Patent Publication Number: US-2023157700-A1

Title: Hemostatic clip with needle passer

Description:
PRIORITY CLAIM 
     The present application is a Continuation of U.S. patent application Ser. No. 16/824,410 filed on Mar. 19, 2020; which is a Continuation of U.S. patent application Ser. No. 15/842,489 filed on Dec. 14, 2017, now U.S. Pat. No. 10,631,872; which is a Continuation of U.S. patent application Ser. No. 14/788,021 filed on Jun. 30, 2015, now U.S. Pat. No. 9,877,732; which claims priority to U.S. Provisional Application Serial No. 62/019,588 filed on Jul. 1, 2014. The disclosure of the above patent(s)/application(s) is incorporated herein by reference. 
    
    
     BACKGROUND 
     Physicians have become more willing to perform more aggressive interventional and therapeutic endoscopic procedures including, for example, removal of larger lesions (e.g., cancerous masses), tunneling under mucosal layers in the gastro-intestinal (GI) tract to treat tissues below the mucosa, full thickness removal of tissue, inserting devices through the GI tract and then penetrating the GI organ to treat tissue outside the GI tract, and endoscopic treatment/repair of post-surgical issues (e.g., post-surgical leaks, breakdown of surgical staple lines, anastomotic leaks). These procedures may increase the risk of perforating the wall of the GI tract, or may require closure of the GI tract wall as part of the procedure. Endoscopic closure reduces cost and may reduce the trauma and inconvenience associated with these procedures. However, conventional tissue closure devices may be insufficient to close certain perforations. 
     SUMMARY 
     The present disclosure relates to a device for treating a tissue opening, comprising a proximal portion including an elongated flexible member, a capsule releasably coupled to a distal end of the flexible member, the capsule extending longitudinally from a proximal end to a distal end and including a lumen extending therethrough, and a clip including a pair of arms movably housed within the lumen of the capsule such that the pair of arms are movable between an open configuration and a closed configuration, the pair of arms being biased toward the open configuration such that when the pair of arms are moved distally with respect to the capsule, distal ends of the pair of arms are separated from one another to receive target tissue therebetween. The device also comprises a suture extending along a first one of the pair of arms and including a loop at a distal end thereof, the loop extending across an opening extending laterally through the first one of the pair of arms and a suture grabbing element extending laterally from a second one of the pair of arms toward the first one of the pair of arms and including a hook so that, when the pair of arms are moved toward the closed configuration, the hook extends through the opening in the first one of the pair of arms to grab the loop extending across the opening to draw the distal end of the suture from the first one of the pair of arms toward the second one of the pair of arms. 
     In an embodiment, the first one of the pair of arms may include a notch in communication with the opening so that the loop is received within the notch to extend across the opening. 
     In an embodiment, the notch may extend one of along an interior surface of the first one of the pair of arms and proximally from a distal edge of the first one of the pair of arms. 
     In an embodiment, the device may further comprise a control member connected to the pair of arms for moving the pair of arms between the open configuration and the closed configuration. 
     In an embodiment, the device may further comprising a locking mechanism for locking the pair of arms in the capsule in the closed configuration. 
     In an embodiment, the capsule may include a wedge feature wedging the suture between the wedge feature and a portion of one of the pair of arms, when the arms are locked within the capsule, so that the suture is restrained from distal translation. 
     In an embodiment, the capsule may further include a cutting feature cutting a portion of the suture extending proximally of a wedged portion of the suture. 
     In an embodiment, the first one of the pair of arms may include a second opening and the second one of the pair of arms includes a wedge element extending laterally therefrom toward the first one of the pair of arms so that, when the pair of arms are locked within the capsule, the wedge element extends through the second opening to wedge the suture between the wedge element and an edge of the second opening. 
     The present disclosure also relates to a device for treating a tissue opening, comprising a proximal portion including an elongated flexible member, a capsule releasably coupled to a distal end of the flexible member, the capsule extending longitudinally from a proximal end to a distal end and including a lumen extending therethrough and a clip including pair of arms movably housed within the lumen of the capsule such that the pair of arms are movable between an open configuration and a closed configuration, the pair of arms being biased toward the open configuration such that when the pair of arms are moved distally with respect to the capsule, distal ends of the pair of arms are separated from one another to receive target tissue therebetween. The device also comprises a needle extending from a first end pivotally connected to a first one of the pair of arms via a releasable connection to a second end, the needle pivotal relative to the first one of the pair of arms between an insertion configuration, in which the second end is moved toward the first one of the pair of arms, and a firing position, in which the second end extends laterally toward a second one of the pair of arms, so that, when the pair of arms are moved toward the closed configuration in the firing position, the needle engages an engaging feature along a second one of the pair of arms, the releasable connection releasing when the pair of arms are moved toward the open configuration after the needle has engage the engaging feature and a suture extending through a portion of the device such that a distal end thereof is connected to the needle. 
     In an embodiment, the needle may be curved along a length thereof. 
     In an embodiment, the engagement feature may include a longitudinal recess extending through a portion of the second one of the pair of arms and retaining tabs extending over a portion thereof to prevent disengagement of the needle therefrom once the needle has been received therein. 
     In an embodiment, the engagement feature may further include a curved surface extending along a distal portion of the longitudinal recess for guiding the needle thereinto. 
     In an embodiment, the device may further comprise a control member connected to the pair of arms for moving the pair of arms between the open configuration and the closed configuration. 
     In an embodiment, the device may further comprise a locking mechanism for locking the pair of arms in the closed configuration. 
     In an embodiment, the capsule may include a wedge feature along an interior surface thereof for locking the suture relative to the clip when the clip is in a locked configuration and a cutting feature for cutting a portion of the suture proximal of a wedged portion of the suture. 
