Patent Publication Number: US-7223274-B2

Title: Method of performing anastomosis

Description:
This patent application is a divisional of U.S. patent application Ser. No. 10/057,745, filed on Jan. 23, 2002 now U.S. Pat. No. 7,029,482, and is a continuation-in-part of U.S. patent application Ser. No. 10/054,795, filed on Jan. 25, 2002 now U.S. Pat. No. 6,686,427. 
    
    
     FIELD OF THE INVENTION 
     The present invention relates generally to anastomosis, and more particularly to an anastomosis device and an integrated tool for deploying it. 
     BACKGROUND 
     Anastomosis is a procedure where two separate tubular or hollow organs are surgically grafted together to form an intercommunication between them. Vascular anastomosis involves creating an anastomosis between blood vessels to create or restore blood flow. The vascular anastomosis procedure is routinely performed during the treatment of a variety of conditions, including coronary artery disease (CAD), neurovascular disease, diseases of the great and peripheral vessels, organ transplantation, traumatic injury and other vascular abnormalities. When a patient suffers from CAD, an occlusion or stenosis in a coronary artery restricts blood flow to the heart muscle. To treat CAD, the area where the occlusion occurs is bypassed to reroute blood flow by placing a graft vessel (in the form of a harvested artery or vein, prosthesis, allograft or xenograft) between two target vessels: the aorta or other supply of arterial blood, and the coronary artery. Placement of the graft vessel bypasses the blocked coronary artery, circumventing the occlusion and restoring adequate blood flow to the heart muscle. This treatment is known as a coronary artery bypass graft procedure (CABG). A CABG procedure can be performed on a stopped heart, where the patient has been placed on a heart-lung machine, or on a beating heart. Access to the thoracic cavity for a CABG procedure can be provided by sawing the sternum and opening the chest, or by creating one or more small openings in the thoracic cavity. Anastomosis may be performed by hand-suturing the graft vessels together or by utilizing an anastomosis device. 
     Regardless of the type of CABG procedure that is performed, or the type of anastomosis performed, an opening is made in the aorta or other artery at the proximal anastomosis site to allow blood to flow into the graft vessel. Typically, an incision is made in the aorta with a scalpel. A distal end of an aortic punch is inserted into the incision, then actuated to cut a larger opening in the aorta. While the combination of the scalpel and the aortic punch is commonly used to form an opening in the aorta, there are drawbacks. This is a problematic approach that does not provide reliable hemostasis during beating heart surgery, and has the potential to allow the location of the incision to become lost. Further, after the aortic punch creates an opening in the aorta, blood will flow out of that opening. Further, the aortic punch is just one tool of a multiple-tool system for creating an opening in the aorta. At least one additional tool is needed for attaching a graft vessel to a target vessel. The use of multiple tools adds steps, time and complexity to the CABG procedure. 
     SUMMARY 
     In one aspect of the invention, an anastomosis device for connecting a graft vessel to a target vessel has a deployable section detachably connected to a discard section. The discard section includes one or more paddles for connection to an application tool and may include a compression segment. The deployable section includes tines connected to a linkage, which in turn is connected to a plurality of outer flange elements. 
     In another aspect of the invention, the deployable section of the anastomosis device is configured to deform such that the tines form an inner flange, the outer flange elements form an outer flange, and the linkage partially expands to form a body linking the inner flange to the outer flange. 
     In another aspect of the invention, an integrated anastomosis tool includes a first mechanism for creating an opening in the wall of a target vessel, and a second mechanism for deploying an anastomosis device into that opening. 
     In another aspect of the invention, the discard section of the anastomosis device is connected to the integrated anastomosis tool. 
     In another aspect of the invention, the integrated anastomosis tool includes a single control for accepting user input associated with creating an opening in the vessel wall and completing an anastomosis between a graft vessel and a target vessel. 
     In another aspect of the invention, deployment of the anastomosis device from the integrated anastomosis tool is controlled by one or more cam paths. One or more cam followers on the mechanism for deploying the anastomosis device engage one or more cam paths. The cam paths may be defined on a cam cylinder. 
     In another aspect of the invention, the components of the integrated anastomosis tool are located outside of the lumen of the graft vessel. In this way, the inner surface of the graft vessel is protected against damage by the integrated anastomosis tool. 
     In another aspect of the invention, a cartridge is detachably connected to the integrated anastomosis tool. A crown and an expander are configured to translate relative to the cartridge, guided along at least one groove, cam path and/or other structure. 
     In another aspect of the invention, the discard section of the anastomosis device is connected to the distal end of the crown. The graft vessel extends through the center of the crown and expander, and is everted over the anastomosis device at the distal end of the crown. 
     In another aspect of the invention, the expander includes an expander tip at its distal end. A number of slots extend substantially axially through the expander tip, and the segments of the expander tip between the slots may be biased away from the axis of the expander tip. 
     In another aspect of the invention, the angular spacing between an expander slot and a first adjacent expander slot is different from the angular spacing between that expander slot and a second adjacent expander slot. In this way, the expander tip is stiffer along some cross-sections than others. 
     In another aspect of the invention, relative motion between the crown and the expander deforms the anastomosis device and deploys the deployable section into an opening in the target vessel. 
     In another aspect of the invention, the expander tip includes a collet that is colleted down by the crown to move the segments of the expander tip inward and allow the expander tip to move proximally relative to the deployed anastomosis device. 
     In another aspect of the invention, the outer flange elements include gripping elements for gripping the outer surface of the target vessel. 
     In another aspect of the invention, at least part of the integrated anastomosis tool is lubricated with a biocompatible lubricant such as sodium stearate. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         FIG. 1  is a side view of an integrated anastomosis tool. 
         FIG. 1A  is a cutaway view of the distal end of an assembly for creating an opening in the wall of a tubular vessel. 
         FIG. 2  is a detail view of the distal end of the assembly of  FIG. 1 . 
         FIG. 3  is a cross-section detail view of an auger and cutter forming part of the assembly of  FIGS. 1 and 2 . 
         FIG. 4  is a cutaway view of the distal end of another embodiment of assembly for creating an opening in the wall of a tubular vessel. 
         FIG. 5  is a detail view of the distal end of the assembly of  FIG. 4 . 
         FIG. 6  is a perspective view of a drive mechanism for use with the assembly for creating an opening in the wall of a tubular vessel. 
         FIG. 7  is an end cross-section view of a first gear and a first driveshaft forming part of the drive mechanism of  FIG. 6 . 
         FIG. 8  is a perspective view of a second driveshaft forming part of the drive mechanism of  FIG. 6 . 
         FIG. 9  is an end view of a knob utilized to operate the drive mechanism of  FIG. 6 . 
         FIG. 10  is a cross-section view of the knob of  FIG. 9 . 
         FIG. 11  is a cutaway view of an integrated anastomosis tool, where the tool is in an initial state. 
         FIG. 12  is a cutaway view of the tool of  FIG. 11  in a deployed state. 
         FIG. 13  is a detail view of the auger and cutter of  FIGS. 4-5 . 
         FIG. 14  is a side view of a first case half. 
         FIG. 15  is a side view of a second case half configured to mate with the first case half of  FIG. 14 . 
         FIG. 16  is a side view of an anastomosis device. 
         FIG. 17  is an end view of the distal end of the anastomosis device of  FIG. 16 . 
         FIG. 18  is a top view of a tubular structure from which the anastomosis device of  FIG. 16  is formed, unrolled into a planar configuration. 
         FIG. 19  is a perspective view of a crown. 
         FIG. 20  is an end view of the crown of  FIG. 19 . 
         FIG. 21  is a side view of the crown of  FIG. 19 . 
         FIG. 22  is a perspective view of a cartridge. 
         FIG. 23  is an end view of the cartridge of  FIG. 22 . 
         FIG. 24  is a cross-section side view of the cartridge of  FIG. 22 . 
         FIG. 25  is a perspective view of an expander. 
         FIG. 26  is an end view of the distal end of the expander of  FIG. 25 , with the expander tip removed. 
         FIG. 27  is a side view of the expander of  FIG. 25 , including the expander tip of  FIG. 28A  at its distal end. 
         FIG. 28  is a perspective view of an expander tip at the distal end of the expander of  FIG. 25 . 
         FIG. 28A  is a side cross-section view of the expander tip of  FIG. 28 . 
         FIG. 29  is a side view of the expander tip of  FIG. 28 . 
         FIG. 30  is an end view of the expander tip of  FIG. 28 . 
         FIG. 31  is a side view of the crown and expander fitted together. 
         FIG. 32  is a graph of force applied to the deployable section of the anastomosis device over time. 
         FIG. 33  is a side view of the anastomosis device partially deployed. 
         FIG. 34  is a side view of the anastomosis device after deployment. 
         FIG. 35  is a top view of the anastomosis device after deployment. 
         FIG. 36  is a side view of the anastomosis device before deployment, showing a graft vessel everted over its distal end. 
         FIG. 37  is a schematic cross-section side view of the anastomosis device after deployment. 
         FIGS. 38A-D  are four different side views of a cam cylinder, showing the cam paths defined therein. 
         FIG. 39  is a perspective view of a portion of the deployable section of the anastomosis device. 
         FIG. 40  is a detail view of a portion of the cam cylinder of  FIGS. 38A-D . 
         FIG. 41  is a perspective view of the introducer tube. 
     
    
    
     The use of the same reference symbols in different figures indicates similar or identical items. 
     DETAILED DESCRIPTION 
     Referring to  FIG. 1 , an integrated anastomosis tool  100  is shown. A casing  98  defines the outer surface of the integrated anastomosis tool  100 . Referring also to  FIGS. 14-15 , the casing  98  is formed by connecting a first case half  120  and a second case half  122 . The case halves  120 ,  122  may be connected by screws, bolts, adhesives, or other structures, mechanisms or methods. Alternately, the casing  98  may be unitary, or may be formed from more than two individual casing components. The casing  98  is composed of plastic or other biocompatible material, and may be constructed by vacuum molding, injection molding, or any other method appropriate for the material utilized. A contact structure  110  is located at the distal end of the casing  98 , and is configured for placement against a vessel wall or other bodily structure. A cartridge  124  is inserted into the casing  98  before the integrated anastomosis tool is operated. The cartridge  124  is described in greater detail below. The casing  98  provides a shell within which other components of the integrated anastomosis tool  100  are located. These components include an assembly for creating an opening in a vessel wall, and an assembly for placing and deploying an anastomotic device into that opening. 
     Referring to  FIGS. 1A-3 , a cutter  4  is connected to an auger  6 . The cutter  4  is constructed from a biocompatible metal, such as stainless steel, but a different biocompatible material may be used if desired. The distal end of the cutter  4  is sharpened to cut the wall of a tubular vessel, such as the aorta or other blood vessel. The cutter  4  is a hollow tubular structure with an open distal end. The distal end of the cutter  4  has a substantially circular shape, and the cutter  4  has a substantially circular cross-section along its length. However, the cutter  4  may take another shape, have a different cross section, or vary in cross section along its length. For example, the cutter  4  may take the shape of a tube having an open slit along its length. That is, the cutter  4  may form of the majority of a cylindrical surface, where the cutter  4  extends along, for example, 350° of the complete 360° perimeter of the cylinder. The cutter  4  has an inner surface  12  and an outer surface  8 . The distal end of the cutter  4  is beveled for sharpness. The distal end of the cutter  4  may be beveled inward, such that the inner surface  12  contacts a vessel wall before the outer surface  8 , or beveled outward, such that the inner surface  12  contacts a vessel wall after the outer surface  8 . Alternately, the distal end of the cutter  4  may be beveled both inward and outward, such that a sharp edge is provided at a location between the inner surface  12  and outer surface  8  of the cutter  4 . 
     The auger assembly  10  is fixed to the cutter  4 , and extends through its hollow center. In one embodiment, the auger assembly  10  extends through at least part of the hollow center of the cutter  4 , and extends to a location proximal to the proximal end of the cutter  4 . The auger assembly  10  is constructed from the same biocompatible metal as the cutter  4 . Alternately, the auger assembly  10  may be constructed from a different biocompatible material. The auger assembly  10  may include a number of components. The auger  6  is one of these components, located at the distal end of the auger assembly  10 . The auger  6  may be an integral part of the auger assembly  10 , or instead may be a separate component that is connected to another portion of the auger assembly  10 . Referring particularly to  FIG. 3 , the auger  6  is substantially coaxial with the cutter  4 . The auger  6  includes a spike  5  at its distal end, and a shaft  7  extending proximally from the spike  5 . The shaft  7  is substantially cylindrical. Alternately, the shaft  7  may be shaped differently. The spike  5  is tapered from its proximal end toward its distal end, and is substantially radially symmetrical. The distal end of the spike  5  is sharp to allow it to readily penetrate tissue, as described in greater detail below. The proximal end of the spike  5  is wider than the shaft  7 , such that a ledge  9  is formed at the proximal end of the spike  5 . The distal end of the spike  5  extends distal to the distal end of the cutter  4 . Further, the spike  5  is positioned relative to the cutter  4  and is shaped such that the ledge  9  extends distally at least as far as the distal end of the cutter  4 . 
     Alternately, the auger  6  and the cutter  4  are configured as described above, but are fixed to one another only axially; they are free to rotate with respect to one another. That is, the auger  6  and cutter  4  are configured to translate together at the same rate in the axial direction, but are free to rotate independently of one another. For example, the auger  6  may include a circumferential flange (not shown) held within a corresponding groove (not shown) in the cutter  4 . The flange can rotate within the groove, and contact between the flange and the groove causes the auger  6  and cutter  4  to translate together. That is, the auger  6  and the cutter  4  are fixed axially, but independent rotationally. While the auger  6  and the cutter  4  are capable of rotating relative to one another, they need not do so, and may rotate together at the same rate if desired. Other mechanisms or structures may be used to configure the auger  6  and the cutter  4  to translate together axially while having the capability of rotating independently. 
