Patent Publication Number: US-2021177421-A1

Title: Anastomotic coupler

Description:
CROSS-REFERENCE TO RELATED APPLICATIONS 
     This application is a continuation application of U.S. application Ser. No. 16/950,209 filed Nov. 17, 2020, which claims the benefit of U.S. Provisional Patent Application No. 62/936,868, filed in the U.S. Patent and Trademark Office on Nov. 18, 2019, and U.S. Provisional Patent Application No. 63/061,303, filed in the U.S. Patent and Trademark Office on Aug. 5, 2020, each of which is incorporated herein by reference in its entirety for all purposes. 
    
    
     FIELD 
     The present disclosure relates generally to an anastomotic coupler. In at least one example, the present disclosure relates to a surgical system and method to utilize an anastomotic coupler to connect two tubular structures such as vessels, esophagus, intestine, lymphatic structure, and/or graft material. 
     BACKGROUND 
     An anastomosis is a connection between two luminal structures. Commonly, these connections can occur with blood vessels (for example, vascular anastomosis), or tubular gastrointestinal structures (for example, intestines, stomach, esophagus). Conventional techniques allow the anastomosis to be completed between two ends (referred to as end-to-end anastomosis), or between the end of one structure and the side of another structure (referred to as end-to-side anastomosis). Procedures requiring these anastomoses are carried out thousands of times per day, globally. Likewise, multiple surgical specialties rely upon the creation of reliable, unobstructed anastomoses for successful treatment of their respective patients. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
       Implementations of the present technology will now be described, by way of example only, with reference to the attached figures, wherein: 
         FIG. 1  illustrates a diagram of an anastomotic coupler; 
         FIG. 2  illustrates a fixation device; 
         FIG. 3  illustrates a tubular structure being received by a fixation device; 
         FIG. 4  illustrates a ring being aligned with a cartridge of the fixation device; 
         FIG. 5  illustrates a cross-sectional view of  FIG. 4 ; 
         FIG. 6  illustrates an exemplary fastener; 
         FIG. 7  illustrates another example of a fastener; 
         FIG. 8  illustrates another example of a fastener; 
         FIG. 9  illustrates a cross-sectional view of the cartridge aligned with the ring; 
         FIG. 10A  illustrates actuation of the fixation device; 
         FIG. 10B  illustrates a cross-sectional view of  FIG. 10A ; 
         FIG. 11  illustrates an exemplary ring; 
         FIG. 12  illustrates an example of another ring; 
         FIG. 13  illustrates a cross-sectional view of two rings coupled with one another to join two tubular structures; 
         FIG. 14  illustrates a cap disposed over the two rings of  FIG. 13 ; 
         FIG. 15  illustrates an exemplary cap; and 
         FIG. 16  is a flow chart of a method for utilizing an anastomotic coupler. 
     
    
    
     DETAILED DESCRIPTION 
     It will be appreciated that for simplicity and clarity of illustration, where appropriate, reference numerals have been repeated among the different figures to indicate corresponding or analogous elements. In addition, numerous specific details are set forth in order to provide a thorough understanding of the examples described herein. However, it will be understood by those of ordinary skill in the art that the examples described herein can be practiced without these specific details. In other instances, methods, procedures and components have not been described in detail so as not to obscure the related relevant feature being described. Also, the description is not to be considered as limiting the scope of the examples described herein. The drawings are not necessarily to scale and the proportions of certain parts may be exaggerated to better illustrate details and features of the present disclosure. 
