Abstract:
A fluid-based anastomosis system, including a body, a fluid power source, an actuator powered by said source and at least two elements coupled to said actuator and adapted to perform at least two different relative motions, responsive to serial powering of said actuator.

Description:
RELATED APPLICATIONS  
       [0001]     This application is a continuation-in-part of PCT Application No. PCT/IL2004/000311, filed on Apr. 4, 2004, which designates the US and which claims the benefit under 35 U.S.C. §119(e) of U.S. Provisional Application No. 60/492,998, filed on Aug. 7, 2003. This application is also a continuation-in-part of PCT Application No. PCT/IL03/00959, filed on Nov. 13, 2003, published as WO 2004/043216, which designates the US. This application also claims the benefit under 35 U.S.C. §119(e) of U.S. Provisional No. 60/561,092, filed on Apr. 8, 2004, U.S. Provisional No. 60/561,091, filed on Apr. 8, 2004, U.S. Provisional No. 60/518,677, filed on Nov. 12, 2003, and U.S. Provisional No. 60/505,946, filed on Sep. 25, 2003. The disclosures of the above applications are incorporated herein by reference. 
     
    
     BACKGROUND OF THE INVENTION  
       [0002]     Two blood vessels can be connected to form an anastomotic connection in many methods, including, for example, using surgical clips, using sutures, and using anastomotic connectors, for example as provided by Kaster in U.S. Pat. No. 5,234,447, the disclosure of which is incorporated herein by reference.  
         [0003]     In the Kaster system and in other systems known in the art, the source of power used in attaching the anastomotic connector is direct mechanical force applied by a human, in some cases using a means of mechanical gain.  
         [0004]     PCT publication WO 99/62415, the disclosure of which is incorporated herein by reference, suggests using a pneumatic or hydraulic pressure build up to shoot a blood vessel penetration tip through a blood vessel wall.  
       SUMMARY OF THE INVENTION  
       [0005]     An aspect of some embodiments of the invention relates to powering an anastomosis delivery system using a pressure source. In an exemplary embodiment of the invention, a hydraulic pressure source is used. Optionally, the hydraulic pressure source is volume controlled, rather than pressure controlled, with different operational states of the delivery system being set by changing a target volume of the hydraulic system (e.g., both the source and the delivery system). In an alternative embodiment, a pneumatic pressure source is used. Optionally, a mechanical means is provided to stop the progress of the anastomosis delivery at stages, so that a user intervention is required to allow the process to progress to a next stage.  
         [0006]     In an exemplary embodiment of the invention, the power source is used to tear off a portion of a connector, after the connector is inserted into place. Optionally, the pressure source is used to both advance and retract portions of the delivery system relative to a target blood vessel. In an exemplary embodiment of the invention, the delivery system completes an anastomosis by the delivery of a connector. In some embodiments, the connector, at least after deployment, comprises a plurality of individual clips.  
         [0007]     In some embodiments, the pressure source is used to power all the actions of the delivery, including, for example, approximation, incision opening, connector locking and tearing. Alternatively, fewer than all actions are powered by the pressure source. In some embodiments of the invention, a combined mechanical/fluid delivery system is used. For example, a mechanical system can be used to control an order of stages and/or the initiation and/or availability of stages, with the pressure providing the power.  
         [0008]     Optionally, advancing of the anastomosis process is provided by manipulating the pressure source, for example, increasing pressure levels.  
         [0009]     In an exemplary embodiment of the invention, a floating cylinder-piston mechanism is provided in which either one of the cylinder and piston can move (when a chamber in the mechanism is expanded), up to a limit defined by a body of the system. This allows both forward and reverse motion to be provided, in stages, with a single cylinder-piston mechanism. Optionally, one or more pins, ball-locks, friction and/or other mechanical means is used to direct the motion.  
         [0010]     In an exemplary embodiment of the invention, a user applies a small force (e.g., pressing a soft button) to control the application of a larger force, which larger force provides a deployment of an anastomosis connector. Optionally, the larger force is separately provided by the user. Alternatively, it is machine provided.  
         [0011]     In an exemplary embodiment of the invention, a user provides control of the activation of various stages in a deployment. Optionally, such control is provided by stepped increases in pressure and/or changes in volume of a fluid source. Optionally, such control comprises positional control, in which a user directs the system to achieve a particular position, rather than a force control, in which a user decides what force to apply. Optionally, the control is fine enough to allow tearing of individual legs of a connector in a serial manner, so that not all legs are torn simultaneously.  
         [0012]     An aspect of some embodiments of the invention relates to a pressure-powered delivery system adapted to fit an anastomosis delivery capsule (i.e., a distal head of a delivery system), which also fits a manually deploying delivery system. Optionally, a single pressure powered handle may be used with various types of capsules, which can be replaced in the handle. The capsules can be used with a mechanically powered system as well.  
         [0013]     An aspect of some embodiments of the invention relates to a pressure-powered delivery capsule adapted to be connected to a pressure source and deploy (e.g., position, lock and/or tear) an anastomosis connector when pressure is applied by said source. Optionally, the deployment is in distinct stages.  
         [0014]     An aspect of some embodiments of the invention relates to a fluid based delivery system in an expanding chamber is adjacent a graft, for example, surrounding the graft to be delivered, behind the graft and/or is to one side thereof. Optionally, the chamber is within 4 cm, 3 cm, 2 cm, 1 cm or less from the graft.  
         [0015]     An aspect of some embodiments of the invention relates to sealing element attached to a graft delivery system, which sealing element gently squeezes a graft to prevent blood flow therethrough. Optionally, the sealing element also prevents flow of blood through and out of the delivery system.  
