Abstract:
Endovascular fastener applicator for endoluminally fastening prosthetic grafts to vessels, are provided. The endovascular fastener applicator includes a delivery assembly configured for positioning within a vessel, and a control assembly mounted to a proximal end of the outer sheath for extracorporeal control of the delivery assembly. The delivery assembly includes an expandable portion disposed adjacent a distal end of an outer sheath and being expandable to support a prosthetic in contact with an inner surface of a vessel; a yoke assembly disposed within the expandable portion; an applicator head assembly pivotably mounted to the yoke assembly and movable between a loading position longitudinally aligned with the yoke assembly, and a firing position oriented substantially perpendicular to the yoke assembly; and a fastener assembly connectable to a distal end of the expandable portion, the fastener assembly retaining at least one fastener therein.

Description:
CROSS-REFERENCE TO RELATED APPLICATIONS  
       [0001]     The present application is a continuation-in-part application which claims benefit of and priority to U.S. patent application Ser. No. 10/053,889, filed on Oct. 23, 2001 which claims the benefit of and priority to International Application No. PCT/US00/10921 filed on Apr. 21, 2000 which in turn claims the benefit of and priority to U.S. Provisional Application Ser. No. 60/130,922 filed Apr. 23, 1999, the entire contents of each of which are hereby incorporated in their entirety by reference. 
     
    
     BACKGROUND  
       [0002]     1. Technical Field  
         [0003]     This disclosure relates generally to vascular grafts for intraluminal delivery, and in particular, to apparatus and methods for repairing diseased or damaged sections of a vessel by fastening a prosthesis within the vessel.  
         [0004]     2. Description of Related Art  
         [0005]     Diseased or damaged blood vessels often cause weakening of the vessel wall resulting in an aneurysm whereby a blood vessel and especially an artery have a section of abnormal blood-filled dilation. For example, an abdominal aortic aneurysm is a sac caused by an abnormal dilation of the wall of the aorta, a major artery of the body, as it passes through the abdomen.  
         [0006]     The abdominal aortic aneurysm usually arises in the infrarenal portion of the arteriosclerotically diseased aorta, for example, below the kidneys. Left untreated, the aneurysm will eventually cause nipture of the sac with ensuing fatal hemorrhaging in a very short time. High mortality associated with rupturing led the state of the art into trans-abdominal surgical repair of abdominal aortic aneurysms.  
         [0007]     Surgery involving the abdominal wall, however, is a major undertaking with associated high risks. This type of surgery, in essence, involves replacing the diseased and aneurismal segment of blood vessel with a prosthetic device which typically is a synthetic tube, or graft, usually fabricated of either DACRON® polyester, TEFLON® fluoropolymer resin available from E.I. du Pont de Nemours and Company, or other suitable material.  
         [0008]     The present state of the art for intraluminal repair of a vessel does not fasten a prosthesis to the remaining aortic wall. For example, U.S. Pat. Nos. 5,571,171 and 5,571,173 disclose a method and apparatus for treating an abdominal aortic aneurysm by supplying a prosthesis or an aortic graft for intraluminal delivery that does not fasten the graft to the remaining aortic wall.  
         [0009]     Presenting an aortic graft through the aorta by intraluminal delivery avoids major invasive surgery. The &#39;171 and &#39;173 patents disclose an aortic graft that is delivered intraluminally to the aneurysm site. The aortic graft is secured to the remaining aortic wall by a balloon that is inflated thereby causing the graft to contact and adhere to the remaining aortic wall.  
         [0010]     The major disadvantages related to the combination of endovascular expanders, such as a balloon or stent, and prosthesis is the dilation of the natural artery with consequent migrations and periprosthetic losses. Upon withdrawal of the expander, the tissue is caused to collapse and the prosthesis disengages from the remaining aortic wall and tends to migrate to a location away from the aneurysm site to be repaired. The migration and movement of the disengaged aortic graft would then obstruct the affected vessel. The migration and movement of the aortic graft requires further treatment on the patient to remove the failed attempt to attach the aortic graft to the remaining aortic wall.  
         [0011]     Further treatment may include major surgery that is hazardous and traumatic to the patient. Major surgery to remove the aortic graft defeats the benefits of intraluminal delivery of the aortic graft. The current state of the art does not disclose a fastener applicator that intraluminally delivers a vascular graft and endoluminally applies internal fasteners to fasten a prosthesis in place.  
         [0012]     Accordingly, there is a present need for a fastener applicator that intraluminally delivers a vascular graft to a site within a vessel and applies fasteners to pass through both a prosthesis and the thickness of a vessel wall. The fastened prosthesis should also have the capability of following dilation of a vessel.  
       SUMMARY  
       [0013]     According to an aspect of the present disclosure, an endovascular fastener applicator for endoluminally fastening a prosthetic graft to a vessel with at least one fastener, is provided. The endovascular fastener applicator includes a delivery assembly configured for positioning within a vessel, and a control assembly mounted to a proximal end of the outer sheath for extracorporeal control of the delivery assembly. The delivery assembly includes an expandable portion disposed adjacent a distal end of an outer sheath and being expandable to support a prosthetic in contact with an inner surface of a vessel; a yoke assembly disposed within the expandable portion; an applicator head assembly pivotably mounted to the yoke assembly and movable between a loading position longitudinally aligned with the yoke assembly, and a firing position oriented off axis to the yoke assembly; and a fastener assembly positioned at a distal end of the expandable portion, wherein the fastener assembly retaining at least one fastener therein.  
         [0014]     The control assembly has a first knob to expand the expandable portion. The control assembly also includes a second knob to pivot the applicator head assembly from the loading position to the firing position. The control assembly further includes a third knob to rotate the applicator head assembly about a longitudinal axis of the outer sheath. Desirably, the second knob of the control assembly withdraws a fastener out of the fastener assembly and drives the fastener into tissue. It is envisioned that the fastener is a helical coil fastener.  
         [0015]     According to another aspect of the present disclosure, an endovascular fastener applicator for endoluminally fastening a prosthetic graft to a vessel with at least one fastener is provided. The endovascular fastener applicator includes an outer sheath; a delivery assembly for delivering a graft to a site within a vessel and for fastening a prosthetic graft to a vessel by passing a fastener therethrough; and a control assembly mounted to a proximal end of the outer sheath for extracorporeal control of the delivery assembly.  
         [0016]     The delivery assembly includes an expandable portion disposed adjacent a distal end of the outer sheath and deployable to support a prosthetic in contact with an inner surface of a vessel; a drive assembly operatively disposed within the expandable portion; and a fastener assembly positioned at a distal end of the expandable portion, wherein the fastener assembly retaining at least one fastener therein.  
         [0017]     The drive assembly includes a yoke assembly for guiding and supporting an applicator head assembly; and an applicator head assembly pivotably mounted to the yoke assembly and movable between a loading position longitudinally aligned with the yoke assembly, and a firing position oriented substantially perpendicular to the yoke assembly.  
