step, as shown in  FIG. 5A , the vascular closure device  500  is provided, S 1 , in the deployment is to advance the vascular closure device  500  over e.g. a pre-existing guidewire  8  until the conical distal tip  502  (possibly provided with a conical nosecone) of an elongated housing  504  of the vascular closure device  500  is positioned, S 2 , and the pusher rods exit the housing proximate to the fascia membrane  3  above an outer surface of a wall the artery  5 , as is shown in  FIG. 5B . Optionally, the vascular closure device  500  may be aligned such that a longitudinal marker on the vascular closure device  500  (as will be further discussed below in relation to  FIGS. 9A-9C , is approximately aligned with the longitudinal axis of the common artery  5  of the patient. 
         [0049]    In this embodiment, one suture  13  for each engagement member  11  is initially routed through the center of the vascular closure device  500 , out the distal tip, and up alongside the outer surface of the vascular closure device  500  and into the slot on the elongated housing  500  containing the undeployed engagement members  11 . Thus, when the engagement members  11  are deployed, S 3 , as shown in  FIG. 5C , the retraction member pulls the suture  13  that is routed from the distal tip  502  of the vascular closure device  500 , up through the (pre-existing) hole in the fascia  3 , and outward to the location of the engagement members  11 , as shown in  FIG. 5D . 
         [0050]    Once a retraction force is applied by the retraction member, S 4 , and the direction of is reversed, the engagement members  11  will mechanically engage the tissue/fascia membrane  3 , as shown in  FIG. 5E , and the pusher rods  12  (i.e. the deployment member) is withdrawn back into the slots, holes or lumens in the elongated housing  504  of the vascular closure device  500  from which they originally extended. 
         [0051]    At this stage, a plurality of engagement members  11  (e.g. four, or any other number of engagement members, also an odd number of engagement members is possible) will be embedded in and secured to the tissue/fascia membrane  3  at locations circumferentially disposed around the passage to be closed in the tissue/fascia membrane  3  at positions on each side of the common femoral artery  5 . In some cases, the engagement members  11  may be symmetrically disposed bilaterally on the medial and lateral sides of the common femoral artery  5 . Each of the engagement members  11  has a suture  13  connected, and that suture  13  runs from the anchor, down through the hole in the fascia  3 , and into the distal tip  502  of the vascular closure device  500 . 
         [0052]    Next, initial tension is applied to the sutures to pull the engagement members  11  (and thus the fascia  3 ) toward the vascular closure device  500 . Now the vascular closure device  500  may be slowly withdrawn until the distal tip  502  is at or just above the fascia layer  3 , keeping tension on the sutures  13  to continue to pull the engagement members  11  together toward the distal tip  502  of the vascular closure device  500 , thereby pulling all the engagement members  11  toward one point and closing the passage, as shown in  FIG. 5F . 
         [0053]    At this point, a locking member, such as a fixation ring  508  or sleeve, through which each of the sutures  13  passes, is deployed from the distal tip  502  of the vascular closure device  500 , as shown in  FIG. 5G . This fixation ring  508  compresses onto the bundle of multiple sutures  13  and locks them in place, thereby preventing the fascia membrane  3  and thus the passage from reopening, thereby indirectly closing the artery  5 . Furthermore, as a desired level of hemostasis is achieved, also the guidewire  8  may be removed while holding tension on the sutures  13 . The guidewire  8  may be for example routed alongside of, but not through, the fixation ring  508 . This may allow the sutures  13  to be fully retracted and the fixation ring  508  to be deployed to lock the sutures  13  in place without removing the guidewire  8 . 
         [0054]    This fixation ring  508  may be spring-like, held open only by its mounting on the vascular closure device  500 , such that it automatically closes down on the sutures  13  after being deployed from the vascular closure device  500 . Alternatively, this locking ring function could be accomplished by another suture loop with a pre-tied knot that is cinched down to anchor the other sutures that are connected to the anchors. In yet another embodiment of the fixation ring  508  could be a fusion mechanism that uses heat and/or pressure to fuse the sutures together to provide fixation. In yet another embodiment a fixation ring could be a small tube through which sutures are initially and slidably routed, said tube being compressed by a mechanism in the housing to trap sutures and create fixation. 
