Patent Publication Number: US-2021169458-A1

Title: Apparatus and methods for sealing a vascular puncture

Description:
RELATED APPLICATION DATA 
     This application is a continuation of co-pending application Ser. No. 12/617,693, filed Nov. 12, 2009, and issuing as U.S. Pat. No. 8,394,122, which claims benefit of co-pending provisional application Ser. No. 61/114,049, filed Nov. 12, 2008, the entire disclosures of which are expressly incorporated by reference herein. 
    
    
     FIELD OF THE INVENTION 
     The present invention relates generally to apparatus and methods for sealing punctures in a body, and more particularly, to apparatus and methods for sealing a vascular puncture extending through tissue into a blood vessel, and to apparatus and methods for delivering a plug, sealant, and/or other material into a percutaneous puncture extending from a patient&#39;s skin to a blood vessel or other body lumen, e.g., to seal the puncture. 
     BACKGROUND 
     Apparatus and methods are known for accessing a patient&#39;s vasculature percutaneously, e.g., to perform a procedure within the vasculature, and for sealing the puncture that results after completing the procedure. For example, a hollow needle may be inserted through a patient&#39;s skin and overlying tissue into a blood vessel. A guide wire may be passed through the needle lumen into the blood vessel, whereupon the needle may be removed. An introducer sheath may then be advanced over the guide wire into the vessel, e.g., in conjunction with or subsequent to one or more dilators. 
     A catheter or other device may be advanced through the introducer sheath and over the guide wire into a position for performing a medical procedure. Thus, the introducer sheath may facilitate accessing and/or introducing various devices into the vessel, while minimizing trauma to the vessel wall and/or minimizing blood loss. Upon completing the procedure, the device(s) and introducer sheath may be removed, leaving a puncture extending between the skin and the vessel wall. 
     To seal the puncture, external pressure may be applied to the overlying tissue, e.g., manually and/or using sandbags, until hemostasis occurs. This procedure, however, may be time consuming and expensive, requiring as much as an hour of a medical professional&#39;s time. It is also uncomfortable for the patient, and may require the patient to remain immobilized in the operating room, catheter lab, or holding area. In addition, a risk of hematoma exists from bleeding before hemostasis occurs. 
     SUMMARY 
     The present invention is directed to apparatus and methods for sealing a puncture in a body, and, more particularly, to apparatus and methods for providing temporary or permanent hemostasis within a vascular puncture extending into a blood vessel, and/or to apparatus and methods for delivering a sealant and/or other material into a percutaneous puncture extending from a patient&#39;s skin to a blood vessel or other body lumen. 
     In accordance with one embodiment, an apparatus is provided for sealing a puncture extending through tissue that includes an elongate member including a proximal end, a distal end sized for insertion into a puncture through tissue, and an expandable member on the distal end. The apparatus also includes a cartridge including a proximal end, a distal end sized for insertion into the puncture, and a lumen extending between the proximal and distal ends sized for receiving the elongate member therein, a sealant disposed within the cartridge lumen adjacent the cartridge distal end, a pusher member disposed within the cartridge lumen adjacent to the sealant, and a tamping or auto advance device on the cartridge proximal end for biasing the pusher member distally relative to the sealant when activated. 
     In accordance with another embodiment, an apparatus is provided for sealing a puncture extending through tissue. The apparatus may include an elongate member, a cartridge, a sealant disposed within the cartridge, a pusher member disposed within the cartridge adjacent to the sealant, and an auto advance device. The sealant may be positioned adjacent to a distal end of the cartridge and the auto advance device may be positioned on a proximal end of the cartridge. The elongate member may optionally include a marker for indicating when the auto advance device is in an active position. 
     In one embodiment, the auto advance device may include a cartridge hub and a slider tube. The slider tube may be fixed to the cartridge proximal end and may be slidable relative to the cartridge hub. The auto advance device may further include a tamping spring and an auto advance spring. The tamping spring may be positioned between the pusher member and a secondary pusher member and, optionally, may be compressible between the pusher member and the secondary pusher member. The elongate member may include an element for engaging with a latch element on the secondary pusher member. The auto advance spring may be compressible between the slider tube and an inner surface of the cartridge hub. 
     In another embodiment, the auto advance device may include a spring for distally advancing the pusher member, thereby compressing the sealant between the pusher member and an expandable member on a distal end of the elongate member. 
     In accordance with yet another embodiment, a tamping apparatus is provided for tamping a sealant delivered within a puncture. The tamping apparatus may include a housing, a slider tube, an auto advance spring, a tamping spring, and an auto advance spring tube. The slider tube is disposed within the housing and may be slidable relative to the housing between an inactive position and an active position. In the inactive position, the tamping spring and the auto advance spring may be extended. In the active position, the tamping spring and the auto advance spring may be compressed. The auto advance spring may be compressible between the slider tube and a proximal rib of the housing and may surround the auto advance spring tube. The tamping spring may be disposed within the slider tube and coupled between a pusher tube and a secondary pusher tube. The apparatus may further include a tamping tube within the slider tube, and the tamping spring may be disposed within the tamping tube. The auto advance spring tube may be configured to protrude into the slider tube, thereby distally advancing the secondary pusher tube and compressing the tamping spring. The secondary pusher tube may include a latch element for engaging with a raised element on an elongate positioning member. 
     In accordance with still another embodiment, a method is provided for sealing a puncture extending through tissue to a body lumen. The method may include advancing a positioning member through the puncture until an expandable element thereon is disposed within the body lumen, expanding the expandable element within the body lumen, and retracting the positioning member until the expanded expandable element contacts a wall of the body lumen adjacent the puncture. A cartridge, carrying a sealant, a pusher member, and a proximal cartridge hub, may be advanced into the puncture, e.g., over the positioning member until a distal end of the cartridge contacts the expandable element and/or an auto advance device in the cartridge hub is activated. The cartridge may be withdrawn from the puncture while maintaining the sealant and the pusher member within the puncture, and the auto advance device may automatically compress the sealant within the puncture, e.g., between the pusher member and the expandable element. 
     In one embodiment, the cartridge hub may be advanced until a distal end of the cartridge contacts the expandable element, and then the cartridge hub may be advanced further to activate the auto advance device. For example, the auto advance device may include one or more biasing elements, e.g., a tamping spring and an auto advance spring, that may be compressed when the cartridge hub is advanced. The tamping spring may be positioned between a pusher member and a secondary pusher member and a latch element on the secondary pusher member may engage with an element on the positioning member during further advancing of the cartridge hub. Withdrawing the cartridge may expand the auto advance spring while the tamping spring may remain compressed. Tamping the sealant may include expanding a tamping spring, thereby advancing the pusher member further into the puncture and compressing the sealant between the expandable member and the pusher member. 
     In one embodiment, the method may further include collapsing the expandable element and removing the positioning member from the puncture, thereby withdrawing the collapsed expandable element through the sealant. The positioning member may optionally include a marker thereon and further advancing the cartridge hub may include advancing the cartridge hub until a cartridge hub proximal end passes the marker, e.g., to provide a visual indicator that the cartridge hub has been advanced sufficiently to activate the auto advance device. 
     In accordance with yet another embodiment, a tamping mechanism is provided that includes a middle hub, a housing, a spring biased so a distal end of the spring displaces a tamping device in a distal direction, a latch coupled to the housing for engaging with a latching detent on the middle hub in one latch position and for engaging with the tamping device in another latch position, and a pusher member slidably disposed within a proximal end of the middle hub, a proximal end of the pusher member for engaging with the tamping device. The pusher member may be movable distally to tamp a sealant when the tamping device is released by the latch. The tamping mechanism may further include a spring clip for biasing the latch in the another latch position. 
     In accordance with still another embodiment, a tamping mechanism is provided that includes a middle hub, a housing, a spring biased so a distal end of the spring displaces a tamping device in a distal direction, a trigger pin slidably disposed within the housing, and a pusher member slidably disposed within a proximal end of the middle hub. A proximal end of the pusher member may engage with the tamping device. The pusher member may be movable distally to tamp a sealant when the tamping device is released. The trigger pin may be moveable proximally upon engagement with the middle hub, thereby releasing a stopper plate. In one embodiment, the tamping device includes a leaf spring for displacing the stopper plate in a position enabling distal movement of the tamping device. In another embodiment, the tamping device includes a spring biased hub latch for displacing the stopper plate in a position enabling distal movement of the tamping device. 
     In accordance with yet another embodiment, a method is provided for sealing a puncture extending through tissue to a body lumen. The method may include advancing a positioning member through the puncture until an expandable element thereon is disposed within the body lumen, expanding the expandable element within the body lumen, and retracting the positioning member until the expanded positioning element contacts a wall of the body lumen adjacent the puncture. 
     A cartridge, carrying a sealant, a pusher member, and a proximal cartridge hub, may be advanced into the puncture until a distal end of the cartridge contacts the expandable element and/or an auto advance device in the cartridge hub is activated, e.g., by compressing a tamping spring and an auto advance spring in the auto advance device. The cartridge may be withdrawn from the puncture while maintaining the sealant and the pusher member within the puncture, and the sealant may be compressed within the puncture, e.g., between the pusher member and the expandable element, by the auto advance device, e.g., by expanding the tamping spring. 