     The present disclosure also relates to a method for treating a tissue opening, comprising inserting a clip to a target area within a patient body, the clip including a pair of arms movable between an open configuration in which distal ends of the pair of arms are separated from one another and a closed configuration in which distal ends of the pair of arms are drawn toward one another to grip tissue received therebetween, and a suture extending along a first one of the pair of arms and including a loop at a distal end thereof, the loop extending across an opening extending laterally through the first one of the pair of arms, positioning the pair of arms over a first portion of tissue along a tissue opening with the clip in the open configuration such that the first portion of tissue is received between the distal ends of the pair of arms, moving the clip toward the closed configuration so that a hook of suture grabbing element extending laterally from a second one of the pair of arms extends through the first portion of tissue and into the opening in the first one of the pair of arms to grab the loop extending across the opening, and moving the pair of arms to the open configuration such that the suture grabbing element is retracted from the first portion of tissue so that the suture is passed through the first portion of tissue. 
     In an embodiment, the method may further comprise, after moving the pair of arms to the open configuration with the suture passed through the first portion of tissue, positioning the pair of arms over a second portion of tissue along the tissue opening substantially opposing the first portion with the clip in the open configuration with the second portion of tissue is received between the distal ends of the pair of arms and moving the pair of arms to the closed configuration such that the pair of arms grip the second portion of tissue between distal ends of thereof. 
     In an embodiment, the method may further comprise pulling the suture proximally relative to the clip to draw the first portion of tissue toward the second portion of tissue. 
     In an embodiment, the method may further comprise locking the clip in the closed configuration. 
     In an embodiment, locking the clip may include locking the suture relative to the clip and cutting a portion of the suture extending proximally from the clip. 
    
    
     
       BRIEF DESCRIPTION 
         FIG.  1    shows a perspective view of a device according to an exemplary embodiment of the present disclosure, in a first configuration; 
         FIG.  2    shows another perspective view of the device of  FIG.  1   , a clip of the device gripping a first portion of tissue of a tissue opening; 
         FIG.  3    shows another perspective view of the device of  FIG.  1   , in a second configuration; 
         FIG.  4    shows a side view of the device of  FIG.  1   , the clip gripping a second portion of tissue of the tissue opening; 
         FIG.  5    shows a perspective view of the device of  FIG.  1   , with the first and second tissue portions drawn toward one another; 
         FIG.  6    shows another perspective view of the device of  FIG.  1   , in a locked configuration; 
         FIG.  7    shows a longitudinal cross-sectional view of a distal portion of the device of  FIG.  1   , in an unlocked configuration; 
         FIG.  8    shows a longitudinal cross-sectional view of the distal portion of the device of  FIG.  1   , in a locked configuration; 
         FIG.  9    shows a perspective view of arms of the clip of the device of  FIG.  1   , including a needle; and 
         FIG.  10    shows a perspective view of arms of a clip according to an alternate embodiment of the device of  FIG.  1   ; 
         FIG.  11    shows a longitudinal side view of a device according to another exemplary embodiment in a first configuration; 
         FIG.  12    shows a longitudinal side view of the device of  FIG.  11   , in a second configuration; 
         FIG.  13    shows a longitudinal side view of the device of  FIG.  11   , in a third configuration; 
         FIG.  14    shows a perspective view of a clip of the device of  FIG.  11   ; 
         FIG.  15    shows another perspective view of the clip of the device of  FIG.  11   ; 
         FIG.  16    shows a longitudinal side view of the device of  FIG.  11   , according to a further embodiment; 
         FIG.  17    shows a perspective view of a device according to an alternate embodiment; 
         FIG.  18    shows a longitudinal cross-sectional view of the device of  FIG.  17   ; 
         FIG.  19    shows a perspective view of a clip according to another exemplary embodiment; 
         FIG.  20    shows a perspective view of a clip according to yet another exemplary embodiment; 
         FIG.  21    shows a perspective view of another exemplary embodiment; 
         FIG.  22    shows a partially transparent side view of a device according to another exemplary embodiment in a preloaded insertion configuration; 
         FIG.  23    shows a perspective view of the device of  FIG.  22   , in a firing position; 
         FIG.  24    shows transparent side view of the device of  FIG.  22   ; 
         FIG.  25    shows another transparent side view of the device of  FIG.  22   ; 
         FIG.  26    shows yet another transparent side view of the device of  FIG.  22   ; 
         FIG.  27    shows a perspective view of the device of  FIG.  22   ; 
         FIG.  28    shows a portion of a clip according to another exemplary embodiment; 
         FIG.  29    shows a perspective view of a portion of a clip according to yet another exemplary embodiment; 
         FIG.  30    shows a transparent side view of the portion of the clip of  FIG.  29   ; 
         FIG.  31    shows a partially transparent perspective view of a device according to another exemplary embodiment; and 
         FIG.  32    shows a partially transparent perspective view of a device according to yet another exemplary embodiment. 
     
    
    
     DETAILED DESCRIPTION 
     The present disclosure may be further understood with reference to the following description and the appended drawings, wherein like elements are referred to with the same reference numerals. The present disclosure relates to devices for tissue closure and, in particular, to an endoscopic tissue closure device. Exemplary embodiments of the present disclosure describe an endoscopic tissue closure device comprising a clip and a suture. The suture may be passed through a first portion of tissue along a tissue opening and the clip may be applied over a second portion of tissue along the tissue opening substantially opposing the first portion so that the first portion of tissue may be drawn toward the second portion by drawing the suture proximally relative to the clip. It should be noted that the terms “proximal” and “distal” as used herein, are intended to refer to a direction toward (proximal) and away from (distal) a user of the device. 