         [0018]     The fastener assembly includes a body portion; a central shaft rotatably disposed within the body portion; and a coil disposed between the body portion and the central shaft configured to operatively engage a coil of a helical fastener. The central shaft defines an elongate slot extending along the length thereof for receiving a tang of a helical fastener therein, the central shaft defining a recess formed in a proximal end thereof for selectively receiving a distal end of a drive shaft therein.  
         [0019]     The expandable portion includes a proximal hub and a distal hub; and a plurality of support members extending between and inter-connecting the proximal and distal hubs. The expandable portion having a un-expanded condition wherein the proximal and distal hubs are in relative spaced relation to one another and the support members in relative close proximity to one another, and an expanded condition wherein the proximal and distal hubs are in relative close proximity to one another and the support members radially expand to define interstitial regions therebetween.  
         [0020]     The drive assembly is rotatable relative to the expandable portion. The applicator head assembly is pivotable between an orientation axially aligned with a longitudinal axis of the yoke assembly and an orientation perpendicular to the longitudinal axis of the yoke assembly.  
         [0021]     In one embodiment, the yoke assembly includes a body portion having a pair of elongate slots formed on either side thereof, the applicator head assembly being operatively disposed within the body portion of the yoke assembly; a pivot pin extending through the body portion and the applicator head assembly, at a location adjacent to the elongate slots; and a clevis operatively disposed within the body portion of the yoke assembly.  
         [0022]     The clevis includes a pair of spaced apart arms; and a cam pin extending from each arm of the clevis and slidably engaging a respective elongate slot of the body portion. Each cam pin slidably engaging a cam slot formed in the applicator head assembly.  
         [0023]     The yoke assembly further includes a driver operatively connected to the clevis; and a pusher operatively engaged with the base portion of the clevis and including a body portion defining a lumen configured to receive the elongate body portion of the driver. The drive may include a coupling member configured to selectively engage a shaped end of the drive screw and a shaped end of a second bevel gear; and an elongate body portion extending from the coupling member and extending through an aperture formed in a base portion of the clevis.  
         [0024]     The applicator head assembly includes a housing defining a cam slot formed on either side thereof, each cam slot being configured to receive a respective can pin of the yoke assembly; and a drive train operatively disposed in the housing. Each cam slot includes a first portion substantially aligned with a longitudinal axis of the housing; and a second portion substantially perpendicular to the longitudinal axis of the housing.  
         [0025]     The drive train of the applicator head assembly includes a drive shaft having a distal end configured to selectively receive a tang of a helical fastener, and a non-circular transverse cross-sectional profile; and a drive screw slidably disposed on a proximal end portion of the drive shaft. The drive screw includes a helical thread configured to engage threads formed in the housing, and a shaped proximal end configured to selectively engage the coupling member of the driver of the yoke assembly when the applicator head assembly is in the loading position.  
         [0026]     The drive train further includes a beveled gear system. The beveled gear system includes a first beveled gear co-axially aligned with and slidably supported on the drive shaft of the drive train; a gear support box slidably and rotatably supported on the drive shaft and including a stub extending therefrom; and a second beveled gear rotatably supported on the stub of the gear support box and operatively engaged with the first beveled gear. The first beveled gear includes a shaped central lumen configured to complement the cross-sectional profile of the drive shaft of the drive train. The second beveled gear includes a shaped end configured to selectively engage the coupling member of the driver of the yoke assembly when the applicator head assembly in is the firing position.  
         [0027]     The applicator head assembly includes an ejection head operatively positioned on a distal end portion of the drive shaft, the ejection head includes a central lumen defining a helical thread formed at a distal end thereof and a recess formed in a proximal edge thereof; and an ejection head stop operatively positioned within the ejection head and supported on the distal end portion of the drive shaft. The ejection head stop includes a key extending therefrom and configured for engagement in the recess formed in the proximal edge of the ejection head and a slot formed in the housing of the applicator assembly.  
         [0028]     The ejection head includes a saw-toothed distal end face for gripping and engaging a prosthetic graft. The applicator head assembly includes a coil spring supported on the drive shaft and positioned between the drive screw and the gear support box, wherein the coil spring biases the drive shaft to a proximal-most position. The pivot pin fixes the axial location of the gear support box relative to the housing.  
         [0029]     The control assembly includes a housing for supporting an expandable portion controller and a drive assembly controller; an expandable portion controller configured to manipulate the expandable portion between the un-expanded condition and the expanded condition; and a drive assembly controller configured to manipulate the applicator head assembly between loading position and the firing position, and to rotate the applicator head assembly about a longitudinal axis of the yoke assembly.  
         [0030]     The expandable portion controller includes a knob rotatably supported in the housing thereof; a spool in threaded engagement with the knob; an outer sheath having a distal end fixedly secured to the proximal hub of the expandable portion, and a proximal end fixedly secured to the spool; a flange fixedly supported in the housing of the control assembly; and a first inner tube extending through the spool and through the outer sheath. The first inner tube has a proximal end fixedly secured to the flange, and a distal end secured to the body portion of the yoke assembly. Accordingly, as the knob is rotated relative to spool, the spool axially translates through the knob causing outer sheath to displace relative to the first inner tube thereby manipulating the expandable portion between the un-expanded condition and the expanded condition.  
         [0031]     The drive assembly controller includes a knob rotatably supported in the housing of the control assembly; and a second inner tube extending through the first inner tube. The second inner tube includes a proximal end fixedly secured to the knob of the drive assembly controller, and a distal end operatively connected to the body portion of the pusher of the yoke assembly. Accordingly, rotation of the knob of the drive assembly controller manipulates the applicator head assembly between the loading position and the firing position.  
         [0032]     The drive assembly controller further includes a drive handle rotatably and translatably supported on the hosing of the control assembly; and a drive shaft extending through the second inner tube and the body portion of the pusher. The drive shaft includes a proximal end fixedly connected to the drive handle and a distal end fixedly connected to the body portion of the driver of the yoke assembly. Accordingly, as drive handle is translated relative to the housing of the control assembly the driver of concomitantly translated to selectively engage and disengage the coupling member of the driver with the shaped proximal end of the drive screw and the shaped end of the second bevel gear. Additionally, when the coupling member is engaged with the shaped proximal end of the drive screw or the shaped end of the second bevel gear, rotation of the drive handle results in rotation of the drive screw or the second bevel gear, respectively. It is envisioned that rotation of the drive screw or the second bevel gear results in rotation of the drive shaft.  
         [0033]     The fastener applicator may further include a cap operatively connectable to a distal end of the fastener cartridge assembly. The cap includes a lumen having a distal end extending through a distal end of the cap and a proximal end extending through a side of the cap. It is envisioned that the lumen is configured and dimensioned to slidably receive a guide wire.  