     In accordance with still another embodiment, a method is provided for sealing a puncture extending through tissue to a body lumen. The method may include advancing a positioning member through the puncture until an expandable element thereon is disposed within the body lumen, expanding the expandable element within the body lumen, and retracting the positioning member until the expanded positioning element contacts a wall of the body lumen adjacent the puncture. 
     A cartridge, carrying a sealant and a pusher member, may be advanced into the puncture until a distal end of the cartridge contacts the expandable element and the pusher member is compressed between a catch on the positioning member and the sealant. An auto advance device on the cartridge is then activated, thereby allowing the compressed pusher member to expand axially and compress the sealant between the pusher member and the expandable element. For example, the pusher member may include a tamping spring and the tamping spring may be compressed, thereby shortening the pusher member, yet biasing the pusher member to extend axially. 
     The cartridge may be withdrawn, leaving the sealant and pusher member within the puncture. The expandable element may be collapsed and the positioning member withdrawn, e.g., through the sealant and pusher member, whereupon the pusher member may be removed. 
     Other aspects and features of the present invention will become apparent from consideration of the following description taken in conjunction with the accompanying drawings. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         FIG. 1A  is a perspective view of an exemplary embodiment of an apparatus for delivering a sealant into a puncture through tissue, including a cartridge carrying the sealant and a positioning member. 
         FIG. 1B  is an exploded cross-sectional side view of a system for delivering a sealant into a puncture through tissue, including the apparatus of  FIG. 1A  and an introducer sheath. 
         FIGS. 2A and 2B  are cross-sectional views of a distal portion of the apparatus of  FIGS. 1A and 1B , with the cartridge in proximal and distal positions, respectively. 
         FIGS. 3A ( 1 )- 3 A( 3 ) are cross-sectional views of a hub of the cartridge of  FIG. 1A  showing components of an auto advance device therein in an inactive position. 
         FIGS. 3B ( 1 )- 3 B( 3 ) are cross-sectional views of a hub of the cartridge of  FIG. 1A  showing components of the auto advance device of  FIGS. 3A ( 1 )- 3 A( 3 ) in an active position. 
         FIGS. 4A, 5A, 6A, 7A, and 8A  are partial cross-sectional views of a patient&#39;s body illustrating a method of using the system of  FIG. 1A  for sealing a puncture through tissue. 
         FIGS. 4B, 5B, 6B, 7B, and 8B  are cross-sectional detail views of the method of  FIGS. 4A, 5A, 6A, 7A, and 8A . 
         FIGS. 6C and 6D  are perspective views of a proximal end of a hub on the cartridge of the system of  FIG. 1A  before and after the hub passes a marker on the positioning member, respectively. 
         FIG. 9  is a cross-sectional view of another embodiment of an apparatus for delivering sealant into a puncture through tissue, including a tamping device. 
         FIGS. 10A-10B  are cross-sectional views of the apparatus of  FIG. 9  in a first position. 
         FIGS. 11A-11B  are cross-sectional views of the apparatus of  FIG. 9  in a second and a third position, respectively. 
         FIGS. 12A-12C  are cross-sectional views of another embodiment of an apparatus for delivering sealant into a puncture through tissue, including a tamping device employing a latch gate configuration. 
         FIG. 13  is a cross-sectional view of another embodiment of an apparatus for delivering sealant into a puncture through tissue, including a tamping device in a position, similar to the embodiment shown in  FIG. 11B . 
         FIG. 14  is a cross-sectional view of yet another embodiment of an apparatus for delivering sealant into a puncture through tissue, including a tamping device in a position, similar to the embodiment shown in  FIG. 11B . 
         FIGS. 15A-15C  are cross-sectional views of an apparatus for delivering a sealant device into a puncture through tissue including a tamping device employing complementary latches. 
     
    
    
     DETAILED DESCRIPTION OF THE EXEMPLARY EMBODIMENTS 
     Turning to the drawings,  FIGS. 1A and 1B  show an exemplary embodiment of an apparatus  101  and a system  10 , respectively, for sealing a puncture through tissue. Generally, as shown in  FIG. 1A , the apparatus  101  includes a cartridge or other tubular member  120 , and a positioning or occlusion member  140  including a positioning member housing  148 . As best seen in  FIG. 1A , the cartridge  120  includes a sealant  2  therein, a plunger, tamping member, advancing member, or other pusher member  130  carried by the cartridge  120 , and a cartridge hub  123 . As shown in  FIG. 1B , the apparatus  101  may be part of a system  10 , e.g., which may also include a delivery, access, procedure, introducer, or other sheath  20 . Optionally, the system  10  may include one or more other components, e.g., a needle, guidewire, and/or other instrument(s) for creating a puncture, a syringe or other source of inflation media and/or vacuum, and/or a source of additional sealing compound (not shown). 
     As best seen in  FIG. 1B , the introducer sheath  20  may be a generally tubular body including a proximal end  22 , a distal end  24  sized for insertion into a puncture through tissue, and a lumen  26  extending between the proximal and distal ends  22  and  24 . The introducer sheath  20  may be formed from a substantially rigid, semi-rigid, and/or flexible tubular body including a hub  23  on the proximal end  22 . The introducer sheath  20  may have sufficient length to extend from a patient&#39;s skin through any intervening tissue into a blood vessel or other body lumen, e.g., having a length between about ten centimeters and twenty centimeters (10-20 cm), and may have an outer diameter between about 1.6 millimeters and four millimeters (1.6-4 mm). The distal end  24  may be tapered and/or may include a substantially atraumatic distal tip  25  for facilitating advancement through tissue and/or a puncture. 
     The introducer sheath  20  may be formed using known materials and/or methods, e.g., plastic with the tubular body and hub  23  substantially permanently connected together, e.g., using one or more of an interference fit, one or more mating connectors (not shown), bonding with adhesive, sonic welding, and the like. The hub  23  generally includes one or more seals (not shown) adjacent an opening  27 , which may prevent flow of blood or other fluids out of the hub  23  from the lumen  26 , yet accommodate insertion of one or more instruments into the lumen  26 , such as the cartridge  120  and/or positioning member  140 . Optionally, as shown, the hub  23  may include a side port  29  communicating with the lumen  26 , e.g., for coupling a source of saline or other fluid (not shown) to the hub  23 . 
     With additional reference to  FIG. 1B , the cartridge  120  is generally an elongate tubular body including a proximal end  122 , a distal end  124  sized for introduction into the lumen  26  of the introducer sheath  20 , and a lumen  126  extending between the proximal and distal ends  122 ,  124 . The cartridge  120  may be substantially rigid, semi-rigid, or flexible, e.g., such that the cartridge  120  may be advanced through the introducer sheath  20  or otherwise into a puncture through tissue. The cartridge  120  may also include a tapered and/or substantially atraumatic distal tip  125  and/or an enlarged handle or hub  123  on the proximal end  122 . In one embodiment, the hub  123  includes a tamping or auto-advance device, as discussed in more detail below. 
     Optionally, the system  10  may include a locking member (not shown) for coupling the introducer sheath  20  to the cartridge  120  during use such that subsequent movement of the cartridge  120 , e.g., proximally during retraction, causes the introducer sheath  20  to be pulled or otherwise moved along with the cartridge  120 . This coupling may prevent accidental proximal movement of the cartridge  120  independent of the introducer sheath  20 , which may otherwise result in deploying the sealant  2  from the cartridge  120  within the introducer sheath  20 , rather than within a puncture itself. Exemplary embodiments of locking elements that may be used are disclosed in co-pending U.S. patent application Ser. No. 11/864,835, filed Sep. 28, 2007, and published as U.S. Publication No. 2009/0088793, the entire disclosure of which is hereby expressly incorporated by reference. 
     The sealant  2  is provided within the distal portion of the cartridge  120  and the pusher member  130  is provided proximal to the sealant  2  within the cartridge  120 . The sealant  2  may include a biocompatible, bioabsorbable, and/or expandable material, such as a freeze-dried hydrogel. The sealant  2  may have a solid or hollow cylindrical shape, a rolled sheet shape, a disk shape, or other shapes or cross-sections, such as elliptical, triangular, square, conical, disk, or polygonal shapes. For example, the sealant  2  may be formed from a solid material including a lumen  4  extending between proximal and distal ends thereof, as shown in  FIG. 1B . The lumen  4  may be created by rolling a sheet of material around a mandrel, by molding, by boring into, or otherwise removing material from an already formed solid material, and the like. The lumen  4  may be dimensioned such that the positioning member  140 , a guidewire, and/or other instruments (not shown) may slide or otherwise pass through the sealant  2 , as described elsewhere herein. 
     The sealant  2  may be substantially homogeneous or may include one or more different materials at one or more locations. For example, in one embodiment, the sealant  2  may include a carrier or core having first and second hydrogel precursors disposed thereon in an unreactive state, which may provide a “sticky” adherent coating when the sealant  2  is exposed to an aqueous environment. In one embodiment, the sealant  2  may be formed from a biocompatible and/or bioabsorbable hydrogel, e.g., polyethylene glycol (“PEG”), or other synthetic material. For example, the hydrogel may include a lyophilized (i.e., freeze-dried) PEG polymer that includes hydrolytically degradable chemical groups, e.g., including a macroporous polymer network, which may uptake fluid and expand when exposed to an aqueous environment. The magnitude of expansion or swelling (pre to post hydration) may be significant, e.g., between about two and ten times ( 2 X- 10 X) its lyophilized size based on volume. 