         [0055]    The vascular closure device  500  removal may be continued at this stage, as the passage closure is complete, as shown in  FIG. 5H . Optionally, once the sutures  13  are fixed in place, a mechanism within the vascular closure device  500  handle may be activated to cut the sutures just above the fixation ring/zone. Alternatively, the sutures  13  may be left at this stage and trimmed at the skin surface by the operator, as shown in  FIG. 5I . The vascular closure device  500  is now fully removed. 
         [0056]    An alternative view of the disclosure is shown in  FIGS. 6A-6F . Note that the fascia membrane  3  is omitted in  FIGS. 6A and 6B  for clarity in these images.  FIG. 6A , the vascular closure device  500  advanced over guidewire  8  until tapered distal tip  502  is positioned such that deployment members (e.g. pusher rods  12 ) exit the housing proximal to the fascia layer above the artery  5 . In  FIG. 6B , engagement members  11  are deployed from the elongated housing  504  of the vascular closure device  500 , pulling along the pre-attached sutures  13  routed through the distal tip  502  of the vascular closure device  500 . In  FIG. 6C , motion is reversed using a retraction member (as will be further elaborated below), thereby embedding the engagement members  11  into the tissue/fascia membrane  3 , for example according to a predetermined pattern surrounding the passage  602  through the tissue/fascia membrane  3 . The engagement members  11  are then released from the deployment member. In  FIG. 6D , the engagement members  11  are in place with sutures  13  attached and the deployment members (e.g. pusher rods  12 ) are retracted using the predetermined retraction force. In  FIG. 6E , the vascular closure device  500  is partially withdrawn until the distal tip  502  is just above fascia membrane  3 , whereby suture tension is applied to pull the engagement members  11  together and to close the passage  602 , i.e. such that a diameter of the passage  602  is reduced. In  FIG. 6F , sutures  13  are fixated, and the vascular closure device  500  is withdrawn. 
         [0057]    Optionally, a hemostasis member (not explicitly shown in these images) may be added to the distal tip  502  of the vascular closure device  500 . This hemostasis member may be initially placed inside the artery  5  as the vascular closure device  500  is advanced to abut the fascia membrane  3 , and the hemostasis device activated to prevent bleeding from the artery  5  during use of the vascular closure device  500 . As the engagement members  11  are being brought together during initial retraction of the vascular closure device  500 , the hemostasis member may be deactivated and withdrawn. One example of a hemostasis member is an inflatable compliant balloon. Furthermore, a hollow lumen may optionally be left in the center of the elongated housing  506 , through which a dilator or cannula may be placed to facilitate initial insertion of the vascular closure device  500 . This dilator may be slowly removed as an aid to maintaining hemostasis during the tightening of the sutures  13 . 
         [0058]      FIGS. 7A-7C  provide a detailed view for the application of a locking member or fixing ring, here provided in the form of a preloaded locking coil  508  arranged to clench the suture  13 . In  FIG. 7A , the locking coil  508  is depicted in its initial position, stretched onto the outer surface of a lumen extending from the distal end of a portion of housing  504 , with sutures  13  passing through this lumen to each of the engagement members  11 , which have been deployed to engage the tissue/fascia membrane  3 . In  FIG. 7B , the retraction member (for example implemented using a mechanism for applying the above-mentioned retraction force) has been used to apply tension to the sutures  13 , resulting in a reduction of distance between the engagement members  13 , thereby closing the passage  602  in the tissue/fascia membrane  3 . The suture retention coil  508  has been pushed off the lumen noted above, and has contracted to grasp and fixate the sutures  13  to retain the engagement members  11  in their proximate positons. In  FIG. 7C , the vascular closure device  500  has been withdrawn and the locking coil  508  has retained the engagement members  11  in their proximate positions, thereby enabling all tension to be released from the suture  13  in preparation for complete removal of the vascular closure device  500 , suture trimming just below the skin level, and completion of the closure procedure. 