     As shown in  FIGS.  1 - 10   , a device  100  according to an exemplary embodiment of the present disclosure comprises a clip  102  including first and second arms  104 ,  106  movable between an open configuration and a closed configuration and a needle  108  extending laterally inward from the first arm  104  toward the second arm  106  to pass a suture  112  coupled to the needle  108  through a first portion of tissue  12  along a tissue opening  10 . The device is inserted to a target spot within the body via, for example, a body lumen accessed via a naturally occurring bodily orifice. The device  100 , however, may be inserted into the patient body in any of a number of different ways such as, for example, via a flexible endoscope, or through a rigid tube, etc. The clip  102  is movable between a closed configuration in which the first and second arms  104 ,  106 , respectively, are drawn together in contact with one another and an open configuration in which distal ends  114 ,  115  of the first and second arms  104 ,  106 , respectively, are separated from one another to permit a portion of tissue to be received therebetween. In the closed configuration, the distal ends  114 ,  115  of the arms  104 ,  106  are drawn toward one another to grip tissue received therebetween. The second arm  106  includes an opening  110  such as a slot or hole extending laterally therethrough. The opening  110  is sized and shaped to receive a portion of the needle  108  therein. The needle  108  is attached to the first arm  104  via a frangible link  116  such that when the arms  104 ,  106  are moved toward the closed configuration over the first portion of tissue  12 , the needle  108  is passed through the first portion of tissue  12  into the opening  110  and locked therein so that when the clip  102  is moved once again to the open configuration, the frangible link  116  is broken leaving the needle  108  lodged in the second arm  110 . As the clip  102  moves to the open configuration, the suture  112  is drawn through the first portion of tissue  12 . The clip  102  is then opened and repositioned over a second portion of tissue  14  (e.g., a second portion of tissue on the periphery of the tissue opening  10  substantially opposite the first portion  12 ). Once the clip  102  has been repositioned as desired, the clip  102  is moved to the closed configuration to grip the second portion of tissue  14 . The loop of suture  112  is then tightened to draw the first portion of tissue  12 , through which the suture  112  is passed, toward the clip  102  until the first portion  12  is drawn against the second portion  14  closing the tissue opening  10 . 
     The clip  102  may further include a capsule  118  in which the first and second arms  104 ,  106  are movably housed. The capsule  118  extends longitudinally from a proximal end  124  to a distal end  126  and includes a lumen  128  extending therethrough. Proximal ends of the first and second arms  104 ,  106  are slidably received within the lumen  128  so that the clip  102  may be moved between the open and the closed configurations. The first and second arms  104 ,  106  may be biased toward the open configuration such that when the first and second arms  104 ,  106  are moved distally out of the capsule  118 , distal ends  114 ,  115  of the arms  104 ,  106  extend away from one another to the open configuration. When the first and second arms  104 ,  106  are drawn proximally into the capsule  118 , however, the first and second arms  104 ,  106  are constrained via an interior surface  132  of the capsule  118  so that distal ends  114 ,  115  of the arms  104 ,  106  are drawn toward one another into the closed configuration. Distal ends  114 ,  115  may include gripping features such as, for example, teeth or tines extending laterally inward for gripping the tissue received therebetween. The clip  102  may be coupled to a proximal portion of the device  100 , not shown, via a control member or other device which permits a user to move the clip  102  proximally and distally relative to the capsule  118  so that the clip  102  moves between the open and closed configurations. 
     In one embodiment, the capsule  118  may be coupled to a handle assembly (not shown), which remains outside of a patient body, via a flexible member to facilitate insertion of the clip  102  to a target area within the patient body through even tortuous paths of the body. The arms  104 ,  106  are moved with respect to the capsule  118  via the control member coupled to a proximal end of the arms  104 ,  106  and extending proximally through the flexible member to the handle assembly. The arms  104 ,  106  may be moved distally and proximally with respect to the capsule  118  between the open and closed configurations by moving the control member distally and proximally, respectively, via an actuator of the handle assembly. Once in the closed configuration, the control member may be drawn further proximally to lock the clip  102  in the closed configuration and disengage the clip  102  from the proximal portion of the device  100 . For example, the clip  102  may be locked in the closed configuration by engagement between a portion of the clip  102  and a locking feature of the capsule  118  and disengaged from the proximal portion of the device by the separation of a frangible link substantially as described in U.S. Pat. No. 7,494,461 issued on Feb. 24, 2009 to Wells et al. In particular, when the control member of this embodiment is drawn proximally after a point of maximum proximal withdrawal of the clip  102  into the capsule  118 , increased tension on the control member causes disengagement of the control member from the arms  104 ,  106 , causing a bushing which connects the capsule  118  to the flexible member to become disengaged therefrom. The structural features of the clip  102 , however, are not limited to those described in U.S. Pat. No. 7,494,461 and that the clip  102  may be deployed in the body in any of a number of ways via the further proximal motion of the control member with respect to the clip  102 . 
     As shown in  FIGS.  7 - 8   , the clip  102  further includes a wedge feature  130  which wedges a portion of the suture  112  within the capsule  118 . For example, the suture  112  may be wedged between one of the arms  104 ,  106  and the interior surface  132  of the capsule  118 , when the clip  102  is in the locked configuration. A distal portion of the capsule  118  may be sized and shaped such that when the arms  104 ,  106  are drawn into the locked configuration, the arms  104 ,  106  and the capsule  118  form a friction fit with the portion of the suture  112  received therebetween locked therein. The capsule  118  may further include a cutting feature  119  along the interior surface  132  thereof for cutting a portion of the suture  112  extending proximally from the wedge. The cutting feature  119  of this embodiment is positioned on a portion of the capsule  118  proximal of the wedge feature. The cutting feature  119  may include, for example, a sharpened protrusion extending laterally inward and distally from the interior surface  132  of the capsule  118 . 
     The needle  108  extends from a first end  120  attached to the first arm  104  via the frangible link  116  to a second end  122  extending laterally from the first arm  104  toward the second arm  106 . The frangible link  116  may include, for example, a tight friction fit between the needle  108  and an opening in the first arm  104 , an adhesive, weld, or solder joint designed to fail when subject to a force exceeding a predetermined threshold level. The frangible link  116  may include any of a variety of coupling mechanisms so long as the frangible link  116  fails when subject to a force exceeding the predetermined threshold level. Although this exemplary aspect is described and shown as including a frangible link  116  connecting the needle  108  to the first arm  104 , the needle  108  may alternatively be connected to the first arm  104  via a releasable coupling. For example, the needle  108  may releasably engage a needle engaging feature in the first arm  104 . The needle  108  may be released from this needle engaging feature via a force applied to the needle  108 . The force may be, for example, a torsional force applied to the needle  108  by the second arm  106 , which causes the needle  108  to rotate out of engagement with the needle engaging feature. Alternatively, the needle  108  may be actively released from the first arm  104 , for example, by the user by means of a trigger mechanism of the like. 
