Patent Publication Number: US-2010125296-A1

Title: Biological tissue closure device and method

Description:
BACKGROUND OF THE INVENTION 
     1. Field of the Invention 
     The present invention relates to the field of closing openings in biological tissue and methods of performing the same. 
     2. Description of the Related Art 
     A number of diagnostic and interventional vascular procedures are now performed translumenally, where a catheter is introduced to the vascular system at a convenient access location—such as the femoral, brachial, or subclavian arteries—and guided through the vascular system to a target location to perform therapy or diagnosis. When vascular access is no longer required, the catheter and other vascular access devices must be removed from the vascular entrance and bleeding at the puncture site must be stopped. 
     One common approach for providing hemostasis is to apply external force near and upstream from the puncture site, typically by manual compression. This method is time-consuming, frequently requiring one-half hour or more of compression before hemostasis. This procedure is uncomfortable for the patient and frequently requires administering analgesics. Excessive pressure can also present the risk of total occlusion of the blood vessel, resulting in ischemia and/or thrombosis. 
     After hemostasis is achieved by manual compression, the patient is required to remain recumbent for six to eighteen hours under observation to assure continued hemostasis. During this time bleeding from the vascular access wound can restart, potentially resulting in major complications. These complications may require blood transfusion and/or surgical intervention. 
     Bioabsorbable fasteners have also been used to stop bleeding. Generally, these approaches rely on the placement of a thrombogenic and bioabsorbable material, such as collagen, at the superficial arterial wall over the puncture site. This method generally presents difficulty locating the interface of the overlying tissue and the adventitial surface of the blood vessel. Implanting the fastener too far from the desired location can result in failure to provide hemostasis. If, however, the fastener intrudes into the vascular lumen, thrombus can form on the fastener. Thrombus can embolize downstream and/or block normal blood flow at the thrombus site. Implanted fasteners can also cause infection and auto-immune reactions/rejections of the implant. 
     Suturing methods are also used to provide hemostasis after vascular access. The suture-applying device is introduced through the tissue tract with a distal end of the device located at the vascular puncture. Needles in the device draw suture through the blood vessel wall on opposite sides of the punctures, and the suture is secured directly over the adventitial surface of the blood vessel wall to close the vascular access wound. 
     To be successful, suturing methods need to be performed with a precise control. The needles need to be properly directed through the blood vessel wall so that the suture is well anchored in tissue to provide for tight closure. Suturing methods also require additional steps for the surgeon. 
     In U.S. Pat. No. 6,56,136 to Weng et al., a hemostatic seal is attempted by the use of high intensity forced ultrasound (HIFU). In commercialized devices utilizing acoustic energy to create hemostasis seals, an acoustic transducer is held near an arteriotomy, and acoustic energy is transmitted to the target location to heat-seal the opening. All other surgical devices are removed from the arteriotomy before application of the acoustic energy. Due to the lack of definite aiming of the acoustic transducer at the arteriotomy, the acoustic energy from the transducer can fail to seal the target arteriotomy, and/or can unintentionally effect surrounding tissue. In addition, the arteriotomy is in the approximate shape of a cylinder, increasing the possibility that walls of the arteriotomy will be too far apart to seal together during energy application. 
     Due to the deficiencies of the above methods and devices, a need exists for a more reliable vascular closure method and device. There also exists a need for a vascular closure device and method that does not implant a foreign substance and is self-sealing. There also exists a need for a vascular closure device and method requiring no or few extra steps to close the vascular site. Furthermore, there exists a need for a vascular closure device using energy to create a hemostatic seal, where the energy is precisely aimed at the vascular site. Additionally, there exists a need for a vascular closure device using energy to create a hemostatic seal for a vascular opening, where the walls of the vascular opening are brought together before application of the energy. 
     BRIEF SUMMARY OF THE INVENTION 
     A device for closing an opening in biological tissue is disclosed. The device has a tensioner and a seal applier. The tensioner is configured to tension the opening. The tensioner can have a first elongated member and a second elongated member. The first elongated member can be configured to bias away from the second elongated member. The second elongated member is configured to bias away from the first elongated member. 
     The seal applier can have an RF transducer, an acoustic (e.g., ultrasound) transducer, a resistive heater, a microwave heater, an inductive heater, a hole (e.g., a microscopic pore), a web, or combinations thereof. The web can have a first fiber and a second fiber. The first fiber can cross the second fiber. The web can be made from a bioabsorbable material. The web can be removably attached to the device. 
     Furthermore, a vascular closure device is disclosed. The vascular closure device uses energy to create a hemostatic seal. The device is configured to deliver energy to an arteriotomy. The device is configured to precisely aim the energy at the arteriotomy. 
     A device for closing an opening in biological tissue is also disclosed. The opening has an internal wall. The device has a wall manipulator, and a seal applier. The wall manipulator is configured to bring a first part of the wall adjacent to a second part of the wall. 