         [0016]     There is thus provided in an exemplary embodiment of the invention, a fluid-based anastomosis system, comprising: 
        a body;     a fluid power source;     an actuator powered by said source; and     at least two elements coupled to said actuator and adapted to perform at least two different relative motions, responsive to serial powering of said actuator. Optionally, at least one of said motions comprises retraction of at least one of said elements relative to said body. Alternatively or additionally, at least one of said motions comprises advancing of at least one of said elements away from said body. Alternatively or additionally, a same actuator both extends and retracts a same element relative to said body, using a positive applied pressure. Alternatively or additionally, said actuator comprises a piston-chamber mechanism that floats relative to said body. Alternatively or additionally, said actuator selectively interlocks with said body. Alternatively or additionally, at least one of said motions comprises rotation of at least one of said elements relative to said body.        
 
         [0021]     In an exemplary embodiment of the invention, said system comprises a triggering mechanism which selectively unlocks at least one of said elements to move.  
         [0022]     Optionally, said motions are controlled by a level of pressure provided by said source. Alternatively or additionally, said motions are controlled by volume provided by said source.  
         [0023]     In an exemplary embodiment of the invention, said actuator is a hydraulic actuator. Alternatively or additionally, said actuator is a pneumatic actuator.  
         [0024]     In an exemplary embodiment of the invention, said body is splittable axially. Alternatively or additionally, said system comprises a stop adapted to stop a movement at a predefined amount of motion.  
         [0025]     In an exemplary embodiment of the invention, said system comprises a stop adapted to stop at least one of said movements at a predefined amount of motion.  
         [0026]     Optionally, at least one of said elements comprises a punch. Alternatively or additionally, at least one of said elements comprises an anastomosis connector. Optionally, said motions comprise advancing and retracting said connector. Alternatively or additionally, said motions comprise tearing said connector.  
         [0027]     In an exemplary embodiment of the invention, body is mounted on a flexible tube. Alternatively or additionally, said body is adapted to be held by hand.  
         [0028]     There is also provided in accordance with an exemplary embodiment of the invention, a method of performing an anastomosis delivery process, comprising; 
        providing an anastomosis related tool at a blood vessel;     applying fluid pressure to actuate said tool; and     further applying fluid pressure to differently actuate said tool.        
 
         [0032]     There is also provided in accordance with an exemplary embodiment of the invention, a connector delivery system, comprising: 
        a fluid power source;     an actuator powered by said source; and     at least two elements coupled to an anastomosis connector, which actuator moves one element relative to the other element to deploy the connector. Optionally, said actuator moves one element relative to the other element in at least two different movements, such that one movement retracts the connector relative to one element and the other movement releases the connector. Alternatively or additionally, the connector is released by being torn. Alternatively or additionally, that the pressure source controls the two movements.        
 
         [0036]     There is also provided in accordance with an exemplary embodiment of the invention, a fluid-based anastomosis system, comprising: 
        a body;     a fluid power source;     an actuator powered by said source; and     at least one tool adapted to be retracted towards said body when said actuator is powered.        
 
         [0041]     There is also provided in accordance with an exemplary embodiment of the invention, 
        a fluid powered anastomotic system, comprising:     a fluid power source;     a handle attached to said source;     an actuator inside said handle; and     a receptacle defined in said body and adapted to receive a mechanically actuated capsule, said actuator adapted to engage a body inserted in said receptacle.        
 
         [0047]     There is also provided in accordance with an exemplary embodiment of the invention, a fluid powered anastomotic system, comprising: 
        a body adapted to receive a graft vessel; and     an expanding fluid receiving chamber adjacent the graft. Optionally, said chamber surrounds said graft. Alternatively or additionally, said chamber is to a side of said graft.        
 
         [0050]     There is also provided in accordance with an exemplary embodiment of the invention, a graft delivery system comprising: 
        a body adapted to receive said graft; and     a flexible apertured element adapted to apply pressure to said graft and prevent blood flow therethrough. Optionally, said element prevents flow out of said body.       
 
     
    
     BRIEF DESCRIPTION OF THE FIGURES  
       [0053]     Non-limiting embodiments of the invention will be described with reference to the following description of exemplary embodiments, in conjunction with the figures. The figures are generally not shown to scale and any sizes are only meant to be exemplary and not necessarily limiting. In the figures, identical structures, elements or parts that appear in more than one figure are preferably labeled with a same or similar number in all the figures in which they appear, in which:  
         [0054]      FIG. 1  is a schematic diagram of a pressure-powered anastomosis connector delivery system, in accordance with an exemplary embodiment of the invention;  
         [0055]      FIGS. 2A and 2B  show an outside view and a cross-sectional view of a powered handle, in a first deployment stage, in accordance with an exemplary embodiment of the invention;  
         [0056]      FIG. 2C  shows a capsule inserted into a powered handle, in accordance with an exemplary embodiment of the invention;  
         [0057]      FIGS. 3A and 3B  show an outside view and a cross-sectional view of a powered handle, in a second deployment stage, in accordance with an exemplary embodiment of the invention;  
         [0058]      FIGS. 4A, 4B  and  4 C show an outside view and two cross-sectional views of a powered capsule, in a first deployment stage, in accordance with an exemplary embodiment of the invention;  
         [0059]      FIGS. 5A, 5B  and  5 C show an outside view and two cross-sectional views of a powered capsule, in a second deployment stage, in accordance with an exemplary embodiment of the invention;  
         [0060]      FIGS. 6A, 6B  and  6 C show an outside view and two cross-sectional views of a powered capsule, in a third deployment stage, in accordance with an exemplary embodiment of the invention;  
         [0061]      FIGS. 7A-7F  are cross-sectional views of an alternative embodiment of a powered capsule, in accordance with an exemplary embodiment of the invention;  
         [0062]      FIGS. 8A and 8B  show a complete powered capsule system before and after deployment, in accordance with an exemplary embodiment of the invention;  
         [0063]      FIG. 9  shows a hydraulic powered punching capsule, in accordance with an exemplary embodiment of the invention; and  
         [0064]      FIG. 10  shows a hollow hydraulic capsule, in accordance with an exemplary embodiment of the invention. 