         [0059]      FIGS. 8A-8C  illustrate the operation of an engagement member  11 , provided as a tube shaped element has been inclined or cut at one end portion. The tube shaped element may, for example, be formed from a cut hypotube  800 . In  FIG. 8A , the hypotube  800  is shown mounted on the tip of the deployment member, here illustrated as arranged at the pushrod  12 , and the suture  13  is here shown attached to a location in the middle region of the hypotube  800 . The sharp/cut end of the hypotube  800  is about to penetrate the fascia membrane  3 . In  FIG. 8B , the hypotube  800  has penetrated the fascia membrane  3 , and the pushrod  12  has been retracted leaving only the hypotube  800  and the attached suture  13  in positon. Tension has been applied to the suture  13 , and since the suture  13  is attached to the hypotube  800  in the middle region of one side, the hypotube  800  is in the process of rotating approximately 90° as it comes to bear on the underside of the fascia membrane  3 . In  FIG. 8C , the rotation process is complete and, as tension in the suture  13  has increased, the hypotube  800  has come into full contact with the fascia membrane  3  with contact occurring along the longitudinal axis of the hypotube  800 , thereby increasing the contact area and reducing the likelihood that the hypotube  800  could simply pull back out of the fascia membrane  3  through the hole created when it originally penetrated the fascia membrane  3 . In some cases, the hypotube  800  may be said to be mechanically captured by the fascia membrane  3  when in such full contact with fascia after the rotation process is complete as shown in  FIG. 8C . 
         [0060]      FIGS. 9A-9C  illustrate a cross section of a further embodiment of a vascular closure  900 .  FIG. 9A  shows the device in its initial configuration. The pushrods  12 , i.e. engagement members, and suture  13  are contained within the device (not directly visible in  FIG. 9A ). A thumb button  902  is in  FIG. 9A  shown as not yet depressed, and an underlying coil spring  904  is in an extended positon. The engagement members  11  are seen in their initial position nestled into the distal end  906  of the housing at the distal end of the engagement members  11 . The vascular closure device  900  further comprises a device-positioning member, in the form of an elongated handle  908 , to be aligned with an expected direction of the blood vessel. 
         [0061]      FIG. 9B  shows the vascular closure device  900  after the engagement members  11  have been deployed. The thumb button  902  has been depressed, thereby compressing the underlying coil spring  904 , and engaging a top clip  910  to retain it in place. The pushrods  12  are visible in their extended position, with the engagement members  11  still attached to the distal tips.  FIG. 9C  shows the vascular closure device  900  in a completion state, where the engaging clip  910  has been released, whereby the coil spring  904  will move back towards its initial position. In moving back to its initial position, a retraction force will be applied (using retraction members, not explicitly shown), whereby the sutures  13  are “drawn” back into the vascular closure device  900 . As discussed above, once the sutures  13  are drawn back into the vascular closure device  900 , the distance between the engagement members  11  will be reduced, consequently reducing the diameter of the passage through the tissue/fascia membrane  3 , indirectly forming the tissue look. Once the sutures have been completely retracted (based on the predetermined retraction force applied by means of the coil spring  904 ), the locking member, such as the fixation ring  508  is positioned to secure the sutures  13  in the retracted state. 
         [0062]    The prior description of the vascular closure device has focused on its initial use to close a vascular access, but in the event this initial use does not provide clinically acceptable hemostasis, it may be possible in some embodiments to use one or more additional vascular closure devices discussed herein to deploy additional engagement members and further support the approximation of the tissue to improve hemostasis to a clinically acceptable level. 
         [0063]    Although the figures may show a sequence, the order of the steps may differ from what is depicted. Specifically, the anchor hook characteristic is shown much larger than actual for illustration purposes. In addition, two or more steps may be performed concurrently or with partial concurrence. Such variation may depend on the structural elements used and on designer choice. All such variations are within the scope of the disclosure. Additionally, even though the present disclosure has been described with reference to specific exemplifying embodiments thereof, many different alterations, modifications and the like will become apparent for those skilled in the art. In addition, any suitable feature, dimension or material of any particular vascular closure device embodiment discussed herein may be used or otherwise combined with any of the other vascular closure device embodiments discussed herein. 
         [0064]    Furthermore, variations to the disclosed embodiments can be understood and effected by the skilled addressee in practicing the present disclosure, from a study of the drawings, the disclosure, and the appended claims. Furthermore, in the claims, the word “comprising” does not exclude other elements or steps, and the indefinite article “a” or “an” does not exclude a plurality.