     A method for closing an opening in a biological tissue is disclosed. The opening has an internal wall. The method includes tensioning the opening and applying a sealer to the opening. Tensioning the opening can include bringing a first part of the wall adjacent to a second part of the wall. The first part of the wall can be brought to less than about 0.51 mm away from the second part of the wall. The first part of the wall can be brought to less than about 0.38 mm away from the second part of the wall. The first part of the wall can be brought to more than about 0.25 mm away from the second part of the wall. The sealer can include energy, such as acoustic energy (e.g., ultrasound), RF energy, conductive heat energy, a liquid adhesive, or combinations thereof. 
     The method can also include aiming the sealer at the opening. Aiming can include deploying an aiming device into the opening. The aiming device can be on or adjacent to the skin surface. The method can also include deploying a web into the opening. The method can also include leaving the web in the opening at least until the web is entirely bioabsorbed. 
     Also disclosed is a method for closing an opening in a biological tissue. The opening has an internal wall. The method includes bringing a first part of the wall adjacent to a second part of the wall and applying a sealer to the opening. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         FIG. 1  illustrates an embodiment of the distal end of the closure device. 
         FIG. 2  illustrates a close-up view of  FIG. 1  centered around the second expander wire. 
         FIGS. 3-6  illustrate various embodiments of the distal end of the closure device. 
         FIG. 7  illustrates an embodiment of the distal end of the closure device in a retracted configuration. 
         FIGS. 8 and 9  are see-through views of an embodiment of the closure device in a retracted configuration. 
         FIG. 10  is a see-through view of an embodiment of the closure device in a retracted configuration. 
         FIGS. 11 through 13  illustrate a method of changing an embodiment of the closure device from a retracted configuration to an extended configuration. 
         FIG. 14  illustrates a close-up view of the distal end of the closure device of  FIG. 11 . 
         FIG. 15  illustrates a close-up view of the distal end of the closure device of  FIG. 13 . 
         FIGS. 16 and 17  illustrate a method for deploying the expander wires into an arteriotomy in a see-through portion of the lumen wall. 
         FIG. 18  illustrates a distant view of the method for deploying the expander wires into an arteriotomy in a see-through portion of the lumen wall of  FIG. 17 . 
         FIGS. 19 through 22  illustrate close-up views of various embodiments for methods of using the closure device in an arteriotomy in a see-through portion of the lumen wall. 
         FIG. 23  illustrates a cut-away view of an embodiment for a method of using the closure device with an external transducer. 
         FIG. 24  illustrates a cut-away perspective view of the embodiment of  FIG. 23 . 
     
    
    
     DETAILED DESCRIPTION 
       FIG. 1  illustrates in an extended (i.e., expanded) configuration, a closure device  2  for biological tissue closure, for example to create hemostasis across an arteriotomy.  FIG. 2  illustrates a close-up of the distal end of the closure device of  FIG. 1 . 
     The closure device  2  can have a delivery guide  4 . The delivery guide  4  can be a tubular member, such as a catheter or sheath on the outer radial side of the closure device  2 . The delivery guide  4  can be hollow. In one configuration, the delivery guide  4  can be on the proximal end of the closure device  2 . In another configuration, the delivery guide  4  can be the entire length of the closure device  2 . The delivery guide  4  can have a low-friction inner surface. The delivery guide  4  can be configured to receive an inner member  6 . The delivery guide  4  can have a distal port  8  at the distal end of the delivery guide  4 . 
     The delivery guide  4  can have a proximally-located handle (not shown). The handle can facilitate manipulation of the delivery guide  4  and the inner member  6 , and operation of the closure device  2 . 
     The closure device  2  can have the inner member  6 . The inner member  6  can be configured to slidably or fixedly attach to the inside of the delivery guide  4 . The inner member  6  can have a member longitudinal axis  10 . The distal port  8  of the delivery guide  4  can be at a non-perpendicular angle with respect to the member longitudinal axis  10 . 
     The inner member  6  can have a first wire port (not shown) and a second wire port  12   b . The wire ports  12   a  and  12   b  can be channels along entire length (e.g., from the distal end to the handle at the proximal end) of the member longitudinal axis  10 . The wire ports  12   a  and  12   b  can have an opening at or near the distal end of the inner member  6 . 
     The inner member  6  can have a sealer channel (not shown). The sealer channel can have an energy conduit and/or a fluid conduit. The sealer channel can be configured to deliver energy (e.g., for tissue adhesion and/or for enhanced cell growth and/or denaturing and recoagulation of the proteins, such as adventitial proteins and/or collagen) and/or a liquid sealant (e.g., a hemostatic agent and/or tissue adhesive and/or volume filler, such as polyethylene glycol (PEG)) to a sealer port  14  at a distal tip of the inner member  6 , and/or to one or more elongated members, such as first and/or second expander wires  16   a  and/or  16   b.    