     
    
     DETAILED DESCRIPTION OF EXEMPLARY EMBODIMENTS  
       [0000]     Overview  
         [0065]      FIG. 1  is a schematic diagram of a pressure-powered anastomosis connector delivery system  100 , in accordance with an exemplary embodiment of the invention. A graft vessel  105  is to be connected to a target vessel  104  at an aperture  106  thereof. In an exemplary embodiment of the invention, an anastomotic connector  108  is held in a delivery module  102 , which is attached by a tube  110  to a hydraulic (or other) pressure source  112 . Various exemplary types of delivery modules are described below. In an exemplary embodiment of the invention, pressure source  112  is a syringe with a movable piston  114 . In an exemplary embodiment of the invention, piston  114  is advanced by rotation, possibly allowing finer user control. Alternatively or additionally, a motorized pressure source is used, in which a pump provides the pressure. Alternatively, pressure is provided from standard hospital systems, for example, a source of CO 2 .  FIG. 1  further shows optional control elements  120 ,  118  and  116 , which are described below.  
         [0066]     In an exemplary embodiment of the invention, connector  108  is of a tearing type described in PCT publication WO 00/56226, for example, in which deployment of the connector includes a process of tearing the connector off of one or more extensions. In an exemplary embodiment of the invention, the pressure from source  112  is used to first close the connection between graft  105  and target vessel  104  by retracting the legs of connector  108  relative to delivery system  100  (or advancing the delivery system  100  towards the blood vessel). Then, the pressure from pressure source  112  is used to tear the connector  108  off of delivery module  102 . As will be noted below, a pressure-based system may also be used for non-tearing connectors, for example connectors wherein a last step of deployment is release of backwards legs, rather than tearing the connector off of the delivery system.  
         [0067]     An advantage of some implementations of the invention is that the large forces involved in such tearing do not interfere with a holding of delivery module  102  in position. In some embodiments, one or more of the following advantages is provided: low recoil, smooth operation, control of various stages of operation, optional pausing in intermediate steps and/or between tearing of individual legs, suitability for keyhole surgery and suitability for robotic surgery.  
         [0000]     Powered Handle  
         [0068]      FIGS. 2A and 2B  show an outside view and a cross-sectional view of a powered handle  200  in a first deployment stage and  FIGS. 3A and 3B  show an outside view and a cross-sectional view of powered handle  200 , in a second deployment stage, in accordance with an exemplary embodiment of the invention. A capsule, for example a connector capsule or a punch capsule may be loaded into powered handle  100 .  
         [0069]      FIG. 2C  shows a capsule  260  inserted into powered handle  200 .  
         [0070]     PCT publications WO 03/026475 and WO 02/30172, the disclosures of which are incorporated herein by reference, describe modular capsules for delivering anastomosis devices, which capsules can be mounted in a delivery handle. In the embodiment of the invention shown in  FIGS. 2-3 , powered handle  200  is used to replace the delivery system of  FIG. 1 , while optionally being adapted to work with other types of (e.g., mechanically actuated) capsules.  
         [0071]      FIG. 2A  is an outside view of handle  200 , showing a nipple  202  (e.g., suitable for locking to a pressure hose) for attaching to a pressure source, and a body  204 . At a distal end of handle  200  is a capsule holder  210  which engages a connector capsule once inserted, to prevent its falling out, for example, if the pressure is reversed and part of the capsule is pushed away from handle  200 . An optional fixed pin  212  is explained below. A slot  206  is optionally provided for advanced manipulation, as described below. Handle body  204  is optionally roughened or includes ridges or finger depressions or other means to assist in holding and/or prevent slipping. In an exemplary embodiment of the invention, the stage shown in  FIG. 2 , is a pre-deployment stage, in which the legs of the connector  108  ( FIG. 1 ) may be inserted into the blood vessel. Various methods of assisting such insertion may be provided, for example, a silicon ring around the legs, which ring is cut after insertion and/or after eversion, and removed using a string attached thereto. Other assisting devices are described in PCT publication WO 03/026475 and PCT application PCT/IL03/00769, published as WO 2004/028377, the disclosures of which are incorporated herein by reference.  
         [0072]      FIG. 2B  is a cross-sectional view of handle  200 .  FIG. 2C  is a cross-sectional view of handle  200  with capsule  260  inserted therein. Fluid arriving through nipple  202  enters a chamber  222 , defined by a cylinder body  226  and a piston  220 . Capsule  260  fits in holder  210  and includes a pull extension  262  which is engaged by an engaging element  230 . Element  230  is coupled to cylinder body  226 . In operation (with reference to  FIG. 3B  as well), entry of fluid into chamber  222 , causes relative motion between piston  220  and cylinder body  226 . In an exemplary embodiment of the invention, pin  212  locks piston  220  to handle body  204  and slidebly fits in a slot  224  of cylinder body  226 . Thus, as piston  220  is fixed to body  204  of handle  200 , expansion of chamber  222  causes retraction of the pull extension and deployment of the connector.  
         [0073]     Delivery capsule  260  fits inside holder  210  and is optionally engaged, for example by an optional inner ridge  234  ( FIG. 2B ). A base  264  of the capsule optionally rests against a step  232 , when pull extension  262  fits in a receptacle  230 . Movement of pull extension  262  relative to the rest of capsule  260  extends, retracts and/or tears (or otherwise deploys) the connector. In some embodiments, rotation of the pull extension is used, for example, for providing the relative motion, for a safety mechanism or for separating different stages. Optionally, a metal lining  248  is provided to hold the capsule. Optionally, a threading  250  is used to attach an extension  252  of the lining to body  204 .  