     In addition or alternatively, the sealant  2  may include pro-thrombotic material, e.g., including one or more biological pro-thrombotics, such as collagen, fibrin, carboxymethylcellulose, oxidized cellulose, alginates, gelatin, or other protein-based material, and/or synthetic materials, such as polyglycolic acids (PGA&#39;s), polyactides (PLA&#39;s), polyvinyl alcohol, and the like. Optionally, the sealant  2  may include one or more therapeutic and/or pharmaceutical agents, e.g., to promote healing, prevent infection, and/or other adverse medical events, and the like. Such agents may be embedded in the sealant material and/or applied as one or more coatings or layers. Exemplary materials and methods for making and using them are disclosed in U.S. Pat. Nos. 6,152,943, 6,165,201, 6,179,862, 6,514,534, 6,379,373, 6,703,047, 7,009,034, 6,887,974, and in co-pending U.S. patent application Ser. No. 10/454,362, filed Jun. 4, 2003, published as US 2004/0249342, Ser. No. 10/982,387, filed Nov. 5, 2004, published as US 2006/0034930, Ser. No. 10/982,384, filed Nov. 5, 2004, published as US 2006/0099238, and Ser. No. 11/465,791, filed Aug. 18, 2006 published as US 2007/0231366. The disclosures of these references are expressly incorporated by reference herein. 
     The sealant  2  may be disposed within the lumen  126  of the cartridge  120  proximate to the distal end  124 , e.g., immediately adjacent the distal tip  125 . Thus, when advanced into the introducer sheath  20  or otherwise within the puncture, the sealant  2  may remain out of direct or indirect contact with blood or other bodily fluids along the blood path. Optionally, the cartridge  120  may include a split distal end (not shown), e.g., formed by creating one or more relatively short longitudinal cuts or slots extending proximally from the distal end  124 . The split distal end may facilitate retraction of the cartridge  120  relative to the sealant  2 , e.g., by providing extra flexibility at the distal end  124 . Such cuts or slots may allow the distal end  124  to separate more easily from the sealant  2 , e.g., as the sealant begins to expand upon being exposed to an aqueous environment, such as blood or other bodily fluids. The lumen  126  may be sized such that the cartridge  120  and sealant  2  are slidable relative to one another, e.g., to allow the cartridge  120  to be retracted proximally relative to the sealant  2  and/or pusher member  130 . 
     With further reference to  FIG. 1B , the pusher member  130  may be an elongate tubular body, e.g., a plunger or catheter, including a proximal end  132 , a distal end  134  sized for introduction into the lumen  126  of the cartridge  120 , and a lumen  136  extending between the proximal and distal ends  132 ,  134 . The pusher member  130  may be sized for being slidably received within the lumen  126  of the cartridge  120 , although the pusher member  130  may abut or otherwise interact with the hub  123  of the cartridge  120  such that the pusher member  130  is advanced distally when the cartridge  120  is advanced distally. The distal end  134  of the pusher member  130  may terminate in a substantially blunt distal tip  135 , e.g., to facilitate contacting, pushing, advancing, tamping, and/or “cinching” the sealant  2  within a puncture, as described further below. In one embodiment, the proximal end  132  of the pusher member  130  interacts with an auto-advance device in the hub  123 , as discussed in more detail below. 
     The pusher member  130  may be substantially rigid, semi-rigid, and/or substantially flexible, having sufficient column strength to allow proximal movement of the cartridge  120  relative to the sealant  2  without buckling the pusher member  130  and/or to allow the distal tip  135  of the pusher member  130  to be “tamped” down on sealant  2  within a puncture, e.g., by pushing from the proximal end  132 , as described elsewhere herein. The lumen  136  of the pusher member  130  may be sized to accommodate the positioning member  140 , a guidewire (not shown), a flowable sealing compound, and/or fluid therethrough. As explained elsewhere herein, the pusher member  130  may include an axially compressible or foreshortenable portion, e.g., that may be compressed, yet is biased to extend axially towards its original length. For example, a tamping spring  210  may be provided adjacent the proximal end  132  of the pusher member  130 , e.g., between the proximal end  132  and a secondary pusher member  230 . 
     Alternatively, the tamping spring  210  may be coupled to and extend from the proximal end  132  of the pusher member  130  without the secondary pusher member  230 . The tamping spring  210  may be compressed by an auto advance device  200  (not shown, see  FIGS. 3A-3B ) within the hub  123  during use, thereby biasing the distal end  134  of the pusher member  130  to move distally, as explained further below. 
     With continued reference to  FIGS. 1A and 1B , the positioning member  140  generally is an elongate member including a proximal end  142 , a distal end  144 , a positioning or occlusion element  146  on the distal end  144 , and a housing  148  on the proximal end  142 . The positioning element  146  may be an expandable member, such as a balloon, a wire mesh structure, an expandable frame, and the like. The positioning element  146  may be selectively expandable, e.g., using a source of inflation media, a pull wire, and/or other actuator (not shown), operable from the proximal end  142  of the positioning member  140 . 
     For example, as shown in  FIGS. 1A and 1B , the positioning element may be a balloon  146 , and the positioning member  140  may be a tubular body including a lumen (not shown) extending between the proximal and distal ends  142 ,  144  and communicating with an interior of the balloon  146 . For example, a syringe  149  (not shown, see  FIGS. 4A, 5A, 6A ) may communicate with the housing  148  (and consequently the lumen and interior of the balloon  146 ) via tubing  147  connected to a port on the housing  148 . Optionally, the positioning member  140  may include an internal pull wire and piston arrangement (not shown) that causes the balloon  146  to shorten during expansion and extend during collapse. Exemplary embodiments of positioning members  140  including balloons that may be used are disclosed in co-pending U.S. patent application Ser. No. 10/454,362, filed Jun. 4, 2003, published as US 2004/0249342, Ser. No. 11/112,877, filed Apr. 22, 2005, published as US 2006/0253072, and Ser. No. 11/112,971, filed Apr. 22, 2005, and published as US 2008/0009794. The entire disclosures of these references are expressly incorporated by reference herein. 
     Alternatively, the positioning element  146  may be biased to an enlarged condition, but may be compressed to a contracted condition, e.g., by an overlying sleeve or other constraint (not shown). The constraint may be removed to expose the positioning element, allowing the expandable element to automatically expand to the enlarged condition. Additional information on expandable structures that may be provided on the positioning member  140  may be found in U.S. Pat. Nos. 6,238,412, 6,635,068, and 6,890,343. The entire disclosures of these references are expressly incorporated herein by reference. 
     Optionally, the positioning member  140  may include a transition cuff (not shown) on the distal end  144  adjacent and distal to the positioning element  146 . The transition cuff may comprise a flexible material similar to the structure of material used in the positioning element  146 , e.g., as described elsewhere herein. The transition cuff may provide the apparatus  101  with a seal to minimize exposure of the sealant  2  to fluids during introduction and/or may provide an atraumatic tip to lessen injury to the vessel during initial insertion of the apparatus  101  into the puncture and vessel. During expansion of the positioning element  146 , the transition cuff may be displaced off the distal end of the positioning element  146  and fold adjacent to the positioning element  146 . A lubricious coating may be applied to the transition cuff and/or positioning element  146  to ease the folding of the transition cuff during the expansion of the positioning element  146 . Additional information on transition cuffs and systems and methods including them may be found in co-pending application Ser. No. 11/854,534, filed Sep. 12, 2007, published as U.S. Publication No. 2008/0082122, the entire disclosure of which is expressly incorporated by reference herein. 
     Turning to  FIGS. 2A and 2B , the apparatus  101  may be used to position and deliver the sealant  2  within a puncture, e.g., extra-vascularly just above or otherwise adjacent to an arteriotomy in a blood vessel or other body lumen communicating with a puncture, as described further elsewhere herein. In one embodiment, as shown in  FIG. 2A , the cartridge  120  (along with the pusher member  130  and sealant  2 ) may be initially provided on the proximal end  142  of the positioning member  140 . For example, the housing  148  (not shown in  FIGS. 2A and 2B , see  FIG. 1A ) on the positioning member  140  and the hub  123  on the cartridge  120  may be initially connected to one another, e.g., using one or more releasable detents (not shown) and the like. The cartridge  120  may be slidable distally along the positioning member  140 , e.g., by disconnecting the hub  123  from the housing  148 , and then advancing the hub  123  and the cartridge  120  until the distal end  124  of the cartridge  120  is disposed adjacent the positioning element  146 , as shown in  FIG. 2B . For example, the detents may simply separate from one another when the hub  123  is advanced away from the housing  148  with sufficient force. Alternatively, one of the hub  123  and housing  148  may include an actuator or lock (not shown) that may be activated to separate the detents and/or otherwise allow the cartridge  120  to be advanced relative to the positioning member  140 . Alternatively, the cartridge  120  and pusher member  130  may be initially provided adjacent the distal end  144  of the positioning member  140 , as shown in  FIG. 2B . 