     A supplemental sealer delivery device  18  can be attached to the sealer port  14 . A natural seal can occur due to natural healing of the tissue of the arteriotomy from being in proximity with itself. Supplemental sealing can be any sealing action in addition to the natural seal, including methods to facilitate, maximize, and/or increase the efficiency of the natural sealing. The supplemental sealer delivery device  18 , or other delivery device, can be configured to deliver a sealer, for example energy, such as acoustic or radio frequency (RF) energy, microwave energy, and/or a biocompatible adhesive liquid. The supplemental sealer delivery device  18  can be an acoustic transducer, such as a high intensity focus ultrasound (HIFU) transducer or image-guided HIFU. The supplemental sealer delivery device  18  can be from a loop extending from, and returning to, the sealer port  14 . The supplemental sealer delivery device  18  can be a spout (not shown) for delivering the liquid sealer. The supplemental sealer delivery device  18  can be a combination of various individual supplemental sealer delivery devices  18  (e.g., an acoustic transducer and a spout). 
     The first expander wire  16   a  and the second expander wire  16   b  can be slidably, and/or rotatably, and/or fixedly attached to the first wire port  12   a  and second wire port  12   b , respectively. The expander wires  16   a  and  16   b  can distally extend from the wire ports  12   a  and  12   b , respectively. The first and second expander wires  16   a  and  16   b  can have first and second expander wire extensions  20   a  and  20   b , respectively, and first and second expander wire tips  22   a  and  22   b , respectively. 
     As exemplarily shown on the second expander wire  16   b  in  FIG. 2 , the expander wire extensions  20   a  and  20   b  can extend radially away from the member longitudinal axis  10 . First and second expander wire tips  22   a  and  22   b  can extend at angles from the first and second expander wire extensions  20   a  and  20   b , respectively. The first and second expander wire tips  22   a  and  22   b  can have tip longitudinal axes  24   a  and  24   b . The first and second tip longitudinal axes  24   a  and  24   b  can be substantially parallel with the member longitudinal axis  10 . The distal ends of the first and second expander wire tips  22   a  and  22   b  can have first (not shown) and second feet  26   b , respectively. The feet  26   a  and  26   b  can extend radially further from the member longitudinal axis  10  than a main portion of the expander wire tips  22   a  and  22   b.    
     The expander wires  16   a  and  16   b  can have wire diameters  28 . The wire diameters  28  can be transverse (i.e., about perpendicular) to the tip longitudinal axes  24   a  and  24   b . The wire diameters  28  can be from about 0.1 mm (0.005 in.) to about 1.2 mm (0.050 in.), for example about 0.38 mm (0.015 in.). 
     The distance from about the member longitudinal axis  10  to about the radially outer side of the expander wire tips  22   a  or  22   b  can be a sealing radius  30 . The sealing radius  30  can be from about 0.51 mm (0.020 in.) to about 5.08 mm (0.200 in.), for example about 2.0 mm (0.080 in.). 
     The expander wire tips  22   a  and  22   b  can have tip lengths  32 . The tip lengths  32  can be from about 0.51 mm (0.020 in.) to about 25 mm (1.0 in.), for example about 4.06 mm (0.160 in.). 
     The expander wire extensions  20   a  and  20   b  can have extension lengths  34 . The extension lengths  34  can be from about 2.54 mm (0.100 in.) to about 25 mm (1.0 in.), for example about 9.65 mm (0.380 in.). 
       FIG. 3  illustrates the closure device  2  that can have the supplemental sealer delivery device  18  that can extend from the sealer port  14 . The supplemental sealer delivery device  18  can extend along the member longitudinal axis  10  to about the same distance as the distal ends of the first and/or second expander wires  16   a  and/or  16   b  are located parallel to the member longitudinal axis  10 . 
     The supplemental sealer delivery device  18  can be configured to transmit RF energy. For example, the supplemental sealer delivery device  18  can be in electrical communication with a conductive wire (e.g., from inside the inner member). The first and/or second expander wires  16   a  and/or  16   b  can be configured to transmit RF energy. For example, the first and/or second expander wires  16   a  and/or  16   b  can be in electrical communication with a conductive wire (e.g., from inside the inner member  6 ). 
     The supplemental sealer delivery device  18  can be configured to transmit microwave energy. For example, the supplemental sealer delivery device  18  can be in electrical communication with a wave guide (e.g., from inside the inner member). The first and/or second expander wires  16   a  and/or  16   b  can be configured to transmit microwave energy. For example, the first and/or second expander wires  16   a  and/or  16   b  can be in electrical communication with a wave guide (e.g., from inside the inner member  6 ). 