         [0034]     According to another aspect of the present disclosure, a method of endoluminally fastening a prosthetic graft to a vessel, is provided. The method includes the steps of providing an endovascular fastener applicator for endoluminally fastening the prosthetic graft to a vessel at the aneurysm site. The endovascular fastener applicator includes a delivery assembly configured for positioning within a vessel. The delivery assembly includes an expandable portion disposed adjacent a distal end of an outer sheath and being expandable to support the prosthetic graft in contact with an inner surface of the vessel; a yoke assembly disposed within the expandable portion; an applicator head assembly pivotably mounted to the yoke assembly and movable between a loading position longitudinally aligned with the yoke assembly, and a firing position oriented substantially perpendicular to the yoke assembly; and a fastener assembly positioned at a distal end of the expandable portion. The fastener assembly retains at least one fastener therein for loading onto the applicator head assembly when the applicator head assembly is in the longitudinally aligned position. The fastener applicator further includes a control assembly mounted to a proximal end of the outer sheath for extracorporeal control of the delivery assembly.  
         [0035]     The method further includes the steps of positioning a prosthetic graft at an aneurysm site; positioning the delivery assembly at the aneurysm site; radially expanding the expandable portion against an inner surface of the prosthetic graft to thereby maintain the prosthetic graft in position at the aneurysm site; connecting the applicator head assembly to the fastener assembly; transferring a helical fastener from the fastener assembly to the applicator head assembly; disconnecting the applicator head assembly from the fastener cartridge assembly; pivoting the applicator head assembly from the loading position to the firing position; and firing the applicator head assembly and driving the helical fastener loaded thereon into the prosthetic graft. 
     
    
     BRIEF DESCRIPTION OF THE-DRAWINGS  
       [0036]     Various embodiments are described herein with reference to the drawings, wherein.  
         [0037]      FIG. 1  is a perspective view of an endovascular fastener applicator in accordance with an embodiment of the present disclosure with a delivery assembly in an extended condition;  
         [0038]      FIG. 2  is a perspective view of the endovascular fastener applicator of  FIG. 1  with the delivery assembly in a bent condition;  
         [0039]      FIG. 3  is a cross-sectional view, in part elevation, of an aortic graft placed at the site of an abdominal aortic aneurysm within the aorta;  
         [0040]      FIG. 4  is an enlarged detail view of a portion of  FIG. 3  illustrating the aortic graft in partial cut-away secured to the remaining aortic wall and maintained in position by helical fasteners;  
         [0041]      FIG. 5  is a cross-sectional view, in part elevation, of an aortic graft for treating an aortic aneurysm affecting the aorta and both ileac arteries;  
         [0042]      FIG. 6  is a perspective view, with parts separated, of a fastener cartridge assembly and drive assembly of the endovascular fastener applicator of  FIGS. 1 and 2 ;  
         [0043]      FIG. 7  is a perspective view of a driver of the drive assembly of  FIG. 6 ;  
         [0044]      FIG. 8  is an end, perspective view of a pusher of the drive assembly of  FIG. 6 ;  
         [0045]      FIG. 9  is a perspective view, with parts separated, of the fastener cartridge assembly of  FIG. 6 ;  
         [0046]      FIG. 10  is an enlarged end view of a central shaft of the fastener cartridge assembly of  FIG. 9  with a coil fastener shown operatively disposed thereon;  
         [0047]      FIG. 11  is a perspective view of the coil fastener shown in  FIG. 10 ;  
         [0048]      FIG. 12  is a perspective view of an expandable portion of the drive assembly of  FIG. 6 ;  
         [0049]      FIG. 13  is a perspective view, with parts separated, of the expandable portion of  FIG. 12 ;  
         [0050]      FIG. 14  is a further perspective view, with parts separated, of the expandable portion of  FIGS. 12 and 13 ;  
         [0051]      FIG. 15  is a perspective view of a yoke assembly of the drive assembly of  FIG. 6 ;  
         [0052]      FIG. 16  is a perspective view, with parts separated, of an arm of the yoke assembly of  FIG. 6 ;  
         [0053]      FIG. 17  is a perspective view of the arm of  FIG. 16 ;  
         [0054]      FIG. 18  is a bottom perspective view of the yoke assembly of  FIG. 15  with an applicator head assembly, according to the present disclosure, operatively associated therewith;  
         [0055]      FIG. 19  is a top, front perspective view of the yoke assembly and applicator head assembly of  FIG. 18 ;  
         [0056]      FIG. 20  is a top, rear perspective view of the yoke assembly and applicator head assembly of  FIGS. 18 and 19   
         [0057]      FIG. 21  is a top, rear perspective view of the applicator head assembly of the present disclosure;  
         [0058]      FIG. 22  is a bottom, front perspective view of the applicator head assembly of  FIG. 21 ;  
         [0059]      FIG. 23  is a top, rear perspective view of the applicator head assembly of  FIGS. 21 and 22 , with the housing removed therefrom;  
         [0060]      FIG. 24  is a bottom, front perspective view of the applicator head assembly of  FIGS. 21 and 22 , with the housing removed therefrom;  
         [0061]      FIG. 25  is a longitudinal cross-sectional view of the applicator head assembly of  FIG. 23  as taken through  25 - 25 ;  
         [0062]      FIG. 26  is a longitudinal cross-sectional view of the applicator head assembly of  FIG. 21  as taken through  26 - 26 ;  
         [0063]      FIG. 27  is a top, rear perspective view, with parts separated, of the applicator head assembly of  FIGS. 21-26 ;  
         [0064]      FIG. 28  is a perspective view of a drive shaft of the applicator head assembly of  FIG. 27 ;  
         [0065]      FIG. 29  is a top, rear perspective view, of a control assembly according to the present disclosure, with a half-section removed therefrom;  
         [0066]      FIG. 30  is a top, front perspective view, of the control assembly as shown in  FIG. 29 ;  
         [0067]      FIG. 31  is a cross-sectional view of the elongated tube of the fastener applicator, as taken through  31 - 31  of  FIG. 2 ;  
         [0068]      FIG. 32  is a perspective view, with parts separated, of the control assembly of  FIGS. 29 and 30 ;  
         [0069]      FIG. 33  is a longitudinal cross-sectional view of the fastener applicator of  FIG. 1 , as taken through  33 - 33  of  FIG. 1 ;  
         [0070]      FIG. 34  is a longitudinal cross-sectional view of the fastener applicator of  FIG. 1 , as taken through  34 - 34  of  FIG. 1 ;  
         [0071]      FIG. 35  is an enlarged view of the area indicated as  35  of  FIG. 33 ;  
         [0072]      FIG. 36  is an enlarged view of the area indicated as  36  of  FIG. 34 ;  
         [0073]      FIG. 37  is an enlarged view of the area indicated as  37  of  FIG. 33 ;  
         [0074]      FIG. 38  is an enlarged view of the area indicated as  38  of  FIG. 34 ;  