     As shown in  FIG.  9   , a portion of the needle  108  includes barbs  134  therealong so that when the needle  108  is received within the opening  110  extending laterally through the second arm  106 , the needle  108  engages the opening  110  so that the needle  108  is locked therewithin. In another embodiment, as shown in  FIG.  10   , the barb features  134 ′ may be included in the opening  110 ′ so that when the needle  108 ′ is received therewithin, the opening  110 ′ engages a groove  136 ′ or other corresponding feature of the needle  108 ′. Although the exemplary embodiments describe barbs, the needle  108  and the opening  110  of the second arm  106  may include any of a variety of corresponding locking features so long as the needle  108  is locked within the opening  110  when received therein. 
     The suture  112  extends from a distal end  120  connected to the needle  108  to a proximal end (not shown) extending proximally through the capsule  118  and the proximal portion of the device  100  to the handle assembly. The suture  112  is slidably received within the capsule  118  so that the suture  112  may be slackened and tightened, as desired. The proximal end of the suture  112  may be coupled to an actuating feature of the handle assembly so that the suture  112  may be tightened via the actuating feature on the handle assembly. Alternatively, the proximal end of the suture  112  may extend from the handle assembly so that the user may draw the proximal end proximally with respect to the device  100  to tighten the suture  112 . The distal end  120  of the suture  112  should be connected to a portion of the needle  108  between the locking feature (e.g., barbs) of the needle  108  and the first end  120  so that locking the needle  108  within the opening  110  does not interfere with the slackening and tightening of the suture  112 . 
     According to a method using the device  100 , the clip  102 , with the needle  108  connected to the first arm  104 , is inserted to a target area in the patient body through, for example, a working channel of an endoscope. The clip  102  may be inserted through the working channel in an insertion configuration with the handle assembly remaining outside the patient&#39;s body. In this insertion configuration, the first and second arms  104 ,  106  are drawn toward one another with the needle  108  connected to the first arm  104 . The needle  108 , however, is prevented from engaging the second arm  106 . Once the clip  102  has reached the tissue opening  10  to be closed, the clip  102  is moved to the open configuration by moving the clip arms  104 ,  106  distally with respect to the capsule  118  so that the arms  104 ,  106  are permitted to revert to their biased open position, as shown in  FIG.  1   . In the open configuration, the arms  104 ,  106  are positioned so that the first portion of tissue  12  may be received therebetween. 
     Once positioned, as desired, the clip  102  is moved to the closed configuration to grip the first portion of tissue  12  between arms  104 ,  106  by drawing the clip arms  104 ,  106  into the capsule  118  so that the arms  104 ,  106  are constrained thereby. As the clip  102  is moved to the closed configuration, as shown in  FIG.  2   , the needle  108  extending laterally from the first arm  104  passes through the first portion of tissue  12  and engages the opening  110  of the second arm  106 . Prior to the needle  108  engaging the opening  110  of the second arm  106 , however, the arms  104 ,  106  may be moved between the open and closed positions to adjust the placement of the arms  104 ,  106  over tissue, as desired. This movement may be controlled by a user interface having incremental closing positions controlled to prevent premature engagement of the needle  108  or via tactile features that have threshold forces to actuate between states. Once the needle  108  has engaged the opening  110  of the second arm  106 , however, the clip  102  is moved to the open configuration so that distal ends  114 ,  115  of the arms  104 ,  106  are once again separated from one another. Since the needle  108  is locked within the opening  110  of the second arm  106 , the separation of the distal ends  114 ,  115  causes the frangible link  116  connecting the first end  120  of the needle  108  to the first arm  104  to break. The needle  108 , however, remains locked in the opening  110  so that the suture  112  is passed through the first portion of tissue  12 . As the clip  102  is moved to the open configuration, the clip  102  is also moved proximally relative to the first portion of the tissue  12 , causing the clip  102  to be moved proximally with respect to the suture  112 , such that a slack in the suture  112  is formed, as shown in  FIG.  3   . 
     The clip  102  is then moved to the second portion of tissue  14  substantially opposing the first portion  12  and positioned thereover such that the second portion  14  is received between the arms  104 ,  106 . As shown in  FIG.  4   , once the clip  102  has been positioned over the second portion, as desired, the clip  102  is moved to the closed configuration to grip the second portion of tissue  14  between the arms  104 ,  106 . The suture  112  is then drawn proximally with respect to the clip  102 , drawing the first portion of tissue  12  toward the second portion of tissue  14  to close the tissue opening  10 , as shown in  FIG.  5   . Although the exemplary embodiments show and describe the clip  102  as being moved to the locked configuration once the clip  102  has been clipped over the second portion of tissue  14  and the first portion of the tissue  12  has been drawn theretoward via the suture  112 , the clip  102  may be repositioned prior to locking, if so desired. For example, clip arms  104 ,  106  may be repositioned to get a better grasp of the second portion of tissue  14 . 
     In another example, the clip  102  may be repositioned to extend over both the first and second portions of tissue  12 ,  14 , once the first and second portions of tissue  12 ,  14  have been drawn toward one another, so that the clip  102  grips both portions of tissue  12 ,  14 . Once the tissue opening  10  is closed, as desired, the clip  102  may be locked, as shown in  FIG.  6   , by drawing the control member further proximally with respect to the clip  102 . As described above, moving the clip  102  to the locked configuration will also cause a portion of the suture  112  to become wedged between one of the clip arms  104 ,  106  and the interior of the capsule  118 . Upon wedging of the suture  112  between the clip arms  104 ,  106 , a portion of the suture extending proximally of the wedge is cut therefrom via the cutting feature along the interior of the capsule  118 . The proximal portion of the device  100  is then removed from the body such that only the clip  102 , the needle  108 , and a distal portion of the suture  112  remain within the body to hold the tissue opening  10  in the closed position. 