     Referring to  FIGS. 4-5 , another embodiment of the auger  6  is shown. The auger  6  has one or more flutes  13  defined on its outer surface. The flutes  13  have a pitch of substantially  16  threads per inch and a thread angle of substantially thirty-seven degrees. Alternately, a different pitch and/or thread angle may be used. In one embodiment, the auger  6  is tapered from its proximal end toward its distal end. The distal end of the auger  6  is sharp, to facilitate its entry into the wall of the tubular vessel, and extends to a location that is further in the distal direction than the distal end of the cutter  4 . Alternately, a piercing member other than the auger  6  is axially fixed to the cutter  4 , such as a barb, harpoon, lance, corkscrew or a needle without flutes. 
     The auger assembly  10  includes a center rod  14  that is connected to the shaft  7  of the auger  6  and that is substantially coaxial with the cutter  4  and with the auger  6 . Alternately, the center rod  14  may be positioned along a different axis. The shaft  7  may be formed as an integral part of the center rod  14 . One or more centering flanges  16  are fixed to the center rod  14 , extending outward radially from the center rod  14  to contact the cutter  4 . One or more of the centering flanges  16  may be fixed to the cutter  4 . The centering flanges  16  are utilized to position the center rod  14  within the cutter  4  along at a desired axis and to provide support and stiffness to the cutter  4 . As described above, the centering flanges  16  may be utilized to center the center rod  14  within the cutter  4 . In one embodiment, the centering flanges  16  are constructed as part of the center rod  14 , thereby forming a unitary structure. However, the centering flanges  16  may be constructed separately from the center rod  14 , then connected to the center rod  14 , such as by adhesive or other fastening mechanism, structure or method. One or more centering flanges  16  may also be formed into or attached to the portion of the center rod  14  that extends proximal to the cutter  4 . These centering flanges  16  may be utilized to position the center rod  14  relative to one or more other structures or mechanisms and/or to provide bearing surfaces for rotation of the auger assembly  10 . The centering flanges  16  may have different thicknesses in the axial direction. 
     The cutter  4  is attached to the auger assembly  10  by dimpling the cutter  4  in one or more locations. One of the centering flanges  16  includes a groove  17  defined substantially circumferentially around it. The centering flange  16  that includes the groove  17  may be wider than one or more other centering flanges  16 . Each dimple  18  is located within the groove  17 . Each dimple  18  is formed by pressing the cutter  4  inward toward the groove  17 , causing that location on the cutter  4  to deform into a dimple  18 . The dimple  18  expands into a portion of the groove  17 , trapping the dimple  18  therein. The cutter  4  thus is fixed to the auger assembly  10 , such that they rotate and translate together. Alternately, the cutter  4  includes one or more partially-circumferential ribs (not shown) extending inward from its inner surface  12 . Each rib is crimped between two centering flanges  16 , and is thereby trapped between them and fixed to them to fix the cutter  4  to the auger assembly  10 . The auger assembly  10  may be connected to the cutter  4  using other or additional suitable mechanisms, structures or methods. Such a connection may be used where the auger  6  is fixed axially to, but free to rotate relative to, the cutter  4 . For example, the auger assembly  10  and the cutter  4  may be molded or otherwise formed together as a single piece. As another example, the auger assembly  10  and the cutter  4  may be fixed together by adhesive. As another example, the auger assembly  10  and the cutter  4  may be fixed together by welding, or may be pinned or screwed together. 
     At least one vent  20  is defined in the auger assembly  10  at or proximal to the proximal end of the cutter  4 . The vent  20  connects a space inside the cutter  4  with a space outside the cutter  4 . Similarly, at least one slot  22  is defined through each centering flange  16 . If a centering flange  16  is located adjacent to the proximal end of the cutter  4 , the slot  22  in that centering flange  16  is aligned with the vent  20 . The vent  20 , in combination with the at least one slot  22  in each centering flange  16 , provides a pathway for fluid such as air or blood to escape from the cutter  4  when the cutter  4  and auger  6  are deployed into the vessel wall. The cutter  4  is vented to prevent fluid from becoming trapped within the cutter  4 , because the pressure of that trapped fluid could potentially prevent the cutter  4  from penetrating the vessel wall or other anatomical structure. Other structures or mechanisms than the vent  20  and the slot  22  may be used to vent the cutter  4 . 
     An actuator  24  is connected to the proximal end of the auger assembly  10 . The center rod  14  extends to the proximal end of the auger assembly  10 , and the actuator  24  connects to the center rod  14 . Advantageously, the actuator  24  is a coil spring that is tightly wound, and the center rod  14  is threaded into the distal end of the spring. Alternately, the spring may be connected to the center rod  14  by adhesive, welding, soldering, compressive force or other methods or mechanisms. In this way, the spring provides flexibility and transmits translational and rotational force to the auger assembly  10 . However, the actuator  24  may be any other structure or mechanism that is capable of transmitting translational and rotational forces to the auger assembly  10 . Additionally, the actuator  24  need not be flexible if the auger  6  and cutter  4  are not moved off-axis, as is described in greater detail below. The actuator  24  is connected at its proximal end to the distal end of a first driveshaft  26 . 
     At least a portion of the auger assembly  10  and the cutter  4  is positioned within a hollow introducer tip  28 . The introducer tip  28  is a tapered element that is narrower at its distal end than at its proximal end. Alternately, the introducer tip  28  is not tapered. The introducer tip  28  has a substantially circular cross-section along its length. The introducer tip  28  is a radially and bilaterally symmetrical shell. Alternately, the introducer tip  28  can take a different shape, symmetry or form. The introducer tip  28  is composed of a biocompatible plastic, although a different material or combination of materials may be used. The inner diameter of the distal end of the introducer tip  28  is substantially the same as the outer diameter of the cutter  4 , as measured at the distal end of the introducer tip  28 . Further, the introducer tip  28  is substantially coaxial with the cutter  4 . Thus, at the distal end of the introducer tip  28 , the cutter  4  substantially seals against the introducer. As with the distal end of the cutter  4 , the distal end of the introducer tip  28  may be beveled inward. Initially, the cutter  4  extends distally from the distal end of the introducer tip  28 , and the distal end of the introducer tip  28  follows the cutter  4  into an opening cut in the wall of a tubular vessel, as is described in greater detail below. The introducer tip  28  may be splittable or expandable, if desired, such that the diameter of its distal end can be enlarged. Such enlargement may be useful in translating an anastomotic device through the introducer tip  28 , or for other purposes. 
     The introducer tip  28  includes a circumferential flange  30  at or near its proximal end, where that flange  30  is held within a circumferential slot  32  in a seal housing  34  at or near its distal end. The introducer tip  28  thereby is secured to the seal housing  34 . Alternately, the flange  30  is not circumferential, and the slot  32  in the seal housing  34  is correspondingly not circumferential. Alternately, the introducer tip  28  is secured to the seal housing  34  by a different structure, mechanism or method, such as by adhesive. The seal housing  34  is a substantially hollow structure into which the proximal end of the auger assembly  10  extends. The seal housing  34  includes an opening  36  at or near its distal end through which the introducer tip  28  and the auger assembly  10  extend. The cutter  4  extends proximally through the opening  36  in the seal housing  34 . Alternately, the cutter  4  does not extend as far proximally as the opening  36  in the seal housing  34 . The actuator  24  extends through the seal housing  34 , and may extend out of an opening  80  at or near the proximal end of the seal housing  34 . Alternately, the actuator  24  does not extend out of the seal housing. 
     The proximal end of the auger assembly  10  extends through the interior of a bushing  38 . The bushing  38  is substantially cylindrical and has a substantially cylindrical opening therethrough. However, the bushing  38  and/or the opening through it may be shaped differently. The distal end of the bushing  38  contacts at least one centering flange  16  that is connected to the center rod  14 . The distal end of the bushing  38  may be free to translate relative to that centering flange  16 , where that centering flange  16  has a diameter larger than the passage through the bushing  38  such that the bushing  38  cannot advance distally past that centering flange  16 . Alternately, the distal end of the bushing  38  contacts the inner surface of the introducer tip  28  instead of or in addition to at least one centering flange  16 . The bushing  38  is restrained from rotation as the cutter  4  and auger assembly  10  rotate due to contact with at least one centering flange  16  and/or the introducer tip  28 . However, registration features, stops or other structures or mechanisms may be used to restrain the bushing  38  from rotation. The bushing  38  may be tapered, such that the distal end of the bushing  38  contacts at least one centering flange  16 , and another, wider location on the bushing  38  near the distal end of the bushing  38  contacts the inner surface of the introducer tip  28 . The bushing  38  is supported by the introducer tip  28 . The proximal end of the bushing  38  may contact a rib  40  or other structure within the seal housing  34 . However, the proximal end of the bushing  38  is not fixed to the rib  40  or similar structure. Thus, the bushing  38  is free to translate proximally with respect to the introducer tip  28 , but is restrained in its forward motion by contact with at least one centering flange  16  and/or introducer tip  28 . One or more centering flanges  16  may be located within the bushing  38 , and each centering flange  16  is connected to the center rod  14 . However, the centering flanges  16  within the bushing  38  are free to rotate relative to the bushing  38 . Thus, the auger assembly  10  may rotate relative to the bushing  38 , and is supported and guided by the bushing  38  during this rotation. 
     A guide  35  is defined in or connected to the inner surface of the seal housing  34 . The guide  35  may be a ramp, slot or other structure or mechanism. Advantageously, two guides  35  are provided, one on the inner surface of each side of the seal housing  34 . For clarity, only one side of the seal housing  34  is shown. Because the seal housing  34  is substantially symmetrical, the guide  35  on the side of the seal housing  34  that is not shown is substantially symmetrical with the guide  35  shown. A guide follower (not shown) extends from the bushing  38  to contact or otherwise engage the corresponding guide  35 . One guide follower is associated with each guide  35 . The guides  35  are configured to guide the bushing  38 , and with it the auger  6 , cutter  4  and captured tissue away from the axis of the introducer tip  28  to a second axis spaced apart from the introducer axis, as is described in greater detail below. Thus, the location and orientation of the guides  35  on the inner surface of the seal housing  34  is dependent upon the location of the second axis. 
     The auger assembly  10  and the cutter  4  can be actuated to rotate and to translate forward in any one of a number of ways. Referring also to  FIG. 6 , the distal end of a first driveshaft  26  is connected to the proximal end of the actuator  24 . The connection between the first driveshaft  26  and the actuator  24  may be made inside or outside the seal housing  34 . The first driveshaft  26  is substantially rigid, and has a number of ribs  42  aligned substantially axially along its surface, extending substantially radially outward. Alternately, the ribs  42  are aligned and/or extend differently. Four ribs  42  are spaced evenly around the circumference of the first driveshaft  26 , but more or fewer ribs  42  may be utilized. The first driveshaft  26  is capable of axial translation relative to a first gear  44  that is substantially coaxial with the first driveshaft  26 . The first gear  44  is mounted to a casing (not shown) or other structure, such that it is free to rotate about its axis but fixed in the axial direction and restrained against axial translation. Such mounting is standard in the art. The first gear  44  has a passage  45  therethrough, wherein a number of ribs (not shown) extend inward toward the rod  24  and are positioned between the ribs  42  on the first driveshaft  26 . Contact between the ribs  42  and at least a portion of the surface of the passage  45  allows the first driveshaft  26  to translate axially relative to the first gear  44 . Alternately, the first gear  44  and the first driveshaft  26  may be configured differently to allow rotary motion to be transmitted between the first driveshaft  26  and the first gear  44  while additionally allowing the first driveshaft  26  to translate axially relative to the first gear  44 . 
     Referring also to  FIGS. 6-8 , the first gear  44  has a number of teeth  46  aligned in a substantially axial direction and extending outward substantially radially. These teeth  46  interface with teeth  48  of a second gear  50 , which correspondingly extend in a substantially axial direction. The second gear  50  has a diameter larger than that of the first gear  44 , such that the gear ratio between the second gear  50  and the first gear  44  is larger than 1:1. Advantageously, the gear ratio is substantially 39:11. A different gear ratio may be used, if desired. The second gear  50  is mounted substantially coaxially to a second driveshaft  52  that is substantially parallel to the first driveshaft  26 . Alternately, the second driveshaft  52  may be positioned in another orientation, and the teeth of the gears  44 ,  50  are constructed to interface at that orientation. Rotation of the second driveshaft  52  at a particular rate causes the first driveshaft  26  to rotate at a faster rate, due to the gear ratio of greater than 1:1 between the second gear  50  and the first gear  44 . 
     The second driveshaft  52  may be driven by any mechanism or method. In one embodiment, the second driveshaft  52  is connected to an impulse source. A force that acts on a body for a short time but produces a large change in its linear or angular momentum is called an impulsive force. As used in this document, the term “impulse source” refers to a source of such an impulsive force. The impulse source is a torsional spring  54 . However, the impulse source instead may be a different mechanism. The duration of the force generated by the spring  54  or other impulse source is substantially 0.05 seconds. However, the duration may be shorter or longer. Referring particularly to  FIG. 8 , the spring  54  surrounds at least a portion of the length of the second driveshaft  52 . The proximal end of the spring  54  is fixed to a slot  56  in the second driveshaft  52 .  FIG. 8  shows a cross-section of the second driveshaft  52  for clarity in illustrating the connection between the spring  54  and the slot  56 . The proximal end of the spring  54  is bent to fit into the slot  56 , and is stiff enough and extends into the slot  56  far enough such that the contact between the proximal end of the spring  54  and the slot  56  holds the spring  54  in place. Alternately, the proximal end of the spring  54  is fixed to the second driveshaft  52  in another way. The distal end  57 of the spring  54  extends outward from the second driveshaft  52 , and is fixed to a casing (not shown) or other structure relative to which the second driveshaft  52  rotates. Before the auger assembly  10  and cutter  4  are actuated, the spring  54  is wound up tightly, thereby storing a quantity of force in a torsioned state. 
     The impulse source may be different from the spring  54 . For example, the impulse source may be a DC motor connected directly or via one or more gears to the second driveshaft  52 . As another example, the impulse source may be a flow of biocompatible liquid such as water through an impeller or other mechanism connected to the second driveshaft  52 . As another example, the impulse source is a magnetic field source coupled to the second driveshaft  52 . A different impulse source than these exemplary ones may be used instead. In another embodiment, the impulse source is not used, and the auger assembly  10  and the cutter  4  are rotated non-impulsively, such as by hand. 