         [0074]     An exemplary mechanism for locking pull extension  262  to holder  200  is illustrated. Engagement element  230  has a lumen  228  surrounded by a plurality of balls  240 , each optionally arranged opposite an aperture  241  in element  230 . An inner stopper  242  in lumen  228  prevents the balls from moving inwards. Insertion of pull extension  262  pushes stopper  242  away so that the balls can enter lumen  228 . A spring  236  is optionally provided to prevent inadvertent motion of stopper  242 . Optionally, an outer tube  244  is used to push balls  240  into lumen  228 . A spring  229  is optionally provided to urge tube  244  in the direction of balls  240 . Inserting the capsule pushes element  230  backwards, while tube  244  stays in place and a forward edge  246  thereof can push balls  240  radially into lumen  228 . Optionally, tube  244  is lightly frictionally engaged by body  204 , so that it can also retract, as shown in  FIG. 3B . In an alternative embodiment, an optional elastic ring  238  urges balls  240  inwards into lumen  228 .  
         [0075]     In an exemplary embodiment of the invention, optional slot (or other aperture)  206  is used for re-priming handle  200  after use. A screwdriver or similar tool is inserted into slot  206  and tube  244  moved away from apertures  241 , so balls  240  can exit the lumen.  
         [0076]     In operation, as shown in  FIG. 3A , cylinder body  226  extends out when chamber  222  ( FIG. 2B ) is filled. Optionally, body  204  is held (e.g., manually), so that the extension of body  226  does not move the connector capsule  260  ( FIG. 2C ). Optionally, a user allows body  226  to move forward during a first extension of chamber  222 , to prevent inadvertent retraction of the connector legs from aperture  106 , tearing of tissue near the aperture and/or distorting of the legs of connector  108 .  
         [0077]     In embodiments where a non-tearing connector is used, the retraction of pull extension  262  can be used to retract an outer tube to release backwards legs of a connector, for example, or to pull back and/or rotate (e.g., with suitable threading) a penetration tip or cutting tube of a punch capsule.  
         [0000]     Powered Capsule  
         [0078]      FIGS. 4A and 4B  show an outside view and a cross-sectional view of a powered capsule  400 , in a first deployment stage, in accordance with an exemplary embodiment of the invention.  FIGS. 5A and 5B  and  FIGS. 6A and 6B  show the capsule at second and third deployment stages.  FIGS. 4C, 5C  and  6 C show a second side cross-sectional view, from a different direction, showing an optional ball-based selective locking mechanism.  
         [0079]     Powered capsule  400 , unlike powered handle  200  includes both a hydraulic deployment mechanism and a connector and graft holder. The connector used may be compatible with mechanical deployment systems. In the example described, a tearing connector is used. However, other connector types may be used as well.  
         [0080]     The capsule embodiment is also used to illustrate an optional two direction of motion mechanism, which advances the connector holder towards the blood vessel, locks the connector and then retracts the connector for tearing. One advantage of this two step motion is that there may be less danger of the connector legs being inadvertently pulled out of aperture  106 . Potential problems with such pulling out include, tearing of the target blood vessel, distortion of the connector and difficulty in re-inserting the legs. This type of mechanism can also be provided in a hydraulic handle.  
         [0081]     Referring to  FIG. 4A , capsule  400  comprises a nipple  402  for providing fluid, a body  404  which is optionally adapted for holding by a human operator and a connector carrying section comprising a sleeve  410 , within which travels a tip  406 , which is optionally splitable. A slot  414  is optionally provided in tip  406 , for removal from a graft after use. As noted in the above mentioned PCT/IL03/00769 application, published as WO 2004/028377, slot  414  may be used for splitting tip  406  so that the graft can be inserted by placing it in tip  106 , rather than by snaking it between apertures  418  and  419 , (described next). An aperture  418  (more visible in  FIG. 4B ) forms an entrance for a graft, which exits from an aperture  419  at a front of tip  406 . An optional connector alignment area  416  is shown, for arranging forward legs of a connector and/or for receiving medallion sections of a medallion and hook type connector, for example as described in PCT application PCT/IL03/00774, published as WO 2004/028373, the disclosure of which is incorporated herein by reference. It should be noted that other connector carrying sections can be provided for different types of connectors and for different deployment methods thereof.  
         [0082]     Also shown in  FIG. 4A  is a pin  412  whose travel is limited by a slot  408  and which selectively locks tip  406  to body  404 , as will be described below.  
         [0083]      FIG. 4B  shows a cross-sectional view of capsule  400 . Nipple  402  is connected to a chamber  422  which is defined by a piston  420  and an outer cylinder body  426 . In the embodiment shown, sleeve  410  is an extension of cylinder body  426 . Tip  406  has a sleeve extension  430 , which slidebly fits inside sleeve  410 . Pin  412  fits in a slot  424  in sleeve  410  and locks piston  420  to sleeve extension  430 .  
         [0084]     The connector (not shown) is held by a connector holder  436 , coupled to sleeve  410  by a pin  432  which fits in a slot  434  of sleeve extension  430 .  
         [0085]     In an exemplary embodiment of the invention, the various slots and pins cooperate to define relative motion between body  404 , sleeve  410  and tip  406 . A particular type of motion which is shown in the embodiment of  FIGS. 4-6  is that of first advancing tip  406  and then retracting connector holder  436  such that the connector is locked and then torn. In some cases, the locking of the connector is provided at the end of the first motion (advancing tip  106 ) and the second motion only tears the connector.  
         [0086]     Referring to all of  FIGS. 4-6 , the stages of deployment are now described.  
         [0087]      FIGS. 4A-4C  show an initial position, in which a graft (not shown) is inserted in aperture  418  and out of aperture  419  and optionally everted on the connector. The connector is then placed into aperture  106 .  