     Optionally, the positioning member  140  and/or pusher member  130  may include one or more elements that engage when the cartridge  120  reaches a predetermined location when advanced distally along the positioning member  140 , e.g., to limit subsequent proximal movement of the pusher member  130  relative to the positioning member  140 . For example, as shown in  FIGS. 2A and 2B , the positioning member  140  may include a locking element, e.g., a stepped-down region or recess  145  at a predetermined location and the pusher member  130  may include a living hinge, tab, or other latch element  137  on the proximal end  132 . Alternatively, the locking element  145  may be a ring, tab, or other raised element (not shown) over which the latch element  137  may pass distally, yet may subsequently engage the latch element  137  to prevent proximal movement of the pusher member  130 , as shown in  FIG. 3B ( 3 ) and described further below. For example, the latch element  137  may simply be an annular notch in the proximal end  132  of the pusher member  130  to bias the proximal end inwardly. 
     As an alternative to the latch element(s)  137 , the pusher member  130  may simply include a relatively narrow region on the proximal end  132 . Further alternatively, the latch element(s)  137  may be replaced by a separate collar or sleeve, one or more inwardly oriented detents, and the like (not shown) attached to or otherwise formed on the proximal end  132  of the pusher member  130 . In an exemplary embodiment, the locking element  145  may be defined by a reduced diameter region on the positioning member  140 , e.g., formed by providing a larger tube around a smaller inner tube or by machining, etching, or otherwise removing a portion of the tubular body of the positioning member  140  distal to the reduced region. The pusher member  130  may include a corresponding element (also not shown) that may allow distal advancement but prevent proximal refraction once the pusher member  130  is advanced a predetermined distance, i.e., over the locking element  145 . Exemplary embodiments of cooperating elements are disclosed in U.S. Publications No. 2006/0099238 and 2009/0088793, incorporated by reference herein. 
     The reduced region or other locking element  145  may be provided at a predetermined location on the positioning member  140 , e.g., a predetermined distance from the positioning element  146  that corresponds to a length of the pusher member  130 , e.g., a relaxed or compressed length of the pusher member  130 . As the cartridge  120  (and consequently the pusher member  130 ) is advanced over the positioning member  140 , e.g., until the sealant  2  is disposed adjacent the positioning element  146 , the latch element  137  may pass freely over the locking element  145 . Thereafter, the latch element  137  may prevent the pusher member  130  from being retracted again past the locking element  145  due to the blunt edge of the latch element  137  abutting the locking element  145 . 
     Alternatively, the pusher member  130  may be fixed relative to the positioning member  140 , for example, mechanically bonded, chemically bonded, interference fit, and the like. For example, the distal end  134  of the pusher member  130  may be fixed a predetermined distance proximal to the positioning element  146 , e.g., to provide the sealant  2  immediately adjacent the positioning element  146 , as shown in  FIG. 2B . Additional information on such alternatives and methods for making and using them may be found in U.S. Publication No. 2008/0082122, incorporated by reference herein. 
     In one embodiment, the hub  123  of the cartridge  120  includes a tamping or auto advance device  200 , depicted in detail in  FIGS. 3A and 3B . Generally, the auto advance device  200  includes a slider tube  204  slidable within the housing  202  and coupled to the cartridge  120 . The slider tube  204  may be biased distally relative to the housing  202  such that movement of the cartridge  120 , sealant  2  (not shown, see  FIG. 1A ), and pusher tube  130  is initially coupled to the housing  202 . Thus, when the hub  123  is directed distally, the cartridge  120 , sealant  2 , and pusher tube  130  are also directed distally. However, the slider tube  204  may be movable proximally within the housing  202 , e.g., when the bias is overcome, to allow the cartridge  120  to move proximally relative to the sealant  2  and pusher member  130 , e.g., during deployment of the sealant  2 , as described further below. 
     As best seen in  FIG. 3A ( 3 ), the proximal end  132  of the pusher member  130  may be disposed within the housing  202  before the apparatus  101  is used. As shown in  FIGS. 3A ( 1 )- 3 A( 3 ), the auto advance device  200  may include an auto advance spring  206  adjacent the slider tube  204 , e.g., for biasing the slider tube  204  distally, yet allowing the slider tube  204  to move proximally within the housing  202  when the spring bias is overcome. It will be appreciated that other springs or biasing mechanisms may be provided for biasing the slider tube  204  distally within the housing  202 , yet allowing proximal movement relative to the housing  202 . In addition, as best seen in  FIGS. 3A ( 1 ) and  3 A( 2 ), the auto advance device  200  may include auto advance spring support tubing  208  fixed relative to the housing  202  and around which the auto advance spring  206  may be disposed. The slider tube  204  may slide over the support tubing  208  when the slider tube  204  is directed proximally within the housing  202 . 
     In addition, the auto advance device  200  may include one or more additional components, e.g., coupled to the pusher member  130 , cartridge  120 , and/or housing  202 . For example, the pusher tube spring  210  may be disposed between the secondary pusher member  230  and the proximal end  132  of the pusher member  130 . The pusher tube spring  210  may be coupled to the pusher member  130  and the secondary pusher member  230 , e.g., by one or more of an interference fit, bonding with adhesive, and the like. In this embodiment, the proximal end  132  of the pusher member  130  is positioned in the distal end  210   a  of the tamping spring  210  and the distal end of the secondary pusher member  230  is positioned within the proximal end  210   b  of the tamping spring  210 . Thus, the outside diameters of the pusher members  130  and  230  are slightly less than the inside diameter of the tamping spring  210 . 
     Optionally, the auto advance device  200  may include an inner cartridge or tamping tube  212  disposed around the pusher tube spring  210  and the secondary positioning member  230 . As best seen in  FIGS. 3A ( 1 ) and  3 A( 2 ), the inner cartridge  212  may be disposed concentrically within the slider tube  204 . The inner cartridge  212  may be coupled to the slider tube  204  such that the inner cartridge  212  moves with the slider tube  204 . For example, the inner cartridge  212  may include a hub  212   a , which may be received in a corresponding pocket or recess  204   a  in the slider tube  204 , thereby coupling movement of the inner cartridge  212  to the slider tube  204 . The inner cartridge  212  may also protect and/or conceal the pusher tube spring  210  therein and may be coupled to the proximal end  122  of the cartridge  120 . As best seen in  FIG. 3A ( 2 ), the inner cartridge  212  may have an outer diameter similar to the diameter of the cartridge  120 , e.g., such that the inner cartridge  212  abuts the proximal end  122  of the cartridge  120 . Alternatively, the inner cartridge  212  may be attached to the proximal end  122  of the cartridge  120 . In a further alternative, the inner cartridge  212  and cartridge  120  may be provided as a single piece, e.g., such that the inner cartridge  212  is merely an extension (not shown) extending proximally from the cartridge  120 . 
     In  FIGS. 3A ( 1 )- 3 A( 3 ), the auto advance device  200  is in an “inactive” position where the springs  206  and  210  are in extended or relatively relaxed states (best seen in  FIG. 3A ( 2 )). In the inactive position, the slider tube  204  may be biased by the auto advance spring  206  such that a flange  218  extending from the slider tube  204  abuts or otherwise contacts a distal rib  214  of the housing  202 , as best seen in  FIG. 3A ( 1 ). Thus, the slider tube  204  may be positioned in a distal portion of the housing  202  in the inactive position. In addition, in the inactive position, the support tubing  208  may be positioned proximally to and/or substantially entirely outside of the slider tube  204 , also as best seen in  FIG. 3A ( 1 ). As shown in  FIG. 3A ( 3 ), the secondary pusher member  230  is located proximal to the locking element  145  in the inactive position, e.g., such that movement of the pusher member  130  and secondary pusher member  230  are initially coupled to movement of the cartridge  120 . 
       FIGS. 3B ( 1 )- 3 B( 3 ) show the auto advance device  200  in an “active” position where the springs  210  and  206  are compressed or in a relatively higher potential energy state. In the active position, the housing  202 , including the cartridge  120 , sealant  2 , pusher member  130 , and slider tube  204  have been advanced distally relative to the positioning member  140  such that the secondary pusher member  202  has been advanced distally past the locking element  145 , as best seen in  FIG. 3B ( 3 ). In the active position, the auto advance spring  206  is compressed between a proximal rib  216  of the housing  202  and the proximal end of the slider tube  204 , and the slider tube  204  is positioned in a proximal portion of the housing  202 . For example, the cartridge  120  and hub  123  may be advanced relative to the positioning member  140  until the cartridge  120  cannot be advanced further, whereupon additional distal movement of the hub  123  causes the auto advance spring  206  to compress as the slider tube  204  (and proximal end  122  of the cartridge  120 ) moves proximally within the housing  202 . In addition, in the active position, the support tubing  208  may extend into the slider tube  204  and abut the secondary pusher member  230 , thus compressing the tamping spring  210  as the pusher member  130  moves proximally with the cartridge  120 , as best seen by comparing  FIG. 3B ( 2 ) with  FIG. 3A ( 2 ). When compressed, the tamping spring  210  applies a distal force against the pusher member  130 , biasing the pusher member  130  distally against the sealant  2 . As explained further below, as the sealant  2  expands and/or softens, e.g., upon exposure to an aqueous environment, the constant force applied by the tamping spring  210  causes the pusher member  130  to automatically advance distally, exerting constant force on the sealant  2 , thereby tamping or “cinching” the sealant  2  between the pusher member  130  and the positioning element  146  during expansion. This method is described in greater detail below. 
