Abstract:
A method and apparatus for closing a punctured blood vessel is described. The apparatus includes a suturing instrument adapted to apply at least one suture to at least a portion of a blood vessel in order to close a puncture wound therein. In a preferred embodiment, the suture is secured by crimping a sleeve member over the free ends of the suture with a crimping instrument.

Description:
CROSS REFERENCE TO RELATED APPLICATIONS  
       [0001]    This application is a continuation of U.S. patent application Ser. No. 09/041,207, filed on Mar. 12, 1998, which has been allowed, which is a continuation of U.S. patent application Ser. No. 08/734,159, filed on Oct. 21, 1996, now U.S. Pat. No. 5,766,183. 
     
    
     
       BACKGROUND OF THE INVENTION  
         [0002]    The present disclosure relates to instruments and a method for closing a hole or puncture in a blood vessel. More particularly, this disclosure relates to applying at least one suture to close a hole in a blood vessel after an intravascular catheterization procedure.  
           [0003]    When performing catheterization procedures, such an angiography or angioplasty, a catheter is generally introduced into the vascular system by first penetrating the skin, underlying muscle tissue and blood vessel with a sharpened hollow needle. Next, a guide wire is commonly inserted through the lumen of the hollow needle and is caused to enter the selected blood vessel. Subsequently, the needle is typically slid off the guide wire and a combination of a dilator and an introducer (or an introducer alone) are fed over the guide wire and pushed through the skin to enter the vessel. The guide wire can then be removed and the desired catheter to carry out the procedure is fed through the lumen of the introducer and advanced through the vascular system until the working end of the catheter is appropriately positioned. Following the conclusion of the catheterization procedure, the working catheter will be withdrawn and, subsequently, the dilator and/or introducer will also be removed from the wound.  
           [0004]    At this point in the procedure, the vessel leakage must be controlled in order to stem the flow of blood through the puncture. Because it is common practice to administer a blood thinning agent to the patient prior to many of the catheterization procedures, stemming the blood flow can be troublesome. A common method of sealing the wound is to maintain external pressure over the vessel until the puncture naturally seals. This method of puncture closure typically takes about thirty minutes, with the length of time usually being greater if the patient is hypertensive or anticoagulated. In some anti-congulated patients, the introducer is left in place for hours to allow the anti-coagulant to wear off. When human hand pressure is utilized, it can be uncomfortable for the patient and can use costly professional time on the part of the hospital staff. Other pressure techniques, such as pressure bandages, sandbags or clamps, have been employed, but these devices also require the patient to remain motionless for an extended period of time and the patient must be closely monitored to ensure their effectiveness.  
           [0005]    Other devices have been disclosed which plug or otherwise provide an obstruction in the area of the puncture. See, for example, U.S. Pat. Nos. 4,852,568 and 4,890,612, wherein a collagen plug is disposed in the blood vessel opening. When the plug is exposed to body fluids, it swells to create a block for the wound in the vessel wall. A potential problem of plugs introduced into the vessel is that particles may break off and float downstream to the point where they may lodge in a smaller vessel, causing an infarct to occur. Collagen material also acts as a nidus for platelet aggregation and, therefore, can cause intraluminal deposition of hemostatic agent, thereby creating the possibility of a thrombosis at the puncture sight. Other plug-like devices are disclosed, for example, in U.S. Pat. Nos. 5,342,393, 5,370,660 and 5,411,520.  
           [0006]    Surgical clips and clip appliers are known have also been used in vascular surgery, particularly to join severed vessels. See, for example, U.S. Pat. No. 4,929,240 (Kirsch, et al). The clips disclosed in the &#39;240 Patent are generally arcuate in shape and have two legs that are biased towards each other by clip applier jaws to capture vessel tissue therebetween. While vascular clips have been successfully used in surgery, the surgical procedures in which the clips are typically used allow the surgeon to view the area to be clipped. In catheter puncture repair procedures, however, the wound is generally not visible, making proper clip application, if attempted, difficult. Commonly assigned U.S. patent application Ser. No. 08/510,834 discloses the use of a guide wire to aid in locating the distal end of a clip applying device.  