     The original technique for vascular suture anastomoses was created by Alexis Carrel between 1901-1910. This pioneering work resulted in Carrel receiving the Nobel Prize in 1912. Despite 100 years of surgical evolution and innovation since that discovery, the majority of vascular anastomoses to this day still employ suture techniques similar to Carrel&#39;s initial description in the early 1900s. In the 1970s, gastrointestinal stapling devices were introduced, which quickly replaced primary suture techniques for bowel anastomoses. However, most surgeons still employ circumferential suture techniques in the serosal layer overlying the stapled anastomosis for added support. Although generally successful, these techniques can take long periods of time, often require additional surgical expertise, and if not performed correctly, may result in leakage (blood, stool contents, gastric contents, lymphatic fluid), constriction, stenosis, and/or obstruction at the anastomotic site. In the case of vascular anastomoses, stenosis and/or obstruction can result in catastrophic complications such as heart attack, stroke, peripheral limb ischemia, amputation, death, and reconstructive failure and soft-tissue loss. For example, in the setting of gastrointestinal anastomoses, these complications can result in extra-luminal leak of gastrointestinal contents, infection, sepsis, obstruction, and death. 
     With the understood importance of reliable, open anastomoses, alternatives to sutures and staples have been used. An example of a vascular anastomotic coupler is described, for instance, in U.S. Patent Pub. No. 2015/0088172 A1 (the &#39;172 Publication). This coupler has two circular ends with spikes or pins. The vessel is brought through the ring and the vessel wall is everted, or rolled over, the pins for securement as shown in  FIGS. 2A and 2B  of the &#39;172 Publication. This is completed on each vessel end, and the two rings are then brought together with the spikes/pins being forced into the opposite ring to join the ends together as shown in  FIG. 1C  of the &#39;172 Publication. However, because of the potential for micro-motion of the vessels and size mismatch due to the anastomotic coupler of the &#39;172 Publication, blood leakage may happen, and/or one of the pins may tear through the vessel wall creating a leak and/or site for platelet aggregation and thrombosis (blood clot formation). Likewise, with the anastomotic coupler of the &#39;172 Publication, for thicker walled, less elastic vessels, particularly arteries, everting vessel edges can be quite difficult and may result in trauma to the vessel wall (intima) and/or stenosis at the anastomosis, both of which can create platelet aggregation, turbid flow, and/or thrombosis with subsequent obstruction of flow. Additionally, the technique of the &#39;172 Publication requires additional specialized equipment (surgical microscope, high-powered loupe magnification) to use. For gastrointestinal stapled anastomoses, many procedures are performed either side-to-side which is not a natural pathway for intestinal smooth muscle propulsion of stool contents (for example, non-longitudinal flow along the length of the intestine), or end-to-end, which requires a separate, remote full-thickness bowel access incision for deployment, thereby creating a secondary weak point for potential leak, or adhesion formation. 
     Referring now to  FIG. 1 , an anastomotic coupler  10  is provided. The anastomotic coupler  10  is provided to create a connection between adjacent tubular structures  12 . The tubular structure  12  can include blood vessels, grafts, prostheses, gastrointestinal structures, esophagus, lymphatics, and/or any other suitable channels of the body or the operation for which the tubular structure  12  is created. The tubular structure  12  forms a lumen  14  through which matter can be passed, for example blood, food, fluids, and/or cells. 
     The anastomotic coupler  10  includes a ring  300  forming an aperture  302 . The ring  300  is operable to receive a tubular structure  12  through the aperture  302 . While the ring  300  as illustrated in  FIG. 1  has a substantially circular shape, the ring  300  can have any suitable shape such as rectangular, triangular, octagonal, hexagonal, and/or oval. Additionally, the ring  300  as illustrated in  FIG. 1  is a singular solid piece, in some examples, for ease of application or manufacturing purposes, the ring  300  can include two semi-circular or arc-type pieces that are joined together around the tubular structure 
     The size of the lumen  302  of the ring  300  can vary based on the application and the size of the tubular structure  12 . For example, the diameter of the lumen  302  can range from about 0.5 millimeters (mm) (for example for lymphatic connections) to about 60 millimeters (for example for gastrointestinal connections). Due to the range of diameters for the ring  300 , and the range of diameters for the tubular structure  12 , the appropriate ring  300  can be selected by measuring the internal diameter of the tubular structure  12 . This can be accomplished, for example, with an intraluminal measurement guide/device. If there is a significant size mismatch (1 mm or greater) between the tubular structure  12  and the ring  300 , then a short, cylindrical tube connector with a corresponding male and female end can be used to allow for gradual transition in size in any direction to accommodate the size difference. For example, a cylindric tube can be provided that tapers in size such that one end is 1 mm-2 mm larger/smaller than the other end, which would enable a connection of a 1 mm vessel to a 2.5 mm-3.5 mm vessel during microsurgical procedures without problem and vice versa. 