         [0075]      FIG. 39  is an enlarged view of the area indicated as  39  of  FIG. 37 ;  
         [0076]      FIG. 40  is an enlarged view of the area indicated as  40  of  FIG. 38 ;  
         [0077]      FIG. 41  is an enlarged view of the area indicated as  41  of  FIG. 33 ;  
         [0078]      FIG. 42  is an enlarged view of the area indicated as  42  of  FIG. 34 ;  
         [0079]      FIG. 43  is a cross-sectional view, in part elevation, of the abdominal aortic aneurysm of  FIG. 3 , with an aortic graft placed at therein and with the distal end of the fastener applicator of  FIGS. 1 and 2  operatively disposed therethrough such that the expandable portion is radially aligned with a reinforcing band of the aortic band;  
         [0080]      FIG. 44  is a cross-sectional view of the control assembly of  FIGS. 29 and 30 , illustrating the operation thereof to expand the expandable portion of the fastener applicator;  
         [0081]      FIG. 45  is an enlarged view of the expandable portion of the fastener applicator, in an expanded position, against the inner wall of the aortic graft;  
         [0082]      FIG. 46  is a cross-sectional view of the control assembly of  FIGS. 29 and 30 , illustrating the operation thereof to engage the applicator head assembly with the fastener cartridge assembly;  
         [0083]      FIG. 47  is a cross-sectional view of the applicator head assembly and the fastener cartridge assembly, illustrating operative engagement thereof;  
         [0084]      FIG. 48  is an enlarged view of the area indicated as  48  of  FIG. 47 , rotated 90° about the longitudinal axis;  
         [0085]      FIG. 49  is a perspective view illustrating the coupling of the drive shaft of the applicator head assembly to the central shaft of the fastener cartridge assembly;  
         [0086]      FIG. 50  is a perspective view illustrating the drive shaft of the applicator head assembly coupled to the central shaft of the fastener cartridge assembly;  
         [0087]      FIG. 51  is a cross-sectional view of the control assembly of  FIGS. 29 and 30 , illustrating the operation thereof to load the applicator head assembly with a fastener from the fastener cartridge assembly;  
         [0088]      FIG. 52  is a cross-sectional view of the applicator head assembly and the fastener cartridge assembly, illustrating the loading of the fastener on to the applicator head assembly from the fastener cartridge assembly;  
         [0089]      FIG. 53  is a cross-sectional view of the control assembly of  FIGS. 29 and 30 , illustrating the operation thereof to disengage the applicator head assembly from the fastener cartridge assembly;  
         [0090]      FIG. 54  is a cross-sectional view of the applicator head assembly and the fastener cartridge assembly, illustrating the disengagement of the applicator head assembly from the fastener cartridge assembly;  
         [0091]      FIG. 55  is a cross-sectional view of the control assembly, as taken through  55 - 55  of  FIG. 2 , illustrating a safety lock-out in a first position;  
         [0092]      FIG. 56  is a cross-sectional view of the control assembly, as taken through  55 - 55  of  FIG. 2 , illustrating the safety lock-out in a second position;  
         [0093]      FIG. 57  is a cross-sectional view of the control assembly of  FIGS. 29 and 30 , illustrating the movement of the safety lock-out from the first position to the second position and the operation of the control assembly to tilt the applicator head assembly from a first, substantially axially aligned position, to a second, rotated position;  
         [0094]      FIGS. 58-60  are schematic side elevational views of applicator head assembly illustrating the pivoting of the applicator head assembly from the first position to the second position;  
         [0095]      FIG. 61  is a cross-sectional view of the control assembly of  FIGS. 29 and 30 , illustrating the operation thereof to engage the driver with the applicator head assembly in the second position and to the expel the fastener therefrom;  
         [0096]      FIG. 62  is a cross-sectional view of the applicator head assembly, illustrating the expelling of the fastener from the applicator head assembly and into the aortic graft and aortic wall;  
         [0097]      FIG. 63  is a cross-sectional view of the distal end of the applicator head assembly, illustrating the driving of the fastener loaded thereon into the aortic graft and the aortic wall;  
         [0098]      FIG. 64  is a cross-sectional view of the applicator head assembly illustrating disengagement of the applicator head assembly from the surface of the aortic graft;  
         [0099]      FIGS. 65-67  are side elevational views of a rotation knob of control assembly, illustrating the operation thereof to rotating the applicator head assembly about the longitudinal axis;  
         [0100]      FIG. 68  is a top view of the expandable portion in the expanded position and the applicator head assembly in the second position, illustrating the rotation of the applicator head assembly, about the longitudinal axis relative to the expandable portion;  
         [0101]      FIG. 69  is a top, rear perspective view of an applicator head assembly according to an alternate embodiment of the present disclosure;  
         [0102]      FIG. 70  is a bottom, front perspective view of the applicator head assembly of  FIG. 69 ; and  
         [0103]      FIGS. 71-76  are schematic side elevational views illustrating the pivoting of the applicator head assembly of  FIGS. 69 and 70  from the first position to the second position.  
     
    
     DETAILED DESCRIPTION OF EMBODIMENTS  
       [0104]     As illustrated in  FIGS. 1 and 2 , the present disclosure relates to an endovascular fastener applicator, generally referred to as  100 . Endovascular fastener applicator  100  includes a delivery assembly  110  and a control assembly  120  operatively connected to delivery assembly  110  by an elongate body portion  108 . Endovascular fastener applicator  100  delivers an aortic graft  50 , as shown in  FIGS. 3-5 , for repairing an abdominal aortic aneurysm  60  in aorta  70  having two iliac arteries  70 L and  70 R associated therewith, as well as a plurality of renal arteries  80  located above aneurysm  60  in fluid communication with aorta  70 . Repairing aneurysm  60  includes fastening aortic graft  50  to aortic wall  72  using fasteners  90  (see  FIGS. 9-11 ). Aortic graft  50 , as well as other prosthesis, may be utilized in the thoracic aorta, and can be used to repair thoracic aneurysms or thoracic dissecting aneurysms. Further, fastener applicator  100  may also treat vascular trauma and other obstructive diseases with various prosthesis. Accordingly, use of the term aortic aneurysm in the specification and claims is intended to relate to and mean both abdominal aortic aneurysms, thoracic aneurysms and related vessel diseases. Delivery assembly  110  includes a drive assembly  130 , an expandable portion  140  operatively connected to drive assembly  130 , a fastener cartridge assembly  150  operatively connected to a distal end of drive assembly  130  and expandable portion  140 , and a cap  102  operatively connectable to a distal end of fastener cartridge assembly  150 .  