       FIG. 4  illustrates the closure device  2  that can have no supplemental sealer delivery device  18 . The first and/or second expander wires  16   a  and/or  16   b  can be configured to transmit one or more sealers, for example energy. The first and/or second expander wires  16   a  and/or  16   b  can be attached to an acoustic energy actuator, for example inside the inner member  6 . The first and/or second expander wires  16   a  and/or  16   b  can be in electrical communication with a single conductive wire or conductive wires for each expander wire  16   a  and  16   b.    
       FIG. 5  illustrates the closure device  2  that can have no supplemental sealer delivery device  18 . The first and/or second expander wires  16   a  and/or  16   b  can be configured to transmit a physical sealer, for example a liquid adhesive sealant. The first and/or second expander wires  16   a  and/or  16   b  can be hollow. The first and/or second expander wires  16   a  and/or  16   b  can have delivery holes  36  (e.g., microscopic pores and/or macroscopic openings) on the surface thereof, for example to delivery liquid adhesive sealant, or any anti-biotic, anesthetic, vaso-restrictors, PEG, or any other agent listed supra or combinations thereof. The delivery holes  36  can be on the first and/or. second expander wire tips  22   a  and/or  22   b . The delivery holes  36  can be on the sides of the first and/or second expander wires  16   a  and/or  16   b  facing the member longitudinal axis  10 . The delivery holes  36  can be arranged along a line, for example parallel to the member longitudinal axis  10 . The first and/or second expander wires  16   a  and/or  16   b  can be attached, and in fluid communication, at a proximal end to a reservoir, and/or pump, and/or valve holding and/or delivering a sealer, for example a liquid adhesive sealant. 
       FIG. 6  illustrates the closure device  2  that can have a web  38  that can be attached to the first and second expander wires  16   a  and  16   b . The web  38  can be fixedly or removably attached to the first and second expander wire tips  22   a  and  22   b . The web  38  can be two or more crossed fibers or wires of material. The web  38  can be a mesh. The web  38  can be a porous surface. The web  38  can be made from a metal, and/or a conductive polymer. The web  38  can be made from a resorbable polymer. The web  38  can be configured to transmit RF energy, or can be inductively heated. For example, the web  38  can be in electrical communication with a conductive wire (e.g., via the first and/or second expander wire tip  22   a  and/or  22   b  from inside the inner member  6  and/or from along the outside of the delivery guide  4  and/or from another tool not a part of the closure device  2 ), and/or have current induced therein (e.g., from an external induction coil). The web  38  can be in fluid communication with the delivery holes  36 , as shown in  FIG. 5 . The fibers or wires of the web  38  can be hollow and/or have holes or pores (not shown). The web  38  can be configured to transmit a physical sealer, for example a liquid adhesive sealant. 
       FIG. 7  illustrates the closure device  2  that can have a retracted (i.e., compressed) configuration. The inner member  6  (not shown) can be retracted into the delivery guide  4 . The first expander wire  16   a  and/or the second expander wire  16   b  can be retracted into the delivery guide  4 . The distal ends of the first expander wire  16   a  and/or the second expander wire  16   b  can be proximal to the distal port. 
       FIGS. 8 and 9  illustrate, in a retracted configuration, the closure device  2  that can check for fluid pressure at the distal port  8 . The closure device  2  can have a pressure check port  40  in the delivery guide  4  and/or inner member  6  (not shown). The pressure check port  40  can be distal to the expander wire tips  22   a  and  22   b  when the expander wire tips  22   a  and  22   b  are in a retracted configuration. The pressure check port  40  can be in fluid communication with the distal port  8  when the closure device  2  is in a retracted position. The pressure check port  40  can be in fluid communication with an outer wall of the delivery guide  4 . The pressure check port  40  can be in fluid communication with a pressure check lumen  42 . The pressure check lumen  42  can be in fluid communication with a sensor or port on or near the handle (not shown) of the delivery guide  4 , such as an external lumen where blood flow can be observed, for example flow from the end of an external tube or port and/or through a transparent or translucent window. 
       FIG. 10  illustrates, in a retracted configuration, the closure device  2  that can have the pressure check port  40  aligned with the distal ends of the expander wire tips  22   a  and  22   b , for example, even with a distal alignment line  43 . 
     When the closure device  2  is used, the distal end of the delivery guide  4  can be inserted across the wall of a vessel until a “flash” of blood enters the pressure check port  40 , flows up the pressure check lumen  42 , and can then be observed by the sensor or port on or near the handle. Once the blood “flash” is observed, the delivery guide  4  can be moved slowly in the proximal direction until the “flash” stops. The “flash” stopping can be an indication of the distal location of the delivery guide (i.e., the pressure check port  40  can be blocked by the lumen wall  54 ). 