     As shown in  FIGS.  11  to  15   , a device  200  according to another exemplary embodiment of is substantially similar to the device  100  described above, comprising a clip  202  including first and second arms  204 ,  206  movable between an open configuration and a closed configuration via, for example, a capsule  218  slid longitudinally thereover as described above in regard to the device  100 . Rather than a needle for passing a suture  212  from the first arm  204  to the second arm  206 , however, the suture  212  extends along a portion of the first arm  204  so that a suture grabbing element  208  extending laterally inward from the second arm  206  hooks a portion of the suture  212  as the clip  202  is moved toward the closed configuration. In use, the clip  202  is positioned in the open configuration over tissue (e.g., along a first side of a tissue opening) so that a first portion of tissue along the first side is received between the first and second arms  204 ,  206 . The clip  202  may then be moved toward the closed configuration so that the suture grabbing element  208  pierces the portion of tissue received between the first and second arms  204 ,  206  as the suture grabbing element  208  is moved toward the first arm  204 . A hook feature  236  at an end  222  of the suture grabbing element  208  interfaces with a portion of the first arm  204  to hook a loop  213  of the suture  212  extending along the first arm  204 . The clip  202  is once again moved to the open configuration so that the suture grabbing element  208 , with the suture  212  hooked thereto, is removed from the first portion of tissue, passing the suture  212  through the first portion of tissue in the process. Similarly to the device  100 , after passing the suture  212  through the first portion of tissue, the clip  202  may then be positioned over a second portion of tissue (e.g., along a second side of the tissue opening) so that the second portion of tissue is received between the first and second arms  204 ,  206 . Once the clip  202  has been repositioned, as desired, the clip  202  is moved to the closed configuration to grip the second portion of tissue. The suture  212  is then tensioned to draw the first portion of tissue, through which the suture  212  has been passed, toward the second portion of tissue, thereby closing the tissue opening. 
     The clip  202  is substantially similar to the clip  102 , described above except as specifically noted. In particular, the clip  202  may, for example, be biased toward the open configuration so that, when the first and second arms  204 ,  206  are moved distally out of the capsule  218 , the first and second arms  204 ,  206  extend away from one another toward the open configuration. When the first and second arms  204 ,  206  are drawn proximally into the capsule  218 , however, the first and second arms  204 ,  206  are constrained via an interior surface of the capsule  218  toward the closed configuration. In one embodiment, the capsule  218  may be coupled to a handle assembly, which remains outside of a patient body, via a flexible member to facilitate insertion of the clip  202  to a target within the patient body. The clip  202  may be moved between the open and closed configuration by moving a control member coupled to a proximal end of the first and second arms  204 ,  206  via an actuator of the handle assembly, as described above in regard to the clip  102 . Once in the closed configuration, the control member is drawn further proximally to lock the clip  202  in the closed configuration and disengage the clip  202  from a proximal portion of the device  200 , as described with respect to the device  100 . 
     The first arm  204  of the clip  202 , however, includes a notch  240  along an interior surface  242  of the first arm  204  at a distal end  214  thereof. The first arm  204  also includes a slot  210  extending laterally through the distal end  214  thereof in communication with the notch  240 . In other words, the slot  210  extends through the first arm  204  and through the notch  240  so that, when a loop  213  of the suture  212  is hooked on the notch  240 , a portion of the loop  213  extends across the slot  210 . Thus, the suture grabbing element  208  passes through the slot  210 , between opposing sides of the notch  240 , to hook a portion of the loop  213 . The first arm  204  may further include an opening  244  extending laterally therethrough, the opening  244  separated from the slot  210  by a small distance. 
     In this embodiment, a length of the suture  212  extends from a proximal end coupled to an actuating feature of the handle assembly through the flexible member and the capsule  218  along an exterior surface  246  of the first arm  204 . Once the suture  212  reaches the opening  244 , however, the suture  212  is fed through the opening  244  so that a remaining distal length of the suture  212  extends along the interior surface  242  of the first arm  204  to be hooked via the loop  213  at its distal end  248 . The loop  213  of the suture  212  is hooked by opposing sides of the notch  240  so that a portion of the loop  213  extends across the slot  210 . Thus, when the suture grabbing element  208  is passed through the slot  210 , the suture grabbing element  208  passes through the loop  213  to grab a portion thereof, hooking the loop  213 . 
     The second arm  206  is substantially similar to the second arm  106  of the clip  102  except as specifically noted below. In contrast to the clip  102 , the second arm  206  includes the suture grabbing element  208  extending laterally from a first end  220  connected to the second arm  206  to a second end  222  extending toward the first arm  204 . The second end  222  includes a hooked recess  236  therein. The second end  222  may also include an angled surface  223  configured so that, as the suture grabbing element  208  is inserted through the slot  210 , the loop  213  of the suture  212  is guided along the angled surface  223  until the loop  213  reaches the hooked recess  236  and is received therein. The suture grabbing element  208  is positioned along the second arm  206  so that, when the clip  202  is moved toward the closed configuration, at least a portion of the suture grabbing element  208  is received within the slot  210  so that the hooked recess  236  hooks the loop  213  of the suture  212  hooked via the notch  240 . The second end  222  may also include an angled surface  223  configured so that, as the suture grabbing element  208  is inserted through the slot  210 , the loop  213  of the suture  212  is guided along the angled surface  223  until the loop  213  reaches the hooked recess  236  and is received therein. The hooked recess  236  is shaped so that, upon hooking the loop  213 , the suture  212  is prevented from being unhooked from the hooked recess  236 . 