         [0105]     With reference to  FIGS. 1, 2 ,  6 ,  9 ,  35  and  36 , cap  102  includes an elongate body portion  102   a,  an atraumatic distal end  102   b  and a proximal end portion  102   c  including connecting means  102   d  (e.g., threads, bayonet-like connecting elements, etc.) for connecting cap  102  to fastener cartridge assembly  150 . As seen in  FIGS. 35-36 , cap  102  further includes a lumen  102   e  including a first portion  102   f  axially aligned with and extending distally from distal end  102   b  and a second portion  102   g  extending transversely through body portion  102   a,  e.g., oriented at an angle toward proximal end portion  102   c.  In use, a guide wire “G” (see  FIGS. 35 and 43 ) may be fed through first and second portions  102   f,    102   g  of lumen  102   e  and used to guide endovascular fastener  100  through arteries  70 L or  70 R and/or aorta  70  to aneurysm  60 .  
         [0106]     With reference to  FIGS. 6 and 9 - 11 , fastener cartridge assembly  150  includes a body portion  152  having a distal end portion  152   a  configured to engage connecting means  102   d  of cap  102 , and a proximal end portion  152   b  configured to engage the distal end of drive assembly  130  and expandable portion  140 . Fastener cartridge assembly  150  further includes a central shaft  154  rotatably disposed within body portion  152 . Central shaft  154  defines an elongate slot  154   a  configured to receive a penetration limit end of tang  92  of helical fastener  90  as seen in  FIG. 10 . Central shaft  154  further includes a recess  154   b  formed at a proximal end thereof (see  FIG. 10 ). Recess  154   b  is configured to receive a distal end portion  163   a  of drive shaft  163 , as seen in  FIGS. 47 and 48 , as will be described in greater detail below.  
         [0107]     Fastener cartridge assembly  150  further includes a coil  156  disposed between body portion  152  and central shaft  154 . Coil  156  operatively engages helical fasteners  90  such that rotation of central shaft  154  results in axial displacement of helical fasteners  90  in a proximal or a distal direction. Accordingly, as central shaft  154  is rotated helical fasteners  90  are deployed from fastener cartridge assembly  150 .  
         [0108]     With reference to  FIGS. 1, 2 ,  6  and  12 - 14 , expandable portion  140  includes a proximal hub  142   a  and a distal hub  142   b  ( FIG. 13 ) interconnected by a plurality of support members  144  extending therebetween. Each hub  142   a,    142   b  includes a series of grooves  146  formed radially therearound for engaging and/or receiving a tongue  148  formed at each end of support members  144 . Expandable portion  140  further includes a proximal locking collar  149   a  and a distal locking collar  149   b.  Locking collars  149   a,    149   b  are each configured and dimensioned to surround a respective hub  142   a,    142   b  and maintain support members  144  in operative engagement therewith.  
         [0109]     With reference to  FIGS. 6 and 15 - 28 , drive assembly  130  includes a yoke assembly  160  (see  FIGS. 6 and 15 - 20 ) and an applicator head assembly  170  (see  FIGS. 6 and 21 - 28 ) operatively supported on yoke assembly  160 . Yoke assembly  160  is operatively engaged with fastener cartridge assembly  150  and operatively disposed within expandable portion  140 . Applicator head assembly  170  is pivotally supported within yoke assembly  160  via a pivot pin  159  extending through body portion  161  of yoke assembly  160  and housing  172  of applicator head assembly  170 .  
         [0110]     Drive assembly  130  is capable of rotational movement relative to expandable portion  140  while applicator head assembly  170  is capable of pivotal movement between two extreme positions, a first extreme position in which applicator head assembly  170  is coaxially aligned along a longitudinal axis of yoke assembly  160  to load a helical fastener  90  thereon (see for instance  FIG. 58 ), and a second extreme position in which applicator head assembly  170  is perpendicular to the longitudinal axis of yoke assembly  160  (see for instance  FIG. 60 ) to deploy a helical fastener  90  therefrom.  
         [0111]     Yoke assembly  160  includes a body portion  161  having a pair of elongate slots  160   a  formed on either side thereof. Elongate slots  160   a  extend in a longitudinal direction with respect to body portion  161 . Pivot pin  159  extends through body portion  161  at a location adjacent to elongate slots  160   a.  Yoke assembly  160  further includes a clevis  162  operatively disposed within body portion  161 . Clevis  162  includes a pair of arms  162   a  each having a cam pin  164  extending therethrough. A first half-portion  164   a  of each cam pin  164  is configured to slidably engage a respective elongate slot  160   a  of body portion  161 . A second half-portion  164   b  of each cam pin  164  is configured to slidably engage a cam slot  176  (see  FIGS. 21, 22  and  27 ) formed in applicator head assembly  170 , as will be described in greater detail below.  
         [0112]     As seen in  FIGS. 6, 7 ,  15 ,  18 - 20 ,  37  and  38 , yoke assembly  160  further includes a driver  166  including a coupling member  166   a  configured to selectively engage a shaped proximal end  178   c  (see  FIGS. 19, 21  and  23 - 27 ) of drive screw  178  and a shaped end  182   d  (see  FIGS. 18 and 24 - 27 ) of second bevel gear  182 . Driver  166  further includes an elongate body portion  166   b  connected to coupling member  166   a  and extending through an aperture formed in base portion  162   b,  between arms  162   a,  of clevis  162  and into a lumen  168   b  of pusher  168  (see  FIG. 6 ), as will be described below.  
         [0113]     As seen in  FIGS. 6, 8 ,  37  and  38 , yoke assembly  160  further includes a pusher  168  including a body portion  168   a  defining a lumen  168   b  therethrough, and a flange  168   c  formed about a distal end of body portion  168   a.  As seen in  FIG. 6 , the distal end of body portion  168   a  of pusher  168  operatively engages the aperture formed in base portion  162   b  of clevis  162  such that flange  168   c  engages base portion  162   b  of clevis  162 . As such, lumen  168   b  is aligned with the aperture of clevis  162 . Lumen  168   b  is configured to slidably and rotatably receive body portion  166   b  of driver  166  therein.  
         [0114]     In an embodiment, as seen in  FIGS. 6 and 18 - 28 , applicator head assembly  170  includes a housing  172  (see  FIGS. 21 and 22 ) and a drive train  174  (see  FIGS. 23 and 24 ) operatively disposed within housing  172 . Housing  172  includes a cam slot  176  (see  FIGS. 21 and 22 ) formed on either side thereof. As seen in  FIGS. 21 and 22 , each cam slot  176  includes a first portion  176   a  substantially aligned with a longitudinal axis of housing  172 , and a second portion  176   b  substantially perpendicular to the longitudinal axis of housing  172 . Each of cam slots  176  is configured and dimensioned to slidably receive a respective second-half portion  164   b  of cam pins  164  therein (see for instance  FIG. 6 ).  