     In the embodiment shown, the springs  210  and  206  are compression springs that are in an expanded condition at their relatively relaxed length and/or lower potential energy state and are in a compressed condition and/or higher potential energy state when a load is applied. Alternatively, instead of the compression springs  210  and  206 , the auto advance device  200  may include other spring arrangements or biasing mechanisms, such as an extension spring, leaf spring, and the like (not shown), e.g., that may be in a compressed condition at its lower energy state length and in an expanded condition when a load is applied. 
     Turning to  FIGS. 4A-8B , an exemplary method is shown for sealing a puncture  90 , e.g., using the system  10  described above to deliver a sealant  2 , e.g., to achieve hemostasis within the puncture  90 . Generally, the puncture  90  extends from a patient&#39;s skin  92  through intervening tissue  96 , e.g., to a body lumen  94 . In an exemplary embodiment, the puncture  90  may be a percutaneous puncture communicating with a blood vessel  94 , such as a femoral artery, carotid artery, and the like. 
     In an exemplary method, the puncture  90  may be created using known procedures, e.g., using a needle, guidewire, one or more dilators, and the like (not shown). Then, as depicted in  FIGS. 4A and 4B , an introducer sheath  20  may be advanced through the puncture  90  into the vessel  94 , e.g., over a guide wire (not shown) placed through the puncture  90  into the vessel  94 . The introducer sheath  20  may provide access into the vessel  94  for one or more instruments, e.g., to allow one or more diagnostic, therapeutic, and/or other interventional procedures to be performed via the vessel  94 . Upon completing the procedure(s) via the vessel  94 , any such instrument(s) may be removed from the puncture  90 , leaving the introducer sheath  20  extending through the puncture  90  into the vessel  94 . 
     The distal end  144  of the positioning member  140  may be introduced into the puncture  90 , e.g., through the lumen  26  of the introducer sheath  20 , with the positioning element  146  in a collapsed condition, as shown in  FIG. 4B . As shown in  FIG. 4A , the cartridge  120  and cartridge hub  123 , along with the sealant  2  and pusher member  130  (not shown in  FIG. 4A  for clarity, see, e.g.,  FIGS. 1A-2B ), may be provided initially on the proximal end of the positioning member  140 , e.g. near the positioning member housing  148 . Thus, the distal end  124  of the cartridge  120  may initially be located outside the puncture  90  when the positioning member  140  is advanced into the puncture  90 . Alternatively, the cartridge  120  may be carried on the distal end  144  of the positioning member  140 , e.g., as shown in  FIG. 2B , such that the cartridge  120  (along with the sealant  2  and pusher member  130 ) is introduced simultaneously with the positioning member  140 , as described in U.S. Publication No. 2008/0082122, incorporated by reference herein. 
     Still referring to  FIGS. 4A and 4B , the distal end  144  of the positioning member  140  may be inserted through the puncture  90  (via the introducer sheath  20 ) and into the vessel  94 . Optionally, the positioning member  140  may include one or more markers (not shown) that may be disposed adjacent the proximal end  22  of the introducer sheath  20  when the distal end  144  extends beyond the distal end  24  of the introducer sheath  20 , e.g., to provide a visual indication that the positioning element  146  is disposed within the vessel  94  beyond the distal end  24  of the introducer sheath  20 . Once the positioning element  146  is disposed within the vessel  94 , i.e., beyond the distal end  24  of the introducer sheath  20 , the positioning element  146  may be expanded to an enlarged condition, as shown in  FIG. 4A  and as shown in phantom in  FIG. 4B . After expanding the positioning element  146 , the positioning member  140  may be at least partially withdrawn until the positioning element  146  contacts the wall of the vessel  94  (shown in  FIGS. 5A and 5B ), e.g., to substantially seal the vessel  94  from the puncture  90 . 
     In an exemplary method, this may involve a two-step process (although it may be completed in a single continuous action). First, with the positioning element  146  expanded within the vessel  94 , as shown in  FIG. 4A  and in phantom in  FIG. 4B , the positioning member  140  may be withdrawn until the positioning element  146  contacts the distal end  24  of the introducer sheath  20 , which may provide a first tactile feedback to the user (i.e., that the positioning element  146  has contacted the introducer sheath  20 , e.g., based upon the increased weight and/or resistance to proximal movement). After encountering the first tactile feedback, the positioning member  140  may be withdrawn further until the positioning element  146  contacts the wall of the vessel  94  and resists further withdrawal, thereby providing a second tactile feedback. The introducer sheath  20  may be pulled proximally by the positioning element  146  as the positioning member  140  is withdrawn, e.g., until the positioning element  146  contacts the wall of the vessel  94  and the distal end  24  of the introducer sheath  20  is withdrawn from the vessel  94  into the puncture  90 , as shown in  FIGS. 5A and 5B . 
     Alternatively, a tension indicator assembly (not shown) may be used for more accurate control of the proximal tension on the positioning member  140 . Exemplary tension indicator assemblies are disclosed in co-pending U.S. patent application Ser. No. 12/098,380, filed Apr. 4, 2008, and published as U.S. Publication No. 2009/0254110, the entire disclosure of which is expressly incorporated herein by reference. 
     The desired amount of proximal tension may be maintained manually or using a tension device (not shown) to provide temporary hemostasis, e.g., during the subsequent steps. Exemplary tension devices are disclosed in co-pending U.S. patent application Ser. No. 10/806,952, filed Mar. 22, 2004 and published as US 2004/0267308, the entire disclosure of which is expressly incorporated herein by reference. 
     Turning to  FIGS. 6A and 6B , the cartridge  120  (carrying the sealant  2 , shown in  FIG. 6B ) may then be advanced distally over the positioning member  140  into the puncture  90 , as indicated by arrow  164 . For example,  FIG. 6A  illustrates the user grasping the hub  123  and pushing the hub  123 , e.g., to separate the hub  123  from the positioning member housing  148  and advance the cartridge  120  distally over the positioning member  140  and into the introducer sheath  20 . The cartridge  120  may be advanced into the introducer sheath  20  until the distal end  124  of the cartridge  120  contacts the expanded positioning element  146 , as shown in  FIG. 6B . 
     In one embodiment, the cartridge  120  may be advanced through the introducer sheath  20  until a hub  123  of the cartridge  120  abuts a hub  23  on the introducer sheath  20 . In another embodiment, the cartridge  120  may be advanced until a locking element (not shown) engages, thereby coupling the cartridge  120  to the introducer sheath  20 . 
     In the embodiment where the cartridge hub  123  includes the auto advance device  200 , the auto advance device  200  is initially in the inactive position (not shown, see, e.g.,  FIGS. 3A ( 1 )- 3 A( 3 )), during distal advancement of the hub  123  and the cartridge  120 . Thus, distal advancement of the hub  123  causes corresponding advancement of the cartridge  120 . Once the cartridge  120  contacts the expanded positioning element  146 , further distal advancement of the cartridge  120  is prevented by the positioning element  146 . 
     Then, when the hub  123  is advanced further distally relative to the cartridge  120  the auto advance device  200  may be activated. For example, as shown in  FIG. 6C , the cartridge  120  and hub  123  may be advanced until a marker  220  on the positioning member  140  becomes initially exposed, which may indicate that the distal end  124  of the cartridge  120  is adjacent to or in contact with the expanded positioning element  146 . At this stage, as shown in  FIGS. 3A ( 1 )- 3 A( 3 ), the slider tube  204  may be in the distal position within the housing  202  of the hub  123 . The hub  123  may then be advanced further, e.g., at least partially over the cartridge  120 , as shown in  FIGS. 3B ( 1 )- 3 B( 3 ). 
     As shown in  FIG. 6D , as the hub  123  is advanced, the marker  220  on the positioning member  140  may become entirely exposed, thereby providing a visual indicator to the user confirming that the auto advance device  200  has been activated. It will be appreciated that other visual and/or audible indicators (not shown) may be provided on the positioning member  140  and/or hub  123  to provide confirmation when the secondary pusher member  230  has been sufficiently advanced and/or the tamping spring  210  has been compressed. Since the cartridge  120  is prevented from moving distally, distal advancement of the hub  123  causes the slider tube  204 , which is fixed to the cartridge  120 , to slide into a proximal portion of the hub  123  so that the proximal end of the slider tube  204  contacts the proximal end of the hub  123 , as shown in  FIGS. 3B ( 1 )- 3 B( 3 ). Distal advancement of the hub  123  further causes the auto advance spring  206  to compress between the proximal end of the slider tube  204  and the proximal rib  216  of the housing  202 . In the active position, the auto advance spring support tubing  208  extends into the tamping tube  212 , thereby pushing the secondary pusher member  230  towards the proximal end  132  of the pusher member  130 , which causes the tamping spring  210  to compress. As the secondary pusher member  230  moves towards the proximal end  132  of the pusher member  130 , the latch element  237  passes over the raised element  145  on the positioning member  140 . Thereafter, the secondary pusher member  230  is prevented from retracting proximally relative to the positioning member  140  and the compression of the tamping spring  210  is maintained, thus providing constant force to the sealant  2  via the pusher member  130 . 