     The device  200  may be used in a manner substantially similar to the device  100 . Rather than passing the suture  212  through the first portion of tissue via a needle, however, the suture is passed through the first portion of tissue via the suture grabbing element  218 . In particular, the clip  202  is positioned along the first portion of tissue (e.g., along a first side of a tissue opening) in the open configuration with the first portion of tissue received between the first and second arms  204 ,  206 . The clip  202  is then moved toward the closed configuration so that the suture grabbing element  208  extends through the first portion of tissue, between opposing sides of the notch  240  into the slot  210  to hook the loop  213  of the suture  212  via the hooked recess  236 . Once the loop  213  has been hooked via the hooked recess  236 , the clip  202  is moved toward the open configuration so that the suture grabbing element  208 , with the suture  212  hooked therethrough, is removed from the first portion of tissue. Removal of the suture grabbing element  208  from the first portion of tissue draws the suture  212  through the first portion of tissue so that the distal end  248  of the suture  212  is now attached to the second arm  206 . 
     The clip  202  is then be moved toward a second portion of tissue (e.g., along a second side of the tissue opening) until the second portion of tissue is received between the first and second arms  204 ,  206  in the open configuration. Opening of the first and second arms  204 ,  206  and moving the clip  202  toward the second side of the tissue opening creates slack in the suture  212  so that a length of the suture  212  extends across the tissue opening. The clip  202  may then be moved toward the closed configuration to grip the second portion of tissue between the first and second arms  204 ,  206 . Once the second portion of tissue has been gripped, as desired, the suture  212  is tensioned by drawing the suture  212  proximally relative to the clip  202 . Tensioning the suture  212  draws the first portion of tissue, through which the suture  212  is passed, toward the second portion of tissue to close the tissue opening. Once the tissue opening is closed, the clip  202  may be locked by drawing the clip arms  204 ,  206  further proximally into the clip  202 . As described above in regard to the device  100 , a wedge feature along an interior of the capsule  218  may wedge the suture  212  between the first arm  204  and the capsule  218  while a cutting feature cuts a portion of the suture  212  extending proximally from the wedge. Similarly to the device  100 , locking the clip  202  in the closed configuration deploys the clip  202 —and a distal portion of the suture  212 —in the body. 
     According to a further embodiment, as shown in  FIG.  16   , the device  200  further comprises a longitudinal extension  252  extending from a distal end  226  of the capsule  218 . The longitudinal extension  252  is sized and configured to interface with the suture grabbing element  208 , as the clip  202  is moved toward the locked configuration. In particular, as the clip  202  is moved toward the locked configuration, the suture grabbing element  208  comes into contact with the longitudinal extension  252 . Further proximal motion of the first and second arms  204 ,  206  relative to the capsule  218  forces the suture grabbing element  208  to bend toward the first arm  204 , reducing the risk of the suture grabbing element  208  causing damage to surrounding tissue upon deployment of the clip  202 . 
     In another exemplary embodiment, as shown in  FIGS.  17  and  18   , a device  200 ′ is substantially similar to the device  200  described above except as described below. Rather than the wedge and cutting features of a capsule, as described above, however, first and second arms  204 ′,  206 ′ of a clip  202 ′ of the device  200 ′ include features for wedging and/or cutting a suture  212 ′. The clip  202 ′ is substantially similar to the clip  202  described above except as distinguished below. The first arm  204 ′, however, in addition to a notch  240 ′, a slot  210 ′ and a first opening  244 ′, includes a second opening  250 ′ extending laterally therethrough, proximally of the first opening  244 ′. The suture  212 ′ may extend from a proximal end, through the flexible member and capsule  218 ′ between the first and second arms  204 ′,  206 ′, until the suture  212  reaches the second opening  250 ′. The suture  212 ′ may be passed from an interior  242 ′ of the first arm  204 ′ through the second opening  250 ′ to an exterior  246 ′ of the first arm  204 ′ so that a portion of a length of the suture  212 ′ extends along the exterior &#39; 246 ′ of the first arm  204 ′ between the second and first openings  250 ′,  244 ′. Upon reaching the first opening  244 ′, the suture  212 ′ is passed through the first opening  244 ′ so that a distal loop  213 ′ of the suture  212 ′ may be hooked onto the notch  240 ′. 
     The second arm  206 ′ includes, in addition to a suture receiving element  208 ′, a wedge element  230 ′ extending laterally therefrom toward the first arm  204 ′ so that, when the clip  202 ′ is moved toward a locked configuration, the wedge element  230 ′ extends through the first opening  244 ′ against an edge thereof to wedge or pinch the suture  212 ′ between the wedge element  230  and the edge of the first opening  244 ′. Upon being moved to the locked configuration, a distal edge  226 ′ of a capsule  218 ′ cuts a portion of the suture  212 ′ extending between the first and second openings  244 ′,  250 ′. The device  200 ′ may be used in manner substantially similar to the device  200 , described above except as distinguished below. 
     Although the device  200 ′ is described as including a wedging of the suture  212 ′ via the wedge element  230 ′ and cutting of the suture  212 ′ between the first and second openings  244 ′,  250 ′ via the distal edge  226 ′ of the capsule  218 ′, in an alternative embodiment, the suture  212 ′ may be cut in a manner substantially similar to the devices  100 ,  200  described above. While the suture  212 ′ may be wedged between an edge of the first opening  244 ′ and the wedge element  230 ′, the suture  212 ′ may be cut via a cutting feature along an interior of the capsule  218 ′. 
     A suture grabbing element and a slot or opening across which a loop of a suture extends may be formed in any of a variety of shapes and configurations, so long as a hook feature of the suture grabbing element is able to pass through the slot or opening to hook the loop of the suture. For example, in one embodiment, as shown in  FIG.  19   , a clip  302  may be substantially similar to the clips  202 ,  202 ′ described above. Rather than a substantially planar suture grabbing element received through a correspondingly shaped slot, a first arm  304  of the clip  302  may include a substantially circular opening  310  extending therein, through a notch extending along an interior surface  342  of the first arm  304 . A suture grabbing element  308  extending laterally from a second arm  306  of the clip  302  may be configured as a needle or wire including a hooked recess  336  extending therein. 