     Any or all elements of the closure device  2  and/or other devices or apparatuses described herein can be made from, for example, a single or multiple stainless steel alloys, nickel titanium alloys (e.g., Nitinol), cobalt-chrome alloys (e.g., ELGILOY® from Elgin Specialty Metals, Elgin, Ill.; CONICHROME® from Carpenter Metals Corp., Wyomissing, Pa.), molybdenum alloys (e.g., molybdenum TZM alloy, for example as disclosed in International Pub. No. WO 03/082363 A2, published 9 Oct. 2003, which is herein incorporated by reference in its entirety), tungsten-rhenium alloys, for example, as disclosed in International Pub. No. WO 03/082363, polymers such as polyester (e.g., DACRON® from E. I. Du Pont de Nemours and Company, Wilmington, Del.), polypropylene, polytetrafluoroethylene (PTFE), expanded PTFE (ePTFE), polyether ether ketone (PEEK), nylon, polyether-block co-polyamide polymers (e.g., PEBAX® from ATOFINA, Paris, France), aliphatic polyether polyurethanes (e.g., TECOFLEX® from Thermedics Polymer Products, Wilmington, Mass.), polyvinyl chloride (PVC), polyurethane, thermoplastic, fluorinated ethylene propylene (FEP), absorbable or resorbable polymers such as polyglycolic acid (PGA), polylactic acid (PLA), polydioxanone, and pseudo-polyamino tyrosine-based acids, extruded collagen, silicone, zinc, echogenic, radioactive, radiopaque materials or combinations thereof. Examples of radiopaque materials are barium sulfate, zinc oxide, titanium, stainless steel, nickel-titanium alloys, tantalum and gold. 
     Any or all elements of the closure device  2  and/or other devices or apparatuses described herein can be or have a matrix for cell ingrowth or used with a fabric, for example a covering (not shown) that acts as a matrix for cell ingrowth. The matrix and/or fabric can be, for example, polyester (e.g., DACRON® from E. I. Du Pont de Nemours and Company, Wilmington, Del.), polypropylene, PTFE, ePTFE, nylon, extruded collagen, silicone or combinations thereof. 
     The elements of the closure device  2  and/or other devices or apparatuses described herein and/or the fabric can be filled and/or coated with an agent delivery matrix known to one having ordinary skill in the art and/or a therapeutic and/or diagnostic agent. The agents within these matrices can include radioactive materials; radiopaque materials; cytogenic agents; cytotoxic agents; cytostatic agents; thrombogenic agents, for example polyurethane, cellulose acetate polymer mixed with bismuth trioxide, and ethylene vinyl alcohol; lubricious, hydrophilic materials; phosphor cholene; anti-inflammatory agents, for example non-steroidal anti-inflammatories (NSAIDs) such as cyclooxygenase-1 (COX-1) inhibitors (e.g., acetylsalicylic acid, for example ASPIRIN® from Bayer AG, Leverkusen, Germany; ibuprofen, for example ADVIL® from Wyeth, Collegeville, Pa.; indomethacin; mefenamic acid), COX-2 inhibitors (e.g., VIOXX® from Merck &amp; Co., Inc., Whitehouse Station, N.J.; CELEBREX® from Pharmacia Corp., Peapack, N.J.; COX-1 inhibitors); immunosuppressive agents, for example Sirolimus (RAPAMUNE®, from Wyeth, Collegeville, Pa.), or matrix metalloproteinase (MMP) inhibitors (e.g., tetracycline and tetracycline derivatives) that act early within the pathways of an inflammatory response. Examples of other agents are provided in Walton et al, Inhibition of Prostoglandin E 2  Synthesis in Abdominal Aortic Aneurysms,  Circulation , Jul. 6, 1999, 48-54; Tambiah et al, Provocation of Experimental Aortic Inflammation Mediators and Chlamydia Pneumoniae,  Brit. J. Surgery  88 (7), 935-940; Franklin et al, Uptake of Tetracycline by Aortic Aneurysm Wall and Its Effect on Inflammation and Proteolysis,  Brit. J. Surgery  86 (6), 771-775; Xu et al, Sp 1 Increases Expression of Cyclooxygenase-2 in Hypoxic Vascular Endothelium,  J. Biological Chemistry  275 (32) 24583-24589; and Pyo et al, Targeted Gene Disruption of Matrix Metalloproteinase-9 (Gelatinase B) Suppresses Development of Experimental Abdominal Aortic Aneurysms,  J. Clinical Investigation  105 (11), 1641-1649 which are all incorporated by reference in their entireties. 
     Method of Manufacture 
     The elements of the closure device  2  can be directly attached by, for example, melting, screwing, gluing, welding, soldering, abrasing, or use of an interference fit or pressure fit such as crimping, snapping, or combining methods thereof. The elements can be integrated, for example, molding, die cutting, laser cutting, electrical discharge machining (EDM) or stamping from a single piece or material. Any other methods can be used as known to those having ordinary skill in the art. 
     Integrated parts can be made from pre-formed resilient materials, for example resilient alloys (e.g., Nitinol, ELGILOY®) that are preformed and biased into the post-deployment shape and then compressed into the deployment shape as known to those having ordinary skill in the art. 