         [0088]     In  FIGS. 5A-5B , fluid has entered chamber  422 , causing its expansion. Optionally, there is some friction between body  404  and cylinder body  426 , so piston  420  moves, until pin  412  reaches the end of slot  408 . This motion is coupled to tip  406  which advances towards a target vessel, while the connector, coupled to holder  436 , which is coupled to sleeve  410 , stays back, thereby causing retraction of the connector relative to tip  406 . The movement of tip  406  is optionally achieved without moving the connector relative to the target vessel, which might cause the connector to pop out of the blood vessel and/or tear the vessel.  
         [0089]     In  FIGS. 6A-6B , more fluid has entered chamber  422 . However, piston  420  is constrained from forward motion by pin  412  contacting the end of slot  408 . As a result, cylinder body  426  and its coupled sleeve  410  are retracted, along with connector holder  436 , thereby tearing the connector and completing the deployment. As noted above, capsule  400  is optionally of a splitting type. In an exemplary embodiment of the invention, tip  406  is pre-disposed to split. Examples of such pre-disposition include, pre-stressing the tip  406 , providing a spring which opens tip  406  and a peg (not shown) mounted on sleeve  410 , which engages a slot in tip  406 , such that retraction of sleeve  410  causes the peg to travel along the slot and widen it. Thus, in the configuration shown in  FIG. 6A , tip  406  would be split apart along slot  414  (and  418 ).  
         [0000]     Ball Lock Mechanism Control  
         [0090]      FIGS. 4C, 5C  and  6 C show an optional embodiment in which a ball lock mechanism is used to control the order of activation instead of or in addition to a friction based mechanism. The view in these cross-sectional figures is perpendicular to that of  FIGS. 4B, 5B  and  6 B, for example, pin  412  is illustrated end on. In the embodiment shown (e.g.,  FIG. 4C ), one or more balls  440  are provided in one or more recesses  442  formed in body  404 . Sleeve extension  430  prevents ball  440  from exiting recess  442 . While in the recess, ball  440  locks recess  442  to an aperture  446  formed in cylinder body  426 , thus preventing the relative motion of body  404  and cylinder body  426 . In  FIG. 5C , sleeve extension  430  has advanced, allowing ball  440  to exit recess  442 . In  FIG. 6C , ball  440  has exited recess  442  and allows body  404  to move relative to cylinder body  426 . Optionally, ball  440  prevents over expansion of chamber  422  by preventing over-advancing of piston  420 . Also shown in these figures is an exemplary effect on a single leg  109  of connector  108 . In  FIG. 4C , it is forward, in  FIG. 5C , it is locked and in  FIG. 6C , it is torn.  
         [0000]     Alternative Capsule with Tabs  
         [0091]      FIGS. 7A-7F  are cross-sectional views of an alternative powered capsule  700 , generally similar in function to capsule  400 , except that the locking mechanism used to prevent motion of the cylinder body relative to the capsule body is based on plastic snap-locking, rather than on a ball lock. The reference numbers are generally corresponding between  FIGS. 7A-7F  and  FIGS. 4-6 , except for being larger by  300  (e.g., chamber  722  corresponds to chamber  422 ). Some elements are not described a second time.  
         [0092]      FIGS. 7A, 7B  and  7 C are side cross-sectional views of capsule  700  at stages corresponding to those of  FIGS. 4, 5  and  6 , respectively, at a view which shows a side of a pin  712 , generally corresponding in function to pin  412 . Some design variations from capsule  400  are also shown, for example, the provision of a gasket  723 , which optionally assists in preventing pressure leakage. Optionally, a sleeve  710  is attached to a cylinder body  726  by a base  725  of sleeve  710  being threaded to cylinder body  726  at a threaded location  727 . Another optional design variation is that capsule  700  is more streamlined.  
         [0093]      FIGS. 7D-7F  show a side view of capsule  700  at the same three stages as  FIGS. 7A-7C , in which the view shows pin  712  end on. The locking mechanism is clearer in this set of figures. In  FIG. 7D , one or more protrusions  740  of sleeve  710  project into a recess  742 , which may be, for example, in the form of an annular groove. While sloped, protrusion  740  is prevented from leaving recess  742 , due to a sleeve extension  730 , which fits inside of sleeve  710 . In  FIG. 7E , sleeve extension  730  advances away from the area of protrusions  740 . In  FIG. 7F , protrusions  740  snap out of recesses  742 . While in the embodiment shown protrusions  740  are mounted on base  725  by elastic extensions, they may be otherwise attached.  
         [0000]     Example System  
         [0094]      FIGS. 8A and 8B  show a complete powered capsule system  800  before and after deployment, in accordance with an exemplary embodiment of the invention.  FIG. 8A  shows capsule  700  attached to a system as shown in  FIG. 1 . Piston  114  is shown as having a thread  802  which matches an inner thread of a syringe cover  804 . Optional lines  806  show the position of a forward end  808  of piston  114 , thereby indicating the operational stage of the system. Optionally, one or more stops are provided between the syringe and the piston, which can be removed serially to allow progression to a next step of delivery. In an alternative embodiment (referring to  FIG. 7F , for example), one or more pins are positioned to interlock piston  720  and the body of capsule  700 , to prevent motion, until the pins are removed. This may be useful for a pneumatic system in which the degree of advance cannot be set based on volume.  
         [0095]      FIG. 8B  shows the end of the deployment, where tip  706  is split open.  
         [0000]     Controls  
         [0096]      FIG. 8A  shows a system where a user manipulates a syringe in order to control the anastomosis delivery. Referring back to  FIG. 1 , in one example of the invention a control  118  is provided on the delivery module  102  and is attached to source  112  via a cable  120 . Control  118  may be, for example, a micro-switch used to advance or retract piston  114  via an electric motor (not shown) or activate a different type of pump (not shown). Alternatively, such an electrical control may be provided on source  112 , for example, a finger switch. Alternatively, a separate switch, for example a foot switch, possibly with both forward and backwards direction, may be provided. Alternatively to an electrical switch, a mechanical switch (e.g., a valve) may be used to selectively admit pressurized fluid from a remote source, for example in the case of a hospital-wide compressed air source.  