     One or more registration features  64  extend substantially radially outward from the second driveshaft  52  and/or the second gear  50 . Each registration feature  64  is a tab. Alternately, the registration features  64  may be different structures than tabs. Where multiple registration features  64  are used, they are spaced evenly around the axis of the second driveshaft  52 , but may be spaced differently if desired. Thus, where two registration features  64  are used, they are located on opposite sides of the second driveshaft  52 , such that they fall substantially in the same plane. Alternately, the registration features  64  are not coplanar. If the registration features  64  are connected to the second gear  50 , they are short enough such that they do not interfere with the operation of the second gear  50 . 
     The registration features  64  are held by, or held relative to, the casing (not shown) or other structure or mechanism until rotation of the second driveshaft  52  is desired. Any appropriate structure or mechanism may be used to hold the registration features  64  relative to the casing. As one example, each registration feature  64  is positioned in a slot (not shown) defined by raised features on the inner surface of the casing, or against a ridge (not shown) extending inward from the casing toward the second driveshaft  52 . The slots, ridges or other structures or mechanisms engage the registration feature or features  64  and restrain the second driveshaft  52  against rotation. Where the impulse source is the spring  54 , the spring  54  biases the registration features  64  against the corresponding slots, ridges or other structures used to restrain the registration features  64 . The registration features  64  are freed from the corresponding slots, ridges or other structures or mechanisms in order to allow rotation of the second driveshaft  52 . For example, a slot holding a registration feature  64  is open at its distal end. Motion of the registration feature  64  distally frees it from the slot, allowing the second driveshaft  52  to rotate under the influence of the impulse source. As another example, a ridge holding a registration feature  64  extends axially. Motion of the registration feature  64  distally moves it beyond the ridge, allowing the second driveshaft  52  to rotate under the influence of the impulse source. Freeing the registration features  64  may be accomplished in a different manner, if desired. 
     As shown in  FIG. 6 , the second driveshaft  52  is in an initial position, in which the registration features  64  are restrained by slots, ridges, or other structures or mechanisms (not shown). This position may be referred to as the restrained position. After the second driveshaft  52  advances distally to free the registration features  64 , the second driveshaft  52  is in a second position that may be referred to as the deployed position. The second gear  50  is fixed to the second driveshaft  52 , such that the second gear  50  advances distally the same distance as the second driveshaft  52 . The first gear  44  is at least as long as the distance that the second gear  50  advances, such that the first gear  44  is in mating contact with the second gear  50  throughout the entire distance that the second gear  50  translates. 
     The registration features  64  described above need not be used if the impulse source does not exert a force against the second driveshaft  52  until rotary motion of the second driveshaft is desired. For example, where the impulse source is a DC motor, the motor may be configured to exert a rotational force on the second driveshaft  52  only when rotary motion of the second driveshaft  52  is desired, and registration features  64  thus need not be provided to restrain the second driveshaft  52  against rotation in the initial position. 
     Referring also to  FIGS. 9-10 , an exemplary embodiment of a knob  88  is shown, where the knob  88  is a component of the integrated anastomosis tool  100 . The knob  88  is one embodiment of a device for accepting user input into the integrated anastomosis tool  100 . A different structure or mechanism than the knob  88  could be used, if desired The knob  88  includes a grip  90  and a hollow shaft  92 . An endplate  94  is connected to the distal end of the shaft  92 . The grip  90 , shaft  92  and endplate  94  may be formed as a single piece, as by injection molding or another process. A slot  96  extends through the endplate  94 . Referring also to  FIG. 11 , the shaft  92  extends into a casing  98 . The casing  98  is substantially hollow, and one or more of the components described above in this document may be located within the casing  98 . The casing  98  protects such components and assists in integrating them into a single integrated anastomosis tool  100 . The slot  96  is shaped to allow the second driveshaft  52  to extend through it, such that the second driveshaft  52  extends distally into the shaft  92  of the knob  88 . 
     Two stops  102  extend outward from opposite sides the second driveshaft  52 . The stops  102  are shaped as substantially rectangular solids. Alternately, one or more stops  102  are shaped differently. Optionally, only one stop  102  may be used, or more than two stops  102  may be used, or the two stops  102  may be arranged differently on the second driveshaft  52 . The stops  102  are initially positioned within the shaft  92  of the knob  88 . The second driveshaft  52  is in the restrained position, as shown in  FIG. 11 , before deployment of the auger  6  and cutter  4 . In this restrained position, the stops  102  are biased against the proximal surface  104  of the endplate  94 , because the second driveshaft  52  is biased distally. A tapered compression spring  106  attached at its narrow end to the second driveshaft  52  performs the biasing, although a different structure or mechanism may be used. The narrow end of the compression spring  106  is positioned distal to the wider end of the compression spring  106 . The wider end of the compression spring  106  presses against a circumferential ridge  108  defined on the casing  98 . In the initial state, the compression spring  106  is compressed against the ridge  108 , resulting in a distal biasing force. The compression spring  106  may be composed of rubber or a similar flexible substance. However, a different material may be used instead. The biasing force exerted by the compression spring  106  biases the stops  102  against the proximal surface  104  of the endplate  94  of the knob  88 . The stops  102  are oriented such that they are not aligned with the slot  96  in the endplate  106 , such that the second driveshaft  52  cannot pass through the slot  96  and thus is restrained against distal motion. Other structures or mechanisms than the compression spring  106  may be used to bias the second driveshaft  52 , such as a coil spring or leaf spring. 
       FIG. 12  shows the second driveshaft  52  in the deployed position, after deployment of the auger  6  and the cutter  4 . The knob  88  has rotated, allowing the stops  102  to align with the slot  96  and slide through the slot  96  under the biasing influence of the compression spring  106 . The compression spring  106  has moved to a less compressed state. The compression spring  106  may still exert a biasing force distally, but the distal end of the second driveshaft  52 , the second gear  50 , or another structure or mechanism contacts the casing  98  or another structure and prevents additional forward motion of the second driveshaft  52 . The details of the motion of the second driveshaft  52  during operation are described in greater detail below. 
     Referring back to  FIG. 6 , the first driveshaft  26  is mounted to a carriage  58 . Referring also to  FIG. 41 , the carriage  58  includes a concave surface  60  on its underside, where that concave surface  60  contacts an introducer tube  62 . The introducer tube  62  is a hollow tube fixed to the seal housing  34 , having a lumen that opens into the interior of the seal housing  34 . That lumen may be substantially coaxial with the axis of the introducer tip  28 . Alternately, the lumen of the introducer tube  62  may have an axis parallel to but not coaxial with, or not parallel to, the axis of the introducer tip  28 . An anastomosis device (not shown) and graft vessel (not shown) may be advanced through the lumen of the introducer tube  62 , such that the anastomosis device can connect the vein graft to a target vessel after the auger  6  and cutter  4  have removed a tissue plug from the wall of the target vessel and created an opening therein. Where the anastomosis is performed as part of a CABG procedure, the target vessel is a coronary artery, and the graft vessel is a blood vessel such as the saphenous vein. However, the anastomosis may be performed between two other anatomical structures. 
     The first driveshaft  26  includes a threaded portion  72  at or near the proximal end of the first driveshaft  26 . Alternately, the threaded portion  72  of the first driveshaft  26  is located at another position on the first driveshaft  26 . A passage  74  through the carriage  58  is correspondingly threaded to engage the threaded portion  72  of the first driveshaft  26 . The threaded portion  72  of the first driveshaft  26  is configured to advance distally as the first driveshaft  26  rotates. Thus, rotary motion of the first driveshaft  26  is used to advance the first driveshaft  26 , such that rotation of the second gear  50  is converted to both rotation and translation of the first driveshaft  26 . Thus, the threaded portion  72  of the first driveshaft  26  is at least as long as the distance the first driveshaft  26  is to advance, and the corresponding threaded portion of the passage  74  through the carriage  58  can be any length that is capable of adequately supporting the first driveshaft  26  during its advancement. Alternately, the threaded portion  72  of the first driveshaft  26  is shorter than the distance the first driveshaft  26  is to advance, and the threaded portion of the passage  74  through the carriage  58  is at least as long as the distance the first driveshaft  26  is to advance. The threads of the threaded portion  72  of the first driveshaft  26  have a pitch of substantially  25  threads per inch. A different pitch may be utilized, if desired. 
     The first driveshaft  26  includes a head  76  at or near its proximal end. Alternately, the head  76  is located at a different position on the first driveshaft  26 . The head  76  is a structure that is wider than the passage  74  through the carriage  58 , such that contact between the head  76  and the carriage  58  stops the distal advancement of the first driveshaft  26 . Thus, the head  76  limits the distal travel of the first driveshaft  26 . Contact between the head  76  and the carriage  58  provides a positive stop after a particular amount of distal travel of the first driveshaft  26 . 
     Alternately, the first driveshaft  26  does not include a threaded portion  72 , and rotation of the second gear  50  causes the first driveshaft  26  to rotate but does not advance the first driveshaft  26  distally. In such an embodiment, a second impulse source (not shown) may be provided, and connected to the carriage  58  or first driveshaft  26  to advance the first driveshaft  26  substantially axially. The second impulse source may be a spring or other mechanism for storing energy and releasing it over a short interval of time. The second impulse source is coordinated with the first impulse source, such as the spring  54 , such that both impulse sources produce an impulse at substantially the same time in order to produce rotational and translational motion of the auger assembly  10  and the cutter  4 . The timing, advancement and retraction of the auger assembly  10  and the cutter  4  can be controlled in a number of ways. A cam cylinder  70  is used to control the advancement of the auger assembly  10  and the cutter  4 . Referring also to  FIGS. 38A-D , the surface of the cam cylinder  70  is shown, along with a number of cam paths defined therein. The cam paths are described in greater detail below. The knob  88  or other control structure is directly connected to and substantially coaxial with the cam cylinder  70 , such that rotation of the knob  88  rotates the cam cylinder  70 . The knob  88  instead may be operationally connected to the cam cylinder  70  via gearing or other mechanisms, such that the knob  88  and cam cylinder  70  can be oriented along different axes. Referring to  FIG. 11 , a first cam follower  66  extends from the introducer tube  62  into a first cam path  68  defined in the cam cylinder  70 . The introducer tube  62  is restrained by the casing  98  and/or other structure or mechanism such that its motion is substantially linear along its axis. Consequently, the first cam follower  66  is restrained to move substantially linearly in a direction substantially parallel to the axis of the introducer tube  62 . Rotation of the cam cylinder  70  causes the first cam path  68  to move relative to the first cam follower  66 . The first cam follower  66  follows the first cam path  68 , and thus can be caused to translate axially or be held stationary as the cam cylinder  70  is rotated. In the initial, restrained position, the first cam follower  66  is prevented from moving substantially distally or proximally by the first cam path  68 , because the first cam path  68  is positioned relative to the first cam follower  66  substantially perpendicular to the direction in which the introducer tube  62  can translate, thereby substantially restraining the introducer tube  62  against translational motion. When the cam cylinder  70  is rotated and the first cam follower  66  encounters a segment of the first cam path  68  that extends in a direction having an axial component, the first cam follower  66  is free to translate a selected distance in the axial direction. Consequently, the introducer tube  62  that is connected to the first cam follower  66  is free to translate a selected distance in the axial direction, as is the seal housing  34  that is connected to the introducer tube  62 . 
     Similarly, a second cam follower  84  extends from the carriage  58  into a second cam path  86  defined in the cam cylinder  70 . The carriage  58  is restrained by the casing  98 , introducer tube  62  and/or other structure or mechanism such that its motion is substantially linear in a direction substantially parallel to the axis of the introducer tube  62 . In the initial, restrained position, as well as during translation of the second driveshaft  52 , the second cam follower  84  is prevented from moving substantially distally or proximally by the second cam path  86 . In that restrained position, the second cam path  86  is positioned relative to the second cam follower  84  substantially perpendicular to the direction in which the carriage  58  can translate, thereby substantially restraining the carriage  58  against translational motion. A segment of the second cam path  86  extends in a direction having an axial component. When the second cam follower  84  encounters such a segment of the second cam path  86 , the second cam follower  84  is free to translate a selected distance in the axial direction, as is the carriage  58  that is connected to the second cam follower  84 . The components connected to the carriage  58 , such as the flexible shaft  24 , the auger assembly  10  and the cutter  4 , are also free to translate a selected distance in the axial direction. Thus, the motion of the auger assembly  10  and the cutter  4 , as well as other components associated with them, can be controlled by rotation of the cam cylinder  70 . That is, the cam paths  68 ,  86  allow translation of the associated followers  66 ,  84  when the cam paths  68 ,  86  are substantially parallel to the axis of the auger assembly  10 , and substantially prevent motion of the associated followers  66 ,  84  when the cam paths are substantially perpendicular to the axis of the auger assembly  10 . Alternately, only one of the cam followers  66 ,  84  is used to control the motion of the auger assembly  10  and the cutter  4 . 
     Instead of a cam cylinder  70 , a linear cam or a cam having another shape may be used to control the motion of the auger assembly  10  and the cutter  4 . Further, in another embodiment, the motion of the auger assembly  10  and the cutter  4  is controlled by one or more different or additional mechanisms. For example, the auger assembly  10  and the cutter  4  may be connected to one or more DC motors or other powered mechanisms, where the motor is controlled by an integrated circuit or other computing device. By controlling the motor, the motion of the auger assembly  10  and the cutter  4  can be controlled. 
     An assembly  82  is advanced distally as a unit at least partially as far as the first driveshaft  26  advances. The assembly  82  includes the first driveshaft  26 , the carriage  58 , the seal housing  34 , the introducer tube  62 , the flexible shaft  24 , the auger assembly  10 , the cutter  4  and the introducer tip  28 . Other components may be included in the assembly  82 . Referring also to  FIG. 1A , a fitting  78  is connected to or formed into the first driveshaft  26  at or near its distal end. The fitting  78  is wider than the first driveshaft  26 , and is substantially cylindrical. Alternately, the fitting  78  may be shaped differently. A shaft stop  79  is positioned proximally to the fitting  78 . The shaft stop  79  is a tubular structure within which the flexible shaft  24  can rotate. The shaft stop  79  may assist in connecting the flexible shaft  24  to the fitting  78  and/or the first driveshaft  26 . For example, the shaft stop  79  may compress a coil spring forming the flexible shaft  24  onto the surface of the distal end of the first driveshaft  26 . The shaft stop  79  may be composed of polyethylene or other plastic, but may be formed from a different material or materials. The shaft stop  79  may be fixed to, or slidable relative to, the fitting  78 . 
