Patent Description:
Health practitioners frequently use sutures to close various openings such as natural anatomical openings, cuts, punctures, and incisions in various places in the human body. Generally, sutures are convenient to use and function properly to hold openings in biological tissue closed thereby aiding in blood clotting, healing, and prevention of scarring.

There are some circumstances under which it is not feasible to use conventional sutures and suturing methods to close an opening. Additionally, there are some circumstances under which the use of conventional sutures and suturing methods require invasive procedures that subject a patient to risk of infection, delays in recovery, increases in pain, and other complications.

Document <CIT> discloses a device for suturing an opening in a tissue. The device includes an elongated shaft with a pair of deployable arms. When deployed, these arms are non-perpendicular to the longitudinal axis of the shaft. The arms may be independently deployable. A first arm may be an anterior arm which is deployed by being rotated less than <NUM> degrees to the longitudinal axis of the shaft, and the second arm is a posterior arm which is deployed by being rotated more than <NUM> degrees to the longitudinal axis of the shaft. A pivot stop may be provided on the elongated shaft to limit rotation of the arms when they reach their fully deployed position. Each of the first and second arms may include a needle receiving portion thereon. Needles may be advanced longitudinally along the shaft toward the needle receiving portions on the arms. The needles may exit through a side wall of the shaft at a location proximal to the arms.

<CIT> discloses a suturing apparatus configured to suture an opening made through an outer wall of the heart is provided, comprising an elongate body having a proximal end, a distal end, a tapered or rounded tip positioned distally of the distal end of the elongate body and configured to be delivered through the opening and into an interior of the heart, and a handle at the proximal end of the elongate body configured to be manipulated from outside of the heart. The elongate body can have a substantially constant outer diameter between the handle and the distal end. The suturing apparatus can include a plurality of arms proximal to the tip arranged symmetrically about the outer diameter of the elongate body. The plurality of arms can be configured to hold portions of suture a distance away from the outer diameter of the elongate body. The plurality of arms can be extendable from said body from a retracted position to an extended position. The plurality of arms in the extended position can point distally and can form an acute angle with a longitudinal axis of the elongate body. The suturing apparatus can include a plurality of needles slidably housed in said elongate body. The plurality of needles can be movable along the longitudinal axis of the elongate body and outwardly from the body to pass through heart tissue into engagement with the suture portions held by the plurality of arms. The plurality of needles can be retractable away from the plurality of arms back through the heart tissue to draw the suture portions through the heart tissue.

The above-mentioned and other features disclosed herein are described below with reference to the drawings of specific embodiments. The illustrated embodiments are intended for illustration, but not limitation. The drawings contain the following figures:.

Examples of suturing devices and methods used to apply sutures and/or suture closed openings at, within, or into a biological structure while maintaining or substantially maintaining haemostasis are described herein. The suturing devices and methods can be used to place sutures prior to performing a surgical procedure and to prepare access for the procedure while maintaining or substantially maintaining haemostasis. The placed sutures can then be used to tighten an opening while any devices or tools are withdrawn, closing the opening while the final device or tool leaves the opening such that the opening is never without a device or tool inside it during the course of the procedure. Embodiments described herein can be used to provide access to and/or suture an access opening to a biological structure where space outside of the biological structure is limited, such as the aorta.

In the embodiments described herein, the disclosed devices are used to place sutures to close an opening into an aorta, although they are not limited to applications within the aorta or the vasculature generally. The aorta can be accessed through a sternotomy or limited thoracotomy, or alternatively the device can pass through a trocar or other element into the thoracic cavity and then be led toward a puncture in the aorta, typically by following a guide wire.

In some embodiments, the suturing devices can be used to close or reduce a variety of other tissue openings, lumens, hollow organs, or natural or surgically created passageways in the body. In some embodiments, the suturing devices can be used to suture prosthetics, synthetic materials, or implantable devices in the body. For example, the devices can be used to suture a pledget within the body.

Further details of suturing devices and methods that may be used to suture openings in a biological structure can be found in <CIT>.

<FIG> illustrates one embodiment of a suturing device <NUM> that can be used to insert sutures through the wall of a biological structure in anticipation of performing a surgical procedure in or through the biological structure while maintaining hemostasis. In some embodiments the device can be used to insert sutures through the wall of a blood vessel, such as the aorta. The device comprises one or more elongate bodies and has a proximal and a distal end. At the proximal end, the suturing device can include a handle <NUM> with various actuation elements <NUM>, such as buttons or levers, that can be used to control various components of the device. Further details regarding handles and associated components, including actuator rods, are provided in <CIT>.