     Returning to  FIGS. 6A and 6B , once the cartridge  120  and hub  123  have been advanced to place the sealant  2  in the desired position within the puncture  90  (best seen in  FIG. 6B ), the cartridge  120  may be retracted, e.g., by pulling proximally on the hub  123 , as indicated by arrow  165  in  FIG. 7A . If the optional locking element (not shown) has coupled the introducer sheath  20  to the cartridge  120 , this action also withdraws the introducer sheath  20  from the puncture  90 . Alternatively, the introducer sheath  20  may be pulled, contacting the hub  123  and thereby withdrawing the cartridge  120  along with the introducer sheath  20 . As the cartridge  120  is retracted, the pusher member  130  may remain in place (e.g., due to the locking element  145 ) to prevent substantial proximal movement of the sealant  2 , the sealant  2  is exposed within the puncture  90 , as shown in  FIG. 7B . In one embodiment, as described above, when the cartridge  120  is retracted, the latch element  237  on the secondary pusher member  230  may abut the locking element  145 , thereby preventing substantial proximal retraction of the secondary pusher member  230  and the sealant  2  adjacent to the distal end  134  of the pusher member  130 . 
     When the sealant  2  is exposed within the puncture  90 , the sealant  2  may be exposed to blood and/or other body fluids within the puncture  90 . This exposure may cause the sealant  2  to absorb fluid, soften and/or expand within the puncture  90 , e.g., to provide hemostasis. The auto advance device  200  may cause the pusher tube  130  to automatically advance as space permits, e.g., when the sealant  2  begins to swell and/or soften, thereby compressing or “cinching” the sealant  2  between the pusher tube  130  and the positioning element  146 . Optionally, if desired, the pusher member  130  may be advanced manually to compress the sealant  2  further, e.g., against the positioning element  146 . This may cause the sealant  2  to expand further radially outwardly and/or press the sealant  2  against the arteriotomy, e.g., to enhance sealing the puncture  90  from the vessel  94 . Optionally, the pusher member  130  may include one or more distance markers (not shown) on or adjacent the proximal end  132 , and the pusher member  130  may be advanced into the puncture  90  a desired distance, which may be confirmed by monitoring the distance markers. 
     Once the sealant  2  has been exposed for sufficient time and/or tamped by the pusher member  130 , the positioning element  146  may be collapsed, and the positioning member  140  withdrawn from the vessel  94  and puncture  90 , e.g., by pulling the collapsed positioning element  146  through the sealant  2  and pusher member  130 , as depicted by arrow  166  in  FIG. 8A . In an exemplary embodiment, the expandable member  146  may have a profile not more than about 0.875 millimeter (035 inch) to facilitate removal of the positioning member  140  without substantially disturbing the deployed sealant  2 . The pusher member  130  may be maintained substantially stationary during withdrawal of the positioning member  140 , e.g., to prevent migration and/or dislodgment of the sealant  2  within the puncture  90 . For example, as shown in  FIG. 8A , the pusher member  130  may be maintained substantially stationary by a user grasping the pusher member  130  during withdrawal of the positioning member  140 . In the embodiment where the system  10  includes the auto advance device  200 , the user may grasp the pusher member  130  rather than the secondary pusher member  230  so that the user may have more control of the force applied to the sealant  2  during withdrawal of the positioning member  140 . In addition, in embodiments where the sealant  2  includes an adherent layer, the “sticky” adherent layer may also aid in securing the sealant  2  to the surrounding tissue. Once the positioning member  140  is completely removed, the pusher member  130  may be removed from the puncture  90 , leaving the sealant  2  within the puncture  90 , as shown in  FIG. 8B . 
     Optionally, after removing the positioning member  140 , liquid hydrogel or other sealing compound, or other material may be delivered into the puncture  90 , e.g., above and/or around the sealant  2 , to assist in achieving hemostasis. For example, such material may be delivered via the lumen  136  of the pusher member  130  and/or by introducing another delivery device (not shown) into the puncture  90 , e.g., after removing the pusher member  130 . 
     Turning now to  FIGS. 9-11B , another exemplary embodiment of an apparatus  301  is shown for delivering a sealant  302  into a puncture through tissue including a tamping device  385 . Similar to other embodiments herein, the apparatus  301  is shown schematically and not to scale, e.g., with the radial and axial dimensions exaggerated to facilitate identification of the components of the apparatus  301 . The apparatus  301  includes an elongate positioning or occlusion member  340 , a cartridge  370 , and a catheter hub  380 . The positioning member  340  includes a proximal end  342 , a distal end  344 , and an expandable positioning element  346 , e.g., similar to previous embodiments, on the distal end  344 . Similar to previous embodiments, optionally, a transition cuff  350  may be located adjacent to the distal end of the expandable member  346 . 
     The cartridge  370  generally includes an outer tubular member  373 , a sealant  302 , an inner pusher member  330 , and a middle hub  376 . The outer tubular member  373  includes a lumen  360  extending between a proximal end  372  and a distal end  374  thereof. The outer tubular member  373  is movable relative to the inner pusher member  330 , which is slidably disposed within the outer tubular member  373 . The middle hub  376  may be attached to the proximal end  372  of the outer tubular member  373 . 
     The sealant  302  and inner pusher member  330  are similar to previous embodiments. The inner pusher member  330  includes a lumen extending between a proximal end  332  and a distal end  334 . The inner pusher member  330  may include a peel away lock  390  or detents  336 , e.g., as shown in  FIGS. 10A-10B , for initially limiting proximal movement of the outer tubular member  373 , e.g., until after removing the lock  390 . 
     The middle hub  376  includes a main cylinder  371 , a first conical surface  377   a , and a second conical surface  377   b . A latching detent  375  is disposed between the first and second conical surfaces  377   a ,  377   b . The main cylinder  371  includes a proximal ridge  371   a , and a distal surface  371   b . The first conical surface  377   a  is tapered from the proximal ridge  371   a  to the latching detent  375 . The distal end of the second conical surface  377   b  includes a diameter larger than the proximal end of the first conical surface  377   a  thereby creating the latching detent  375 . Alternatively, the first conical surface  377   a  may be tapered using multiple angles or may be tapered gradually. 
     The catheter hub  380  includes an outer housing  380   a  including proximal and distal ends  382 ,  384  that are substantially fixed relative to the proximal end  342  of the positioning member  340 . For example, the catheter hub  380  may include an inner housing  380   b  fixed relative to the outer housing  380   a  and coupled to a handle or balloon inflator  396  on the positioning member  340 . The hub  380  may also include a tamping device  385 , latch  387 , and a tamping spring  381  disposed between the tamping device  385  and the balloon inflator  396 . The catheter hub  380  may further include centering surfaces  386 , e.g., on the inner housing  380   b . The material of the catheter hub  380  and other components may be formed from suitable durable plastics, metals, and/or composite materials. During operation of the apparatus  301 , the interior of the handle or balloon inflator  396  may communicate via a lumen (not shown) of the positioning member  340  with the interior of the expandable member  346  to provide a fluid to expand the expandable member  346 , e.g., similar to other embodiments described elsewhere herein. Optionally, the handle  396  may include a tension indicator (not shown), e.g., also similar to the other embodiments described herein. 
     The tamping device  385  includes a proximal surface  385   a , a distal surface  385   b , a proximal nub  385   c , and a recess  385   d . The recess  385   d  extends partially through the tamping device  385  between the distal surface  385   b  and a most distal portion  385   e  of proximal nub  385   c . The recess  385   d  is sized to receive the proximal end  332  of the inner pusher member  330  therein without allowing the inner pusher member  330  to pass entirely through the tamping device  385 . 
     The latch  387  includes a proximal arm  387   a , a distal arm  387   b , and an intermediate arm  387   c . The proximal, distal, and intermediate arms  387   a ,  387   b ,  387   c  each include a proximal, distal, and intermediate tip  388   a ,  388   b ,  388   c , respectively. The distal tip  388   b  may be shaped to mate with the latching detent  375  of the middle hub  376 , and the intermediate tip  388   c  may be shaped with a nub for making initial contact with the proximal end  378  of the middle hub  376 . A circular spring clip  383  abuts the proximal arm  387   a  to bias the proximal arm  387   a  radially inwardly (away from the inner housing  380   b . The inwardly biased proximal arm  387   a  causes the proximal tip  388   a  to prevent distal movement of the tamping device  385  when the latch  387  is in the position shown in  FIG. 9 . 
     The centering surfaces  386  are located proximally to the distal end  384 . The centering surfaces  386  may be conically shaped and/or otherwise sized and/or shaped for cooperating with conical surfaces  377   a ,  377   b  on the middle hub  376 . The cooperation of centering surfaces  386  with conical surfaces  377   a ,  377   b  provides automatic centering during engagement of the middle hub  376  to the catheter hub  380 . 