     Referring also to  FIG. 2 , the anastomotic coupler  10  also includes a fixation device  100 . The fixation device  100  is operable to couple the tubular structure  12  with the ring  300 . The fixation device  100  can include a housing  102  and a cartridge  200 . The cartridge  200  includes a plurality of fasteners  206  (as shown in  FIGS. 5-10B ). The fasteners  206  are operable to puncture the tubular structure  12  and be partially received in the ring  300  to couple the tubular structure  12  with the ring  300 . In at least one example, the cartridge  200  can be removably coupled with the housing  102 . Accordingly, the cartridge  200  may be replaceable to allow multiple uses of the fixation device  100 . In some examples, the cartridge  200  may not be removable such that the fixation device  100  is provided for a one-time use. The fixation device  100  can include a pusher rod  150  operable to actuate the fixation device  100  to drive the fasteners  206  from the cartridge  200 . Upon actuation of the fixation device  100 , the pusher rod  150  can translate along a longitudinal axis. 
     The fixation device  100  includes stop  104  to receive the tubular structure  12 . In at least one example, the stop  104  can be formed as a portion of the cartridge  200  to ensure alignment with the cartridge  200 . In some examples, the stop  104  can be formed as a portion of the housing  102 . The stop  104  extends radially from the housing  104  such that a free end of the tubular structure abuts the stop  104 . As illustrated in  FIG. 3 , the housing  102  receives the free end of the tubular structure  12  such that the cartridge  200  is inserted into the lumen  14  of the tubular structure. When correctly positioned, the free end of the tubular structure  12  abuts the stop  104 . The stop  104  ensures the placement and alignment of the ring  300 , the cartridge  200 , and the free end of the tubular structure  12 . The alignment of the ring  300 , the cartridge  200 , and the free end of the tubular structure  12  is critical to ensure adequate connection between the tubular structure  12  and another tubular structure  12 . 
     As illustrated in  FIG. 4 , after the tubular structure  12  is received by the fixation device  100  and abuts the stop  104 , the ring  300  can be positioned to abut the stop such that the ring  300  is aligned with the free end of the tubular structure  12 . 
     The stop  104  can include a plurality of alignment components  106  which correspond with alignment components  304  of the ring  300 . Accordingly, when the ring  300  is aligned and/or correctly positioned, the alignment components  106  of the stop  104  are aligned with the alignment components  304  of the ring  300 . In some examples, the alignment components  106 ,  304  can include one or more alignment markers  108 ,  304 . The alignment markers  108 ,  304  can be shaped, for example as triangles. Accordingly, to align the ring  300 , the tips of the triangles for the alignment markers  108 ,  304  can point towards one another. In some examples, the alignment components  106 ,  304  can include one or more alignment pins  110  and corresponding alignment receivers  308 . When the ring  300  is aligned, the alignment pins  100  can be received by the alignment receivers  308 . While the figures illustrate the alignment pins  100  being disposed on the fixation device  100  and the alignment receivers  308  being disposed on the ring  300 , in some examples, the alignment pins  100  may be disposed on the ring  300  and the alignment receivers can be disposed on the fixation device  100 . 