At the distal end of the suturing device <NUM>, the suturing device can include a distal assembly <NUM>. The distal assembly can include, whereby embodiments according to the invention include an elongate body <NUM> that has a distal end and a proximal end. The distal assembly can also include whereby embodiments according to the invention include one or more distal suture arms <NUM> and can include one or more proximal extensions or arms <NUM> that are positioned proximal to the distal suture arms. When the device is assembled, it includes a sheath <NUM> that surrounds at least a portion of the elongate body, and an outer sleeve or needle carriage <NUM> that also surrounds at least a portion of the elongate body. As described further below, according to the invention, the needle carriage includes a plurality of needles.

In some embodiments, the sheath and/or the needle carriage can move axially relative to the elongate body. According to the invention, the needle carriage <NUM> surrounds at least a portion of the sheath <NUM> when the device is assembled. Preferably, the needle carriage can rotate relative to the sheath and/or the elongate body, but in some embodiments the needle carriage can have a fixed orientation relative to the sheath and/or the elongate body. In some embodiments, as described further below, a suturing device can have elements such as mechanical stops and/or detents that provide an indexing or alignment function, allowing an operator of the device to determine when the needle carriage has been moved and/or rotated into a desired position.

<FIG> and <FIG> illustrate a perspective view of the distal assembly <NUM>. As illustrated, embodiments according to the invention include a plurality of distal arms and can include a plurality of proximal extensions <NUM> that can also be arms. <FIG> illustrates the distal and proximal arms in a retracted position, in which the arms are at least partially within the elongate body <NUM>. In <FIG>, the distal and proximal arms are illustrated in an extended position, in which the arms extend outward from the elongate body. In some embodiments, as illustrated, the arms can extend from the elongate body at approximately a <NUM> degree angle, but in other embodiments the arms can extend at an angle less than <NUM> degrees. In some embodiments, the proximal arms in an extended position may extend from the elongate body at approximately a <NUM> degree angle, while the distal arms in an extended position may extend from the elongate body at an angle less than <NUM> degrees. In some embodiments, the distal arms may extend from the elongate body in the extended position at approximately <NUM> degrees, while the proximal arms extend from the elongate body in the extended position at an angle less than <NUM> degrees.

In various embodiments the distal assembly <NUM> can have a varying number of arms <NUM>, <NUM>. In some embodiments the distal assembly has four distal arms <NUM> spaced approximately <NUM> degrees apart from each other and four proximal arms <NUM> spaced approximately <NUM> degrees from each other. In some embodiments the distal assembly can comprise fewer than four distal arms <NUM>, such as two distal arms, or more than four distal arms. In some embodiments, for each distal arm there can be a second distal arm positioned <NUM> degrees about the elongate body from the first distal arm.

In some embodiments the distal assembly can comprise fewer than four proximal extensions or arms <NUM>, such as two proximal arms, or more than four proximal arms. In some embodiments, for each proximal arm there can be a second proximal arm positioned <NUM> degrees about the elongate body from the first proximal arm. In some embodiments, the distal assembly has the same number of proximal arms as distal arms, though in some embodiments they differ in number. In some embodiments, each proximal arm can be aligned with a corresponding distal arm along a line parallel to a longitudinal axis of the elongate body <NUM>.

In some embodiments, the proximal extensions or arms <NUM> can be one or more extensions that extend circumferentially around a portion of the elongate body <NUM>. In some embodiments, proximal extensions can each extend around a quarter, a third, or a half of the circumference of the elongate body. In some embodiments, proximal extensions <NUM> can be a single extension. The single extension can wrap around the circumference of the elongate body. As described above, proximal extensions can have a retracted position in which the extensions are within the elongate body and an extended position in which they extend out of the elongate body. Also as described above, the extensions can extend from the elongate body at varying angles when in the extended position, including at <NUM> degrees.

As further illustrated in <FIG> and <FIG>, in some embodiments the elongate body <NUM> can include a tapered distal tip <NUM>. The tapered tip can help when inserting the elongate body into or through biological tissue. The elongate body can also have a central lumen <NUM> that can be used to receive a guidewire, as discussed further below.