           [0007]    The use of suturing instruments to close a vessel puncture are disclosed in U.S. Pat. No. 5,417,699 (Klein et al.), wherein one of the instruments has a pair of needles, with the points oriented in a proximal direction, releasably disposed at a distal end thereof. A cannula is used to pass the distal end of the instrument and the needles through a vessel puncture and into the vessel. Once in the vessel, the cannula is moved in a proximal direction to expose the needles. Thereafter, proximal movement of the instrument causes the needles to pass through the vessel wall (from the inside to the outside) on either side of the vessel puncture and the needles are withdrawn. A strand of suture material secured between the blunt ends of the needles is also drawn through the needle puncture holes, thereby leaving a span of suture across the hole on the inside of the vessel. The suture can then be tied to close the vascular puncture. A disadvantage to this approach is the traumatic step of passing the cannula and distal end of the suturing instrument through the vascular hole and then exposing sharp needle tips within the vessel. Also, the instruments disclosed in the &#39;699 Patent are relatively complex and may be unreliable in some vessels and costly to manufacture.  
           [0008]    Another suturing instrument is disclosed in U.S. Pat. No. 5,431,666 (Sauer et al.). The Sauer &#39;666 instrument uses a pair of longitudinally movable needles to pick up corresponding ferrules at a distal end of the instrument. The ferrules have a strand of suture material disposed therebetween and are initially separated from the needles by a gap in the instrument. In use, tissue to be sutured is disposed in the gap between the needles and ferrules. A first needle punctures the tissue, engages a ferrule and draws the ferrule back through the tissue. The instrument can then be relocated to another portion of tissue and the second needle is actuated to pick up and draw the second ferrule therethrough. The suture material can then be tied or otherwise cinched in place to secure the tissue portions. When using the device disclosed in Sauer et al. &#39;666, the surgeon is typically able to view the surgical site.  
           [0009]    Therefore, there is a need for surgical techniques and instrumentation suitable for dosing punctures in blood vessels, particularly those created during catheterization procedures. This need requires a reliable hemeostasis of the puncture in a quick and efficient manner with minimal trauma the surrounding vascular tissue.  
           [0010]    The instrumentation must also allow the user to close the puncture without directly viewing the punctured site. 
       
    
    
     BRIEF DESCRIPTION OF THE DRAWINGS  
       [0011]    Various embodiments of the surgical apparatus of the subject application will be described herein below with reference to the drawings, wherein:  
         [0012]    [0012]FIG. 1 is a perspective view of the apparatus for suturing body tissue;  
         [0013]    [0013]FIG. 2 is an exploded perspective view of the surgical suturing apparatus of FIG. 1;  
         [0014]    [0014]FIG. 3 is a cross-sectional view taken along lines  3 - 3  of FIG. 1 showing the engagement of the second link and the proximal needle driver of the apparatus;  
         [0015]    [0015]FIG. 3A is a cross-sectional view taken along lines  3 A- 3 A of FIG. 1 showing the engagement of the first link with the distal needle driver;  
         [0016]    [0016]FIG. 4 is a side view, in partial cross-section, of the body portion illustrating the first and second levers in the initial (closed) position;  
         [0017]    [0017]FIG. 4A is a side view, in partial cross-section, of the tubular portion corresponding to the position of the levers in FIG. 4 and illustrating the first needle prior to engagement with its respective ferrule;  
         [0018]    [0018]FIG. 4B is a top view, in partial cross-section, of the tubular portion corresponding to the position of the levers in FIG. 4 and illustrating both needles in the retracted position prior to engagement with their respective ferrules;  
         [0019]    [0019]FIG. 5 is a front view of the apparatus of FIG. 1 illustrating the configuration of the tongue;  
         [0020]    [0020]FIG. 6 is a cross-sectional view taken along lines  6 - 6  of FIG. 4A illustrating the engagement of the tongue and outer tube;  
         [0021]    [0021]FIG. 7 is a cross-sectional view taken along lines  7 - 7  of FIG. 4A;  
         [0022]    [0022]FIG. 8 is a cross-sectional view taken along lines  8 - 8  of FIG. 4A showing the engagement of the tongue with the face and the outer tube of the apparatus;  
         [0023]    [0023]FIG. 9 is a view similar to FIG. 4 illustrating the second lever in the initial position and the first lever in the open position to advance the first needle into engagement with the ferrule;  