     The shaft stop  79  has a diameter larger than the diameter of the opening  80  in the seal housing  34  through which the flexible shaft  24  extends. The fitting  78  may similarly have a diameter larger than the diameter of the opening  80 . The fitting  78  is positioned on the first driveshaft  26  at a location relative to the opening  80  such that the distal end of the fitting  78  engages the shaft stop  79 , which in turn engages the seal housing  34  next to the opening  80 , as the first driveshaft  26  is advanced distally. If the shaft stop  79  is fixed to the fitting  78 , then the shaft stop  79  and the fitting  78  are already considered to be engaged upon distal advancement of the first driveshaft  26 . Thus, the seal housing  34  is impelled distally along with the first driveshaft  26 , due to contact between the shaft stop  78  and the seal housing  34 . The initial distance between the shaft stop  78  and the seal housing  34  is related to the distance along which the assembly  82  is translated. As the seal housing  34  advances, the introducer tip  28  fixed to it is advanced into the opening created by the auger  6  and the cutter  4  in order to maintain hemostasis, as is described in greater detail below. Where the shaft stop  79  is not used, contact between the fitting  78  and the seal housing  34  impels the seal housing  34  distally. Further, the fitting  78  may be beveled or tapered at its distal end, and the seal housing  34  may include a beveled or tapered area adjacent to the opening  80  corresponding to any beveling or tapering of the fitting  78 . 
     Alternately, the assembly  82  does not advance as a unit. Instead, the first driveshaft  26  advances the flexible shaft  24  distally, and the auger assembly  10  and cutter  4  advance distally as a result. The introducer tip  28  may be configured to advance into the opening created by the auger  6  and the cutter  4  at a later time, or may be configured to rest on the target vessel before the auger assembly  10  and the cutter  4  advance distally. 
     The operation of the auger assembly  10  and the cutter  4  of  FIGS. 1-3  will now be described. Referring to  FIGS. 11-12 , a contact structure  110  is connected to or formed into the casing  98 , and has an open perimeter. The perimeter of the contact structure  110  may take the shape of a circle with an arc removed, a U-shape, or other shape. The contact structure  110  is placed against the vessel to substantially stabilize its surface within the perimeter of the contact structure  110 , such that the tubular vessel is not substantially flattened by the pressure applied to it via the contact structure  110 . The cutter  4  and the auger assembly  10  are free to rotate and translate a fixed amount relative to the contact structure  110 . Thus, the total translation of the cutter  4  and auger  6  relative to the contact structure  110  is known. The cutter  4  and auger  6  are placed on the vessel at a location where the diameter of the vessel is large enough to ensure that the cutter  4  and auger  6  do not encounter the rear wall of the vessel during their travel relative to the contact structure. 
     The distal end of the spike  5  of the auger  6  extends distally beyond the distal surface of the contact structure  110 . Thus, as the contact structure  110  is moved toward against the vessel, the distal end of the spike  5  penetrates the vessel wall before the contact structure  110  contacts the vessel. The entry into the vessel wall of the spike  5  prior to actuation of the cutter  4  and the auger  6  facilitates tissue removal from the vessel wall. The vessel wall is intact before the spike  5  enters it, and no separate incision need be made in the vessel wall before the spike  5  encounters it. 
     Energy is applied impulsively to the auger assembly  10  and the cutter  4 . The auger assembly  10  and the cutter  4  then begin to rotate, as they advance distally into the vessel wall. Rotation begins at substantially the same time as translation. However, rotation or translation may begin first. The auger  6  advances into the wall of the tubular vessel as the cutter  4  advances and cuts. The cutting action of the cutter  4  is both rotational and axial. By constructing the auger  6  and the cutter  4  to be substantially smooth and radially symmetrical, the rotary motion of these structures creates a substantially smooth and clean hole through the vessel wall. The tissue of the tubular vessel may be strain rate sensitive, such as the tissue of the aorta. Strain rate sensitive tissue is easier to cut when the cutting is performed rapidly than when it is performed slowly. By actuating the auger  6  and the cutter  4  impulsively, they move rapidly such that the cutter  4  can better cut strain rate sensitive tissue. 
     After the cutter  4  has penetrated the entire vessel wall, it has cut tissue from that vessel wall, and formed an opening corresponding to the former position of that tissue. The cutter  4  cuts a substantially cylindrical tissue plug from the vessel wall due to its tubular shape. The spike  5  is positioned relative to the cutter such that the tissue plug is held within the cutter  4  due to engagement with the ledge  9  after the tissue plug has been cut. That is, the ledge  9  has advanced completely through the vessel wall before the cutter  4 , such that the tissue plug cut from the vessel wall is located proximally to the ledge  9  upon its creation. The ledge  9  is wide enough to reliably hold the tissue plug within the cutter  4 . The shaft  7  extends axially through the tissue plug, such that contact between the shaft  7  and the tissue plug acts substantially to prevent radial motion of the tissue plug in the cutter  4 . 
     The distal translation of the cutter  4  and auger  6  continues through a fixed distance greater than the thickness of the vessel wall, to ensure that the cutter  4  has completely penetrated the vessel wall. Thus, the cutter  4  and auger  6  may continue to advance for a short distance after the tissue plug has been cut out of the vessel wall having a particular wall thickness. The cutter  4  and auger  6  are then retracted through the introducer tip  28 . As they are retracted, they retract the tissue plug, leaving an opening in the vessel wall. 
     The introducer tip  28  follows the cutter  4  and the auger  6  into the vessel wall, and remains in the opening thus formed, in order to provide hemostasis with regard to that opening. The introducer tip  28  is hollow, and has a diameter slightly larger than the opening. Thus, the introducer tip  28  fits snugly within that opening in order to prevent leakage of fluid from within the vessel between the introducer tip  28  and the opening. Fluid such as blood enters the seal housing  34  through the introducer tip  28 , and the seal housing  34  maintains hemostasis with regard to the fluid in the vessel. Alternately, the introducer tip  28  is not used, such that fluid such as blood enters the seal housing  34  through the cutter  4 . One or more tools deployed through the introducer tube  62  have an outer diameter slightly smaller than the inner diameter of the introducer tube  62 , such that the close fit between the introducer tube  62  and the tools deployed within it substantially provides hemostasis and prevents leakage from the seal housing  34 . Alternately, a valve or seal (not shown) may be provided between the introducer tube  62  and the seal housing  34  to substantially prevent blood from entering the lumen of the introducer tube  62 . Thus, the seal housing  34  maintains hemostasis in conjunction with the introducer tip  28  and/or the cutter  4 . The introducer tip  28  may be omitted where the auger  6  and cutter  4  are part of an independent cutting tool rather than an integrated anastomosis tool or other integrated tool. 
     The auger assembly  10  and cutter  4  work similarly where the auger  6  is configured as shown in  FIGS. 4-5 . The contact structure  110  is placed against the vessel wall. The auger  6  and the cutter  4  initially are located proximal to the distal surface of the contact structure  110  and do not contact the vessel wall. As described above, energy is applied impulsively to the auger assembly  10  and the cutter  4 , which begin to rotate and also begin to translate toward the wall of a tubular vessel. Thus, the auger assembly  10  and the cutter  4  each have both angular and linear momentum when they encounter the wall of the tubular vessel. The auger  6  encounters the vessel wall before the cutter  4 , because the tip of the auger  6  extends distally beyond the distal end of the cutter  4 . The vessel wall is intact before the auger  6  encounters it. That is, no separate incision need be made in the wall of the tubular vessel before the auger  6  and cutter  4  encounter it. 
     Referring also to  FIG. 13 , half of the cutter  6  is cut away in order to illustrate the auger  6  more completely. The auger flutes  13  have a pitch X, meaning that the flutes  13  cause the auger  6  to penetrate a distance 1/X into the wall of the tubular vessel for each revolution of the auger  6 . Thus, at a pitch of 16 threads per inch, the auger  6  advances into the tubular vessel 1/16 inch each revolution of the auger  6 . Similarly, the threads of the threaded portion  72  of the first driveshaft  26  have a pitch Y. Thus, at a pitch of 25 threads per inch, the auger  6  and the cutter  4  translate distally 1/25 inch each revolution of the first driveshaft  26 . The auger assembly  10  and the first driveshaft  26  are fixed to one another and thus rotate at the same rate. The distance 1/X is greater than the distance 1/Y. Both distances are measured relative to the contact structure  110 , which provides a point of reference as to the motion of the auger  6  and the cutter  4 . The auger  6  advances into the wall of the tubular vessel faster than the cutter  4 , even though the auger  6  and cutter  4  are impelled distally at the same rate. As a result, the auger  6  pulls the wall of the tubular vessel proximally as the cutter  4  advances distally, thereby pulling tissue into the cutter  4 . The auger  6  pulls the wall of the tubular vessel intramurally; that is, by engaging the wall across its thickness using the flutes  13 , to firmly and reliably engages the wall of the tubular vessel. 
     The cutter  4  is translated distally through the wall of the tubular vessel as the auger  6  holds a portion of the wall and pulls it proximally relative to the cutter  4 . Thus, the cutter  4  cuts the tubular vessel from the outside while the auger  6  holds the wall of the tubular vessel. The auger  6  advances into the wall of the tubular vessel as the cutter  4  advances and cuts. The cutting action of the cutter  4  is both rotational and axial. The tissue of the tubular vessel may be strain rate sensitive, such as the tissue of the aorta. Strain rate sensitive tissue is easier to cut when the cutting is performed rapidly than when it is performed slowly. By actuating the auger  6  and the cutter  4  impulsively, they move rapidly such that the cutter  4  can better cut strain rate sensitive tissue, and enter the tissue quickly enough to minimize any effects of the tissue pulling outward from the opening in directions substantially perpendicular to the motion of the cutter  4 . The pitch of the auger flutes  13  and the distance traveled by the cutter  4  during one rotation of the auger  6  are selected such that the auger  6  and cutter  4  cut a substantially cylindrical tissue plug from the wall of the tubular vessel. Alternately, the pitch of the auger flutes  13  and the distance traveled by the cutter  4  during one rotation of the auger  6  are selected such that the auger  6  and cutter  4  cut a substantially conical tissue plug from the wall of the tubular vessel. The conical tissue plug may be wider at its distal end or at its proximal end, depending on the selected pitch of the auger flutes  13  and the distance traveled by the cutter  4  during one rotation of the auger  6 . 
     After the cutter  4  has penetrated the entire vessel wall, it has cut a tissue plug from that wall, and formed an opening corresponding to the former position of that tissue plug. The tissue plug is held firmly in the cutter  4  due to engagement with the auger flutes  13 . The distal translation of the cutter  4  and auger  6  continues through a fixed distance greater than the thickness of the vessel wall, to ensure that the cutter  4  has completely penetrated the vessel wall. Thus, the cutter  4  and auger  6  may continue to advance for a short distance after the tissue plug has been cut out of the vessel wall. The cutter  4  and auger  6  are then retracted through the introducer tip  28 . As they are retracted, they retract the tissue plug, leaving an opening in the wall of the tubular vessel. 
     Actuation of the auger  6  and the cutter  4  to remove a tissue plug from a vessel wall and create an opening therein may be performed in a number of different ways. Referring to  FIGS. 11-12 , in one exemplary embodiment, the cutter  4  and auger  6  are part of an integrated anastomosis tool  100 . A single control on the integrated anastomosis tool  100  may be operated by the user to actuate the cutter  4  and the auger  6  and create an opening in the wall of the tubular vessel. This single control may be the knob  88 , which is rotated through a preselected number of degrees in order to deploy the cutter  4  and auger  6 , cut a tissue plug from the wall of the tubular vessel to form an opening in that wall, and retract the tissue plug out of the opening. A different control than the knob  88  may be provided, such as a lever, a slider, a button, or other control. The single control may be hand-driven, where force transmitted through the operator&#39;s hand drives at least part of the operation of the cutter  4  and auger  6 , or may be powered, such that the operator simply presses a button or actuates a different control such that a powered mechanism such as a motor drives at least part of the operation of the cutter  4  and auger  6 . 
     Referring to  FIG. 11 , the integrated anastomosis tool  100  is in the initial state; the auger  6  and the cutter  4  have not yet been deployed and the knob  88  is in an initial position. The user places the contact structure  110  against the wall of the tubular vessel in the location where the opening is to be made, without substantially deforming the tubular vessel. The user then begins to turn the knob  88 . The stops  102  on the second driveshaft  52  are biased against the proximal surface  104  of the endplate  94  of the knob  88 , as described above. The second driveshaft  52  does not substantially rotate upon rotation of the knob  88 , because the registration features  64  connected to the second driveshaft  52  restrain the second driveshaft  52  against rotational movement, as described above. Initially, the slot  96  in the endplate  94  of the knob  88  is not aligned with the stops  102 ; instead, the stops  102  are in contact with the endplate  94  of the knob  88 . At a preselected point in the angular travel of the knob  88 , the slot  96  aligns with the stops  102 , freeing the stops  102  to translate distally through the slot  102  and allowing the second driveshaft  52  to advance distally under the influence of the compression spring  106 . Thus, the rotation of the knob  88  advances the second driveshaft  52  distally at a preselected point in the angular travel of the knob  88 . 
     The distal advancement of the second driveshaft  52  translates the second gear  50  axially relative to the first gear  46 . As described above, the first gear  46  is fixed, and engages the second gear  50  both before and after its advancement. As the second driveshaft  52  advances distally, the registration feature or features  64  advance distally relative to the structures or mechanisms that had previously restrained the second driveshaft  52  against rotation, freeing the registration feature or features  64 . The second driveshaft  52  is then rotationally free, and begins to rotate driven by the energy stored within the spring  54 . This stored energy is impulsively delivered, and in one embodiment causes the second gear  50  to rotate substantially three times. The gear ratio between the first gear  44  and the second gear  50  is chosen to produce the desired number of rotations of the second gear  50  upon release of stored energy from the spring  54 . The second gear  50  rotates with the second driveshaft  52 , causing the first gear  46  and the first driveshaft  26  to rotate in the opposite direction. Rotation of the first gear  46  also causes the first driveshaft  26  to advance distally, as described above. The actuator  24  transmits the rotary and translational motion of the first driveshaft  26  to the auger assembly  10  and the cutter  4 . 