     In another example, as shown in  FIG.  20   , a clip  402  may be substantially similar to the clips  202 ,  302  describe above, comprising first and second arms  404 ,  406 . The first arm  404 , however, includes a substantially circular opening  410  extending laterally through a distal end  414  thereof. The notch, however, is configured as a slot  440  extending proximally into the first arm  404  from a distal edge  414  thereof, between an interior  442  and exterior surface  446  of the first arm  404 . Thus, when a suture loop is inserted into the slot  440 , a portion of the loop extends across the opening  410 . A suture grabbing element  408  may be configured as a circular protrusion  409  extending laterally from a distal end  415  of the second arm  408  and including a hook  436  extending therefrom. 
     In an alternate embodiment, as shown in  FIG.  21   , a device  500  comprises a clip  502  substantially similar to the clips  202 ,  302 ,  402  described above except as distinguished below. The clip  502  includes first and second arms  504 ,  506  and the first arm  504 , however, includes a slotted opening  510  open to a distal end  514  thereof. A notch is configured as a second slot  540  extending proximally from and open to the distal end  514  so that, when a suture loop is received within the second slot  540 , a portion of the loop extends across the slotted opening  510 . The second arm  506  includes a suture grabbing element  506  extending laterally therefrom, toward the first arm  508 . The suture grabbing element  508  may be substantially similar to the suture grabbing element  208  described above in regard to the device  200 , including a hooking recess  538  extending therein so that, when the first and second arms  504 ,  506  are drawn toward one another, the suture grabbing element  508  extends through the slotted opening  510  to hook the portion of the suture extending thereacross. 
     As shown in  FIGS.  22 - 27   , a device  600  according to another exemplary embodiment may be substantially similar to the device  100  described above except as noted below, comprising a clip  602  including first and second arms  604 ,  606  movable relative to one another between an open configuration and a closed configuration and a needle  608  releasably coupled to the first arm  604  to pass a suture  612  connected to the needle  608  through a first portion of tissue along a first side of tissue opening. Although not shown, the clip  602  may be moved between the open and closed configurations via a capsule in a manner substantially similar to that described above for the capsule  118 . Similarly to the device  100 , when the clip  602  is moved toward the closed configuration over the first portion of tissue, the needle  608  is passed through the first portion of tissue to engage with an engaging feature  610  of the second arm  606  so that, when the clip  602  is moved once again to the open configuration, the needle  608  is released from the first arm  604 , leaving the needle  608  engaged with the second arm  606 . As the clip  602  moves to the open configuration, the suture  612  is drawn through the first portion of tissue. The clip  602  is then opened and repositioned over a second portion of tissue (e.g., along a second side of a tissue opening). Once the clip  602  has been repositioned as desired, the clip  602  is moved to the closed configuration to grip the second portion of tissue between the first and second arms  604 ,  602 . The suture  612  is then tensioned to draw the first portion of tissue, through which the suture  612  has been passed, toward the second portion of tissue, over which the clip  602  is clipped, until the first portion of tissue is drawn against the second portion of tissue, closing the tissue opening. 
     In this embodiment, the second arm  606  may be substantially rigid while the first arm  604  is pivotally coupled thereto to be moved relative to the second arm  606  between the open and the closed configurations. The needle  608  is preloaded onto the first arm  604  and is coupled thereto via a releasable hinge  616  at an end thereof. The hinge  616  of the needle  608  is received within a correspondingly shaped recess  617  along an interior  642  of the first arm  604  via a snap fit which permits the needle  608  to pivot about the hinge  616  when received within the recess  617 . The needle  606  may be curved along a length thereof and movable between a preloaded insertion configuration, as shown in  FIG.  22   , and a firing position, as shown in  FIG.  23   . In particular, when the hinge  616  is engaged with the recess  617 , the needle  608  pivots about the hinge  616  at a first end  620  of the needle  608  so that a second end  622  of the needle  608  may be moved from the preloaded insertion configuration, in which the second end  622  extends toward the first arm  604 , to a firing position in which the second end  622  extends toward the second arm  606 . Although the needle  608  is described and shown as being coupled to the first arm  604  via a hinge  616 , the needle  608  may be releasably coupled to the first arm  604  in any of a variety of ways so long as the needle  608  is pivotal relative thereto, as described above. 
     The second arm  606  includes the engaging feature  610  which may be configured as a longitudinal recess  654  extending through a portion of the second arm  606  along with restraining tabs  656  extending over a portion of the longitudinal recess  654  to prevent the needle  608  from being disengaged from the second arm  606  once the needle  608  is received within the longitudinal recess  654 . The longitudinal recess  654  is sized and shaped to receive the needle  608  and may include a curved surface  658  for guiding the needle  608  thereinto as the clip  602  is moved toward the closed configuration. Once the needle  608  has been received therein, the needle  608  is prevented from being disengaged therefrom via the restraining tabs  656 . 
     Similarly to the devices  100 ,  200 , the suture  612  may extend from a proximal end coupled to a handle assembly of the device  600 , through a flexible member and capsule coupled to the clip  602  to a distal end  648  connected to the needle  608 . Similarly to the clip  202 , the first arm  604  may include an opening  644  through which the suture  612  may extend from the interior  642  of the first arm  604  to an exterior  646  of the first arm  604 . In the preloaded insertion configuration, the suture  612  extends along the exterior  646  about a distal end  614  of the first arm to the distal end  648  connected to the needle  608 , which is pivotally coupled to the interior  642  of the first arm  604  via the hinge  616 . 