         [0024]    [0024]FIG. 9A is a view similar to FIG. 4B corresponding to the position of the levers in FIG. 9 and illustrating the first needle engaged with the ferrule and the second needle in the retracted position;  
         [0025]    [0025]FIG. 10 is a view similar to FIG. 9A illustrating the first needle in the retracted position after engagement with the ferrule;  
         [0026]    [0026]FIG. 11 is a view similar to FIG. 4 illustrating the first lever in the closed position and the second lever in the open position to advance the second needle into engagement with the ferrule;  
         [0027]    [0027]FIG. 11A is a view similar to FIG. 4B corresponding to the position of the levers in FIG. 11 and illustrating advancement of the second needle into engagement with the ferrule;  
         [0028]    [0028]FIG. 12 is a view similar to FIG. 4B illustrating the first and second needles in the retracted position after engagement with their respective ferrules;  
         [0029]    [0029]FIG. 13 is a perspective view of the apparatus for crimping the suture securing member;  
         [0030]    [0030]FIG. 14 is an exploded perspective view of the apparatus of FIG. 13;  
         [0031]    [0031]FIG. 15 is a longitudinal cross-sectional view of the body portion of the apparatus of FIG. 13 illustrating the lever in the initial (open) position;  
         [0032]    [0032]FIG. 16 is a longitudinal cross-sectional view of the tubular portion of the apparatus corresponding to the position of the lever in FIG. 15 and illustrating the jaws in the open position;  
         [0033]    [0033]FIG. 17 is a cross-sectional view similar to FIG. 16 illustrating the suture securing member being loaded into the tubular portion of the apparatus;  
         [0034]    [0034]FIG. 18 is a cross-sectional view similar to FIG. 17 illustrating the suture securing member loaded in the tubular portion of the apparatus;  
         [0035]    [0035]FIG. 19 is a cross-sectional view similar to FIG. 15 illustrating the lever in the closed position to close the jaws;  
         [0036]    [0036]FIG. 20 is a cross-sectional view similar to FIG. 16 corresponding to the position of the lever in FIG. 19 and illustrating the jaws in the closed position to crimp the suture securing member around a suture;  
         [0037]    [0037]FIG. 21 is a cross-sectional view taken along lines  21 - 21  of FIG. 16 showing the positioning of the suture tube;  
         [0038]    [0038]FIG. 22 is a cross-sectional view taken along lines  22 - 22  of FIG. 19 illustrating the engagement of the collar with the drive block of the apparatus;  
         [0039]    [0039]FIG. 23 is a cross-sectional view similar to FIG. 20 showing the suture securing member crimped on a suture and the apparatus being withdrawn from the surgical site;  
         [0040]    [0040]FIG. 24 is a cross-sectional view of a blood vessel and surrounding tissue illustrating a guide wire disposed within the blood vessel;  
         [0041]    [0041]FIG. 25 is a view similar to FIG. 24 illustrating a cannula and obturator assembly disposed over the guide wire;  
         [0042]    [0042]FIG. 25A is an enlarged view of a portion of the obturator assembly of FIG. 25 illustrating an aspiration port;  
         [0043]    [0043]FIG. 26 is a cross-sectional view of a blood vessel and surrounding tissue illustrating the surgical suturing apparatus of FIG. 1 passing through a cannula and applying a suture adjacent the inferior side of the vessel puncture wound;  
         [0044]    [0044]FIG. 27 is a cross-sectional view of a blood vessel and surrounding tissue illustrating the surgical suturing apparatus of FIG. 1 passing through a cannula and applying a suture adjacent the superior side of the vessel puncture wound;  
         [0045]    [0045]FIG. 28 is a cross-sectional view of a blood vessel and surrounding tissue with a suture applied across a puncture in the vessel and further illustrating the distal end of the suture securing device of FIG. 13 with the suture passing therethrough;  
         [0046]    [0046]FIG. 29 is similar to FIG. 28 with the suture securing device passing through the cannula and approaching the vessel puncture; and,  
         [0047]    [0047]FIG. 30 is a surgical kit including a cannula and obturator assembly, a suturing device and a suture securing device. 
     
    
     DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS  
       [0048]    Referring now to the drawings, wherein like reference numerals identify similar or identical elements throughout the several views, an apparatus for applying a suture to body tissue is illustrated in FIGS.  1 - 12  and is designated generally by reference numeral  10 . Another apparatus is also disclosed, designated by reference numeral  200  and illustrated in FIGS.  13 - 23 , for applying a connecting sleeve around the suture after it has been applied to the body tissue by apparatus  10  in order to secure the suture. Note that the terms first and “second” as used herein are for the reader&#39;s convenience and should not be interpreted as necessarily denoting the order in which the components are actuated.  