         [0000]     Control Logic  
         [0097]     As noted above, an anastomosis delivery process can be viewed as a multi-step process. From a user&#39;s point of view, these steps are optionally delimited and optionally not. In one exemplary embodiment, once the pressure source is activated, the process continues to completion (e.g., tearing and splitting) without human intervention.  
         [0098]     In an alternative embodiment, separate controls are provided for some or all of the stages, for example so that one control advances tip  706  and another retracts sleeve  410 . In one example, a user can visually verify that all the connector legs are in place, before continuing with locking and tearing.  
         [0099]     As noted above, in some embodiments of the invention, the control is volume based, which means that each position of the system has a corresponding volume of fluid that determines that position. In an exemplary embodiment of the invention, fine control is available using this method. For example, selective individual tearing of legs as described in PCT/IL03/00774, published as WO 2004/028373, or PCT/IL03/00770, published as WO 2004/028376 the disclosures of which are incorporated herein by reference, may be provided. As described in those applications, a connector leg can have two ends, one proximal, which is being pulled back at a pulling point and one distal, which is being held in place at a holding point. If the distance between the pulling element and the holding element is greater than the length of the leg between the pulling point and the holding point, the leg tears. Different legs can have different such lengths. Thus, as pull extension  262  ( FIG. 2C ) which pulls on the leg is retracted more, the distance between the pull extension and tip  206  (which holds the leg) increases. As the distance equals the length of a leg, that leg stretches a small amount and tears. By providing fine control of the distance using a hydraulic means, a user can select to tear only some of the legs, for example to allow incision shaping using the leg (e.g., as described in PCT application PCT/IL03/00769, published as WO 2004/028377). It should be noted that it may be difficult for a user to apply such fine control using a lever based or spring based mechanical lever. In a non-hydraulic embodiment, a screw is used to better control the distance, however, this may interfere with steady holding of the delivery system.  
         [0100]     In some embodiments of the invention, a force control (e.g., based on air pressure) is provided. This may be useful, for example, to ensure that forces applied to the connector and/or tissue at certain stages in the deployment do not exceed a desired amount. In addition, this may be useful for connectors which have different deployment configurations at different applied forces (e.g., some legs tear at one force and some legs tear at another). Optionally, steps in a delivery process are set using blocking tabs which break at certain applied pressures (e.g., being arranged to block motion of the piston relative to the chamber past certain extensions) and thus allow the process to proceed to a next step.  
         [0101]     Optionally, a damping of motion is provided, for example by providing the fluid slowly or by adding friction to the delivery mechanism. This, optionally, allows a user time to notice if something is going wrong and/or allows the user to move the delivery system if desired towards or away from the target vessel, while the pressure actuated actions are in progress.  
         [0102]     Optionally, a ratchet mechanism is provided, so once a certain expansion of chamber  722  is reached, piston  720  cannot be retracted. In one example, the inside of cylinder  726  includes steps or hooks which engage gasket  723  if it starts moving in a reverse direction.  
         [0103]     Optionally, a pressure release valve, for example, on tube  110 , is provided for volume based embodiments, for example to limit the applied forces.  
         [0000]     Alternative Mechanisms  
         [0104]     Several mechanisms using hydraulic pressure for deploying tearable connectors have been described. Non-tearing connectors, in some embodiments of the invention are deployed by first pulling back the connector such that its forward legs engage the inside of a target blood vessel and then releasing backward legs. In an exemplary embodiment of the invention, the backward legs are released by retracting an overtube which kept them constrained. In an exemplary embodiment of the invention, the designs shown above are modified so that instead of pulling back the connector to tear it, such an overtube is pulled back to reveal the backwards legs of the connector. Retracting of the forward legs is optionally replaced by advancing the tip (e.g., tip  706 ).  
         [0105]     Other connectors may require more complex deployment, for example, including four or more deployment stages. This can be achieved, for example, by providing another tab and sleeve mechanism as shown in  FIG. 7  and/or another pin mechanism between tubes.  
         [0106]     A rotation effect can be achieved, for example, by providing a peg on an inner (or outer) tube and a matching thread on an outer (or inner) tube, so that axial advancing also includes a component of rotation.  
         [0107]     In the embodiment shown, nipple  702  is at an end of the capsule  700 . Alternatively, it may be attached at a central portion, with, for example the piston pointed towards the proximal end rather than the connector end of the capsule. Alternatively or additionally, multiple fluid intake points are provided, for example each intake controlling a different stage of deployment.  
         [0108]     Alternatively or additionally, both an input and an output are provided on the capsule, for example, to allow the hydraulic fluid to operate by powering a hydraulic motor, rather than a piston. Such a motor can rotate a screw which will advance and/or retract parts in the connector, for example as described in U.S. Provisional Application No. 60/505,946, the disclosure of which is incorporated herein by reference. Such a motor may also be provided for use with a pneumatic pressure source. Optionally, a pressure release valve is provided in capsule  700 , for example to release over pressure of gas or liquid, for example, to prevent leakage or distortion of the capsule.  
         [0109]     In an alternative embodiment, the hydraulic source is located in capsule  700 , for example, powered by an electric motor (e.g., with an on-board battery or a power supply attached by wire).  
         [0110]     Optionally, reducing the fluid pressure is used to retract a step in the anastomosis delivery process.  
