AGA MEDICAL CORPORATION AMPLATZER PICCOLO OCCLUDER; OCCLUDER, PATENT DUCTUS, ARTERIOSUS
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Model Number 9-PDAP-04-04-L |
Device Problems
Migration or Expulsion of Device (1395); Off-Label Use (1494)
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Patient Problem
Embolism (1829)
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Event Date 04/23/2020 |
Event Type
Injury
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Manufacturer Narrative
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The device was not returned, and therefore a physical analysis related to the reported migration and embolization condition could not be completed.There were no observed artifacts related to the design, or assembly, or device acceptance inspections that indicate the design or the manufacture of the present occluder is the root cause of the observed device migration.The complaint device was retrieved without additional patient effects, and the next size larger device remained implanted.
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Event Description
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On (b)(6) 2020, a 4-4 amplatzer piccolo was selected for implant.The (b)(6) old, (b)(6) patient has the following pda dimension: ao: 4.36mm, mid: 2.14mm, pulmonary: 3.27mm, and length: 9.33mm.The device was implanted intraductal, but embolized from the duct to the left pulmonary artery 2 minutes after deployment.The device was snared and removed from the left pulmonary artery.The device was exchanged with a 5-4 piccolo and the device was successfully implanted.The patient is doing well with no reported adverse consequences.
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Manufacturer Narrative
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Correction information for d2.Additional information for g4, g7, h2, h10.
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Manufacturer Narrative
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Additional information: g4, g7, h2, h6, and h10.An event of device embolization was reported.A more comprehensive assessment could not be performed since the device was not returned for analysis, and the investigation was limited to the device history record and reported dimensions of the pda taken during imaging in the field.The device history record was reviewed to ensure that each manufacturing and inspection operation was performed and the product met all specifications.A review of the instructions for use arten600042307 rev.A sizing table t2 for patients greater than 2 kg found that the correct size for the reported pda was a 4-6 piccolo occluder.The under-sizing of the 4-4 occluder and causal relationship to the subsequent embolization could not be independently verified; however, a larger device was successfully implanted.
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