       FIG. 5  illustrates a cross-sectional view of the tubular structure  12 , the ring  300 , and the cartridge  200  aligned. In addition to ensuring the ring  300  aligns with the free end of the tubular structure  12 , the ring  300  is aligned with the cartridge  200 . When the ring  300  is properly aligned with the cartridge  200 , a plurality of receiving portions  310  of the ring  300  are aligned with the plurality of fasteners  206  of the cartridge  200 . 
     The fasteners  206  can be any suitable fastener  206  to couple the ring  300  with the tubular structure  12  and prevent movement between the ring  300  and the tubular structure  12 . For example, the fasteners  206  can include tacks  600 ,  700  (as shown in  FIGS. 6 and 7 ), staples  800  (as shown in  FIG. 8 ), pins, adhesive, internal ring, internal mesh, wire, clamp, coil, and/or suture. 
     As illustrated in  FIG. 6 , the tack  600  can include a puncturing portion  602  which is operable to puncture the tubular structure  12 . An abutment surface  603  abuts against a surface of the corresponding receiving portion  310  of the ring  300 . A body  604  spans the thickness of the wall of the tubular structure  12 , and an end  606  includes an abutment surface  608  which abuts against the inner surface of the tubular structure  12 . The abutment surfaces  603 ,  608  prevent the fastener  206  from being removed from the tubular structure  12  and the ring  300 . 
     As illustrated in  FIG. 7 , the tack  700  can include a puncturing portion  702  which is operable to puncture the tubular structure  12 . The exemplary tack  700  does not include as long of a puncturing portion  702  as the puncturing portion  602  as illustrated in  FIG. 6 . An abutment surface  703  abuts against a surface of the corresponding receiving portion  310  of the ring  300 . A body  704  spans the thickness of the wall of the tubular structure  12 , and an end  706  includes an abutment surface  708  which abuts against the inner surface of the tubular structure  12 . The abutment surfaces  703 ,  708  prevent the fastener  206  from being removed from the tubular structure  12  and the ring  300 . 
     As illustrated in  FIG. 8 , the staple  800  can include two puncturing portions  802  which are operable to puncture through the tubular structure  12  and be received in the corresponding receiving portion  310  of the ring  300 . A body  804  spans between the puncturing portions  802  and is operable to abut the inner surface of the tubular structure  12  to prevent the fastener  206  from being removed from the tubular structure  12 . In at least one example, the puncturing portions  802  may be operable to bend or deform when received in the receiving portion  310  to prevent the puncturing portions  802  from being removed from the ring  300 , ensuring coupling of the tubular structure  12  with the ring  300 . 
     Referring to  FIGS. 5 and 9 , the cartridge  200  can include a plurality of drivers  204  corresponding with the plurality of fasteners  206 . Upon actuation of the fixation device  100 , the drivers  204  activate to push the corresponding fasteners  206  radially outward from the cartridge  200 . The drivers  204  may include rods which abut the fasteners  206  and towards the center of the body  202  of the cartridge  200 . In some examples, the drivers  204  may be spring loaded. 
     The pusher rod  150 , as illustrated in  FIG. 5 , is tapered from a front portion  154  with a smaller diameter D 1  to a rear portion  152  with a larger diameter D 2  which is greater than the smaller diameter D 1 . The drivers  204  may abut the fasteners  206  on one end while extending into the cartridge  200  so that the opposing end of the fasteners  206  abut the pusher rod  150 . 
     Referring to  FIGS. 10A and 10B , the fixation device  100  is actuated. Actuation of the fixation device  100  can include translating the pusher rod  150  along the longitudinal axis through the cartridge  200  from the front portion  154  towards the rear portion  152 . The pusher rod  150 , increasing in thickness, then activates the drivers  204  to drive the fasteners  206  radially outward from the cartridge  200 , through the tubular structure  12 , and into the receiving portions  310  of the ring  300 . Once the ring  300  is coupled with the tubular structure  12 , the fixation device  100  can be removed from the tubular structure  12 . The ring  300  is then affixed or secured to the end of the tubular structure  12 , maintaining the structure of the lumen of the tubular structure  12 . 