     The expander wires  16   a  and  16   b  can be made from pre-formed resilient materials, for example resilient alloys (e.g., Nitinol, ELGILOY®) that are preformed and biased into the post-deployment shape and then compressed into the deployment shape. The post-deployment shape can be the configuration shown in  FIG. 2  and elsewhere herein. 
     Any elements of the closure device  2 , or the closure device  2  as a whole after assembly, can be coated by dip-coating, brush-coating or spray-coating methods known to one having ordinary skill in the art. For example, the expander wires  16   a  and  16   b  can be spray coated, dip-coated or brushed-coated. 
     One example of a method used to coat a medical device for vascular use is provided in U.S. Pat. No. 6,358,556 by Ding et al. and hereby incorporated by reference in its entirety. Time release coating methods known to one having ordinary skill in the art can also be used to delay the release of an agent in the coating, for example the coatings on the expander wires  16   a  and  16   b.    
     Method of Use 
       FIGS. 11 through 13  illustrate a method for changing the closure device  2  from a first configuration to a second configuration.  FIGS. 14 and 15  also show close-up views of distal ends of the closure device  2  of  FIGS. 11 and 13 , respectively. As shown in  FIGS. 11 and 14 , the closure device  2  can be in a fully retracted configuration. The inner member  6  and the expander wires  16   a  and  16   b  can be concealed within the delivery guide  4 . 
     As shown in  FIG. 12 , the closure device  2  can be in a partially deployed configuration. The inner member  6  can be pushed or pulled to be translated, as shown by arrow  44 , distally relative to the delivery guide  4 , and/or the delivery guide  4  can be pushed or pulled to be translated, as shown by arrow  46 , proximally relative to the delivery guide  4 . 
     The delivery guide  4  can restrict (e.g., by interference fit) the expander wires  16   a  and  16   b  from expanding away from the member longitudinal axis  10 . The expander wires  16   a  and  16   b , can move distally, as shown by arrows  47 , relative to the delivery guide  4 . The expander wires  16   a  and  16   b  can be attached to the inner member  6 , such that the inner member  6  pushes the expander wires  16   a  and  16   b  when the inner member  6  is pushed. 
     As shown in  FIGS. 13 and 15 , the closure device  2  can be in a fully deployed configuration. The inner member  6  can be pushed or pulled to be translated, as shown by arrow  48 , distally relative to the delivery guide  4 , until the inner member  6  reaches a stop (not shown) with respect to the supplemental sealer delivery device. The stop can be an interference fit between the delivery guide  4  and the inner member  6 . The delivery guide  4  can be pushed or pulled to be translated, as shown by arrow  50 , proximally relative to the delivery guide  4 , until the delivery guide  4  reaches the stop. 
     The expander wires  16   a  and  16   b , can move distally, as shown by arrows  51 , relative to a location at which the expander wires  16   a  and  16   b  exit the wire ports  12   a  and  12   b . The location at which the expander wires  16   a  and  16   b  exit the respective wire ports  12   a  and  12   b  can move beyond the distal port  8  and the delivery guide  4 . The expander wires  16   a  and  16   b  can expand radially, as shown by arrows  51 , away from the member longitudinal axis  10 . 
       FIG. 16  illustrates that the closure device  2  can be inserted, as shown by arrow, into an opening in tissue, for example the arteriotomy  52  in a lumen wall  54 . The closure device  2  can be in the retracted configuration when the closure device  2  is inserted into the arteriotomy  52 . After inserting the closure device  2 , the distal end of the closure device  2  can be located in or outside and distal to the arteriotomy  52 . The lumen wall  54  can have an inner lumen wall surface  56 , and can surround a lumen  57 . 
     The arteriotomy  52  can have an arteriotomy diameter  58 . The arteriotomy diameter  58  can be from about 0.5 mm (0.020 in.) to about 40 mm (1.5 in.), yet a narrower range from about 1.0 mm (0.040 in.) to about 10.2 mm (0.400 in.), for example about 2.54 mm (0.100 in.). When in the retracted configuration, the closure device  2  can have a diameter smaller than the arteriotomy diameter  58 . 
     The lumen wall  54  can have a lumen wall thickness  60 . The lumen wall thickness  60  can be from about 0.51 mm (0.020 in.) to about 5.08 mm (0.200 in.), for example about 1.0 mm (0.040 in.). 
       FIGS. 17 and 18  illustrate expanding the closure device  2  after the closure device  2  has been inserted into the arteriotomy  52 . The delivery guide  4  can be moved proximally relative to the inner member  6 . The expander wires  16   a  and  16   b  can expand, as shown by arrows  62 , away from the member longitudinal axis  10 . The expander wire tips  22   a  and  22   b  can be located inside the arteriotomy  52 . The expander wire tips  22   a  and  22   b  can expand, for example laterally, against the arteriotomy  52 . The arteriotomy  52  can change shape in response to tensioning forces applied by the expander wire tips  22   a  and  22   b , for example, during expansion. The feet  26   a  and  26   b  can pressure and/or interference fit with the arteriotomy  52  and/or the inner lumen wall surface  56 . 
