AGA MEDICAL CORPORATION AMPLATZER PICCOLO OCCLUDER; OCCLUDER, PATENT DUCTUS, ARTERIOSUS
|
Back to Search Results |
|
Model Number 9-PDAP-04-04-L |
Device Problems
Migration or Expulsion of Device (1395); Off-Label Use (1494)
|
Patient Problem
Embolism (1829)
|
Event Date 04/24/2020 |
Event Type
Injury
|
Manufacturer Narrative
|
The results/method and conclusion codes along with investigation results will be provided in the final report.
|
|
Event Description
|
On (b)(6) 2020, a 4-4 amplatzer piccolo was selected for implant for a patent ductus arteriosus (pda) in a (b)(6) old (b)(6) female patient.The pda has the following dimensions: minimal diameter: 3.4mm, aortic ampulla diameter: 4.6mm, length: 10.0mm.The device placement was intraductal.The device embolized into the left pulmonary artery upon release.The device was retrieved and exchanged with a 5-2 piccolo (lot # 7277280).The patient is currently stable, clinically well, and weaning off respiratory support.
|
|
Manufacturer Narrative
|
Correction information for d2.Additional information for g4, g7, h2, h10.
|
|
Manufacturer Narrative
|
The device subject to the embolization complaint was not returned, and therefore a physical analysis was not able to be completed.There were no additional complaints related to the manufacturing lots of the complaint device or replacement device.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 device is the root cause of the observed, post-implant embolization.The documented surgical intervention of removal and replacement with a device of a different size resulted in a positive outcome.The replacement, re-sized device remains implanted.
|
|
Manufacturer Narrative
|
Additional information for g4, g7, h2, h6, and h10.An event of 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 t3 for patients less than or equal to 2 kg found that the correct size for the reported pda was a 5-2 piccolo occluder.The under-sizing of the 4-4 occluder and causal relationship to the subsequent embolization could not be independently verified; however, the successfully implanted 5-2 piccolo occluder is further evidence of device under-sizing which was a potential contributing factor to the device embolization.
|
|
Search Alerts/Recalls
|
|
|