         [0115]     Turning again to  FIGS. 23 and 24 , drive train  174  includes a drive shaft  163  having a distal end portion  163   a  and a proximal end portion  163   b.  Distal end portion  163   a  is provided with a slot  163   c  (see  FIG. 27 ) extending therefrom and configured to receive penetration limit end of tang  92  of a helical fastener  90  therein (not shown). Drive shaft  163  has a non-circular transverse cross-section defined by a flattened region  163   d  extending substantially along a length thereof. Drive train  174  further includes a drive screw  178  operatively attached to, e.g., slidably disposed on, proximal end portion  163   b  of drive shaft  163 . Turning to  FIG. 25 , drive screw  178  includes a helical thread  178   a,  a passage  178   b  (see  FIG. 27 ) extending therethrough for receiving proximal end portion  163   b  of drive shaft  163  therein, and a shaped proximal end  178   c  configured to selectively engage coupling member  166   a  (see for instance  FIG. 7 ) of driver  166 , as will be discussed in greater detail below. Helical thread  178   a  engages threads  172   a  formed in housing  172 , as seen in  FIG. 26 .  
         [0116]     As best seen in  FIGS. 22-27 , drive train  174  further includes a beveled gear system  180  operatively associated herewith. As seen in  FIG. 22 , beveled gear system  180  includes a first bevel gear  181  co-axially aligned with and slidably supported on (e.g., keyed, pined, adhered, screwed, etc.) drive shaft  163 , and a second bevel gear  182 , orthogonally oriented with respect to drive shaft  163  and operatively engaged with first bevel gear  181 . As seen in  FIG. 27 , first bevel gear  181  preferably includes a shaped central lumen  181   a  configured to engage flattened portion  163   d  of drive shaft  163 . In this manner, as drive shaft  163  or first bevel gear  181  is rotated the other of drive shaft  163  and first bevel gear  181  is also rotated. Second bevel gear  182  is rotatably supported on a stub  182   a  extending from a gear support box  182   b  which is rotatably and slidably supported on drive shaft  163 . A C-clamp  182   c  may be used to maintain second bevel gear  182  in position on stub  182   a.    
         [0117]     In operation, as drive shaft  163  is rotated first bevel gear  181  is rotated about the longitudinal axis which in turn causes second bevel gear  182  to rotate about stub  182   a  (e.g., an axis orthogonal to the longitudinal axis). Likewise, as second bevel gear  182  is rotated about stub  182   a,  first bevel gear  181  is rotated to rotate drive shaft  163 . Second bevel gear  182  includes a shaped end  182   d  configured to selectively engage coupling member  166   a  (see  FIG. 7 ) of driver  166 , as will be discussed in greater detail below.  
         [0118]     Applicator head assembly  170  further includes an ejection head  190  operatively positioned on distal end portion  163   a  of drive shaft  163 . Ejection head  190  includes a central lumen  191   a  (see  FIG. 27 ) defining a helical thread  191   b  (see  FIGS. 25 and 26 ) formed at a distal end thereof. Helical thread  191   b  is configured and dimensioned to operatively receive a fastener  90 .  
         [0119]     Applicator head assembly  170  further includes an ejection head stop  192  operatively positioned on, e.g., rotatably supported on, distal end portion  163   a  of drive shat  163 . Ejection head stop  192  includes a radially oriented key  192   a  configured to engage a corresponding recess  190   c  formed in a proximal end of ejection head  190  and a slot  172   a  (see  FIG. 22 ) formed in housing  172  of applicator head assembly  170 . In operation, as drive shaft  163  is rotated, ejection head stop  192  and ejection head  190  are prevented from rotating as a result of the engagement of key  192   a  with slot  172   a  of housing  172 . Ejection head  190  may include a saw-toothed distal end face  194  for engaging and griping aortic graft  50 .  
         [0120]     Applicator head assembly  170  further includes a coil spring  179  supported on drive shaft  163  between drive screw  178  and gear support box  182   b.  A C-clamp  179   a  may be provided about drive shaft  163  between spring  179  and drive screw  178 . In this manner, drive shaft  163  is spring biased by coil spring  179  to a proximal-most position as seen in  FIGS. 23-26 . The axial location of gear support box  182   b  relative to housing  172  is fixed due to a pivot pin  159  (see  FIG. 26 ) extending through housing  172  and gear support box  182   b.  In this manner, drive shaft  163  is axially translatable relative to housing  172 , as will be described in greater detail below.  
         [0121]     With reference to  FIGS. 1, 2 ,  29 - 32 ,  41  and  42 , control assembly  120  includes a housing  122  having a pair of half-sections  122   a,    122   b,  configured and adapted to support an expandable portion controller  124  and a drive assembly controller  126  (see  FIG. 32 ).  
         [0122]     Expandable portion controller  124  controls the expansible force “A” (see  FIG. 45 ) exerted by expandable portion  140  between at least two extreme positions, a first extreme position in which support members  144  of expandable portion  140  are collapsed (i.e., not radially expanded) and a second extreme position in which support members  144  are radially expanded.  
         [0123]     Expandable portion controller  124  includes a knob  124   a  rotatably supported in housing  122 , a spool  124   b  is in threaded engagement within knob  124   a,  and an outer tube/sheath  124   c  (see  FIG. 31 ). Outer sheath  124   c  has a proximal end fixedly secured between a distal end of spool  124   b  and a slide block  124   d.  Slide block  124   d  is fixedly secured to spool  124   b  and prevents spool  124   b  from rotating relative to knob  124   a.  As seen in  FIGS. 37 and 38 , a distal end of outer sheath  124   c  is fixedly secured to proximal hub  142   b  of expandable portion  140  (see  FIGS. 39 and 40 ). Accordingly, in use, as knob  124   a  is rotated relative to spool  124   b,  the threads cause spool  124   b  to axially translate through knob  124   a  as slide block  124   d  prevents spool  124   b  from rotating relative to housing  122 .  
         [0124]     Expandable portion controller  124  further includes a flange  125  supported in housing  122  in such a manner that flange  125  is prevented from axial movement relative to handle  122 , and a first inner tube  125   a  (see  FIG. 31 ) is fixedly secured to flange  125  and extends through spool  124   b  and outer sheath  124   c.  As seen in  FIGS. 37 and 38 , a distal end of first inner tube  125   a  is secured to body portion  161  of yoke assembly  160  which in turn is operatively associated with distal hub  142   a  of expandable portion  140  (see  FIGS. 39 and 40 ). Accordingly, in use, as will be described in greater detail below, as knob  124   a  is rotated, spool  124   b  is displaced distally or proximally, relative to knob  124   a,  causing outer sheath  124   c  to displace relative to first inner tube  125   a  to thereby manipulate expandable portion  140  between the first extreme position in which support members  144  of expandable portion  140  are collapsed (i.e., not radially expanded) and the second extreme position in which support members  144  are radially expanded, as described above.  