         [0049]    Turning first to the apparatus  10  for applying a suture, and with particular reference to FIGS. 1 and 2, apparatus  10  includes a body portion  12  and an elongated tubular portion  14  extending from a distal end of the body portion  12 . The tubular portion  14  includes a window  15  configured to receive the body tissue to the sutured. Housed within tubular portion  14  are a pair of needles with are advanced by respective levers through the tissue positioned in window  15  and into engagement with ferrules supported at the distal end of the apparatus. Each ferrule is attached to one end of a suture so that advancement of the needles into engagement with the ferrules effectively engages the suture. Subsequent retraction of the needles into the tubular body portion pulls the suture through the body tissue. This is discussed in detail below.  
         [0050]    Turning initially to the tubular portion  14 , and with continued reference to FIGS. 1 and 2, tubular portion  14  includes an outer tube  30  having an axial bore  32  dimensioned to receive a proximal needle guide  60  and a distal needle guide  50 . Also mounted within outer tube  30 , at the distal portion  33 , is a face  46  having a first opening  47 a to receive first needle  20  and a second opening  47   b  to receive second needle  22 . Openings  47   a  and  47   b  are in axial alignment with longitudinal grooves  52   a ,  52   b  and  62   a,    62   b  of needle guides  50  and  60 , respectively.  
         [0051]    Extending from distal end portion  33  of outer tube  30  is a tongue  36  on which mounts a ferrule holder  40 . More specifically, tongue  36  includes a base  37  terminating in a T-shaped extension  38  which extends through a notch  55  in distal needle guide  50  and through a notch  34  in outer tube  30  (see also FIGS. 4A and 6) to fixedly mount tongue  36  to outer tube  30  and guide  50 . Alternately, the tongue  36  can be brazed to the outer tube. Face  46  is snapped onto base  37  in front of T-extension  38 . Ferrule holder  40  has projecting surfaces  41  which sit within correspondingly configured grooves within the tongue  36  as best seen in FIG. 4A. Lip  36   a,  in conjunction with the projection and groove arrangement, functions to retain ferrule holder  40  on base  37  of tongue  36 . Tongue  36  also has a distal opening  39 , axially aligned with the central bore  103  of body portion  12 , to allow passage of guide wire tube  82  to accommodate a guide wire (not shown in FIG. 2) in order to locate the instrument for the reasons discussed below. Exit opening  39   a,  formed at a bottom surface of tongue  36  as viewed in FIG. 4A, provides a passageway for radiopaque dye or other medium if injected through guide wire tube  82 .  
         [0052]    With reference to FIGS. 2, 4A and  12 , ferrule holder  40  has a pair of recesses to receive ferrules  70  and  72 . These ferrules, as shown, are mounted to opposite ends of the suture  75 , and have a central opening dimensioned to frictionally engage sharp tips  21 ,  23  of needles  20 ,  22 . FIG. 4B shows needles  20 ,  22  prior to engagement where they are initially spaced from ferrules  70 ,  72 , with the distal tips  21 ,  23  positioned in openings  47   a ,  47   b  of face  46 .  
         [0053]    When the first needle  20  is advanced by first lever  101  in the manner described below, needle  20  passes through opening  47   a  and through the body tissue positioned in window  15  into the recess of ferrule holder  46  so-that tip  21  frictionally engages ferrule  70  as illustrated in FIG. 9A. Subsequently, when needle  20  is retracted, ferrule  70  is likewise retracted into opening  47   a , pulling the portion of suture  75  through the body tissue as shown in FIG. 10. In a similar manner, when needle  22  is advanced by second lever  102 , it passes through opening  47   b  in ferrule holder  46  and through the body tissue so that tip  23  enters the recess of ferrule holder  46  to frictionally engage ferrule  72  as shown in FIG. 11A. When subsequently retracted, needle  22  pulls ferrule  72  through opening  47   b  in face  46  to pull suture  75  through the body tissue as shown in FIG. 12.  
         [0054]    Turning now to the body portion  12  of apparatus  10  which contains the actuating mechanisms for driving the needles  20 ,  22 , and with initial reference to FIGS. 1 and 2, the body portion  12  includes first and second levers  101 ,  102  pivotably mounted thereto. The first lever  101  is operatively connected to first needle  20  by link  104  and the second lever  102  is operatively connected to the second needle  22  by link  106 . Lever  101  is seated in its initial position within cavity  180   a  of body portion  12  such that the bottom surface  101   a  of the lever  101  contacts the planar surface  181  inside the cavity  180   a  as shown in FIG. 3A. Lever  102  is similarly seated in a cavity  180   b  (not shown in FIG. 2) such that surface  102   a  abuts planar surface  183  (see FIG. 3).  