As illustrated in <FIG>, the distal arms <NUM> may be distal suture arms <NUM> that include one or more suture mounts or clasps <NUM> at a distal end of the suture arms. The suture clasps <NUM> can be adapted to releasably retain a suture portion, as described further below. In some embodiments, a suture portion can run from inside the elongate body along the length of an arm <NUM> to a suture clasp. As illustrated and according to the invention, when the distal suture arms <NUM> and the proximal extensions or arms <NUM> rotate from the retracted to the extended position, or from the extended to the retracted position, a free end of the arms will move towards a distal end of the elongate body. In embodiments according to the invention, the suture arms <NUM> are configured and the extensions or arms <NUM> can be configured to rotate from the retracted to the extended position, or from the extended to the retracted position, such that as the arms rotate from the extended to the retracted position their free ends will move towards a proximal end of the suturing device. In some embodiments, the arms can slide or move in other ways from the retracted to the extended position or from the extended to the retracted position.

In some embodiments, the distal suture arms <NUM> can simultaneously move from a retracted to an extended position or from an extended to a retracted position. In some embodiments, the arms <NUM> can move independently. Similarly, in some embodiments the proximal extensions or arms <NUM> can move independently or simultaneously.

In some embodiments, the proximal extensions or arms <NUM> can be shorter than the distal suture arms <NUM>. In some embodiments, when the proximal extensions or arms <NUM> are in an extended position, their distal ends can be closer to the elongate body than the distal ends of the distal suture arms <NUM> are when the distal suture arms are in an extended position. This can help minimize the space that the device requires outside of a biological structure.

<FIG> illustrate various embodiments of the needle carriage <NUM>. It is understood that various features, components, or other elements discussed with respect to any of these embodiments is not limited to the particular embodiment in which it appears, but can be included in combination with features, components, or elements illustrated or discussed with respect to any other described embodiment. Generally, the outer sleeve or needle carriage <NUM> includes a central lumen <NUM> and one or more outer lumens <NUM>. One or more of the outer lumens can be used to house a suture catch mechanism or needle <NUM>, as illustrated and described in more detail below. In some embodiments, the needle carriage <NUM> can have four outer lumens spaced symmetrically about a central axis of the needle carriage. In some embodiments, the needle carriage can have more than four or fewer than four outer lumens. In some embodiments, the needle carriage can have as many outer lumens as there are distal suture arms <NUM>.

In some embodiments, as illustrated in <FIG>, the needle carriage <NUM> can have one or more sections, such as a first section 76A and a second section 76B. The first and second sections can be separated by one or more weakened areas <NUM> that allow the first section and second section to be broken apart and separated from each other so that the carriage can be removed from around the elongate body of a suturing device, as described below.

In some embodiments, the weakened area <NUM> can be a complete dislocation, such that the first section and second section are not integral. In some embodiments, a clasp or ring <NUM> can be used to maintain the first and second sections together until an operator decides to separate them. In some embodiments, the needle carriage can have a plurality of sections separated by weakened areas or complete disclocations.

In some embodiments, as illustrated in <FIG>, the needle carriage <NUM> can include one or more keys or detents <NUM> along a distal facing surface. The detents can be used to help align the needle carriage with the proximal extensions or arms <NUM>, as described in more detail below. In some embodiments, as illustrated in <FIG>, the needle carriage can include a spreader section <NUM> at a distal end. The spreader section can be used to help deflect needles exiting the outer lumens <NUM> such that they exit at a desired angle relative to a central axis of the needle carriage. In some embodiments, the spreader section can be a ring or other attachment connected to the body <NUM> of the needle carriage. In some embodiments, the spreader section can be integrally formed with and be part of the body <NUM> of the needle carriage.

In some embodiments, as illustrated in <FIG>, a needle carriage <NUM> can include one or more keys or detents <NUM> that project into the central lumen <NUM>. In some embodiments, keys or detents that project inward can interact with recesses on the elongate body to act as an index point, as described further below.

<FIG> illustrate cross-sectional views of the embodiments illustrated in <FIG>, respectively. <FIG> illustrate a suture catch mechanism or needle <NUM> positioned within the outer lumens <NUM>. The needles are illustrated in a retracted position within a corresponding outer lumen. In some embodiments, the needles can move to a deployed position in which a distal tip of the needle extends out of the lumen, as described in more detail below. Figure 5C illustrates the spreader section <NUM>. The spreader section can include a spreader ramp or angled face <NUM> that can be used to deflect the needles away from the needle carriage <NUM> when they move to a deployed position. As illustrated in Figure 5D, in some embodiments a key or detent <NUM> extends into the central lumen <NUM> of the needle carriage <NUM>. In some embodiments, the key <NUM> can have an angled or beveled surface <NUM>. The angled surface can help the key <NUM> move out of a corresponding recess on the elongate body, as described further below.