     The arteriotomy  52  can have an arteriotomy width  64  and an arteriotomy height  66 . The arteriotomy width  64  can be about half the circumference of the arteriotomy  52 . The arteriotomy width  64  can be from about 1.0 mm (0.040 in.) to about 10.2 mm (0.400 in.), for example about 4.06 mm (0.160 in.). 
     The arteriotomy height  66  can be about the wire diameter  28 . The arteriotomy height  66  can be less than about 0.51 mm (0.020 in.), more narrowly, less than about 0.38 mm (0.015 in.). The arteriotomy height  66  can be from about 0.1 mm (0.005 in.) to about 1.3 mm (0.050 in.), for example about 0.38 mm (0.015 in.). The arteriotomy height  66  can be small enough to enable cell growth, blood clotting, acoustic sealing, heat sealing, gluing, enhanced self-sealing and combinations thereof across the arteriotomy  52 . 
       FIG. 19  illustrates a method for applying energy (e.g., acoustic) to the tensioned arteriotomy  52 . The closure device  2  can have the supplemental sealer delivery device  18 . The supplemental sealer delivery device  18  can be an acoustic (e.g., ultrasound) transducer. For example, because the expander wires  16   a  and  16   b  can produce opposite forces on opposite sides of the inside of the arteriotomy  52 , the supplemental sealer delivery device  18  can be automatically aimed and automatically centered (e.g., aligned along the member longitudinal axis  10  with about the center of the arteriotomy  52 ). The supplemental sealer delivery device  18  can transmit acoustic energy to the arteriotomy  52 . 
       FIG. 20  illustrates a method for applying energy (e.g., RF or microwave) to the tensioned arteriotomy  52 . The supplemental sealer delivery device  18  can extend into about the center of the arteriotomy  52 . The supplemental sealer delivery device  18  can be an RF transducer. The first and/or second expander wires  16   a  and/or  16   b  can be RF or microwave transducers (e.g., microwave antenna). For example, the first and/or second expander wires  16   a  and/or  16   b  can be first RF poles, and the supplemental sealer delivery device  18  can be a second RF pole. 
       FIG. 21  illustrates a method for applying the sealer (e.g., energy or liquid) into the tensioned arteriotomy  52  using the web  38 . The web  38  can be an RF transducer, and/or a resistive heater, and/or an inductive heater and/or microwave heater. The web  38  can be hollow and have holes or pores (not shown). The web  38  can be in fluid communication with a hollow first and/or second expander wires  16   a  and/or  16   b . The web  38  can transfer a liquid, for example a sealer, into the arteriotomy  52 . 
     Once the web  38  applies the sealer to the tensioned arteriotomy  52 , the web can be removed from the expander wire tips  22   a  and  22   b , and left in the arteriotomy  52  when the remainder of the closure device  2  is removed. The web  38  can be absorbed by the tissue surrounding the arteriotomy  52 . 
       FIG. 22  illustrates a method for applying liquid sealer into the tensioned arteriotomy  52 . The liquid sealer can flow, as shown by arrows, from the delivery holes  36  into the arteriotomy  52 . Liquid sealers (e.g., biocompatible adhesives, biocompatible epoxies, PEG) for filling and sealing arteriotomies  52  are known to those having ordinary skill in the art. The sealer can act as an adhesive. The adhesive can act as a filler, for example PEG. The sealer can be bioabsorbable. 
     The arteriotomy  52  can be partially or completely sealed by the energy. Fluid flow can be substantially and/or completely stopped (i.e., hemostasis). Fluid flow through the arteriotomy  52  can be partially or completely sealed by the energy. 
     The supplemental sealer delivery device  18 , and/or the web  38 , and/or the expander wire tips  22   a  and  22   b  can be electrical resistive heater elements. The sealer can be direct heat transferred through conduction, and/or convection, and/or radiative heating. The supplemental sealer delivery device  18  can heat the arteriotomy directly through conduction. 
     Any combination of energies, in any proportion, can be applied to the arteriotomy  52 . For example, RF or other heating energy can initially be applied to the tensioned arteriotomy  52 . The RF or other heating energy can then be stopped and acoustic energy can be applied to the tensioned arteriotomy  52 . 
     Resistive heat energy (i.e., conducted heat generated by electrical resistors) and acoustic energy can be applied simultaneously and in any proportion to the arteriotomy  52 . RF energy and resistive heat energy can be applied simultaneously and in any proportion to the arteriotomy  52 . Acoustic energy and RF energy can be applied simultaneously and in any proportion to the arteriotomy  52 . Acoustic energy and inductive energy can be applied simultaneously and in any proportion to the arteriotomy  52 . Resistive heat energy, acoustic energy, RF energy, inductive energy and/or microwave energy can be applied simultaneously and in any proportion to the arteriotomy  52 . 