         [0055]    The first lever  101  is pivotably mounted to the distal end of body portion  12  by a lever mounting pin  110  extending through distal apertures  108  and through the illustrated openings in the body portion  12 . First link  104  is mounted to lever  101  by a link pin  114  extending through apertures  112  in lever  101  and through the distal openings  116  in link  104 . The proximal end of link  104  is mounted to tab  154  of distal or first needle driver  150  by a link pin  118  extending through proximal apertures  120  and tab opening  152  of needle driver  150 .  
         [0056]    Needle driver  150  functions to advance first needle  20  into engagement with ferrule  70 . Needle driver  50  is positioned in cavity  13   b  of body portion  12  and has a first longitudinal opening  153  dimensioned to frictionally mount a proximal portion of first needle  20  such that distal movement of needle driver  50  advances needle  20  distally. Needle driver  50  also has a second longitudinal opening  155 , dimensioned slightly larger than the first longitudinal opening  153  and the diameter of the first needle  20 , to allow unobstructed passage of second needle  22  therethrough. Consequently, when lever  101  is pivoted from the initial (closed or prefired) position of FIG. 4 to the open (fired) position of FIG. 9, link  104  slides needle driver  150  distally to the position shown in FIG. 9. Note that tab  154  will engage projection  142  of stop  140  (positioned in recess  13   a  of body portion  12 ) to limit the distal travel of needle guide  150 . As the needle driver  150  is advanced distally, it carries the needle  20  out of the opening  47 A in face  46 , through window  17  and into engagement with ferrule  70 . After engagement of pointed tip  21  of needle  20  with ferrule  70 , lever  101  is returned to the initial position of FIG. 4 causing link  104  to slide the distal needle driver  150  back to its initial (proximal) position with the needle  20  retracting the ferrule  70  proximally into face  46  of tubular portion  14 .  
         [0057]    The second lever  102 , as shown in FIGS. 2, 4 and  9 , functions in a similar manner to first lever  101  and is designed to advance second needle  22 . Distal apertures  122  of lever  102  receive mounting pin  124  to pivotably connect lever to body portion  12 . Lever pin  128  connects second link  106  to lever  102  as it extends through apertures  126  in lever  102  and distal openings  130  in link  106 . The proximal end of second link  106  is connected to proximal or second needle driver  160  via link pin  132  extending through proximal openings  134  in link  106 , aperture  162  in tab  164  of needle driver  160 , and through the illustrated openings in body portion  12 .  
         [0058]    Proximal needle driver  160  has an opening  163  dimensioned to frictionally mount proximal portion of needle  22 . When lever  102  is pivoted from its initial position of FIG. 4 away from body portion  12  to the open position shown in FIG. 11, link  106  will advance proximal needle driver  160  to cause distal advancement of needle  22  through opening  47   b  in face  46  to engage ferrule  72  (Note that the second needle  22  slides through first longitudinal opening  153  of distal needle driver  150  as discussed above). In this manner, as illustrated in FIG. 11A, pointed tip  23  of needle  22  frictionally engages ferrule  72 . Tab  164  of needle driver  160  abuts projection  148  of stop  146  to limit its distal advancement which in turn limits the travel of needle  22 . When lever  102  is returned to its initial position of FIG. 4, proximal needle driver  160  is retracted to its original position thereby retracting needle  22  and ferrule  72  back into face  46  through opening  47   b.    
         [0059]    End cap  170  is mounted on the proximal end of body portion  12  and has recesses  172 ,  174  configured and dimensioned for receipt of the user&#39;s finger to facilitate actuation of first and second levers  101 ,  102 . End cap  170  also includes first opening to allow passage of tube  80  and a second opening to allow passage of tube  82 .  
         [0060]    Supported within tubular portion  14  and extending through axial bore  103  of body portion  12  and end cap  170 , are suture tube  80  and guide wire tube  82 . More specifically, tubes  80  and  82  extend through aligned notches  51 ,  61  of distal and proximal needle guides  50 ,  60  respectively (see e.g. FIGS. 4A and 7), through notch  156  in distal needle driver  150  and through notch  165  of proximal needle driver  160 . Tube  80  is designed to receive the suture  75  to retain it within the apparatus. Tube  82  is configured to receive a guide wire for locating the apparatus  10  during use as will be described below. Additionally, tube  82  can function to transport fluid, such as radiopaque dye, which can be ejected out of opening  36 A in tongue  36  (see FIG. 4).  