     The fixation device  100 , the ring  300 , and/or the fasteners  206  can be made from mechanically suitable materials that are approved, and have sufficient strength, for use in the human or animal body. For example, the following materials, alone or in any combination, can be used: metals, in particular titanium or stainless steel, including the special alloys used for implants and medical instruments, nitinol, carbon materials, including carbon fiber meshes, soft plastic, for example silicone, hard plastic, for example Teflon, ceramic material, and/or bioresorbable material. The fixation device  100 , the ring  300 , and/or the fasteners  206  can be provided entirely or partially with a coating and/or structure that prevents or at least reduces the adherence of blood constituents. Such a coating can be composed of a material that smooths the surface. In at least one example, the coating can also contain anti-thrombotic medicaments (e.g. heparin). 
     The above process of coupling the ring  300  with the tubular structure  12  can be repeated for a second tubular structure  12  with a second ring  300 . For example,  FIG. 11  illustrates an exemplary male ring  350 , and  FIG. 12  illustrates an exemplary corresponding female ring  350 . Similar to the ring  300  discussed above, the male ring  350  and the female ring  360  each include an aperture  302  operable to receive a tubular structure  12 , receiving portions  310  operable to receive the fasteners  206 , and alignment portions  304 ,  308 . The male ring  350  includes a mating portion  352 , and the female ring  360  includes a corresponding mating portion  362 . The mating portion  352  is operable to couple with the mating portion  362  to couple the male ring  350  and the female ring  360  with one another. As illustrated in  FIGS. 11 and 12 , the mating portion  352  of the male ring  350  extends from the ring  350  and is operable to be received by the mating portion  362  of the female ring  360 . In some examples, the rings  300  can be coupled with one another by, for example, fastening, snapping, clamping, tacking, pinning, loop and hook, adhesive, and/or other connecting method so long as the rings  300  are securely coupled with one another. 
     As illustrated in  FIG. 13 , when the rings  350 ,  360  are coupled with one another, the lumens  14  of the two tubular structures  20 ,  22  are aligned in fluid communication with one another. In at least one example, the rings  350 ,  360  can create a seal to prevent fluid leakage. Accordingly, the anastomotic coupler  10  provides a more reliable, faster, more secure anastomotic coupling device to create a sealed, leak-proof, open connection between the ends of the tubular structures  20 ,  22  and allow for “stented” unobstructed flow of luminal contents through the connection/anastomosis (e.g. blood, lymph, fluid, stool contents, gastric contents, etc.). This connection can be strong enough to withstand tension, traction, and high flow pressure, which may occur with distal obstruction. 
     As illustrated in  FIG. 14 , a cap  1400  can be provided over the two rings  350 ,  360 . The cap  1400  can assist in ensuring the connection between the rings  350 ,  360 , as well as protecting the rings  350 ,  360  from external damage. As illustrated in  FIG. 15 , the cap  1400  can include a recess  1402  which is operable to receive the two rings  350 ,  360 . An opening  1404  can be formed such that the cap  1400  can be deformed to snap over the two rings  350 ,  360 . 
     Referring to  FIG. 16 , a flowchart is presented in accordance with an example embodiment. The method  1600  is provided by way of example, as there are a variety of ways to carry out the method. The method  1600  described below can be carried out using the configurations illustrated in  FIG. 1-15 , for example, and various elements of these figures are referenced in explaining example method  1600 . Each block shown in  FIG. 16  represents one or more processes, methods or subroutines, carried out in the example method  600 . Furthermore, the illustrated order of blocks is illustrative only and the order of the blocks can change according to the present disclosure. Additional blocks may be added or fewer blocks may be utilized, without departing from this disclosure. The example method  1600  can begin at block  1602 . 
     At block  1602 , a first tubular structure is received in an aperture of a first ring. 