<FIG> illustrates one embodiment of a distal suture arm <NUM>. As described above, the suture arm can include a suture mount or clasp <NUM> that can releasably retain a suture portion (not illustrated). The suture clasp can include an opening that extends through the arm, which allows a suture catch mechanism or needle to pass through the opening when extended and then catch the suture when retracted, drawing the suture with it. As illustrated, in some embodiments a distal suture arm can include a sharp edge <NUM>, or any hook point needle tip knurling or other roughening on a surface that faces towards a proximal end of the elongate body when the suture arm is in the extended position. A sharp edge or other roughening can help retain the suture arm in a position against body tissue, as described below.

<FIG> illustrate one embodiment of a proximal extension or arm <NUM>. <FIG> illustrates a top view of the arm and <FIG> illustrates a cross-section of the arm along the line 6B-6B of <FIG>. In some embodiments, a proximal arm can include a needle receiving end <NUM> that has a needle receiving or needle guiding section <NUM>. The needle receiving end can include one or more extensions <NUM> that at least partially surround the needle guiding section, limiting the lateral motion of a needle passing through the needle guiding section.

In some embodiments, a proximal extension or arm <NUM> can include a spreader ramp or angled surface <NUM>. This can be used to help deflect a needle through the needle guiding section <NUM> and toward a suture mount or clasp of a distal arm. Also as illustrated in <FIG>, in some embodiments a proximal arm <NUM> can include a detent mating recess <NUM>, which can be used to mate with a detent <NUM> of a needle carriage <NUM>, ensuring alignment between the outer lumens <NUM> and the needle guiding section <NUM>. In some embodiments, the arm can include a protruding detent, and the needle carriage can have one or more corresponding detent mating recesses. In some embodiments, engagement of the protruding and recessed detents can indicate to an operator of the device that the needle carriage is in a desired position relative to the elongate body <NUM>.

In some embodiments, the elongate body <NUM> of a suturing device can have one or more key or detent recesses <NUM> instead of or in addition to proximal extensions or arms. In some embodiments, each of the key recesses can be configured to mate with a corresponding key projection on a needle carriage.

<FIG> illustrates a schematic cross-sectional view of a portion of a distal assembly <NUM> that has a plurality of key recesses instead of proximal extensions to help identify when the needle carriage is in a desired position relative to the elongate body <NUM>. As illustrated, the detents <NUM> can fit into the recesses <NUM>. In some embodiments, the needle carriage <NUM> can be biased into the illustrated position but can flex outward. In such embodiments, when moving the needle carriage proximally from the illustrated position, the angled surface <NUM> on the detent <NUM> can contact a corner of the recess <NUM>, which pushes the detent outward, allowing the carriage to be retracted. Additionally, when the sheath <NUM> is moved distally relative to the carriage <NUM>, the sheath can contact the angled surface <NUM> and flex the needle carriage outward, allowing the sheath to pass the detent <NUM>.

In some embodiments, as further illustrated in <FIG>, needles <NUM> can be longitudinally aligned with suture clasps <NUM>. In some embodiments, the needle can be in longitudinal alignment with a position medial to the suture clasps <NUM>, and the needle carriage can include a spreader section, as described above. <FIG> also illustrates an embodiment in which suture portions <NUM> extend outward from the elongate body <NUM> and loop into position with their distal ends in the suture clasps <NUM>.

<FIG> illustrate one method of using a suturing device <NUM> to place sutures through tissue near an opening <NUM> in a biological structure, such as the aorta <NUM>. The device can further be used to position a sheath through the opening to allow for entry of other devices, while maintaining or nearly maintaining hemostasis. In the illustrated method a suturing device <NUM> is inserted into the chest cavity through a trocar in the chest wall to access the aorta, though as discussed above the suturing device can be used with a variety of other biological structures. The device <NUM> can follow a guidewire <NUM> through a puncture in the aortic wall <NUM>, the tapered distal end <NUM> widening the opening <NUM> as the device enters further into the aorta. The device is preferably inserted until the distal suture arms <NUM> have completely passed through the hole <NUM> in the wall <NUM> and are completely within the aorta.