     The device  600  may be used in a manner substantially similar to the device  100  described above. In particular, the clip  602  is inserted into a living body to the tissue opening to be treated in the preloaded insertion configuration shown in  FIG.  22   . Upon reaching the tissue opening, the clip  602  is moved toward the open configuration such that distal ends  614 ,  615  of the arms  604 ,  606  are separated from one another. The needle  608  is then pivoted about the hinge  616  to the firing position, shown in  FIG.  23   , by tensioning the suture  612  connected thereto (i.e., drawing the suture  612  proximally relative to the clip  602 ) so that the second end  622  of the needle  608  extends toward the second arm  606 . The clip  602  is positioned adjacent to the first portion of tissue with the first portion of tissue is received between the second end  622  of the needle  608  and the second arm  606 . Once the clip  602  is positioned over the first portion of tissue, as desired, the clip  602  is moved toward the closed configuration such that the needle  608  is moved toward the second arm  606 , piercing the first portion of tissue and sliding into the longitudinal recess  654  of the second arm  606 . As the needle  608  is received within the longitudinal recess  654 , the needle  608  comes into contact with the curved surface  658  thereof, as shown in  FIG.  24   , to be guided along a length thereof. Thus, the needle  608  pivots about the hinge  616  as the needle  608  is received proximally through the longitudinal recess  654 , as shown in  FIG.  25   . 
     When the needle  608  is received within the longitudinal recess  654 , the restraining tabs  656  lock the needle  608  therein such that the needle  608  cannot be disengaged from the second arm. A force of the engagement between the needle  608  and the restraining tabs  656  is greater than a force of the engagement between the hinge  616  and the recess  617  so that moving the clip  602  toward the open configuration causes the hinge  616  to be disengaged from the first arm  604  while the needle  608  remains locked to the second arm  606 , as shown in  FIGS.  26  and  27   . Thus, as the clip  602  is moved toward the open configuration, the suture  612  is drawn through the first portion of tissue. 
     After passing the suture  612  through the first portion of tissue, the clip  602  is positioned adjacent to the second portion of tissue, creating slack in the suture  612  as the clip  602  is moved to a desired position relative to the second portion of tissue. When the second portion of tissue has been received between the first and second arms  604 ,  606 , the clip  602  may be moved toward the closed configuration to grip the second portion of tissue therebetween. Similarly to the devices  100 ,  200  described above, the suture  612  may then be tensioned to draw the first portion of tissue toward the second portion of tissue, thereby closing the tissue opening. The clip  602  may be locked in the closed configuration, similarly to the clips  102 ,  202  described above in regard to the devices  100 ,  200 . Locking the clip  602  in the closed configuration may wedge and cut the suture  612  via, for example, a wedge and cutting feature along an interior of the capsule, so that the clip  602  and a distal portion of the suture  612  may be deployed within the body. 
     As shown in  FIG.  28   , a device  700  according to another exemplary embodiment may be substantially similar to the device  600  described above except as discussed below. Rather than being coupled to a first arm  704  of a clip  702  via a hinge, however, a needle  708  of the device  700  is coupled to the first arm  704  via tabs  716  extending therefrom and engaged within correspondingly shaped slots  717  in the first arm  704 . The tabs  716  and corresponding slots  717  are configured to permit movement (e.g., pivoting) of the needle  708  relative to the first arm  704  similarly to the device  600  described above. The tabs  716  remain engaged with the slots  717  until the needle  708  is received within the engagement feature along a second arm (not shown) of the clip  702 . 
     As shown in  FIGS.  29 - 30   , a device  800  may be substantially similar to the device  600  described above except as discussed below. A second arm  806  of a clip  802  of the device  800 , however, includes an engagement feature  810  that further includes an elastic member  860  in addition to a longitudinal recess  854  and retaining tabs  856 . The elastic element  860  extends within the longitudinal recess  845  and may be configured as a leaf spring. In particular, the elastic element  860  is biased in capture configuration in which the elastic member  860  extends into the longitudinal recess  854 . Thus, when a needle, which may be substantially similar to any of the needles described herein (e.g., needle  608 , needle  708 ) extends into the longitudinal recess  854 , the elastic element  860  is deflected to permit the needle to be received therein. Once the needle is received within the longitudinal recess  854 , the elastic element  860  reverts toward the biased configuration to retain the needle in the longitudinal recess  854  by pushing the needle against the retaining tabs  856 . 
     According to another example, as shown in  FIG.  31   , a device  900  may be substantially similar to the devices  600 - 800  described above except as discussed below. A needle  908 , however, may be pivotally coupled to a first arm  904  of a clip  902  via a C-Shaped connector  916  at an end of the needle  908 , which is mounted over a pin  917  extending across a distal portion of the first arm  904 . The C-shaped connector  916  and the pin  917  together create a hinge mechanism so that the needle  908  may be pivoted about the pin  917  between a preloaded insertion configuration and a firing position, as described above in regard to the device  600 . The C-shaped connector  916  also permits the needle  908  to disengage the first arm  904 , once the needle engages an engagement feature  910  of the second arm  906 . 
     A device  1000 , as shown in  FIG.  32   , may also be substantially similar to the devices  600 - 800  except as discussed below and comprises a clip  1002  including first and second arms  1004 ,  1006 . A needle  1008  is coupled to the first arm  1004 , however, via a ball-shaped connectors  1016  at an end thereof, which are received within corresponding shaped recess  1017  within the first arm  1004 . The ball-shaped connectors  1016  permit the needle  1008  to pivot with respect to the first arm between a preloaded insertion configuration and a firing position. Although the above embodiments of the devices  600 - 1000  describe particular examples of a pivotal connection between a needle and an arm of a clip, the needle may be connected to the arm in any of a number of different ways so long as the needle is releasably coupled to the arm and permits a pivotal motion of the needle relative to the arm. 
     While embodiments have been described above, a number of modifications and changes may be made without departing from the scope of the disclosure. Thus, it is intended that the present disclosure cover modifications and variations provided that they come within the scope of the appended claims and their equivalents.