     At block  1604 , a fixation device receives the first tubular structure such that a first cartridge is inserted into a lumen of the first tubular structure. 
     At block  1606 , the first ring is aligned with the first cartridge such that a plurality of receiving portions of the first ring are aligned with a plurality of fasteners of the first cartridge. 
     At block  1608 , the fixation device is actuated such that the plurality of fasteners puncture the first tubular structure radially outward from the lumen. The cartridge can include a plurality of drivers corresponding with the plurality of fasteners. Upon actuation of the fixation device, the drivers activate to push the corresponding fasteners radially outward from the cartridge. In at least one example, the fixation device can include a pusher rod. The pusher rod can be tapered from a front portion with a smaller diameter to rear portion with a larger diameter. Upon actuation of the fixation device, the pusher rod can translate along a longitudinal axis to activate the drivers. In at least one example, to activate the drivers, the pusher rod translates along the longitudinal axis and passes through the cartridge from the front portion to the rear portion such that the pusher rod abuts and pushes the drivers and the corresponding fasteners radially outward from the cartridge. 
     At block  1610 , the first tubular structure is coupled with the first ring by the receiving portions receiving the plurality of fasteners. 
     In at least one example, a second tubular structure can be received in an aperture of a second ring. A fixation device can receive the second tubular structure such that a second cartridge is inserted into a lumen of the second tubular structure. In at least one example, the fixation device may be the same fixation device that was utilized for the first ring. In some examples, the fixation device may be the same fixation device utilized for the first ring with a second cartridge that replaced the first cartridge. In some examples, the fixation device may be a second fixation device. The second ring can be aligned with the second cartridge such that a plurality of receiving portions of the second ring are aligned with a plurality of fasteners of the second cartridge. The fixation device can be actuated such that the plurality of fasteners puncture the second tubular structure radially outward from the lumen. The second tubular structure can be coupled with the second ring by the receiving portions receiving the plurality of fasteners. 
     The first ring can be aligned with the second ring such that the lumen of the first tubular structure and the lumen of the second tubular structure are aligned in fluid communication with one another. The first ring can be coupled with the second ring to join the first tubular structure with the second tubular structure, providing a continuous passage between the first tubular structure and the second tubular structure. In at least one example, a cap can be positioned about the first and the second ring to ensure the connection between the first ring and the second ring. 
     Numerous examples are provided herein to enhance understanding of the present disclosure. A specific set of statements are provided as follows. 
     Statement 1: An anastomotic coupler is disclosed comprising: a ring including a plurality of receiving portions; a fixation device including a cartridge, the cartridge including a plurality of fasteners, wherein the ring is aligned with the cartridge such that the plurality of receiving portions are aligned with the plurality of fasteners, wherein upon actuation of the fixation device, the plurality of fasteners puncture the tubular structure and are received by the receiving portions such that the tubular structure is coupled with the ring. 
     Statement 2: An anastomotic coupler is disclosed according to Statement 1, wherein the fixation device includes a stop, the stop extending radially from the housing such that a free end of the tubular structure abuts the stop. 
     Statement 3: An anastomotic coupler is disclosed according to Statement 2, wherein the stop includes a plurality of alignment components corresponding with alignment components of the ring, wherein when the ring is aligned, the alignment components of the stop are aligned with the alignment components of the ring. 
     Statement 4: An anastomotic coupler is disclosed according to any of preceding Statements 1-3, wherein the cartridge includes a plurality of drivers corresponding with the plurality of fasteners, wherein upon actuation of the fixation device, the drivers activate to push the corresponding fasteners from the cartridge. 
     Statement 5: An anastomotic coupler is disclosed according to Statement 4, wherein the fixation device includes a pusher rod, wherein upon actuation of the fixation device, the pusher rod translates along a longitudinal axis to activate the drivers. 
     Statement 6: An anastomotic coupler is disclosed according to Statement 5, wherein the pusher rod is tapered from a front portion with a smaller diameter to a rear portion with a larger diameter. 