       FIG. 9  shows the apparatus  301  in a first position, e.g., where the cartridge  370  is disposed adjacent a distal end  344  of the positioning member  340 . This first position may be a configuration in which the apparatus  301  is delivered from a manufacturer to a user. In the first position, the transition cuff  350 , if included, is fully extended over the distal end  374  of the outer tubular member  373 . Further, in the first position, the expandable member  346  may be fully disposed within the lumen  376  of the outer tubular member  373 , the tamping device  385  may rest against the proximal tip  388   a  of the proximal arm  387   a , and the tamping spring  381  may be compressed. 
     Turning to  FIG. 10A , the apparatus  301  of  FIG. 9  is shown in a second position limited by a peel away lock  390 . Alternatively, the apparatus  301  may be provided to the user initially in the second position, i.e., with the cartridge  370  disposed adjacent the catheter hub  380  but without activating the tamping device  385 . For example, proximal movement of the cartridge  370  into the catheter hub  380  past the second position may be prevented until the peel away lock  390  is removed. The peel away lock  390  includes a passage extending between a proximal end  392  and a distal end  394  that surrounds the inner pusher member  330 . The peel away lock  390  may be disposed between the proximal end  378  of the middle hub  376  and the distal surface  385   b  of the tamping device  385 . In the second position, the cartridge  370  may be positioned proximally relative to the expandable member  346  such that the expandable member  346  is fully exposed distal to the distal end  374 . In addition, in the second position, the distal end of the sealant  302  may be disposed adjacent the distal end  374  of the cartridge  370 , and the latch  387  may remain in contact with the distal surface  385   b  of the tamping device  385 . 
     Turning to  FIG. 10B , an alternative embodiment of the apparatus  301 ′ is shown that is generally similar to the embodiment of  FIGS. 9 and 10A . Similar to  FIG. 10A , the apparatus  301 ′ is shown in the second position; however, unlike the apparatus  301  that is only limited from further proximal movement, the apparatus  301 ′ is positively locked in the second position by a locking bar  379   a .′ The apparatus  301 ′ also includes a modified middle hub  376 ′ and a modified inner pusher member  330 .′ The modified middle hub  376 ′ includes a pushbutton  379 ′ coupled to the locking bar  379   a .′ The pushbutton  379 ′ and the locking bar  379   a ′ are disposed within a lumen  379   b ′ extending between an outer and inner surface of the main cylinder  371 .′ The pushbutton  379 ′ may be spring loaded to bias the locking bar  379   a ′ into a detent  336 ′ on the pusher member  330 .′ The pushbutton  379 ,′ familiar to those of ordinary skill in the art, may be a single action type or a double action type used to retract the locking bar  379   a ′ from the detent  336 .′ The spring loaded locking bar  379   a ′ may be extended into the detent  336 ′ when the positioning member  340 ,′ sealant  302 ,′ and inner pusher member  330 ′ are advanced in a distal direction until the locking bar  379   a ′ aligns with the detent  336 .′ The locking bar  379   a ′ prevents further proximal movement of the cartridge  370 ′ until the pushbutton  379 ′ is pressed to retract the locking bar  379   a .′ As shown, in the second position, the tamping device  385 ′ remains in contact with the latch  387 .′ 
     Turning now to  FIG. 11A , after removing the lock  390 , the apparatus  301  of  FIGS. 9 and 10A  is shown in a third position, i.e. at a trigger point, which is a frozen instant in time when the tamping device  385  is initially activated. After releasing the cartridge  370 , e.g., by removing the lock  390  or releasing the pushbutton  379 ,′ the cartridge  370  may be moved proximally to expose the sealant  302 . As the cartridge  370  enters the catheter hub  380 , the conical surfaces  377   a ,  377   b  may engage the centering surfaces  386  to align the middle hub  376  with the catheter hub  380 . The proximal end  378  of the middle hub  376  first touches the intermediate tip  388   c  of the intermediate arm  387   c , causing the latch  387  to rotate. The latch contact generally occurs before the conical surfaces  377   a ,  377   b  and the centering surfaces  386  have fully engaged each other. 
     Continued proximal movement of the cartridge  370  into the catheter hub  380  to expose the sealant  302  causes the proximal arm  387   a  and proximal tip  388   a  to rotate upward away from the tamping device  385 , thereby releasing the tamping device  385 , as explained further below. Also at the trigger point, the distal arm  387   b  and distal tip  388   b  may rotate down into the latching detent  375  to secure the middle hub  376  to the catheter hub  380 , thereby securing the cartridge  370  relative to the catheter hub  380  in a latched position. 
     As shown in  FIG. 11A , the expandable member  346  may have been previously expanded and at least partially withdrawn within a body lumen (not shown) as discussed elsewhere herein until the expanded expandable member  346  substantially seals the body lumen from a puncture (also not shown). 
     Turning now to  FIG. 11B , the apparatus  301  is shown in a third position after the trigger point of  FIG. 11A , i.e., with the sealant  302  being tamped and/or compressed. The sealant  302  is tamped between the distal end  334  of the inner pusher member  330 , which is biased to move distally, and the expanded expandable member  346 . As can be seen, the tamping device  385  is released when the latch  387  is rotated to disengage the proximal arm  387   a  from the distal surface  385   b  of the tamping device  385 . The tamping spring  381  biases the inner pusher member  330  distally because the proximal end  332  of the inner pusher member  330  is disposed within the recess  385   d , thereby biasing the distal end  334  of the inner pusher member  330  distally to compress the sealant  302  towards the expandable member  346  (and/or against an arteriotomy, not shown). The outer surface of the tamping device  385  maintains the proximal arm  387   a  in an upwardly rotated position, thereby preventing the latch  387  from moving from the latched position. 
     Thereafter, once the sealant  302  is sufficiently compressed and/or hydrated within the puncture, the catheter hub  380  may be pulled proximally, thereby withdrawing the cartridge  370  from the puncture, leaving the inner pusher member  330  and sealant  302  within the puncture around the positioning member  340 , similar to the previous embodiments. The expandable member  346  may then be collapsed and the positioning member  340  removed through the sealant  302  and inner pusher member  330 , also similar to the previous embodiments. Finally, the inner pusher member  330  may be removed, leaving the sealant within the puncture. 
     Turning now to  FIG. 12A-12C , an alternative embodiment of an apparatus  401  is shown for sealing a puncture. The apparatus  401  generally includes an elongate occlusion or positioning member  440 , a cartridge  470 , and a catheter hub  480 , similar to the previous embodiments. The positioning member  440  is generally similar to those described elsewhere herein and includes a proximal end  442 , a distal end  444 , and an expandable member  446 . Optionally, the apparatus  401  may include a transition cuff (not shown), similar to those described elsewhere herein. 
     The cartridge  470  includes an outer tubular member  473 , a middle hub  476 , and a lumen  460  extending between a proximal end  472  and distal end  474  thereof. A sealant  402  and an inner pusher member  430  are disposed within the outer tubular member  473 , generally similar to the previous embodiments. The inner pusher member  430  includes a lumen extending between a proximal and distal end  432 ,  434 . The middle hub  476  may be similar to the previous embodiments, e.g., including a main cylinder  471 , first conical surface  477   a , and second conical surface  477   b . A latching detent  475  may be provided, e.g., between the first and second conical surfaces  477   a ,  477   b , also similar to the previous embodiments. The middle hub  476  may also include a pushbutton  479  and/or locking bar  479   a  for cooperating with a detent  436 , similar to the previous embodiments. 
     The catheter hub  480  generally includes a body or outer housing  480  including proximal and distal ends  482 ,  484 . The body  480  may additionally include a handle or balloon inflator  496 , tamping device  485 , latch gate  487 , and tamping spring  481  disposed between the tamping device  485  and the balloon inflator  496 . A trigger pin  498  is coupled between the body  480  and the latch gate  487 . The trigger pin  498  includes a proximal end  498   a , an intermediate member  498   b , and a distal end  498   c . The intermediate member  498   b  is sized smaller than the proximal and distal ends  498   a ,  498   c  for releasing the latch gate  487 . The body  480  may further include centering surfaces  486 . The balloon inflator  496  may be similar to those described elsewhere herein. The latch gate  487  may be initially offset vertically down in the body  480 , e.g., with lower and upper ends  487   a ,  487   b  disposed in lower and upper guiding grooves  488   a ,  488   b . A channel  487   c  is included in the latch gate  487  for receiving the proximal end  498   a  of the trigger pin  498 . A cavity and spring (both not shown) in the body  480  may also be included for receiving the proximal end  498   a . A leaf spring  483  may be used to bias the latch gate  487  in a downward direction. 
       FIG. 12A  shows the apparatus  401  in a second position, similar to the apparatus  301  shown in  FIG. 10A . Prior to the second position, the apparatus  401  may have been provided initially in a first position, similar to the first position of the apparatus  301  shown in  FIG. 9 , or the apparatus  401  may be provided already in the second position. In the first and second positions, the compressed tamping spring  481  may bias the tamping device  485  into contact with the latch gate  487 . In the second position, the cartridge  470  may be retracted proximally until the expandable member  446  is fully exposed distal to the distal end  474  and the locking bar  479   a  is extended into detent  436  in the pusher member  430 . 