         [0061]    In use, in the initial position, levers  101  and  102  are seated within the respective cavities  180   a,    180   b  in the body portion  12  as shown in FIG. 4. In this position, links  104  and  106  are substantially parallel to the respective levers  101 ,  102  and the needle drivers  150 ,  160  are in the proximal position. When it is desired to advance needle  20  through the body tissue positioned in window  15 , lever  101  is pivoted away from body portion  12 , thereby moving distal needle driver  150  to a distal position, limited by stop  140 , to carry needle  20  distally. Consequently, needle  20  is guided along grooves  62   a,    52   a  of needle guides  60 ,  50 , exits through opening  47   a  in face  46 , and advances through the body tissue into the ferrule holder  40  to engage ferrule  70  as shown in FIG. 9A to pick up one end of suture  75 . Lever  101  is then returned to its initial position of FIG. 4, sliding distal needle driver  150  to its proximal position to retract the needle  20  and attached ferrule  70  inside face  46  to the position of FIG. 10, thereby pulling one end of suture  75  through the body tissue.  
         [0062]    Subsequently, second lever  102  is pivoted away from body portion  12  to the position of FIG. 11. This moves proximal needle driver  160  to a distal position to advance second needle  22 . Second needle  22  is guided in grooves  62   b,    52   b  of needle guides  60 ,  50 , through opening  47   b  in face  46 , and through the body tissue positioned in window  17  into ferrule holder  40  to engage ferrule  72  as shown in FIG. 11A to pick up the other end of suture  75 . Lever  102  is returned to the initial position of FIG. 4 to slide proximal needle driver  160  to its original position to retract needle  20  and attached ferrule  72  inside face  46  as shown in FIG. 12. This pulls the second end of suture  75  through the body tissue. It should be appreciated that lever  102  can be actuated before lever  101  if desired.  
         [0063]    Turning now to the apparatus  200  for securing the suture  75  applied by apparatus  10 , and with initial reference to FIGS.  13 - 16 , apparatus  200  includes a cylindrical body portion  212  and a tubular portion  210  extending from a distal end of the body portion  212  and housing jaw assembly  218  for crimping a suture securing member or connecting sleeve  216  held in the jaws. A lever  214  is pivotably mounted to the body portion  212  and is movable from the initial (open) position illustrated in FIGS. 13 and 15 to a closed position illustrated in FIG. 19 to cam the jaws to a closed position to crimp the suture securing member  216  in the manner described below.  
         [0064]    Referring to FIGS.  14 - 16 , tubular portion  210  includes a drive tube  228 , a jaw closer  230 , a jaw assembly  218  and an outer tube  220 . Outer tube  220  is seated within an axial bore  224  of cylindrical tube retainer  222  which is fixedly mounted in the distal end of body portion  212 . This retains the outer tube  220  in a fixed position.  
         [0065]    Inner or drive tube  228  is received in longitudinal bore  226  of outer tube  220  and is frictionally mounted at its proximal end within axial bore  285  of drive block  282  which is positioned in body portion  212 . Thus, drive tube  228  is reciprocated by drive block  282  in the manner described below. Also mounted within outer tube  220  is jaw closer  230 . Jaw closer  230  has a proximal mounting rod  236  seated within axial bore  229  of drive tube  228  such that head  231  abuts the distal edge. The jaw closer  230  is moved by the drive tube  228  from a proximal position as shown in FIG. 16 to a distal position as shown in FIG. 18 to move the jaws to the closed position. More specifically, jaw closer  230  has a camming surface  234  at its distal end  232  which engages the underside of lower jaw  250  (as viewed in FIG. 14) to force lower jaw  250  towards upper jaw  270 . This is described in more detail below.  
         [0066]    Jaw assembly  218 , mounted to outer tube  220  by mounting pin  278  (or alternatively brazed into the outer tube), includes a movable jaw  250  and a stationary jaw  270  which are hinged at the proximal end  251  and are spaced apart thereafter to form a gap  253  therebetween. Movable jaw  250 , as best shown in FIGS. 16 and 18, has a camming edge  252  on its lower surface (as viewed in FIG. 16) which cooperates with the camming surface  234  of the jaw closer  230 . A pair of arms  257  at the distal end form a receiving recess  254  for mounting the suture securing element  216 . Stop surface  256  on arm  257  limits the travel of jaw  250  towards jaw  270 . Cutting blade  260 , positioned proximally of arms  257 , is also cammed towards stationary jaw  270  by camming surface  234  and is configured to engage and cut the suture concomitantly with the crimping of the suture securing member  216 .  