     Statement 7: An anastomotic coupler is disclosed according to any of preceding Statements 1-6, wherein the plurality of fasteners include tacks, staples, pins, adhesive, internal ring, internal mesh, wire, clamp, coil, and/or suture. 
     Statement 8: A system is disclosed comprising: a first ring including a plurality of receiving portions; a second ring including a plurality of receiving portions; a fixation device including a cartridge, the cartridge including a plurality of fasteners, wherein the first and/or second ring is aligned with the cartridge such that the corresponding plurality of receiving portions are aligned with the plurality of fasteners, wherein upon actuation of the fixation device, the plurality of fasteners puncture a first tubular structure and/or a second tubular structure and are received by the receiving portions such that the first tubular structure is coupled with the first ring and the second tubular structure are joined such that a lumen of the first tubular structure and a lumen of the second tubular structure are aligned in fluid communication with one another. 
     Statement 9: A system is disclosed according to Statement 8, wherein the first ring and the second ring create a seal to prevent fluid leakage. 
     Statement 10: A system is disclosed according to Statements 8 or 9, wherein the cartridge includes a plurality of drivers corresponding with the plurality of fasteners, wherein upon actuation of the fixation device, the drivers activate to push the corresponding fasteners from the cartridge. 
     Statement 11: A system is disclosed according to Statement 10, wherein the fixation device includes a pusher rod, wherein upon actuation of the fixation device, the pusher rod translates along a longitudinal axis to activate the drivers. 
     Statement 12: A system is disclosed according to Statement 11, wherein the pusher rod is tapered from a front portion with a smaller diameter to a rear portion with a larger diameter. 
     Statement 13: A system is disclosed according to any of preceding Statements 8-12, wherein the plurality of fasteners include tacks, staples, pins, adhesive, internal ring, internal mesh, wire, clamp, coil, and/or suture. 
     Statement 14: A method is disclosed comprising: aligning a ring with a cartridge such that a plurality of receiving portions of the ring are aligned with a plurality of fasteners of the cartridge; actuating a fixation device such that the plurality of fasteners puncture a tubular structure; and coupling the tubular structure with the ring by the receiving portions receiving the plurality of fasteners. 
     Statement 15: A method is disclosed according to Statement 14, further comprising: aligning a second ring with a second cartridge such that a plurality of receiving portions of the second ring are aligned with a plurality of fasteners of the second cartridge; actuating a fixation device such that the plurality of fasteners puncture a second tubular structure; and coupling the second tubular structure with the second ring by the receiving portions receiving the plurality of fasteners. 
     Statement 16: A method is disclosed according to Statement 15, further comprising: aligning the ring with the second ring such that a lumen of the first tubular structure and a lumen of the second tubular structure are aligned in fluid communication with one another; and coupling the ring with the second ring to join the tubular structure with the second tubular structure. 
     Statement 17: A method is disclosed according to any of preceding Statements 14-16, wherein the cartridge includes a plurality of drivers corresponding with the plurality of fasteners, wherein upon actuation of the fixation device, the drivers activate to push the corresponding fasteners from the cartridge. 
     Statement 18: A method is disclosed according to Statement 17, wherein the fixation device includes a pusher rod; wherein the pusher rod is tapered from a front portion with a smaller diameter to rear portion with a larger diameter; wherein upon actuation of the fixation device, the pusher rod translates along a longitudinal axis to activate the drivers. 
     The disclosures shown and described above are only examples. Even though numerous properties and advantages of the present technology have been set forth in the foregoing description, together with details of the structure and function of the present disclosure, the disclosure is illustrative only, and changes may be made in the detail, especially in matters of shape, size and arrangement of the parts within the principles of the present disclosure to the full extent indicated by the broad general meaning of the terms used in the attached claims. It will therefore be appreciated that the examples described above may be modified within the scope of the appended claims.