         [0000]     Alternative Processes  
         [0111]     U.S. Provisional Application No. 60/505,946, describes a system which both punches a hole and deploys a connector in the hole. In this system, a punch mechanism is pulled back and to the side, to make room for the advancing of a connector. In an exemplary embodiment of the invention, that system is powered using a mechanism as described herein. Optionally, two hydraulic chambers are provided, one for retracting the punch (by expansion of a chamber in the handle, instead of advancing the handle), thereby causing a piston attached to the punch mechanism to advance proximally and retract the punch and one for deployment of the connector (using a second chamber as described herein). The two chambers may be connected, for example, by a flexible tube, to pass pressure from one chamber to the other. Optionally, pressure can flow from the first chamber to the second chamber only once the piston passes by and reveals a port from the first chamber to the second chamber. A third chamber is optionally provided (between the first and second chambers) for advancing the connector capsule into a hole made by the punch.  
         [0112]     In an alternative implementation, two chambers are attached to a same fluid source, a first chamber having a smaller diameter and a second one having a second diameter. Thus, the motion rate of pistons in the two chambers is different. Optionally, the smaller diameter (or cross-section) chamber is used to pull back a punch section, for example using a flexible rod, which, once the punch pulled back sufficiently, urges it to one side. At the same time, the second chamber advances a connector deployment section, for example of the type described herein. A third chamber, with an even greater diameter (and optionally larger extent of motion) may be used to retract the connector section after use, for example for tearing the legs and/or approximation. Alternatively, a valve is rotated to cause the second chamber to operate in an opposite direction, with pressure being applied from an opposite side of the piston. Optionally, a plain capsule is used, which interlocks with the overtube and/or with the body. The interlocking with the overtube pulls back the overtube when the second chamber pulls back and the interlock with the body of the device tears the legs.  
         [0113]     In an alternative embodiment, handle  200  is used to power a punching mechanism capsule (e.g., pulling back a penetration tip thereof and/or rotating a cutting tube thereof) and then the punch capsule is removed and replaced by a connector capsule. The punch capsule may leave an overtube with a valve in the punched blood vessel, to reduce leakage.  
         [0114]      FIG. 9  shows a hydraulically actuated capsule  900 , in accordance with an exemplary embodiment of the invention, illustrating the possibility of optionally features of mechanical triggering and/or rotation using a hydraulic power source. These features may be used in other embodiments as well. The rotating mechanism described below, for example, may be used in a handle-type device, to rotate a portion of a mechanical capsule.  
         [0115]     When pressured fluid (e.g., saline or gas) enters a chamber  904  through a connector  902 , it applies force against a surface  908  of a piston  912 , which is thereby advanced distally. An optional gasket  910  prevents leakage against a wall  904  of the chamber. A rod  914  is coupled to piston  912  and includes a threading  916 , so that advancing of piston  912  will rotate rod  914 . A cutting tube  920  is optionally coupled via a base section  918  to rod  914 , so that rotation of rod  914  can optionally rotate cutting tube  920 . A penetration tip  922 , for example as provided in the below referenced applications, optionally includes barbs. Optionally, a trigger  924  is provided, so that rotation of tube  924  and/or a retraction of penetration tip  922  are triggered by contact of the trigger with a blood vessel wall (e.g., indicating deep penetration of penetration tip  922  into a blood vessel).  
         [0116]     In an exemplary embodiment of the invention, the following trigger/locking mechanism is used. A locking pin  930  locks base  918  against the body of capsule  900 . A spring  932  tends to urge the pin out of this locking configuration. When trigger  924  moves proximally, an aperture  938  in the trigger aligns with an extension  934  of pin  930  and allows the pin top be urged out of a locking configuration.  
         [0117]     Alternatively or additionally, a locking ball  940  is allowed to release penetration tip  922  to be spring-retracted (spring not shown), when an aperture  942  of trigger  924  is aligned with the ball. Similar and other triggering mechanism can be used as well.  
         [0118]     Optionally, chamber  906  is elastic so that it can conform somewhat to increased fluid pressure provided therein, even if rod  914  is locked and cannot rotate.  
         [0119]      FIG. 10  shows a hollow hydraulic delivery system  1000  in accordance with an exemplary embodiment of the invention. A graft  1018  is passed through a body  1002  of system  1000 . Optionally, a flexible cap  1014  has an opening  1016  to receive the graft and squeezes it gently shut, to prevent blood flow through the graft and/or through body  1002 . This type of seal may also be used in non-hydraulic systems and in side mounted systems (e.g., as described above).  
         [0120]     A connector comprising a plurality of retracting forward legs  1008  and a plurality of fixed backward legs  1012 , is shown. In operation, fluid is provided into a chamber  1004 , causing a piston  1006  to retract away from legs  1012 , carrying legs  1008  with it. This causes engagement and locking of the connector. Further retraction can then tear legs  1012 . Chamber  1004  is, for example, a ring shaped chamber or is only on one side of body  1002 , for example on a side of attachment  1010  which attaches the fluid source to the body.  
         [0121]     An optional band  1020  holds device  100  together, so that it can be easily removed after use. Body  1002  is optionally pre-split or is cut after use. Alternatively, piston  1006  meets a narrowing of an inner diameter of body  1002 , so that further expansion splits body  1002 . Chamber  1004  can be, for example, a slotted ring.  
         [0000]     Applications  
         [0122]     The above description has focused on a hand-held device. In other embodiments, the delivery system is controlled by a robot. In another embodiment, the delivery system is used for keyhole surgery. It should be noted that in an exemplary embodiment of the invention, a single hydraulic cable suffices for both power and control of the whole anastomotic deployment process, and can be used, for example, at the end of a flexible delivery tube. For example, the diameter of the system (e.g., the more forward section thereof, for example 10 cm) can be 10%, 30%, 50%, 100% or any smaller, intermediate or larger percentage than a diameter of connector to be deployed. Optionally, in an expanding connector, the diameter can be the same or smaller than a deployed connector.  