       FIGS. 23 and 24  illustrate a treatment area that can have skin  68  separated from the vessel  70  by subcutaneous tissue  72  (e.g., fat, muscle, other vessels). An external transducer  74  can be in contact with or adjacent to the skin  68 . A gel or other contact supplement known to one having ordinary skill in the art can be sued to improve energy conduction between the external transducer  74  and the skin  68 . 
     After the arteriotomy is substantially sealed, the holes in the lumen wall  54  from which the expander wires  16   a  and  16   b  and/or the supplemental sealer delivery device  18  are removed can be inconsequentially small so that bleeding from the holes can be negligible. Sealing (e.g., heating) can be performed as the closure device  2  is removed from the arteriotomy  52  so as to close an holes in the lumen wall  54  formed by the removal of the closure device  2 . 
     The external transducer  74  can be an acoustic transducer, such as an ultrasonic imager, HIFU, image guided HIFU; a radiological transducer, such as an x-ray imager; a magnetic imager, such as a magnetic resonance imager (MRI); therapeutic versions of the aforementioned imagers, or combinations thereof. 
     The external transducer  74  can be used to send energy waves  76  to the arteriotomy  52 . The energy waves  76  can reflect from, transmit through, and/or resonate from the arteriotomy  52  and/or the expander wire tips  22   a  and  22   b . Reflected and/or transmitted and/or resonated energy waves  76  can be received by the external transducer  74  and used to detect the condition (e.g., morphology, structure) and location of the arteriotomy  52  and the expander wire tips  22   a  and  22   b . The external transducer  74  can track the location of the arteriotomy  52  and the expander wire tips  22   a  and  22   b.    
     The expander wire tips  22   a  and  22   b  can have a material or configuration that enhances the ability of the external transducer  74  to detect the expander wire tips  22   a  and  22   b : For example, the expander wire tips  22   a  and  22   b  can have an echogenic and/or radiopaque material and/or configuration, such as radiopaque materials listed supra. The first and second expander wire tips  22   a  and  22   b  can frame the arteriotomy  52  location and provide a target got an image-guided external transducer  74  (e.g., image guided HIFU). The energy waves  76  can be therapeutic energy, for example used to seal the arteriotomy  52 . The energy waves  76  can be focused on the arteriotomy  52 , and can transmit minimal energy into surrounding tissue. For example, the energy waves  76  can be therapeutic ultrasound broadcast from a phased array such that a node of the energy waves  76  is located at the arteriotomy  52 . 
     The closure device  2  can be removed from the arteriotomy  52 . The closure device  2  can be directly withdrawn from the arteriotomy, for example in a parallel direction with the tip longitudinal axes  24   a  and  24   b . The closure device  2  can be withdrawn from the arteriotomy  52  while the first and second expander wires  16   a  and  16   b  are in an expanded configuration. 
     Before the closure device is withdrawn from the arteriotomy  52 , and/or subcutaneous tissue track, the inner member  6  can be retracted into the delivery guide  4 , with or without fully retracting the expander wires  16   a  and  16   b  into the first and second wire ports  12   a  and  12   b . The delivery guide  4  can be moved distally relative to the inner member  6 , reversing the method shown in  FIGS. 11 through 16 , and changing the closure device  2  into a retracted configuration. The closure device  2  can then be removed from the arteriotomy  52  with the expander wires  16   a  and  16   b  in an expanded or retracted configuration. 
     If the arteriotomy  52  was created by a surgical procedure using a hollow member, such as a catheter, or there is otherwise a catheter in the arteriotomy  52  prior to performing the methods described herein, the already-deployed catheter can be used as the delivery guide  4 , or as a sheath for the delivery guide  4 . 
     The closure devices and methods shown and described herein can be used integrally and/or in other combinations with access and closure devices and methods shown and described in U.S. patent application Ser. No. 10/844,247 filed 12 May 2004, and incorporated herein by reference in its entirety. For example, the arteriotomy  52  can be at an angle with respect to the lumen, wherein the angle can be from about 20° to about 90°, more narrowly from about 30° to about 60°, for example about 45°, or otherwise described in U.S. patent application Ser. No. 10/844,247. Also for example, the arteriotomy  52  can have a shape as described by U.S. patent application Ser. No. 10/844,247. The devices and methods described herein can be used in combination with the supplemental closure devices, such as tensioners, clips, toggles, sutures, and combinations thereof, described by U.S. patent application Ser. No. 10/844,247. 
     It is apparent to one skilled in the art that various changes and modifications can be made to this disclosure, and equivalents employed, without departing from the spirit and scope of the invention. Elements shown with any embodiment are exemplary for the specific embodiment and can be used on other embodiments within this disclosure.