     The knob  88  is connected to the cam cylinder  70 , such that rotation of the knob  88  rotates the cam cylinder  70 . When the knob  88  is rotated to the position at which the second driveshaft  52  is allowed to advance distally, the first cam path  68  is positioned relative to the first cam follower  66  on the introducer tube  62  such that the first cam follower  66  and the introducer tube  62  are free to advance distally. The second cam follower  84  extending from the carriage  58  is prevented from moving substantially distally or proximally by the second cam path  86 , which at this time is substantially perpendicular to the direction of motion of the introducer tube  62 . Because the carriage  58  is held substantially fixed, the rotation of the threaded portion  72  of the first driveshaft  26  relative to the threaded passage  74  in the carriage  58  is converted to distal translation of the first driveshaft  26  as well. As the first driveshaft  26  advances distally, the fitting  78  on the first driveshaft  26  engages the shaft stop  79 , which in turn engages the seal housing  34  and impels it forward. The seal housing  34  is connected to the introducer tube  62 , and is free to advance distally along with the introducer tube  62 . Thus, the seal housing  34  and the components fixed to it, such as the introducer tip  28 , advance distally. The integrated anastomosis tool  100  is then in the deployed state of  FIG. 12 . 
     Where the auger  6  is fluted, as is  FIGS. 4-5 , the cam cylinder  70  controls the motion of the auger  6  and cutter  4  in the same manner as described above. The portions of the cam paths  68 ,  86  allowing for translation are longer than described above, because the auger  6  and the cutter  4  are initially spaced apart from the vessel wall, and thus travel a further distance during their actuation. The auger  6  and the cutter  4  penetrate the intact vessel wall, cut a tissue plug to form an opening, and retract the tissue plug from the opening in the same manner as described above. 
     The user continues to rotate the knob  88 . After the tissue plug has been cut from the wall of the tubular vessel, it is restrained within the cutter  4  as described above. The auger  6  and cutter  4  continue advancing until they have traveled the entire preselected distance extending distally from the contact structure  110 . The auger  6  and the cutter  4  then are retracted. The second cam follower  84  travels within the second cam path  86  in the cam cylinder  70 . As the cam cylinder  70  rotates as the knob  88  is turned, the second cam path  86  moves proximally relative to the second cam follower  84 . That is, the second cam path  86  has an axial component, such that contact between the second cam path  86  and the second cam follower  84  translates the second cam follower proximally. Because the second cam follower  84  is connected to the carriage  58 , the carriage  58  also is moved proximally, such that the auger  6  and the cutter  4 , as well as the tissue plug they restrain, are removed from the opening in the wall of the tubular vessel through the introducer tip  28 , which remains in the opening. The bushing  38  is retracted along with the auger assembly  10 . Thus, an assembly that includes the cutter  4 , the auger assembly  10  and the bushing  38  is retracted from the opening in the wall of the tubular vessel. The orientation of the auger  6  before this retraction defines a first axis. 
     As the bushing  38  moves proximally, the guide follower or followers on the bushing  38  are guided by the guides  35  within the seal housing  34 . The guides  35  extend away from the first axis in order to move the bushing  38  away from the first axis as the bushing is moved proximally. That is, the auger  6  and the cutter  4  are moved off-axis during retraction. In one embodiment, moving proximally, each guide  35  slopes in a direction toward the opening  80 . Thus, as the bushing  38  is retracted proximally, the guide followers encounter the upward-sloping guides  35 , which cause the bushing  38  to move off the first axis to a second axis. The guide followers need not contact the guides  35  at all points during the retraction of the bushing. Indeed, the actuator  24  itself may be configured to bias the bushing  38 , auger assembly  10  and cutter  4  away from the first axis. In this way, the auger  6 , cutter  4  and the tissue plug that they retain, as well as the bushing  38 , are moved off the first axis such that an anastomosis device can be deployed along the first axis through the introducer tube  62 . Further, moving the auger  6  and cutter  4  off the first axis allows the tissue plug to be removed from the opening without being retracted through the graft vessel. By moving the tissue plug into a location within the seal housing  34 , hemostasis is maintained. 
     Alternately, the guides  35  and guide followers need not be provided. For example, the guides  35  and guide followers may be unnecessary where the auger  6  and cutter  4  are not part of an integrated tool. As another example, the bushing  38 , auger assembly  10  and cutter  4  may be retracted substantially along the first axis, and an anastomosis device is moved from another axis to the first axis for deployment. In such an example, the bushing  38  need not be moved off the first axis, and the guides  35  and guide followers are not required. 
     After the auger  6  and cutter  4  have created the opening in the vessel wall, the anastomosis device  140  is placed in the opening in the vessel wall and deployed. Referring to  FIGS. 16-18 , the anastomosis device  140  is composed of 316L stainless steel. A different type of stainless steel may instead be used. Further, a different biocompatible material or combination of materials may be used. The anastomosis device  140  is constructed by laser-cutting through the walls of a hollow tube. The walls of the hollow tube are substantially 0.008 inches thick. Another method of construction and/or another wall thickness may be used. Referring to  FIG. 18 , a view of the laser-cut tube unrolled into a planar configuration is shown. The hollow tube is then shaped at its distal end to form the anastomosis device  140 , which has an initial, pre-deployment shape as shown in  FIGS. 16-17 . 
     The anastomosis device  140  includes a deployable section  142  and a discard section  144 . The deployable section  142  is configured to be placed in and deployed into the opening in the vessel wall. The discard section  144  is retained by the integrated anastomosis tool  100  after the deployable section  142  is deployed. The discard section  144  is located at the proximal end of the anastomosis device  140 , and the deployable section  142  is located at the distal end of the anastomosis device  140 . The entire anastomosis device  140 , including both the deployable section  142  and the discard section  144 , is substantially radially symmetrical about its axis  143 . Alternately, the deployable section  142 , the discard section  144 , or both may be radially asymmetrical. 
     One or more connection structures are located at the proximal end of the discard section  144 . The connection structures are used to connect the anastomosis device  140  to the integrated anastomosis tool  100 , as described in greater detail below. As one example, paddles  146  may be used as interface structures. However, other interface structures may be used, if desired. The paddles  146  have an arcuate cross-section with a radius of curvature substantially the same as the tube from which the anastomosis device  140  was manufactured. Alternately, the paddles  146  have a different radius of curvature, or are substantially flat. The paddles  146  are each substantially the same radial distance from the axis  143  of the anastomosis device  140 . The paddles  146  each extend substantially axially, but may be oriented differently if desired. Optionally, referring to  FIG. 18 , at least one paddle  146  may include a registration feature  148  defined in its proximal end, where contact between the registration feature  148  and a corresponding feature within the integrated anastomosis tool  100  is used to ensure the proper placement of the anastomosis device  140 . Referring back to  FIGS. 16-17 , at least one leg  150  extends substantially axially from each paddle  146 . One or more legs  150  may extend in a different direction, if desired. The legs  150  are used in connecting the anastomosis device  140  to the integrated anastomosis tool  100 , as described below. The legs  150  also connect each paddle  146  to a compression segment  152  on the anastomosis device  140 . 
     The compression segment  152  is a section of the anastomosis device  140  that is located distal to the legs  150 . The compression segment of  152  extends axially in a distal direction from the legs  150 . The compression segment  152  is a linkage that has a substantially circular cross-section, as viewed along the axis  143  of the anastomosis device  140 . The function of the compression segment  152  is described in greater detail below. The compression segment  152  includes at its proximal end first struts  154 , two of which extend distally from each leg  150 . Each first strut  154  also extends at an angle to the direction of the leg  150  which it is connected. Thus, the distal ends of the adjacent struts  154  are connected to one another. The first struts  154  viewed alone form a substantially zigzag configuration. A first expandable member  156  is connected at each end to the distal end of adjacent struts  154 . The first expandable members  156  are oriented in a substantially circumferential direction around the compression segment  152 . Two second struts  158  extend distally to and angularly outward from each intersection between two adjacent first expandable members  156 . Each second struts  158  intersects with the adjacent second struts  158  at a location distal to the first expandable members  156 . A second expandable member  160  is connected at each end to the distal end of adjacent struts  158 . The second expandable members  160  are oriented in a substantially circumferential direction around the compression segment  152 . Two third struts  162  extend distally to and angularly outward from each intersection between two adjacent second expandable members  160 . Each second strut  158  is substantially aligned with a third struts  162  distal to it. Thus, adjacent pairs of second struts  158  and third struts  162  form an X-shaped configuration. The expandable members  156 ,  160  allow for radial expansion, but also limit radial expansion. That is, each expandable member  156 ,  160  is configured to expand a predetermined amount. When that amount of expansion has been reached, the expandable members  156 ,  160  substantially stop expanding, thereby substantially halting radial expansion. In this way, the final diameter of the anastomosis device  140  can be preselected and controlled. 
     The third struts  162  connect the compression segment  152  to the separation area  164 . Within the separation area  164 , two fourth struts  166  extend distally to and angle outward from each intersection between two third struts  162 . The distal end of each fourth strut  166  is connected to the proximal end of a spreader arm  168 . With regard to the two fourth struts  166  connected to a particular spreader arm  168 , the proximal end of each such fourth strut  166  is connected to a different intersection between two third struts  162 . The linear distance between those two intersections may be called the first distance  170 . The first distance  170  is substantially the same between any two such adjacent intersections. Alternately, the first distance  170  may vary between different adjacent intersections. These two intersections are also positioned at a first radial distance from the axis  143 . The proximal end of each spreader arm  168  may include one or more holes  172  therethrough for stress management. Further, the width of each spreader arm  168  at its proximal end may be less than the width of the spreader arm  168  at a more distal location. The distal ends of the spreader arms  168  initially may be angled outward from the axis  143  a small amount. Alternately, a single, wide fourth strut  166  is connected to the proximal end of each spreader arm  168 , in which case the first distance  170  is the width of the proximal end of the fourth strut  166 . Alternately, three or more fourth struts  166  may be used, in which case the first distance  170  is the linear distance between the two furthest-separated fourth struts  166 . 
     The distal end of each spreader arm  168  is connected to two outer flange arms  174  in such a way as to allow each spreader arm  168  and its associated outer flange arms  174  to move outward at an angle to the axis  143 , then separate the two, as described in greater detail below. Each spreader arm  168  narrows in width at its distal end. The outer flange arms  174  connect to the sides of the distal end of the spreader arm  168 , such that a space is located distally from the distal end of the spreader arm  168 . The contact area between the spreader arm  168  and the connected outer flange arms  174  is selected to allow them to hinge relative to one another and move outward away from the axis  143 . The width of the distal end of the spreader arm  168  may be called the second distance  178 . The distal end of the spreader arm  168  is positioned at a second radial distance  178  from the axis  143  of the anastomosis device  140 . 
     A crossbar  176  links the two outer flange arms  174  that are connected to a single spreader arm  168 , and is spaced distally away from the distal end of the spreader arm  168 . Each outer flange arm  174  may include a number of gripping elements  175  formed into it. Referring also to  FIGS. 34-35 , each pair of outer flange arms  174  and connecting crossbar  176  forms an outer flange element  173  in the deployed state. Moving distally, the two outer flange arms  174  connected to a single spreader arm  168  extend circumferentially outward relative to each other. At its distal end, each outer flange arm  174  intersects an adjacent outer flange arm  174 . The distance between the distal ends of the two outer flange arms  174  connected to a single spreader arm  168  may be called the third distance  180 . The distal ends of those two outer flange arms  174  are also each located at a third radial distance from the axis  143  of the anastomosis device  140 . The third distance  180  is greater than the second distance  178 , and the first distance  170  is greater than the second distance  178 . Advantageously, the third distance  180  is greater than the first distance  170 . Further, the first radial distance and the third radial distance are greater than the second radial distance  178 . Alternately, a single differently-configured outer flange element  173  is used in place of the combination of two outer flange arms  174  and a crossbar  176 , in which case the third distance  180  is the width of the distal end of the single outer flange element  173 . Alternately, more than two outer flange arms  174  may be used in conjunction with one or more crossbars  176  to form an outer flange element  173 , in which case the third distance  180  for that outer flange element  173  is the linear distance between the two furthest-separated outer flange arms  174 . 
     Optionally, a chevron  139  is associated with each pair of outer flange arms  174  connected to a single spreader arm  168 . The chevron  139  is a V-shaped element that has two ends, each connected to an outer flange arm  174  at or distal to the intersection between that outer flange arm  174  and the corresponding spreader arm  168 . The chevron  139  extends distally from each intersection with an outer flange arm  174  such that its pointed tip is positioned at a distance approximately halfway between two adjacent outer flange arms  174 . The chevrons  139  assist in gripping the outer surface of the target vessel, as described below. 
     The distal ends of the outer flange arms  174  are connected to a linkage  182  that forms the body of the deployable section  142 . The linkage  182  curves inward at its distal end. The section of the linkage  182  that curves inward may be referred to as the ring  183 . The linkage  182  is configured to expand radially at its distal end during deployment, as is described in greater detail below. Thus, a number of expandable members  184  are positioned substantially circumferentially around the linkage  182 , such that the linkage  182  is free to expand radially upon the application of an appropriate force. 
     Tines  196  extend distally from the distal end of the linkage  182 . The tines  196  extend substantially parallel to the axis  143  of the anastomosis device  140 . Alternately, the tines  196  may be angled slightly inward, or may instead angle outward slightly relative to the axis  143  of the anastomosis device  140 . Each tine  196  has a sharp point at its distal end, and a number of teeth  198  defined along its length. When deployed, the tines  196  form the inner flange of the deployable section  142 . The tines  196  are mounted on expandable members  184  of the linkage  182 . Thus, as the linkage  182  expands radially upon the application of appropriate force, the intersections between each tine  196  and the corresponding expandable member  184  expand away from each other. The teeth  198  on the tines  196  assist in gripping the inner surface of the target vessel and holding the deployable section  142  securely onto the target vessel. 
