ABBOTT MEDICAL AMPLATZER VASCULAR PLUG II; DEVICE, VASCULAR, FOR PROMOTING EMBOLIZATION
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Model Number 9-AVP2-008 |
Device Problem
Difficult to Fold, Unfold or Collapse (1254)
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Patient Problem
No Clinical Signs, Symptoms or Conditions (4582)
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Event Date 06/16/2022 |
Event Type
malfunction
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Event Description
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It was reported that on (b)(6) 2022, a 8mm amplatzer vascular plug 2 (avp2) was selected for implant using a 6f amplatzer torqvue delivery system.It was noted during procedure that the plug exhibited an umbrella shaped deformation when being deployed.The deformed 8mm amplatzer vascular plug was never released from the delivery cable while inside the patient.There was no noted interaction with cardiac structures during deployment.The decision was made to remove the 8mm amplatzer vascular plug 2 and replace it with another one of the same size to complete the procedure.The plugs had been sized using fluoroscopic and echocardiographic examination.The patient remained hemodynamically stable throughout the procedure.There was no clinically significant delay in the procedure and no adverse patient effects reported.The patient was stable at the time of report.
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Manufacturer Narrative
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Investigation is not yet complete.A follow-up report will be submitted with all additional relevant information.
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Manufacturer Narrative
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An event of device deformity could not be confirmed.The device was returned to abbott for investigation and the device met functional specifications when analyzed under non-physiological conditions.The device history record was reviewed to ensure that each manufacturing and inspection operation was performed and the product met all specifications.There were no complaints associated with any other devices from the lot.Possible causes of device deformity include use of the incorrect size delivery system, anatomical interference, and angulation or kink in the delivery system upon deployment.No anatomical interference was noted, however a larger than recommended delivery system was used to implant the device, which could have contributed to the reported event.
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