         [0125]     Drive assembly controller  126  includes a knob  127   a  rotatably supported in housing  122 , and a second inner tube  127   b  (see  FIG. 31 ), extending through first inner tube  125   a,  and fixedly secured to knob  127   a  by a collet  127   c  (see  FIG. 32 ). As seen in  FIGS. 37 and 38 , a distal end of second inner tube  127   b  is operatively connected to body portion  168   a  of pusher  168 . Accordingly, in use, as will be described in greater detail below, as knob  127   a  is rotated, applicator head assembly  170  (see  FIG. 27 ) is manipulated between the two extreme positions, as described above.  
         [0126]     Turning again to  FIG. 32 , drive assembly controller  126  further includes a drive handle  128  rotatably and translatably supported on housing  122  and a drive shaft  129  (see  FIG. 31 ) fixedly secured to drive handle  128  and extending through second inner tube  127   b  and lumen  168   b  of body portion  168   a  of pusher  168  (see  FIGS. 37 and 38 ). As seen in  FIGS. 37 and 40 , a distal end of drive shaft  129  is fixedly secured to body portion  166   b  of driver  166 . Accordingly, in use, as will be described in greater detail below, as drive handle  128  is advanced or retracted, driver  166  is advanced or retracted such that coupling member  166   a  thereof selectively engages or disengages shaped proximal end  178   c  of drive screw  178  or shaped end  182   d  of second bevel gear  182 . In addition, when coupling member  166  is engaged with drive screw  178  or second bevel gear  182 , rotation of drive handle  128  results in rotation of drive screw  178  or second bevel gear  182 . In turn, rotation of drive screw  178  or second bevel gear  182  results in rotation of drive shaft  163 .  
         [0127]     Drive handle  128  may include a series of annular grooves  128   a  provided at a distal end thereof. Grooves  128   a  are configured to engage a lock member  128   b  which is configured to maintain the axial position of drive handle  128  relative to housing  122  and still allow rotation of drive handle  128 . Drive handle  128  may be biased to a proximal-most position by a spring  128   c.    
         [0128]     With reference to  FIGS. 1-69 , and more particularly to  FIGS. 33-69 , operation of endovascular fastener applicator  100  is shown and described. As seen in  FIG. 43 , with aortic graft  50  positioned at the aneurysm site, endovascular fastener applicator  100  is fed over and along guide wire “G” until expandable portion  140  of delivery assembly  110  is positioned within aortic graft  50 .  
         [0129]     As seen in  FIGS. 44 and 45 , control assembly  120  is then manipulated to radially expand expandable portion  140 , in the direction of arrows “A”, from the first extreme position to the second extreme position (i.e., an expanded position). In particular, knob  124   a  of control assembly  120  is rotated, in the direction of arrow “B”, thus causing expandable portion  140  to radially expand. As knob  124   a  is rotated, in the direction of arrow “B” (see  FIG. 44 ), spool  124   b  is moved in a distal direction, as indicated by arrows “C” (see  FIG. 44 ). Since flange  125  is fixed relative to spool  124   b,  as spool  124   b  is advanced in direction “C”, relative to first inner tube  125   a  (see  FIGS. 31 and 44 ), proximal hub  142   b  is advanced in direction “C” relative to distal hub  142   a  thereby causing support members  144  to radially expand in direction “A”, as seen in  FIG. 45 . Radial expansion of expandable portion  140  results in the formation of interstitial regions  143  between support members  144  through which helical fasteners  90  may be fired into aortic graft  50 . In addition, radial expansion of expandable portion  140  results in support members  144  pressing against the inner surface of aortic graft  50  to thereby maintain aortic graft  50  in position at the site of the aneurysm.  
         [0130]     As seen in  FIGS. 46-50 , loading of a helical fastener  90 , retained/stored in fastener cartridge assembly  150 , onto applicator head assembly  170 , will be shown and described. In particular, drive handle  128  is advanced in a distal direction, as indicated by arrow “D”, until coupling member  166   a  of driver  166  engages shaped proximal end  178   c  of drive screw  178 . In advancing drive handle  128  in the “D” direction, once proximal end portion  163   b  of drive shaft  163  bottoms out in coupling member  166   a  further advancement of drive handle  128  in the “D” direction results in drive shaft  163  also advancing in the “D” direction. As seen in  FIGS. 49 and 50 , drive handle  128  (see  FIG. 46 ) is advanced in a distal or “D” direction until distal end portion  163   a  of drive shaft  163  engages (i.e., is coupled with, received in, mated with, etc.) recess  154   b  formed at the proximal end of central shaft  154  of fastener cartridge assembly  150 .  
         [0131]     As seen in  FIGS. 51 and 52 , with distal end portion  163   a  of drive shaft  163  engaged with recess  154   b  of central shaft  154 , drive handle  128  is rotated in the direction of arrow “E”. Rotation of drive handle  128  in the “E” direction results in the rotation of each of drive shaft  129 , driver  166 , drive shaft  163  and central shaft  154  in the “E” direction. Drive handle  128  is rotated in the “E” direction until a proximal-most helical fastener  90  is backed-out of fastener cartridge assembly  150  and loaded onto/into ejection head  190  of applicator head assembly  170 .  
         [0132]     As seen in  FIG. 52 , rotation of drive handle  128  also causes drive screw  178  to be displaced in the “D” direction and to compress spring  179  against gear support box  182   b.  Drive screw  178  presses against C-clamp  179   a  which in turn displaces drive shaft  163  distally. Additionally, ejection head  190  is moved distally such that saw-toothed distal end face  194  extends distally out of housing  172  of applicator head assembly  170 .  
         [0133]     In addition, as seen in  FIG. 46 , lock member  128   b  may be employed to engage grooves  128   a  of drive handle  128 . In this manner, lock member  128   b  may maintain drive handle  128  in the distally advanced position at least during rotation of drive handle  128  for loading of helical fastener  90  into applicator head assembly  170 .  
         [0134]     With a helical fastener  90  loaded into applicator head assembly  170 , as seen in  FIGS. 53 and 54 , lock member  128   b  may be manipulated to disengage from drive handle  128  and enable drive handle  128  to be withdrawn in the direction of arrow “F” to disengage driver  166  from drive screw  178 . As seen in  FIG. 54 , drive shaft  163  remains in the advanced/distal position by the interaction of threads  178   a  of drive screw  178  with threads  172   a  of housing  172 .  