     Referring also to  FIG. 39 , at least one horn  186  extends from the linkage  182  in proximity to each intersection between the linkage  182  and a tine  196 . Advantageously, two horns  186  are provided adjacent each tine  196 , one on either side. The horns  186  extend at least partially in a radial direction, inward toward the axis  143  of the anastomosis device  140 . The horns  186  are configured to engage the expander tip  280  at an appropriate time during the deployment of the anastomosis device  140 , as described below. 
     Optionally, the anastomosis device  140  may be configured to actively counteract intimal hyperplasia. Intimal hyperplasia is a condition in which the intimal cells lining a vessel proliferate into the anastomosed graft. While the anastomosis device  140  is not expected to cause intimal hyperplasia in most patients, it may be desirable to provide the capability for the anastomosis device  140  to counteract it. For example, the anastomosis device  140  may be drug-eluting, meaning that it releases a drug over time into the surrounding tissue, where that drug acts to inhibit or counteract intimal hyperplasia in the vicinity of the anastomosis device  140 . Such drugs may include rapamycin, paclitaxel, and actinomycin D. One or more of these drugs may be directly applied to the surface of the anastomosis device  140 , or may be contained in a carrier matrix (not shown) attached to or formed in the anastomosis device  140 . As another example, the anastomosis device  140  may include a source of ionizing radiation, which may be useful in inhibiting or counteracting intimal hyperplasia in the vicinity of the anastomosis device  140 . Optionally, the anastomosis device  140  may be configured to elute a different drug or an additional drug to treat one or more other conditions of the patient as well. 
     Referring also to  FIGS. 19-21  and  36 , the anastomosis device  140  is connected to a crown  200 . A crown collar  202  is located at the distal end of the crown  200 . The crown collar  202  is a substantially tubular structure defining a lumen therethrough. A ridge  204  extends substantially radially around the circumference of the distal end of the crown collar  202 . Alternately, the ridge  204  extends in a direction other than radially, and/or does not extend around the entire circumference of the distal end of the crown collar  202 . At least one slot  206  is defined in the ridge  204 . Each slot  206  is oriented substantially radially, and extends substantially axially. However, the slots  206  may be oriented differently, or extend in a different direction. A second ridge  208  also extends substantially radially around the circumference of the proximal end of the crown collar  202 . Thus, a ledge  210  is present at the intersection of the distal end of the second ridge  208  and the crown collar  202 . 
     Referring also to  FIGS. 16-17 , the proximal ends of the paddles  146  of the anastomosis device  140  may abut the ledge  210 , in order to facilitate construction of the integrated anastomosis tool  100  and provided positive confirmation of the axial position of the paddles  146  with regard to the crown collar  202 . If a registration feature or features  148  are provided on one or more paddles  146 , then the surface of the crown collar  202  or the ledge  210  includes corresponding features for mating with those registration features  148 . The crown collar  202  is configured to receive the paddles  146  on its surface. Thus, the shape of the surface of the crown collar  202  substantially matches the cross-section of the paddles  146 . Before the anastomosis device  140  is placed onto the crown  200 , the paddles  146  are bent outward at an angle to the axis  143  of the anastomosis device  140 . This outward bending may be performed at the same time as the distal end of the anastomosis device  140  is shaped, or at a different time. The paddles  146  are bent outward substantially ninety degrees, but may instead be bent at a different angle. The anastomosis device  140  is then brought into proximity with the crown collar  202 , such that the legs  150  of the anastomosis device  140  are located radially outward from the slots  206 . The paddles  146  are then bent inward toward the axis  143  of the anastomosis device  140 . This bending motion of the paddles  146  causes the legs  150  to rotate along an axis perpendicular to the axis  143  of the anastomosis device  140 . The legs  150  are thereby impelled into the slots  206  in the ridge  204  to a final position in which the legs  150  are substantially parallel to the axis  143 . The slots  206  and the legs  150  are aligned relative to one another to allow the legs  150  to enter the slots  206 . The slots  206  and corresponding legs  150  are sized relative to one another to fit tightly, such that contact between the slots  206  and legs  150  alone is sufficient to hold the anastomosis device  140  onto the crown collar  202 . Optionally, additional structures, mechanisms or methods may be used to provide a stronger bond between the anastomosis device  140  and the collar  202 . For example, a heat-shrinkable material may be placed circumferentially around the crown collar  202 , on top of the paddles  146 , after which heat is applied to it. That shrinkable material provides additional holding force between the crown collar  202  and the paddles  146 . As another example, an adhesive may be placed between the paddles  146  and the crown collar  202 . As another example, the anastomosis device  140  could be heat-staked onto the crown collar  202 . As another example, the anastomosis device  140  could be insert-molded to the crown collar  202 . 
     A crown body  212  extends proximally from the proximal end of the crown collar  202 . The crown body  212  is an open half-tube, having a semicircular cross-section. The opening configuration of the crown body  212  allows the crown  200  to receive an expander, which is described in greater detail below. A rail  213  extends along at least one of the two edges of the crown body  212 . Each rail  213  extends in a direction substantially tangent to the curvature of the crown body  212  at the edge of the crown body  212 . The outer surface of each rail  213  is substantially flush with the outer surface of the crown body  212 . An interface  214  is located at the proximal end of the crown body  212 . The interface  214  includes a semicircular recess  216  aligned with the crown body  212 . A third cam follower  218  extends downward from the interface  214 . Referring also to  FIGS. 38A-D , the third cam follower  218  is configured to engage a third cam path  220  defined in the cam cylinder  70 . The interface  214  also includes two flanges  222  configured to slide within corresponding grooves in a cartridge, which is described in greater detail below. A tab  224  extends substantially upward from the one of the flanges  222 . Referring also to  FIG. 41 , the crown  200  is positioned within, and is configured to slide relative to, the introducer tube  62 . The outer radius of curvature of the crown body  212  is substantially the same as the inner radius of curvature of the introducer tube  62 . Thus, the introducer tube  62  substantially stabilizes the crown  200  radially and guides the translational motion of the crown  200 . 
     Referring to  FIGS. 22-24 , the crown  200  is slidably connected to the cartridge  124 . The cartridge  124  includes an outer shell  125  and a substantially hollow interior into which one or more structures are formed. The cartridge  124  is composed of the same material as the casing  98 , and is manufactured in the same way. Alternately, the. cartridge  124  may be composed of a different material and/or manufactured differently. At least one groove  226  is defined within the interior of the cartridge  124 . The groove or grooves  226  extend substantially axially, wherein the axial direction is defined relative to the mated position of the cartridge  124  within the integrated tool  100 . Each groove  226  is configured to receive at least one flange  222  of the interface  214  of the crown  200 , and to allow the received flange or flanges  222  to slide within it. The groove or grooves  226  are positioned within the cartridge  124  relative to the outer shell  125  to provide adequate space within the cartridge  124  for the interface  214  and other components of the crown  200  to slide freely within the cartridge  124 . A stop  228  is defined within the cartridge  124 . The tab  224  connected to the interface  214  of the crown  200  is configured to engage the stop  228 . In this way, the stop  228  acts to restrict the proximal motion of the tab  224  and provides a positive stop for crown  200  placement when the cartridge  124  is inserted into the casing  98 . In this way, the initial axial position of the crown  200  is positively identified. 
     The cartridge  124  also includes one or more flexures  230 . The flexures  230  are molded or otherwise formed into the cartridge  124 . A wedge  232  or similar element is located at the distal end of each flexure  230 , directed upward. The wedge  232  is biased upward into the corresponding groove  226  by the flexure  230 . One flexure  230  and corresponding wedge  232  are positioned in one of the grooves  226  such that the space between the wedge  232  and the upper surface of that groove  226  is less than the height of the flange  222  of the crown  200 . The other flexure  230  and corresponding wedge  232  are positioned in the other groove  226  such that the space between the wedge  232  and the upper surface of that groove  226  is less than the thickness of the flange  266  of the expander  260  and the flange  222  of the crown  200 . The wedges  232  thus hold the flanges  222 ,  266  within the cartridge  124  before the cartridge  124  is loaded into the casing  98 . Alternately, only one flexure  230  and wedge  232  are used, thus directly restraining only one of the flanges  222 ,  266 . 
     The cartridge  124  may also includes at least one stop  234  configured to engage the tab  224 , in order to limit the proximal motion of the crown  200  and expander  260 . A passage  236  is defined through the cartridge  124  in order to receive a graft vessel therethrough. The passage  236  is substantially aligned with the axis of the crown  200 . Thus a graft vessel can be pulled through the passage  236 , the crown collar  202 , the crown body  212  and the semicircular recess  216  of the crown  200 . 
     Referring also to FIGS.  1  and  14 - 15 , the cartridge  124  is connected to the casing  98 . The cartridge  124  includes at least one outer groove  237 . Each outer groove  237  is substantially parallel to the other, and to the inner grooves  226 . Alternately, the outer grooves  237  are not parallel to the inner grooves  226 . The outer grooves  237  are substantially parallel to one another, and to the inner grooves  226 . The cartridge  124  is connected to the casing  98  by sliding each outer groove  237  over a corresponding rail  238  defined in each case half  120 , 122 . The rails  238  guide the motion of the cartridge  124  as it is installed onto the casing  98 . A feature  239  is provided in the casing  98  adjacent one or more of the rails  238 , where that feature  239  is configured to engage a wedge  232  in the cartridge  124  and bias it out of the groove  226 . Thus, the flange or flanges  222 ,  266  previously restrained by the wedge  232  and corresponding flexure  230  are free to translate along the corresponding groove  226 . 
     A ridge  240  may additionally be defined in each case half  120 ,  122 , such that a ledge  242  located above each outer groove  237  that in part defined as the outer groove  237  and/or inner groove  226  contacts and rides along the ridge  240 . The use of the ridge  240  in conjunction with a rail or rails  248  provides for additional guidance of the cartridge  124  as it is inserted into the casing  98 . The cartridge  124  includes at least one locking flexure  250  for engaging the casing  98 . Each locking flexure  250  extends into an outer groove  237  of the cartridge  124 , and extends outward into the outer groove  237  at its proximal end. The locking flexure  250  is flexed inward while the cartridge  124  is slid onto the casing  98 , and engages a recess  252  on the corresponding case half  122  when the cartridge  124  has been completely slid onto the casing  98 . The recess  252  may instead be a slot, tab, or other structure adapted to engage the locking flexure  250 . When the cartridge  124  has reached the end of its travel along the rail or rails, the locking flexure  250  is positioned relative to the recess  252  such that its proximal end can move into the recess  252 . Substantial proximal motion of the cartridge  124  is then restricted, because interference between the locking flexure  250  and the recess  252  prevents such motion. 
     Referring to FIGS.  28 A and  25 - 31 , an expander  260  couples to the crown  200  and extends through the crown collar  202 . The expander  260  includes an expander interface  262  at its proximal end. A fourth cam follower  264  extends outward from the expander interface  262 . The fourth cam follower  264  is configured to engage a fourth cam path  221  defined in the cam cylinder  70 . One or more flanges  266  also extend from the expander interface  262 . Referring also to  FIG. 22 , one or more flanges  266  are configured to engage the inner groove  226  of the cartridge  124 . Thus, the flanges  266  translate along the inner groove  226  in the same manner as the flanges  222  of the crown of  200 . The expander interface  262  also includes a passage  268  defined therethrough. This passage  268  allows a graft vessel to pass through the expander interface  262 . An expander body  270  extends distally from the expander interface  262 . The expander body  270  is shaped similar to the crown body  212  of the crown  200 . The expander body  270  is a half-tubular structure having a substantially semicircular cross-section. The expander body  270  includes a rail  272  extending substantially axially along, and at a distance inward from, at least one edge of the expander body  270 . Thus, a ledge  274  is formed between each edge of the expander body  270  and the corresponding rail  272 . The rail  213  of the crown  200  is configured to be received adjacent to the ledge  274  of the expander body  270  and outward from the rail  272 . Thus, each rail  272  of the expander body  270  is positioned adjacent to the corresponding rail  213  of the crown body  212 . Where two rails  213 ,  272  are used on both the expander body  270  and the crown body  212 , the rails  213 ,  272  register the expander  260  to the crown  200  such that the expander body  270  and the crown body  212  together form a substantially tubular structure having a hollow lumen. Further, the use of the rails  213 ,  272  allows the expander body  270  to translate axially relative to the crown body  212  while maintaining axial registration therebetween. In this way, the rails  213 ,  272  guide and stabilize the motion of the expander  260  relative to the crown  200 . 
     An expander collar  276  is connected to the distal end of the expander  260 . The expander collar  276  is narrower than the expander body  270 . Alternately, the expander collar  276  may have a different diameter. Referring also to  FIGS. 28-30 , an expander tip  280  is connected to the expander collar  276 . Alternately, the expander collar  276  is not used, and the expander tip  280  is connected directly to the expander body  270 . The expander tip  280  is formed from hardened stainless steel, and includes a thin cylindrical shell  282  at its proximal end. The expander collar  276  is also substantially cylindrical, and has a diameter slightly smaller than the inner diameter of the shell  282  at the proximal end of the expander tip  280 . The expander tip  280  is connected to the expander collar  276  by placing the shell  282  over the expander collar  276  and dimpling it to fix it to the expander collar  276 . That is, a force is applied to one or more points on the shell  282 , causing it to dimple, such that the bottom of the dimple digs into the expander collar  276  to hold the shell  282  and the expander collar  276  together. Alternately, the expander tip  280  may be connected to the expander collar  276  in a different way, such as by the use of locking tabs, adhesives, threading, or insert molding, or by other structures, mechanisms, or methods. 
     The expander collar  276  is positioned proximally to the crown collar  202 . Further, the expander collar  276  is substantially coaxial with the crown collar  202 . The expander tip  280  extends distally from the expander collar  276  through the crown collar  202 . The body  284  of the expander tip  280  is substantially cylindrical, and has a smaller diameter than the shell  282 . The body  284  is sized to fit snugly against, while sliding free from interference with, the inner diameter of the crown collar  202 . Thus, the body  284  of the expander tip  280  can translate through the crown collar  202  upon the application of a force at or above a preselected level. Further, the snug fit between the inner diameter of the crown collar  202  and the body  284  of the expander tip  280  assists in providing hemostasis relative to the seal chamber  34 , because the fit is snug enough to prevent substantial motion of fluid between them. The outer diameter of the shell  282  is smaller than the inner diameter of the crown body  212 , such that the shell  282  can be received into the crown body  212  and translate relative to it. 