As illustrated in <FIG>, once the distal arms <NUM> are completely within the aorta they can be moved into the extended position. An operator of the device can then withdraw the device until the arms contact the aortic wall <NUM>, as illustrated in <FIG>. In some embodiments, a sharp edge or roughening in the suture arms <NUM>, as described above, can help maintain the distal assembly <NUM> in position. In <FIG>, the proximal arms <NUM> have been moved into an extended position within the chest cavity, and the device now has both sets of arms in the extended position with the distal arms braced against the aortic wall <NUM>. As discussed above, the distal and proximal arms are preferably in alignment.

Once the proximal arms <NUM> have been extended, the needle carriage <NUM> can be advanced until it contacts or is adjacent the proximal arms <NUM>, as illustrated in <FIG>. In some embodiments, the proximal arms <NUM> can serve as an index point, and an operator of the device can rely upon contact with the proximal arms to indicate that the needle carriage has advanced to a desired position along the length of the elongate body <NUM>. As described above, in some embodiments the needle carriage and proximal arms can have corresponding detents which can help ensure that the needle carriage is properly aligned circumferentially relative to the proximal arms. Where the proximal and distal arms <NUM> are aligned, aligning the needle carriage with the proximal arms also aligns the needle carriage with the distal arms. In some embodiments, other alignment mechanisms can be used to ensure proper alignment. In some embodiments, the outer lumens of needle carriage can each be aligned with a corresponding proximal arm and a corresponding distal arm.

As illustrated in <FIG>, once the needle carriage <NUM> is positioned against or near the proximal arms <NUM> and aligned as desired, the needles <NUM> can be extended from a retracted position in which the needles are within the needle carriage and a distal point of the needles is proximal to the proximal arms, to a deployed position in which a distal point of the needles extends out from the needle carriage and into a corresponding suture mount. As illustrated, the needles in the deployed position must pass through the aortic wall <NUM> to reach a corresponding suture mount or clasp <NUM>.

As described above, the needle carriage can include a spreader or deflector section that can deflect the needles at an angle outward from a longitudinal axis of the needle carriage and elongate body. In some embodiments, rather than having a spreader section in the needle carriage, the proximal arms <NUM> can include a spreader ramp or angled surface <NUM> that can be used to deflect the needles outward, as discussed above. In some embodiments, both the needle carriage <NUM> and proximal arms <NUM> can have a spreader ramp or angled surface that can help deflect the needles when the needles move from a retracted to a deployed position.

To provide a clearer illustration of the relationship between various components of the distal assembly <NUM> in the illustrated embodiment, <FIG> illustrates a cross-sectional view of the section identified as 13B in <FIG>. As illustrated, the suture catch mechanism or needles <NUM> are in a deployed position, extending out of the outer lumens <NUM> of the needle carriage <NUM>. A spreader ramp or angled surface <NUM> on the proximal arms <NUM> has deflected the needles away from the elongate body and from the needle carriage. Within the central lumen <NUM> of the needle carriage <NUM> is the sheath <NUM> and walls <NUM> of the elongate body.

The needles in the deployed position can engage the sutures <NUM>, releasably positioned in the suture clasps <NUM>, such that when the needles retract back into the needle carriage they draw the suture ends with them, as illustrated in <FIG>. In some embodiments, the needles can move from the retracted to deployed (and from the deployed to the retracted) position simultaneously. In some embodiments, the needles can move sequentially between positions. In some embodiments, the needle carriage may have only a single needle that catches a suture end from a first suture clasp, rotates with the needle carriage into alignment with a second suture clasp, and then catches a suture end from the second suture clasp.

Once the needles have fired and drawn sutures through the aortic wall <NUM>, the needle carriage can be withdrawn from within the chest cavity, drawing the suture ends with it. As illustrated in <FIG>, the ends of suture captured by the needles will run from within the elongate body <NUM>, through the aortic wall <NUM>, and then out of the body cavity, such as through a trocar <NUM> through the chest wall <NUM>. Once the needles have been withdrawn, the needle carriage can be moved to a position that is out of the way. In some embodiments, this can include moving the needle carriage proximally out of the body cavity. In some embodiments, the needle carriage can be separated into different sections, as described above, and removed entirely from around the elongate body.