         [0067]    Stationary jaw  270  has an abutment surface  274  which cooperates with stop surface  256  of movable jaw  250  to limit travel thereof. Backstop  272  facilitates cutting of the suture when contacted by cutting blade  260 .  
         [0068]    Jaw assembly  218  has a conically shaped proximal end  219 , best shown in FIG. 21, to mount suture tube  320 . This conical shape facilitates threading of the suture through the instrument as described below. Suture tube  320  extends through axial bore  229  of drive tube  228  and through central bore  288  of body portion  212 , exiting through a side portion as shown in FIG. 15.  
         [0069]    An end cap  276  is mounted at the distal end of the jaw assembly  218  and has an opening to enable loading and removal of the suture securing member  216 . The suture securing member  216 , as shown in FIG. 17 has a cylindrical tubular portion  240  dimensioned for reception in receiving recess  254  of arms  257 . Head  244  is designed to abut the sutured tissue. Examples of alternate configurations for the suture securing member are disclosed in pending U.S. application Ser. No. 08/201,864, filed Feb. 24, 1994, the contents of which are incorporated herein by reference.  
         [0070]    Turning now to the body portion  212  of apparatus  200 , and with reference to FIGS. 14 and 15, drive block  282 , biased proximally by spring  297 , is seated within central bore  288  and as mentioned above has an opening  285  to frictionally receive the proximal end of drive tube  228 . Proximal of head portion  283  is a recessed area, defined by reduced diameter rod portion  284 , for mounting locking collar  286 . More particularly, spaced apart fingers  291  of locking collar  286  straddle rod portion  284  as best shown in FIG. 22. Locking collar  286  operatively connects the lever  214  and link  306  to the drive block  282 .  
         [0071]    Lever  214  is mounted at its distal end to body portion  212  via lever pin  314  extending through distal apertures  304  and through openings  246  in the body portion  212 . Lever  214  is connected at its proximal end to link  306  via link pin  312  extending through apertures  308  and  302 . The distal end of link  306  is seated in locking collar  286  such that collar pin  316  extends through aperture  310  in link  306  and through apertures  293  in the locking collar  286 . As shown, in the initial position of FIG. 15, lever  214  extends at an angle to the longitudinal axis of body portion  212 . When the lever  214  is pivoted to the closed position of FIG. 19 to actuate the instrument, it moves into recess  280  (FIG. 14) in body portion  212  and buts planar surface  281  of drive block  282 .  
         [0072]    Body pins  290 A and  290 B extend through openings  212   a,    212   b  in the body portion  212  to engage slots  225  formed in tube retainer  222 . This holds tube retainer  222  fixed with respect to body portion  212 .  
         [0073]    As can be illustrated, lever  214  is connected to the locking collar  286  via link  306 . Locking collar  286 , in turn, straddles drive block  282  which mounts drive tube  228 . Drive tube  228  mounts jaw closer  230 . Consequently, movement of lever  214  to its closed position slides locking collar  286 , drive block  282 , drive tube  228 , and jaw closer  230  distally to cam the jaws to the closed position. Outer tube  220  and jaw assembly  218  remain fixed during this movement as outer tube  220  is mounted to fixed tube retainer  222  and jaw assembly  218  is mounted to stationary outer tube  220 .  
         [0074]    In use, in the initial (prefired) position of FIG. 15, lever  214  is positioned at an angle to the longitudinal axis of body portion  212 , spaced from recess  280 , such that locking collar  286  and drive tube  282  are in the proximal position (biased by spring  297 ). Thus, drive tube  228  and jaw closer  230  are also in the proximal position such that camming surface  234  of closer  230  is spaced from the cooperating camming edge  252  of movable jaw  250  (see FIG. 16). When it is desired to crimp the suture securing member  216  positioned in arms  257  between movable jaw  250  and stationary jaw  270 , lever  214  is moved towards body portion  212  and into receiving recess  280 . This slides the locking collar  286  and drive block  282  distally against the force of spring  297  to the position shown in FIG. 19. This longitudinal translation of the drive block  282  slides the drive tube  228  and jaw closer  230  distally to cause the camming surface  234  to engage camming edge  252  of movable jaw  250  to force the movable jaw  250  towards stationary jaw  270  (see FIG. 20). This crimps the suture securing member  216  between the jaws  250 ,  270 . As the movable jaw  250  is moved to the closed position, cutting blade  260  contacts and cuts the suture against the backstop  272  of stationary jaw  270 . When pressure on lever  214  released, lever  214  returns to its open position and drive tube  228  returns to its proximal position under the force of spring  297 .  