     The expander tip  280  also includes an expander head  286  and an expander collet  287 . Both the expander head  286  and the expander collet  287  have a larger diameter than the expander body  284 , and extend substantially circumferentially around the expander tip  280 . The expander head  286  is smoothly tapered from its distal end to its proximal end. Referring in particular to  FIG. 28A , the expander head  286  includes a shoulder  288  at its intersection with the body  284  of the expander tip  280 . The shoulder  288  forms an angle  290  with the surface of the body  284  of the expander tip  280 . This angle  290  is substantially 95 degrees. However, a different angle  290  may be utilized, if desired. The angle  290  is substantially the same around the entire expander tip  280 . However, the angle  290  may vary in different locations around the expander tip  280 . A lumen  292  extends through the expander tip  280 , where that lumen  292  is substantially coaxial with the crown collar  202  and with the expander collar  276 . The lumen  292  may itself taper to a smaller diameter toward the distal end of the expander head  286 . This tapering acts to protect the graft vessel as it is pulled through the lumen  292 . The tines  196  of the anastomosis device  140  are located distal to the distal end of the lumen  292 . By tapering the lumen of the expander tip  280  to direct the graft vessel inward away from the tines  196  before that graft vessel is everted over them, the graft vessel is protected. The collet  287  is substantially circumferential around the expander tip  280 , and is located proximal to the expander head  286 . The collet  287  has a larger diameter than the body  284  of the expander  280 . The collet  287  and the expander head  286  are translated relative to the crown  200  to deploy the anastomosis device  140  into a vessel wall, as is described in greater detail below. 
     The expander tip  280  includes slots  294  defined therein. The slots  294  extend substantially axially from the distal end of the expander tip  280  through the expander head  286  and collet  287 , extending proximally to the collet  287 . The segments  289  of the expander tip  280  between the slots  294  are each biased outward relative to the axis of the expander tip  280 , as may be seen most clearly in  FIG. 28A . Alternately, the segments  289  are not biased outward relative to the axis of the expander tip  280 . The slots  294  allow these segments  289  of the expander tip  280  to move inward toward the axis of the expander tip  280  at a point in the deployment of the anastomosis device  140  to allow the expander tip  280  to move proximally to the deployed anastomosis device  140 . Thus, the slots  294  are sized to allow the segments  289  to move close enough to one another to allow the expander tip  280  to move proximally to the deployed anastomosis device  140 . The outward force generated by the expander tip  280  acts to substantially center the anastomosis device  140  on the expander tip  280  during deployment, such that the axis of the anastomosis device  140  remains substantially coaxial with the axis of the expander tip  280 . 
     Referring particularly to  FIG. 29 , the slots  294  are not spaced evenly along the circumference of the expander head  286 . Four slots  294  are used, where each slot  292  is separated by a major angle  293  and a minor angle  295  from the slots adjacent to it. The major angle  293  is substantially 103°, and the minor angle  295  is substantially 77°. These angles  293 ,  295  may be different, if desired. Thus, each segment  289  of the expander tip  280  has one of two different sizes. As a result, two segments  289  are larger than the other two segments, and therefore are stiffer than the smaller segments  289 . Referring also to  FIG. 1 , the expander tip  280  advantageously is oriented relative to the contact structure  110  on the casing  98  such that the segments  289  that are less stiff than the other segments  289  are substantially aligned with each other and with the opening in the perimeter of the contact structure  110 . This facilitates the removal of the integrated anastomosis tool  100  from an anastomosed graft vessel. 
     The segments  289  of the expander tip  280  between the slots  294  are each biased outward relative to the axis of the expander tip  280 , as may be seen most clearly in  FIG. 28A . This outward bias assists in deployment of the anastomosis device  140 , as is described in greater detail below. Alternately, the segments  289  of the expander tip  280  between the slots  294  are not biased outward relative to the expander tip  280 . Alternately, a ring (not shown) may be provided between the collet  287  and the expander head  286 , or may be provided instead of the collet  287 . The ring slides freely relative to the expander tip  280 , and is used to compress the segments  289  toward the axis  143  of the anastomosis device  140  at the appropriate point in the deployment process. 
     Referring to  FIG. 9 , the knob  88  includes a recess  89 . The recess  89  is positioned relative to the cam cylinder  70  such that the cartridge  124  can only be inserted into the casing  98  when the knob  88  is in the correct starting position. The cartridge  124  slides into the casing  98  substantially linearly, as described above. The interfaces  214 ,  262  of the crown  200  and the expander  260  slide through the recess  89  when the knob  88  is in the correct starting position. If the knob  88  is at another position, it will interfere with the  214 ,  262  of the crown  200  and the expander  260 , preventing insertion of the cartridge  124 . The user must then rotate the knob  88  to the correct starting position before inserting the cartridge  124  into the casing  98 . 
     When the cartridge  124  is inserted into the casing  98 , the crown  200  and the expander  260  are connected to the cartridge  124  and held relative to it by the flexures  230  and wedges  232  described above. Referring also to  FIG. 36 , a graft vessel  310  has been pulled through the passage  236  and the combined bodies of the expander  260  and the crown  200 , and has been everted over the anastomosis device  140  at the distal end of the crown  200 . The crown body  212  and the expander body  270  together form a substantially cylindrical body having an outer diameter slightly less than the inner diameter of the introducer tube  62 . The crown body  212  and the expander body  270  are slidable within the lumen of the introducer tube  62 . In this way, the introducer tube  62  can support and guide the crown  200  and expander  260  during their translation. Further, the close fit between the inner surface of the introducer tube  62  and the outer surface of the crown body  212  and the expander body  270  substantially seals the introducer tube  62  relative to the seal chamber  34 , such that fluid in the seal chamber  34  does not substantially leak out of the seal chamber  34  between the introducer tube  62  and the crown  200  or expander  260 . A separate seal may be provided between the introducer tube  62  and the seal chamber  34  if desired. 
     One or more features may be provided within the integrated anastomosis tool  100  to prevent premature deployment. Referring to  FIGS. 6 ,  11 ,  38 A-D, and  40 , a notch  400  may be defined in the cam cylinder  70 . The notch  400  extends in a direction substantially perpendicular to the axis of the cam cylinder  70 . The cam cylinder  70  is biased proximally by a spring (not shown) or other component or mechanism. A stop  402  corresponding to the notch  400  is defined on the inner surface of the casing  98 . The stop  402  is oriented substantially perpendicular to the axis of the cam cylinder  70 . The cam cylinder  70  is initially positioned such that the notch  400  is biased against the stop  402  before the cartridge  164  is loaded into the casing  98 . The notch  400  is shaped such that its contact with the stop  402  substantially prevents rotational motion of the cam cylinder  70 . 
     Referring also to  FIGS. 14 ,  15 ,  22 - 24 , and  25 - 26 , when the cylinder  164  is loaded into the casing  98 , the tab  224  of the crown  200  engages the stop  228  in the cartridge  164 , thereby restraining the crown  200  and the expander  260  against proximal motion. The crown  200  and the expander  260  thus move distally along with the cartridge  164 . The cam followers  264 ,  218  of the expander  260  and the crown  200  are impelled forward in the third and fourth cam paths  220 ,  221 . The third cam path  220  includes a bend  404  that the cam follower  218  of the crown  200  encounters upon loading of the cartridge  164 . The bend  404  is at substantially  45  degrees to the axis of the cam cylinder. Because the expander  260  and crown  200  are constrained against proximal motion by the cartridge  164 , the cam follower  218  of the crown  200  pushes the cam cylinder  70  forward and rotates it as it encounters the bend  404 . The forward motion of the cam cylinder  70  acts against the proximal bias of the cam cylinder  70 , causing the notch  400  to disengage from the stop  402 . Further, the rotational motion of the cam cylinder  70  causes the notch  400  to rotate relative to the stop  402 , such that the cam cylinder  70  can no longer move proximally to seat against the stop  402 . The cam cylinder  70  is thus free to rotate. 
     A safety switch  296  may be provided on the integrated anastomosis tool  100 . The safety switch  296  engages a fifth cam path  298  defined in the cam cylinder  70  with a cam follower (not shown) or other engagement structure. The fifth cam path  298  is defined in the cam cylinder  70  such that the knob  88  cannot be rotated substantially until the safety switch  296  is moved to a position in which the cam follower allows the cam cylinder  70  to move. The remainder of the fifth cam path  298  lies substantially in a plane perpendicular to the axis of the introducer tip  28 , such that the cam cylinder  70  may then rotate freely. The safety switch  296  is optional, and may be omitted. 
     The integrated tool  100  is operated to insert the anastomosis device  140  into the opening in the vessel wall and deploy it. After the auger  6  and cutter  4  have removed tissue from the vessel wall, they are retracted off-axis from the introducer tip  52 , as described above. The introducer tip  52  is thereby open, such that the anastomosis device  140  can be advanced through it. The combination of the crown body  212  and the expander body  270  forms a tube that is substantially coaxial with the axis of the introducer tip  52 . Thus, the crown  200 , the anastomosis device  140  connected to the distal end of the crown  200 , and the expander  260  can be translated distally into the introducer tip  52 . Alternately, the auger  6  and the cutter  4  retract tissue substantially along the axis of the introducer tip  52 , and the crown  200 , anastomosis device  140  and expander  260  are translated off-axis to the axis of the introducer tip  52  for passage through it. 
     Referring to  FIG. 36 , a graft vessel  310  is pulled through the expander  260  and the crown  102  and everted over the tines  196  of the anastomosis device. The graft vessel  310  thus extends through the lumen  292  of the expander tip  280 , and proximally through the combined expander body  270  and crown body  212 . Thus, no components of the integrated anastomosis tool  100  extend into the lumen of the graft vessel  310 . 
     Initially, the distal end of the expander tip  280  is located within the anastomosis device  140 , proximal to the curved portion of the linkage  182 . This relative positioning is controlled by the third and fourth cam paths  220 ,  221  and associated cam followers  218 ,  264 . The third and fourth cam paths  220 ,  221  are also configured to prevent the crown  200 , the anastomosis device  160  and the expander  260  from interfering with the auger  6 , the cutter  4 , the bushing  38 , or any other component of the integrated anastomosis tool  100  used for creating an opening in the vessel wall. The third and fourth cam paths  220 ,  221  are configured to translate the crown  200 , the anastomosis device  140  and the expander  260  distally as the opening is made in the vessel wall. Alternately, the crown, anastomosis device  140  and expander  260  are not translated distally until after the opening has been made in the vessel wall. 
     The distal end of the expander head  286  is initially located substantially adjacent to the ring  183  of the linkage  182 . As described above, the segments  289  of the expander tip  280  between the slots  294  are biased outward. These segments  289  of the expander tip  280  are configured to exert radial force on the anastomosis device  140  while the expander tip  280  is in its initial position. The ring  183  of the linkage  182  counteracts that radial force, preventing deformation of the linkage  182  and the anastomosis device  140 . 
     After creating the opening in the vessel wall, the user continues to turn the knob  88 . The third and fourth cam paths  220 ,  221  cause the expander  260  and the crown  200  to translate toward that opening through the introducer tube  62  into the seal housing  34 , because the third cam follower  218  connected to the crown  200  rides within the third cam path  220 , and the fourth cam follower  264  connected to the expander  260  rides within the fourth cam path  221 . The third cam follower  218  is restrained to move substantially linearly in a direction substantially parallel to the axis of the introducer tube  62 , and the fourth cam follower  264  is restrained to move substantially linearly in a direction substantially parallel to the axis of the introducer tube  62 . Rotation of the cam cylinder  70  causes the cam paths  220 ,  221  to move relative to the cam followers  218 ,  264 , thereby causing the cam followers  218 ,  264  to translate axially, or holding them stationary in the axial direction. Alternately, the distal ends of the expander  260  and the crown  200  are already located within the seal housing  34  after the opening is created in the wall of the target vessel. 
     The third and fourth cam paths  220 ,  221  are substantially parallel, such that the crown  200  and the expander  260  translate at substantially the same rate, and maintain substantially the same distance with regard to each other during this translation. The anastomosis device  140  is not substantially tensioned or compressed at this time. The distal end of the anastomosis device  140  enters the opening. The tines  196  enter the lumen of the vessel. The third and fourth cam paths  220 ,  221  are configured such that crown  200  and the expander  260  move the distal ends of the tines  196  a preselected amount relative to the distal end of the contact structure  110 . Thus, by measuring the diameter of the vessel in advance, it can be determined whether the lumen of the vessel is large enough to receive the anastomosis device  140 , because the maximum distance between the distal ends of the tines  196  and the distal end of the contact structure  110  is known. As the tines  196  enter the opening in the target vessel wall, a portion of the everted graft vessel is brought into contact with the walls of the opening. Because the graft vessel has been everted, the inner layer of the graft vessel is thus in contact with the inner layer of the target vessel after the anastomosis device  140  is deployed. Where the anastomosis surgery is a CABG procedure, this results in intima-to-intima contact between the graft vessel and the target vessel. 
     As the knob  88  continues to rotate, the third cam path  220  restrains the crown  200  in the axial direction, while the fourth cam path  221  causes the expander  260  to translate distally through the crown collar  202 . The rotary force on the knob  88  that is transmitted to the expander  260  via the cam cylinder  70  and third cam path  220  is sufficient to move the body  284  of the expander tip  280  through the crown collar  202 . Distal translation of the expander  260  causes the expander tip  280  to translate distally relative to the anastomosis device  140 , which is connected to the crown  200 . The expander head  286  thus encounters the ring  183  of the linkage  182 . The expander head  286  is smoothly curved, such that it encounters the ring  183  and expands it radially outward without catching on the ring  183 . 
     The ring  183  includes a number of expandable elements  141 , where each expandable element  141  connects two adjacent tines  196 . The expandable elements  141  are curved, where the curve has a component in the axial direction. As the ring  183  translates distally into the ring  183 , the ring  183  expands radially, because the diameter of the expander head  286  is wider than the diameter of the ring  183 . That is, the axial motion of the expander head  286  causes hoop stress in the ring  183 , and the expandable elements  141  deform and lengthen under the influence of this hoop stress. 
