As reported, while administering chemotherapy drugs cisplatin and doxorubicin during a transcatheter arterial chemoembolization (tace) procedure of the liver, a cook three-way plastic stopcock leaked.The stopcock was changed and the procedure was continued.The patient did not require any additional procedures due to this occurrence.According to the initial reporter, the patient did not experience any adverse effects due to this occurrence.
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Blank fields on this form indicate the information is unknown, unavailable, or unchanged.Initial report.As reported, while administering chemotherapy drugs cisplatin and doxorubicin during a transcatheter arterial chemoembolization (tace) procedure of the liver, a cook three-way plastic stopcock leaked.The stopcock was changed and the procedure was continued.The patient did not require any additional procedures due to this occurrence.According to the initial reporter, the patient did not experience any adverse effects due to this occurrence.Investigation ¿ evaluation.Reviews of the complaint history, device history record, documentation, drawing, manufacturer¿s instructions, quality control procedures, and a visual inspection of the returned device were conducted during the investigation.One stopcock was returned.A possible crack was noted on the device; however, when leak test was performed no leak was detected.Although the device did not leak the failure mode will be confirmed based on customer testimony.Additionally, a document-based investigation evaluation was performed.The evidence indicates the product was made to specifications.A review of the device history record showed no nonconforming events which could contribute to this failure mode.It should also be noted there were no other reported complaints for this lot number.No gaps were discovered in the manufacturing instructions, specifications, drawing, or quality control procedures for this device.Cook has concluded that sufficient inspection activities are in place to identify this failure mode prior to distribution.Based on the information provided and the examination of the returned product, cook has concluded that the conclusion from previously completed root cause investigation aligns with the conclusion of this complaint.The stopcock stems molded of nylon 6 have the potential to absorb moisture resulting in an increase in diameter raising the potential for cracking of the stopcock body contributed to this incident.We will continue our monitoring of similar complaints and have notified the appropriate personnel of this event.Per the quality engineering risk assessment no further action is required.This report is required by the fda under 21 cfr part 803.This report is based on unconfirmed information submitted by others.Neither the submission of this report nor any statement made in it is intended to be an admission that any cook device is defective or malfunctioned; that a death or serious injury occurred; or that any cook device caused or contributed to; or is likely to cause or contribute to a death or serious injury if a malfunction occurred.
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