     In  FIG. 12B , a snapshot of an instant in time illustrates a trigger point of the apparatus  401 , similar to the trigger point of the previous embodiments. At the trigger point, the middle hub  476  may be coupled to the catheter hub  480 . For example, the conical surfaces  477   a ,  477   b  may engage the centering surfaces  486  to align the middle hub  476  within the catheter hub  480  as the middle hub  476  enters the catheter hub  480 . The middle hub  476  displaces the trigger pin  498  proximally until the intermediate member  498   b  is positioned in the channel  487   c  of the latch gate  487 , thereby allowing the latch gate  487  to lower and the tamping device  485  to advance distally due to the force of the tamping spring  481 . The latch gate  487  is lowered due to the bias of the leaf spring  483 . During use, the expandable member  446  may be expanded and at least partially withdrawn similar to earlier embodiments until the expanded expandable member  446  substantially seals a body lumen from a puncture, thereby placing the sealant  402  within the puncture adjacent the body lumen. 
     Turning to  FIG. 12C , the apparatus  401  is shown in a third position with the tamping device  485  fully displaced and the tamping spring  481  extended. The sealant  402  is compressed between the distal end  434  of the inner pusher member  430  and the expanded expandable member  446  (and/or tissue above the arteriotomy) due to the displacement of the tamping device  485  distally. Cooperating connectors (not shown) on the middle hub  476  and the distal end  484  of the body  480  may be used to couple the middle hub  476  to the catheter hub  480  upon activation, similar to the previous embodiments. 
     Turning to  FIG. 13 , still another alternative embodiment of an apparatus  501  is shown for sealing a puncture similar to the apparatus  401  of  FIGS. 12A-12C . The apparatus  501  includes a cartridge  570 , and a catheter hub  580  similar to the previous embodiments. The apparatus  501  includes a hub latch  552  for displacing the latch gate  587 . The hub latch  552  may include a leaf spring (not shown) for biasing the hub latch  552  in an upward direction, thereby displacing the latch gate  587  in an upward direction. 
     In  FIG. 13 , the apparatus  501  is shown in a third position similar to  FIGS. 11B and 12C , where a tamping spring  581  is extended, similar to previous embodiments. Previously, the apparatus  501  may have been in an initial first position (not shown), and/or a second position (not shown), where the tamping spring  581  is compressed, also similar to the previous embodiments. In the third position, as shown, the middle hub  576  is fully mated with the catheter hub  580 . Further, the trigger pin  598  is displaced proximally to release the latch gate  587  to be displaced upward by the raised hub latch  552 , the hub latch  552  being raised by a leaf spring (not shown) or similar expanding device. The distal tip  552   a  of the raised hub latch  552  may be coupled to the latching detent  575  to secure the middle hub  576  to the catheter hub  580 . 
     An expandable member  546  may be expanded and at least partially withdrawn similar to earlier embodiments until the expanded expandable member  546  substantially seals a body lumen from a puncture. A sealant  502  is compressed between the expanded expandable member  546  and an inner pusher member  530  affected by a full distal displacement of a tamping device  585  by the tamping spring  581 . 
     Turning to  FIG. 14 , yet another alternative embodiment of an apparatus  601  is shown for sealing a puncture similar to the apparatus  401  of  FIGS. 12A-12C . The apparatus  601  includes an elongate occlusion or positioning member  640 , a cartridge  670 , and a catheter hub  680 , generally similar to the previous embodiments. The apparatus  601  may further include a hub latch  652  attached to a distal end  698   b  of a trigger pin  698 . The hub latch  652  includes a first and second tip  652   a ,  652   b . The trigger pin  698  includes a displacement spring  683  for biasing the trigger pin  698 . The displacement spring  683  may be disposed within an enclosure  654  of the catheter hub  680 . 
     The apparatus  601  is shown in a third position, where a tamping spring  681  is extended, similar to the previous embodiments. Previously, the apparatus  601  may have been in an initial first position, and/or a second position (neither shown), where the tamping spring  681  is compressed, similar to the previous embodiments. In the third position, a middle hub  676  is fully mated with the catheter hub  680 . Further, the first tip  652   a  of hub latch  652  is mated with the latching detent  675  and the second tip  652   b  is displaced proximally by a proximal end  678  of the middle hub  676 . The proximal displacement of the second tip  652   b  also proximally displaces the trigger pin  698  to release the latch gate  687 , the latch gate  687  being biased upward by a leaf spring (not shown) or similar expanding member. The upwardly displaced latch gate  687  releases the tamping device  685  to be distally displaced by the tamping spring  681 . 
     The expandable member  646  may be expanded and at least partially withdrawn similar to earlier embodiments until the expanded expandable member  646  substantially seals a body lumen from a puncture. The sealant  602  is compressed between the expanded expandable member  646  and the inner pusher member  630  affected by full distal displacement of a tamping device  685  by the tamping spring  681 . 
     Turning now to  FIG. 15A-15C , yet another embodiment of an apparatus  701  is shown for sealing a puncture. The apparatus  701  includes an elongate occlusion or positioning member  740 , a cartridge  770 , and a catheter hub  780 . The positioning member  740  may be similar to those described elsewhere herein and includes a proximal end  742 , a distal end  744 , and an expandable member  746 . Additionally, the positioning member  740  may include a ring  748  sized for displacing an inner pusher member  730 , as described further below. 
     The cartridge  770  includes an outer tubular member  773 , and a middle hub  776 . The outer tubular member  773  includes a lumen  760  extending between a proximal end  772 , and distal end  774  thereof. A sealant  702  and inner pusher member  730  are disposed within the outer tubular member  773 . The inner pusher member  730  includes a lumen extending between a proximal and distal end  732 ,  734 . The middle hub  776  is similar to previous embodiments and includes a main cylinder  771 , first conical surface  777   a , and second conical surface  777   b . Included between the first and second conical surfaces  777   a ,  777   b  is a latching detent  775 . The middle hub  776  may also include a pushbutton and a locking bar (both not shown) for cooperating with a detent (also not shown) in the inner pusher member  730 , similar to the previous embodiments, e.g., to prevent proximal movement of the cartridge  770  until the pushbutton (not shown) is pressed. In addition or alternatively, the apparatus  701  may include a peel away lock (not shown) to prevent proximal movement of the cartridge  770 . 
     The catheter hub  780  generally includes a body or outer housing  780  including proximal and distal ends  782 ,  784 . The body  780  includes a balloon inflator  796 , tamping device  785 , and lower and upper tamping latches  752 ,  754 . The body  780  may further include centering surfaces  786 , lower and upper hub latches  756 ,  758 , and carriage  753 . A circular spring clip  783  is used to bias the lower and upper tamping latches  752 ,  754  in a radially inward direction. The carriage  753  includes lower and upper release slots  755   a ,  755   b  for displacing the tamping latches  752 ,  754  in an outward direction when the carriage  753  is displaced in a proximal direction. A tamping spring  781  is compressed between the tamping device  785  and the balloon inflator  796 . 
       FIG. 15A  shows the apparatus  701  in a second position. Prior to the second position, the apparatus  701  may have occupied a first position (not shown) similar to the first position described in previous embodiments. In the second position, the positioning member  740  is advanced distally until the expandable member  746  is fully exposed distal to the distal end  774 . A pushbutton (not shown) and locking bar (not shown) may be used with a cooperating detent (not shown) on the inner pusher member  730 , e.g., as described in the previous embodiments, to secure the apparatus  701  in the second position. 
       FIG. 15B  is a snapshot of an instant in time illustrating a trigger point of the apparatus  701 . As shown, at the trigger point, the middle hub  776  is coupled with the catheter hub  780 , and the conical surfaces  777   a ,  777   b  have mated with the centering surfaces  786 . The middle hub  776  has displaced the carriage  753  proximally thereby rotating the tamping latches  752 ,  754  outwardly away from the tamping device  785 . The outwardly rotating tamping latches  752 ,  754  cause the proximal ends of hub latches  756 ,  758  to rotate downwardly to a latch position to mate with latching detents  775 . The tamping device  785  is then free to release in the distal direction. The expandable member  746  may be expanded and at least partially withdrawn similar to earlier embodiments until the expanded expandable member  746  substantially seals a body lumen from a puncture. 
     Turning to  FIG. 15C , the apparatus  701  is shown in the third position with the tamping device  785  fully displaced distally and the tamping spring  781  extended, thus compressing or tamping the sealant  702  between the inner pusher member  730  and the expanded expandable member  746 . The displacement of the tamping device  785  forces the ring  748  to distally displace the inner pusher member  730 . The middle hub  776  is secured to the catheter hub  780  by the downwardly rotated hub latches  756 ,  758 , which are maintained in the latch position by the outwardly rotated tamping latches  752 ,  754 . Distal tips  752   a ,  754   a  of tamping latches  752 ,  754  rest in contact with an outer surface of the carriage  753 . Construction and operation of these embodiments generally proceed similar to one another. 
     While the invention is susceptible to various modifications, and alternative forms, specific examples thereof have been shown in the drawings and are herein described in detail. It should be understood, however, that the invention is not to be limited to the particular forms or methods disclosed, but to the contrary, the invention is to cover all modifications, equivalents, and alternatives falling within the scope of the appended claims.