As illustrated in <FIG>, the proximal arms <NUM> can be moved back into a retracted position and the sheath <NUM> can be advanced distally through the hole in the aortic wall <NUM>. Preferably, the sheath is advanced until it contacts the distal suture arms <NUM>, thus providing an operator with confirmation that the sheath is within the hole in the aortic wall. Once the sheath is within the hole, the sheath can be relied upon to maintain hemostasis, the distal arms <NUM> can be returned to a retracted position, and the suturing device can be removed from within the sheath, as illustrated in <FIG>. Thus, the suture portions <NUM> that were within the suturing device will pass through the sheath and out of the body cavity, and the remaining suture will pass as previously illustrated as described.

In some embodiments, suture arms <NUM> that are positioned approximately <NUM> degrees apart from each other can be preloaded with a single piece of suture. In such embodiments, when the device is removed from the sheath <NUM>, the suture portions extending through the sheath are joined together and the only ends of suture extend outside of the sheath. The ends extending outside of the sheath can be pulled, and the joined suture portions can be pulled through the sheath and into the vessel as illustrated in <FIG>.

In some embodiments, if a single piece of suture is not used and the suture portions passing through the sheath need to be secured together, they can be secured together with a knot or other device prior to pulling on the ends of suture passing outside of the sheath. Further details regarding a device for joining sutures are provided in <CIT>.

In some embodiments, suture ends that pass through the sheath can be secured together in pairs, each pair having suture ends that had been releasably attached to arms <NUM> spaced about <NUM> degrees apart around the circumference of the elongate body <NUM>. By then pulling on one or more of the remaining free suture ends, the joined suture <NUM> can be pulled through the sheath and into the blood vessel, as illustrated in <FIG> only shows one suture, but other sutures can pass in planes other than the illustrated plane. In some embodiments, a second suture can pass through the aorta in a plane substantially perpendicular to the illustrated cross-section.

Further details regarding procedures for tying sutures and methods for closing openings can be found in <CIT>, filed on May <NUM>, <NUM>.

Once the suture <NUM> has been pulled into the aorta as illustrated in <FIG>, a suturing or other surgical device can be inserted through the sheath <NUM> and into the aorta. In some embodiments, prior to inserting a device into the aorta, it may be desirable to replace the sheath with a different sheath. This can be done by standard procedures known in the art, and can also be done while maintaining a sheath within the opening to thereby maintain hemostasis. For example, an obturator may be slid over the sheath <NUM>. The sheath <NUM> can then be removed, and a larger sheath may be delivered over the obturator.

Once the desired procedure or procedures have been performed, the sheath can be withdrawn while tightening the sutures to close the opening around the sheath as the sheath is withdrawn. In some embodiments, a tapered sheath can be inserted prior to closing the opening, which can make it easier to close the opening tightly around the sheath as the sheath is withdrawn from the aorta. In some embodiments, a knot delivery device, such as the device mentioned above and described in <CIT> can be preloaded with two or more of the end portions of sutures <NUM> and delivered into the body cavity alongside the sheath, making it easier to maintain a tightening pressure as the sheath is withdrawn. The opening in the aorta wall can then be closed by applying or tying a knot to the suture ends or by other known methods.

Although the foregoing description of the preferred embodiments has shown, described and pointed out the fundamental novel features of the invention, it will be understood that various omissions, substitutions, and changes in the form of the detail of the apparatus as illustrated as well as the uses thereof, may be made by those skilled in the art.

Furthermore, the particular features, structures or characteristics of any embodiment described above may be combined in any suitable manner, as would be apparent to one of ordinary skill in the art from this disclosure, in one or more embodiments.

Claim 1:
A suturing system, comprising:
a suturing device (<NUM>) comprising an elongate body (<NUM>) having a proximal end and a distal end;
a plurality of arms (<NUM>) near the distal end, wherein each arm is configured to rotate between a first position wherein the arm is retracted within the elongate body, and a second position wherein the arm has a free end extending away from the elongate body, each arm comprising at least one suture mount (<NUM>) at the free end;
a sheath (<NUM>) adapted to surround at least a portion of the elongate body;
a needle carriage (<NUM>) comprising a plurality of outer lumens (<NUM>) and a central lumen (<NUM>) adapted to surround at least a portion of the sheath;
a plurality of needles (<NUM>), each needle configured to move between a retracted position in which the needle is within a corresponding outer lumen to a deployed position in which a distal point of the needle extends out of the corresponding outer lumen and into a corresponding suture mount; and
a plurality of suture portions, wherein each suture portion has a suture end releasably retained within a suture mount of a corresponding arm of the plurality of arms.