     The ring  183  also expands both axially and radially as a result of its contact with the expander head  286  during axial motion of the expander head  286 . That is, each point on the ring  183  is moved both axially in the distal direction, and away from the axis  143  in the radial direction, by contact with the expander head  286 , as a consequence of the shape and size of the expander head  286 . The expandable elements  141  are long enough to allow radial expansion of the ring  183  without a resultant axial compression of the ring  183 . The expandable elements  141  are configured to deform and lengthen a sufficient amount under the influence of hoop stress in the ring  183  to allow the ring  183  to expand radially without causing an associated axial compression. That is, the expandable elements  141  provide the ring  183  with sufficient flexibility such that radial expansion of the ring  183  does not result in axial compression of the ring  183 . The expander head  286  additionally pushes the elements of the ring  183  distally, causing expansion in the axial direction. Thus, axial expansion of the deployable section  142  accompanies radial expansion of the deployable section  142 . As a result, the distance between the tines  196  and the outer flange arms  174  increases as the ring  183  expands radially. The portion of the linkage  182  proximal to the ring  183  substantially does not expand radially, because it is already at least as far from the axis  143  as the widest part of the expander head  286 . 
     Referring also to  FIG. 16 , the distal translation of the expander tip  280  causes the expander head  286  to exert tensile force on the anastomosis device  140 . This tension causes expansion of the linkage  182 . This expansion causes the intersections between each tine  196  and the linkage  182  to expand radially outward from the axis  143  of the anastomosis device  140 , thereby moving the tines  196  away from one another. Referring to  FIG. 32 , a qualitative graph of the force exerted on the anastomosis device  140  over time is shown. As shown in  FIG. 32 , the tension in the anastomosis device  140  increases as the knob  88  is rotated. 
     As the expander head  286  translates distally, it contacts the horn or horns  186  associated with each tine  196 . The horns  186  extend toward the axis  143  of the anastomosis device  140 . As the expander head  286  encounters the horns  186 , it exerts a force distally on the horns  186 . The horns  186  are initially angled relative to the axis  143 , and advantageously are substantially perpendicular to the axis  143 . Thus, the axial motion of the expander head  286  exerts an axial force on the horns  186 , causing the horns  186  to rotate to a position substantially parallel to the axis  143 . The tines  196  are connected to and substantially perpendicular to the horns  186 . The rotation of the horns  186  causes the tines  196  to rotate away from the axis  143 , such that they move to an angle pointing away from the axis  143 . The curvature of the expander head  286  as well as the position and shape of the ring  183  are chosen to result in the desired angle relative to the axis  143  upon deployment. 
     Referring as well to  FIGS. 34-35 , at the point of maximum tension  311 , the tines  196  have been fully deployed to form an inner flange  300 . In this fully-deployed position, each tine  196  forms an angle of substantially ninety degrees with the axis  143  of the anastomosis device  140 . Alternately, the tines  196  form a different angle with the axis  143  of the anastomosis device  140 . Alternately, one or more tines  196  form a different angle with the axis than one or more other tines  196 . Upon full deployment of the inner flange  300 , the segments  289  of the expander tip  280  are freed to spread outward away from the axis  143 , because the inner diameter of the inner flange  300  is larger than the largest outer diameter of the expander head  286 . 
     At this time, the inner flange  300  is located in the lumen of the target vessel, spaced apart from the inner wall of the target vessel. The user continues to rotate the knob  88 . The third and fourth cam paths  220 ,  221  cause both the crown  200  and the expander  260  to translate proximally at substantially the same rate, such that the crown  200  and the expander  260  remain substantially the same distance from each other. The proximal translation of the crown  200 , which is connected to the anastomosis device  140 , causes the anastomosis device  140 , and hence the inner flange  300 , to translate proximally. During this translation, the inner flange  300  comes into contact with the inner wall of the target vessel, and seats against the inner wall of the target vessel. 
     The inner flange  300  has thus reached its deployed position relative to the inner wall of the target vessel. The inner flange  300  holds the distal end of the graft vessel  310  against the edges of the opening in the vessel wall. The linkage  182  forms a body  302  that extends through the opening in the vessel wall. The body  302  holds at least part of the everted portion of the graft vessel  310  against the walls of the opening. Referring in particular to  FIG. 16 , the portion of the linkage  182  proximal to the ring  183  and proximal to the expandable members  184  does not expand radially or axially during deployment of the inner flange  300 . This portion of the linkage  182  initially has the same diameter as its deployed diameter, and initially has the same axial length as its deployed distal length. 
     The operator continues to rotate the knob  88 . The third and fourth cam paths  220 ,  221  are configured to hold the expander  260  in substantially the same axial position and to translate the crown  200  distally. This relative axial motion between the expander  260  and the crown  200  axially compresses the anastomosis device  140 , as seen in  FIG. 33 . Further, the inner surface of the body  302  of the anastomosis device  140  may contact the segments  289  of the expander tip  280 , and this contact may at least partly compress the segments  289  toward the axis  143  of the anastomosis device  140 . The compressive stress within the anastomosis device  140  increases as the expander  260  continues to translate proximally and the crown  200  continues to translate distally. This compressive stress increases until buckling occurs at the intersections between the spreader arms  168  and the outer flange arms  174 . The buckling stress  320  is shown on  FIG. 32 . Buckling is designed to occur at these intersections as a result of the relationships between the first distance  170 , the second distance  178  and the third distance  180 . Because the first distance  170  is located radially closer to the axis  143  than the second distance  178 , and the third distance  180  is located radially closer to the axis  143  than the second distance  178 , an outward moment is produced on the anastomosis device  140  at the second distance  178  as a result of the axial compressive stress exerted on the anastomosis device  140 . This outward moment results in an outward force that causes buckling at the intersections between the spreader arms  168  and the outer flange arms  174 , such that buckling occurs at those intersections rather than at other locations on the anastomosis device  140 . 
     Referring also to  FIG. 33 , the spreader arms  168  and the outer flange arms  174  each begin to angle outward from the axis  143  after buckling at the intersections between them, under the effect of the continuing relative motion of the expander  260  and the crown  200 . As seen in  FIG. 32 , the anastomosis device  140  continues to experience compressive stress, but at a lower level than at the point of buckling. The outward bias of the segments  289  of the expander tip  280  acts to axially center the anastomosis device  140  during deployment. Alternately, where the segments  289  are not biased outward, a ring (not shown) may encircle the body  284  of the expander tip  280  between the expander head  286  and the expander collet  287 . The spreader arms  168  and outer flange arms  174  spread outward to deploy the outer flange  304 , which is formed from the outer flange elements  173 . The ring translates distally along the body  284  of the expander tip  280 , urged in this direction by contact with the distal end of the crown  200 . Distal motion of the ring causes the segments  289  to move radially. Thus, the crown  200  compresses the segments  289  with the ring. 
     As rotation of the knob  88  continues, the hinging motion between the outer flange arms  174  and the spreader arms  168  continues. This hinging motion is driven by the relative motion of the expander  260  and the crown  200 . Compressive stress at the intersections between the outer flange arms  174  and the spreader arms  168  decreases as the outer flange arms  174  and the spreader arms  168  continue to rotate. The intersections between the spreader arms  168  and the outer flange arms  174  reach their fracture point at a point in their relative rotation, causing the outer flange arms  174  to separate from the spreader arms  168 . 
     The compression segment  152  of the anastomosis device  140  transmits compressive force to the deployable section  142  of the anastomosis device  140 . The compression segment  152  may enter the opening in the target vessel wall during deployment of the anastomosis device  140 . As a result, the compression segment  152  acts as a thin spacer for transmitting compressive force. Additionally, the compression segment  152  may acts to extend the axial distance along which compressive stress is applied, in order to prevent premature fracturing between the spreader arms  168  and the outer flange arms  174 . The compression segment  152  thus also acts to spread the compression of the anastomosis device  140  out over a longer period of time. In this way, the deployment of the deployable section proceeds smoothly, and the axial forces acting on the deployable section  142  are substantially balanced around its circumference. Alternately, the compression segment  152  is configured differently than described above, and still acts to control the compressive stress in the anastomosis device  140 . Alternately, the compression segment  152  is omitted from the anastomosis device  140 . 
     The outer flange  304 , and hence the deployable section  142 , are free from the discard section  144  of the anastomosis device  140 , and therefore free from the integrated anastomosis tool  100  as well. After deployment, the deployable section  142  may be referred to as the implant  142 . Referring also to  FIG. 37 , the outer flange arms  174 , in their deployed position, form angles slightly greater than ninety degrees with the axis  143  of the anastomosis device  140 , such that the outer flange arms  174  angle toward the outer wall of the target vessel  314  to provide gripping strength. The outer flange arms  174  may form a different angle, if desired. The outer flange arms  174 , chevrons  139 , and gripping elements  175  grip the outer wall of the target vessel without penetrating it. The deployed outer flange  304  compresses the wall of the target vessel  314  against the inner flange  300 . The everted graft vessel  310  is circumferentially positioned against the walls of the opening in the target vessel  314 , thereby assisting in sealing the opening and providing for contact between the inner surface of the graft vessel  310  and the inner surface of the target vessel  314 . The body  302  may act to press the graft vessel  310  against the walls of the opening in the target vessel  314 . The deployed outer flange  304  also grips any portion of the everted graft vessel  310  that may extend outward through the opening in the wall of the target vessel  314 , pressing it downward and sealing the edges of the opening. In this way, a positive seal is established, and the implant  142  firmly connects the graft vessel to the target vessel. 
     Compressive stress continues within the implant  142  after deployment, because the separated spreader arms  168  still exert a compressive force upon the deployed outer flange  304 . The expander head  268  is still located distal to the body  302  of the implant  142  after the implant  142  has been deployed. The third and fourth cam paths  220 ,  221  are configured to translate the expander  260  distally after the implant  142  has separated from the discard section  144 . The collet  287  is located at a position on the expander tip  280  such that the collet  287  enters the crown collar  202  shortly after the implant  142  has separated from the discard section  144 . The outer diameter of the collet  287  is larger than the inner diameter of the crown collar  202 . Thus, when the collet  287  moves into the crown collar  202 , the collet  287  contracts, counteracting the outward biasing force exerted by the expander tip  280 , and causing the expander tip  280  to radially contract. This radial contraction causes the expander head  286  to contract to an outer diameter substantially equal to the inner diameter of the body  302  of the implant, so that the expander tip  280  can translate distally through the body  302 . At the time of colleting  325 , the expander collet  287  causes the deployed implant  142  to experience a compressive force. After the expander tip  280  is colleted down, compressive force again increases as the expander tip  280  translates proximally through the deployed implant  142 . This compressive force reaches a maximum substantially at the time  300  the expander tip  280  exits the proximal end of the body  302  of the implant  142 , then quickly returns to zero as the integrated anastomosis tool  100  is removed from the implant  142 . The profile of force over time as shown in  FIG. 32  and described above is merely exemplary and qualitative, in order to describe one possible mode of operation of the integrated anastomosis tool  100  and the anastomosis device  140  deployed by that tool. The integrated anastomosis tool  100  and/or the anastomosis device  140  may be configured differently to result in a different force over time profile, if desired. 
     Alternately, where the collet  287  is not used, the angle of the shoulder  288  is selected to cause deployment of the outer flange of the deployable section  142  and to compress the segments  289  together to allow the expander tip  280  to translate proximally away from the implant  140 . In such an embodiment, the angle  290  of the shoulder  288  is substantially 65 degrees, but a different angle could be used. After the expander tip  280  has translated out of the body  302 , the anastomosis is complete, and the integrated anastomosis tool  100  can be removed from the target vessel. The contact structure  110  has an open perimeter, so the integrated anastomosis tool  100  can be moved to one side such that the graft vessel can pass through the open portion of the contact structure  110 . 
     As described above, rotation of the knob  88  occurs in a single direction to create an opening in the vessel wall and deploy the anastomosis device  140  into it, in order to simplify operation of the integrated anastomosis tool  100 . That is, the knob  88  is rotated clockwise or counter-clockwise relative to the longitudinal axis of the cam cylinder  70 . However, the knob  88  and the cam cylinder  70  may be configured such that the knob  88  is rotated sequentially in different directions in order to create an opening in the vessel wall and deploy the anastomosis device  140  into it. 
     The motion of the expander  260  and crown  200  outside and in proximity to the opening in the target vessel wall takes place within the seal housing  34  in order to maintain hemostasis. As described above, the fit between the inner diameter of the introducer tube  62  and the expander body  270  and the crown body  212  is tight enough to minimize loss of blood through the space between the inner diameter of the introducer tube  62  and the expander body  270  and the crown body  212 . Alternately, the seal housing  34  is not provided. Instead, the anastomosis device  140  is slid into the opening in the vessel wall quickly after the opening is made, thereby resulting in minimal blood loss. Alternately, a biocompatible viscous liquid is used to fill gaps between parts, thereby providing hemostasis. 
     One or more of the components of the integrated anastomosis tool  100  may be lubricated with a lubricious biocompatible substance, such as sodium stearate or another substance. The lubricious substance may be used to coat one or more components of the integrated anastomosis tool  100 , or may otherwise be applied to components of the integrated anastomosis tool  100 . Advantageously, the cam cylinder  70  is coated with lubricant, such that the cam paths  68 ,  86 ,  220 ,  221  are coated with it, and the cam followers  66 ,  84 ,  218 ,  264  are similarly coated with lubricant. In this way, travel of the cam followers  66 ,  84 ,  218 ,  264  relative to the cam paths  68 ,  86 ,  220 ,  221  is facilitated. 
     While the invention has been described in detail, it will be apparent to one skilled in the art that various changes and modifications can be made and equivalents employed, without departing from the present invention. Although embodiments have been described above with regard to a CABG procedure, the apparatus and method described above are not limited to use in such a procedure. It is to be understood that the invention is not limited to the details of construction and/or the arrangements of components set forth in the above description or illustrated in the drawings. Therefore, the invention is not to be restricted or limited except in accordance with the following claims and their legal equivalents.