Catalog Number FVM14100 |
Device Problems
Positioning Failure (1158); Fracture (1260); Misfire (2532)
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Patient Problem
No Clinical Signs, Symptoms or Conditions (4582)
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Event Date 04/05/2023 |
Event Type
malfunction
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Event Description
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It was reported that during a stent graft placement procedure for elimination of an iliaco-ureteral fistula at the level of the right iliac bifurcation, the stent graft allegedly could not be released.It was further reported that the catheter allegedly could not be withdrawn and stronger actuation of the pull-back release mechanism caused the y-piece to tear away from the outer skin.Reportedly, the stent was removed and the procedure was completed using a stent-graft-in-stent-graft technique using additional stents.There was no reported patient injury.
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Manufacturer Narrative
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H10: the catalog number identified in section d4 has not been cleared in the us but is similar to the fluency plus endovascular stent graft that are cleared in the us.The pro code and 510 k number for the fluency plus endovascular stent graft are identified in d2 and g4.H10: as the lot number for the device was provided, a review of the device history records is currently being performed.The return of the sample is pending.The investigation of the reported event is currently underway.H10: d4 (expiration date: 07/2025).H11:section a through f - the information provided by bd represents all of the known information at this time.Despite good faith efforts to obtain additional information, the complainant / reporter was unable or unwilling to provide any further patient, product, or procedural details to bd.H3 other text : device pending return.
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Manufacturer Narrative
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H10: the catalog number identified in section d4 has not been cleared in the us but is similar to the fluency plus endovascular stent graft that are cleared in the us.The pro code and 510 k number for the fluency plus endovascular stent graft are identified in d2 and g4.H10: manufacturing review: the lot history records of this lot were reviewed with special attention to the manufacturing and inspection of this product and the product was found to have met the specification prior to shipment.Based on the information available it is not reasonably suggested that a manufacturing process may have caused or contributed to the reported issue.Investigation summary: the physical device was returned for evaluation.The returned sample was contaminated.A partial deployment and fracture of the outer sheath was noticed.The system was flushed and the right accessories were used.Additionally the system should be straightened prior to deployment and the proximal end of the stent graft should be placed in a straight section of the lumen prior to deployment.In this case these steps were reportedly followed.Based on the provided information the investigation is closed with a confirmation for partial deployment and fracture.A definite root cause for the reported event could not be determined.Labeling review: in reviewing the relevant labeling, it was found that the instructions for use sufficiently address the potential risks.Regarding preparation of the device the instructions for use state that 'prior to loading the vascular system over a guide wire, both ports must be flushed with sterile saline.Flushing these lumens will also facilitate stent graft deployment'.Regarding the anatomy of the placement site the instructions for use states: 'prior to stent graft deployment, ensure that the proximal stent graft end is positioned in a straight section of the lumen to reduce the risk of increased deployment forces and possible failure to deploy.' regarding stent graft deployment the instructions for use states: 'during release of the stent graft, the entire length of the flexible deployment system should be kept as straight as possible.Regarding accessories the instructions for use states: 'a super stiff guide wire (0.035 in.) is advanced from a femoral artery puncture site.Use an introducer sheath for the implant procedure'; the packaging pictograms indicate an introducer size of 10f and a 0.035" guidewire.H10: d4 (expiration date: 07/2025), g3, h6 (device).H11: section a through f ¿ the information provided by bd represents all the known information at this time.Despite good faith efforts to obtain additional information, the complainant/reporter was unable or unwilling to provide any further patient, product, or procedural details to bd.H3 other text : see h10.
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Event Description
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It was reported that during a stent graft placement procedure for elimination of an iliaco-ureteral fistula at the level of the right iliac bifurcation, the stent graft allegedly could not be released.It was further reported that the catheter allegedly could not be withdrawn and stronger actuation of the pull-back release mechanism caused the y-piece to tear away from the outer skin.Reportedly, the stent was removed and the procedure was completed using a stent-graft-in-stent-graft technique using additional stents.There was no reported patient injury.
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Manufacturer Narrative
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The catalog number identified in section d4 has not been cleared in the us but is similar to the fluency plus endovascular stent graft that are cleared in the us.The pro code and 510 k number for the fluency plus endovascular stent graft are identified in d2 and g4.Manufacturing review: the lot history records of this lot were reviewed with special attention to the manufacturing and inspection of this product and the product was found to have met the specification prior to shipment.Based on the information available it is not reasonably suggested that a manufacturing process may have caused or contributed to the reported issue.Investigation summary: the physical device was returned for evaluation.The returned sample was contaminated.A partial deployment and fracture of the outer sheath was noticed.The system was flushed and the right accessories were used.Additionally the system should be straightened prior to deployment and the proximal end of the stent graft should be placed in a straight section of the lumen prior to deployment.In this case these steps were reportedly followed.Based on the provided information the investigation is closed with a confirmation for partial deployment and fracture.A definite root cause for the reported event could not be determined.Labeling review: in reviewing the relevant labeling, it was found that the instructions for use sufficiently address the potential risks.Regarding preparation of the device the instructions for use state that 'prior to loading the vascular system over a guide wire, both ports must be flushed with sterile saline.Flushing these lumens will also facilitate stent graft deployment'.Regarding the anatomy of the placement site the instructions for use states: 'prior to stent graft deployment, ensure that the proximal stent graft end is positioned in a straight section of the lumen to reduce the risk of increased deployment forces and possible failure to deploy.' regarding stent graft deployment the instructions for use states: 'during release of the stent graft, the entire length of the flexible deployment system should be kept as straight as possible.Regarding accessories the instructions for use states: 'a super stiff guide wire (0.035 in.) is advanced from a femoral artery puncture site.Use an introducer sheath for the implant procedure'; the packaging pictograms indicate an introducer size of 10f and a 0.035" guidewire.D4 (expiration date: 07/2025).H11: section a through f ¿ the information provided by bd represents all the known information at this time.Despite good faith efforts to obtain additional information, the complainant/reporter was unable or unwilling to provide any further patient, product, or procedural details to bd.
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Event Description
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It was reported that during a stent graft placement procedure for elimination of an iliaco-ureteral fistula at the level of the right iliac bifurcation, the stent graft allegedly could not be released.It was further reported that the catheter allegedly could not be withdrawn and stronger actuation of the pull-back release mechanism caused the y-piece to tear away from the outer skin.Reportedly, the stent was removed and the procedure was completed using a stent-graft-in-stent-graft technique using additional stents.There was no reported patient injury.
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Search Alerts/Recalls
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