         [0000]     Materials  
         [0123]     The capsule may be made of any suitable material known in the art, in particular plastics. As noted above, high wear and/or high tolerance parts may be made of plastic. Alternatively or additionally, where a good seal is needed, rubber or other soft materials such as silicones may be used. In some embodiments, however, perfect sealing is not provided or intentional leaks are provided, for example to use the working fluid to keep the capsule free of blood and/or other debris or to keep the area of the anastomosis clear. Alternatively or additionally, the working fluid serves as a lubricant in the capsule or delivery handle.  
         [0124]     It should be noted that for one time use of the device, distortion as a result of use may be allowed and/or weaker materials may be used.  
         [0000]     Connector and Anastomosis Tools  
         [0125]     As noted above, embodiments of the present invention may be used with various types of anastomotic connectors, anastomosis assisting tools and delivery systems. In particular, the following documents, describe connectors, delivery systems and/or other tools and methods which are useful in conjunction with embodiments of the prevent invention: 
        PCT/IL02/00790, filed on Sep. 25, 2002, now published as WO 03/026475;     PCT/IL02/00215, filed on Mar. 18, 2002, now published as WO 02/074188;     PCT/IL01/01019, filed on Nov. 4, 2001, now published as WO 02/47532;     PCT/IL01/00903, filed on Sep. 25, 2001 now published as WO 02/30172;     PCT/IL01/00600, filed on Jun. 28, 2001, now published as WO 02/47561;     PCT/IL01/00267, filed on Mar. 20, 2001, now published as WO 01/70091;     PCT/IL01/00266, filed on Mar. 20, 2001, now published as WO 01/70090;     PCT/IL01/00074, filed on Jan. 25, 2001, now published as WO 01/70119;     PCT/IL01/00069, filed on Jan. 24, 2001, now published as WO 01/70118;     PCT/IL00/00611, filed on Sep. 28, 2000, now published as WO 01/41624;     PCT/IL00/00609, filed on Sep. 28, 2000, now published as WO 01/41623;     PCT/IB00/00310, filed on Mar. 20, 2000, now published as WO 00/56228;     PCT/IB00/00302, filed on Mar. 20, 2000, now published as WO 00/56227;     PCT/IL99/00674, filed on Dec. 9, 1999, now published as WO 00/56223;     PCT/IL99/00670, filed on Dec. 8, 1999, now published as WO 00/56226;     PCT/IL99/00285, filed on May 30, 1999, now published as WO 99/62408; and     PCT/IL99/00284, filed on May 30, 1999, now published as WO 99/62415. The disclosures of all of these applications, which designate the US and were filed in English, are incorporated herein by reference.        
 
         [0143]     In addition, the following PCT unpublished applications, all filed on Sep. 25, 2003, in English and designating the US, the disclosures of which are incorporated herein by reference describe tools and connectors which may be useful: PCT/IL03/00774, “Anastomotic Connectors”, now published as WO 2004/028373, PCT/IL03/00773, “Snare”, PCT/IL03/00770, “Sliding Surgical Clip”, now published as WO 2004/028376, PCT/IL03/00771, “Blood Vessel Cutter”, now published as WO 2004/028380 and PCT/IL03/00769, “Anastomotic Leg Arrangement”, now published as WO 2004/028377.  
         [0144]     The following US provisional applications, the disclosures of which are incorporated herein by reference, also describe tools which may be of use, U.S. Provisional Application No. 60/492,998, filed on Aug. 7, 2003 and U.S. Provisional Application No. 60/505,946, filed on Sep. 25, 2003.  
         [0145]     Some of these applications describe anastomosis delivery systems, hole making apparatus and/or other connectors useful in cooperation with the present invention.  
         [0146]     While the above delivery system has been described in general for any type of blood vessel, it should be appreciated that particular modifications may be desired for certain vessel types. For example, the aorta is thicker, while a coronary vessel is thinner, thus suggesting different amounts of motion of the tip and the retracting sleeve. For example, an aorta may be 3 mm thick, while a coronary vessel may be less than 1 mm thick.  
         [0147]     It should be noted that the term “connector” should be construed broadly to include various types of connectors, including one part, two part and multiple part connectors, some of which when deployed, result in a plurality of individual clip-like sections.  
         [0148]     The term “eversion”, where used means not only complete eversion of 180 degrees, but also partial eversion or flaring, for example of 90 degrees. Also, in some embodiments, mounting without eversion is provided.  
         [0149]     Measurements are provided to serve only as exemplary measurements for particular cases. The exact measurements stated in the text may vary depending on the application, the type of vessel (e.g., artery, vein, xenograft, synthetic graft), size of connector, shape of hole (e.g., incision, round) and/or sizes of vessels involved (e.g., 1 mm, 2 mm, 3 mm, 5 mm, aorta sized).  
         [0150]     While the term “tube” and other geometrical shapes have been described and used for generality, it should be appreciated that this tube need not have a full body nor have a circular cross-section, in some embodiments.  
         [0151]     In some embodiments, one or more of the devices, generally sterilize, described above, are packaged and/or sold with an instruction leaflet, describing the device dimensions and/or situations for which the device should be applied. Also within the scope of the invention are surgical kits comprising sets of medical devices suitable for making anastomotic connections.  
         [0152]     It should be appreciated that the above may be varied and still fall within the scope of the invention, for example, by changing the order of steps or by providing embodiments which include features from several described embodiments or by omitting features described herein. Section headings where are provided are intended for aiding navigation and should not be construed to limiting the description to the headings.  
         [0153]     When used in the following claims, the terms “comprises”, “comprising”, “includes”, “including” or the like means “including but not limited to”.  
         [0154]     It will be appreciated by a person skilled in the art that the present invention is not limited by what has thus far been described. Rather, the scope of the present invention is limited only by the following claims.