         [0075]    [0075]FIGS. 17 and 18 illustrate the suture securing member  216  being manually loaded through end cap  276  into the apparatus  200 . As shown, the suture securing member  216  is seated within receiving recess  254  between arms  257  of the movable jaw  250 . It should be understood that alternatively, apparatus  200  can be provided with the suture securing member preloaded in the apparatus.  
         [0076]    Referring now to FIGS.  23 - 29 , a preferred method of dosing a puncture in a blood vessel is disclosed. FIG. 24 illustrates guide wire  506  passing extracorporeally through tissue  504  and puncture  502  in vessel  500 . Vessel  500  is typically the femoral artery, wherein puncture  502  was created to access the circulatory system to perform, for example, an angioplasty or angiography procedure. External pressure (indicated by arrow X) can be applied to reduce or eliminate blood flow through puncture  502 . As shown and described herein, the distal end of guide wire  506  is directed towards the torso of the patient.  
         [0077]    Turning to FIG. 25, cannula  508  and obturator assembly  509  have been inserted such that the distal end of the cannula  508  is disposed substantially adjacent puncture  502 . Obturator assembly  509  preferably includes flexible outer sleeve  510  having a lumen through which passes flexible tubular member  512 . Alternately, sleeve  510  and tubular member  512  can be combined into one unit with two channels. Tubular member  512  also has a lumen passing therethrough which is sized to receive guide wire  506 . In use, guide wire  506  is used to direct the cannula and obturator assembly to puncture  502 . The proximal end of obturator assembly has valve assembly  516  having fittings  518  and  520  in communication therewith. Guide wire  506  passes through fitting  520  while fitting  518  is in fluid communication with outer sleeve  510 . As best seen in FIG. 25A, sleeve  510  has aspiration port  514  that is disposed within vessel  500  when the obturator assembly is placed in a desired position. Fluid communication between orifice  514  and fitting  518  allows for blood aspiration to positively indicate proper positioning of cannula  508  and for the injection of fluids into vessel  500 , if desired.  
         [0078]    After cannula  508  has been properly placed, obturator assembly  509  is slid off guide wire  506  and the previously described surgical suturing apparatus  10  is threaded over the guide wire by passing the guide wire through opening  39  in tongue  36  (see, for example, FIG. 5) and through instrument  10 . The suturing instrument can then be directed through cannula  508 . Tongue  36  at the distal end of apparatus  10  is passed through puncture  502  such that vessel tissue adjacent the puncture is disposed in window  15 , between tongue  36  and face  46  of apparatus  10 . Lever  101  (not shown) can then be manipulated as previously described to draw a ferrule and suture through the vessel. As shown, a preferred method is to first direct a suture through the inferior side of the puncture. The suturing device can then be rotated to the other side of puncture  502 , i.e., the superior side, and lever  102  (not shown) can be manipulated to draw the second ferrule and suture through the vessel. After application of the suture, instrument  10  is withdrawn from cannula  508 , leaving suture  75  behind.  
         [0079]    Turning to FIGS.  28 - 29 , a. preferred method for tightening and securing suture  75  to close puncture  502  is illustrated. The loose ends of suture  75  are threaded through the distal end of a suture securing device, such as device  200  shown and previously described with respect to FIGS.  13 - 23 . As shown in FIG. 29, device  200  with the suture passing therethrough is introduced into cannula  508 . The suture is pulled tight (FIGS. 18 and 20), and lever  214  of device  200  is actuated to simultaneously crimp a securing member and cut suture  75 . Device  200  and cannula  508  can then be removed and a topical bandage applied.  
         [0080]    [0080]FIG. 30 illustrates a surgical kit  600  useful for dosing a puncture in a blood vessel. The kit preferably includes suturing device  10 , suture crimping device  200 , cannula  508  and an obturator assembly including two coaxial flexible tubular members  510 ,  512 . The kit packaging can be at least partially fabricated from thermoformed plastic  602  fabricated from polyethylene fibers, (such as TYVEK* available from Dupont) to facilitate sterilization.  
         [0081]    It will be understood that various modifications can be made to the embodiments disclosed herein. Therefore, the above description should not be construed as limiting but merely as examples of preferred embodiments. Those skilled in the art will envision other modifications.