         [0135]     As seen in  FIGS. 55-57 , a safety/lock-out  128   c  is moved in the direction of arrow “H” in order to free knob  127   a  and enable axial displacement of knob  127   a  in the direction of arrow “I”. With knob  127   a  free to move in an axial direction, as seen in  FIGS. 57-60 , knob  127   a  is displaced in a distal direction, i.e., the “I” direction. As seen in  FIGS. 58-60 , movement of knob  127   a  in the “I” direction results in pivoting of applicator head assembly  170  about pivot pin  159 , as indicated by arrow “K”, from the first extreme position to the second extreme position, as described above. In particular, as knob  127   a  is moved in the “I” direction second inner tube  127   b  advances pusher  168  which in turn advances clevis  162  thereby advancing cam pins  164  through elongate slots  160   a  (see  FIGS. 15 and 40 ) of body portion  161  and cam slots  176  of applicator head assembly  170 . As cam pins  164  travel through elongate slots  160   a  and cam slots  176 , cam pins  164  urge applicator head assembly  170  to approximately 90° from an axially aligned position to an orthogonal position.  
         [0136]     As seen in  FIGS. 61-64 , with applicator head assembly  170  in the second extreme position (i.e., ejection head  190  of applicator head assembly  170  is oriented toward aortic graft  50 ), drive handle  128  is once again advanced in the distal or “D” direction such that coupling member  166   a  of driver  166  engages shaped end  182   d  of second bevel gear  182 . With driver  166  in operative engagement with second bevel gear  182 , drive handle  128  is rotated in the direction of arrow “L”. Rotation of drive handle  128  in the “L” direction results in rotation of drive shaft  129 , driver  166 , and second bevel gear  182  in the “L” direction. Rotation to second bevel gear  182  in the “L” direction transmits rotation, in the direction of arrow “M”, to drive shaft  163  via its inter-engagement with first bevel gear  181 .  
         [0137]     As seen in  FIG. 63 , as drive handle  128  is rotated in the “L” direction, helical fastener  90 , loaded onto applicator head assembly  170 , is driven out of ejection head  190  and into aortic graft  50  and aortic wall  72  as indicated by arrow “N”. As seen in  FIG. 64 , as helical fastener  90  is being driven into aortic graft  50  by rotation of drive shaft  163 , drive screw  178  is simultaneously returned to its position in housing  172 , as indicated by arrow “P”, thereby withdrawing drive shaft  163  and ejection head  190  from aortic graft  50 .  
         [0138]     With helical fastener  90  in place, applicator head assembly  170  may be returned to the first extreme condition and re-loaded with another helical fastener  90  retained in fastener cartridge assembly  150  and re-oriented (i.e., rotated to an adjacent interstitial region  143  between support members  144 ). In particular, as seen in  FIGS. 65-68 , as knob  127   a  is rotated in a direction indicated by arrow “L” applicator head assembly  170  is caused to be rotated. It is envisioned that a rotation limiter  127   d,  including camming surfaces  127   e,  may be provided which indicates to the user when applicator head assembly  170  has been rotated to an adjacent interstitial region  143  for application of another helical fastener. Preferably, as many helical fasteners  90  may be deployed as are necessary to adequately fasten aortic graft  50  to aortic wall  72 .  
         [0139]     Turning now to  FIGS. 69-76 , an applicator head assembly, in accordance with an alternate embodiment of the present disclosure, is generally designated as  270 . Applicator head assembly  270  is substantially similar to applicator head assembly  170  and will only be described in detail herein to the extent necessary to identify differences in construction and operation.  
         [0140]     As seen in  FIGS. 69-76  and, in particular,  FIGS. 69 and 70 , applicator head assembly  270  includes a housing  272  defining a cam slot  276  formed in either side thereof. Each cam slot  276  includes a first portion  276   a  substantially aligned with a central longitudinal “X” axis of housing  272 , a second portion  276   b  extending substantially perpendicularly to the longitudinal “X” axis of housing  272 , and a third portion  276   c  angled with respect to the longitudinal “X” axis of housing  272 . Second portion  276   b  of cam slot  276  extends through a bottom of housing  272 . Third portion  276   c  of cam slot  276  extends at an angle from the intersection of first portion  276   a  and second portion  276   b  of cam slot  276 . Third portion  276   c  is angled at about 45° relative to the longitudinal “X” axis. Cam slots  276  are disposed distal of pivot pin  259  (see  FIGS. 71-76 ) when applicator head assembly  270  is in the first extreme position.  
         [0141]     Turning now to  FIGS. 71-76 , the pivoting of applicator head assembly  270  about pivot pin  259 , from the first extreme position to the second extreme position, is shown and described. In particular, as seen in  FIGS. 71 and 72 , as knob  127   a  (see  FIG. 57 ) is moved in the “I” direction, second inner tube  127   b  (see  FIG. 57 ) axially moves pusher  168  (see  FIGS. 6, 40  and  56 - 60 ) which in turn axially moves clevis  162  (see  FIGS. 6 and 40 ), thereby axially moving cam pins  164  (see  FIGS. 6 and 40 ) through elongate slots  160   a  (see  FIGS. 6 and 40 ) of body portion  161  (see  FIGS. 6 and 40 ) and through first portion  276   a  of cam slot  276  of applicator head assembly  270 . As seen in  FIG. 73 , cam pins  164  are axially moved through first portion  276   a  of cam slot  276  until cam pins  164  contact or otherwise operatively engage a shoulder  276   d  (i.e., the intersection between second portion  276   b  and third portion  276   c  of cam slot  276 ). Upon continued axial movement of cam pins  164  through elongate slots  160   a,  cam pins  164  enter third portion  276   c  of cam slots  276  and cause applicator head assembly  270  to begin to rotate about pivot pin  259 , as indicated by arrow “K”.  
         [0142]     As seen in  FIGS. 73-75 , cam pins  164  move axially past pivot pin  259 . In particular, continued axial movement of cam pins  164  through elongate slots  160   a,  beyond pivot pin  259 , causes applicator head assembly  270  to rotate, about pivot pin  259 , to the second extreme position. As seen in  FIG. 76 , when applicator head assembly  270  has been rotated to the second extreme position, second portion  276   b  of cam slot  276  is substantially axially aligned with the longitudinal axis of elongate slots  160   a.  Accordingly, with applicator head assembly  270  in the second extreme position, cam pin  164  may move through second portion  276   b  of cam slot  276 . This process is reversed (i.e., cam pins  164  are moved in a direction opposite to arrow “I”) in order to return applicator head assembly  270  to the first extreme position.  
         [0143]     It will be understood that various modifications may be made to the embodiments disclosed herein. For example, while specific preferred embodiments of the endovascular fastener applicator have been described in detail, structures that perform substantially the same function in substantially the same way to achieve substantially the same result may also be used. For example, the expandable portion may include expanding wires for supporting a prosthetic device in contact with a vessel wall. Also the fastener guide may be implanted completely through the thickness of the aortic graft. Further, the helical fasteners may be constructed from various suitable materials or may embody one continuous fastener that is severable at the point of insertion. Therefore, the above description should not be construed as limiting, but merely as exemplifications of preferred embodiments, those skilled in the art will envision other modifications within the scope and spirit of the present disclosure.