The device was returned for analysis.The reported difficult to remove mandrel was unable to be replicated in a testing environment due to the condition of the returned device.The reported premature activation was able to be confirmed.A review of the lot history record identified no manufacturing nonconformities issued to the reported lot that would have contributed to this event.Additionally, a review of the complaint history identified no other incidents from this lot.Reportedly, the device was not flushed prior to taking out the mandrel.It should be noted that the absolute pro vascular self-expanding stent system instructions for use (ifu) states: 1.Holding the tip mandrel in place, inject heparinized saline into the lumen through the proximal luer fitting at the end of the housing assembly.Flush until fluid is observed exiting distally near the stent and at the distal end of the outer jacket.2.Gently twist and pull to remove the tip mandrel.If the tip mandrel is not easily removed, do not use the device.3.Continue flushing until fluid is observed exiting at the distal portion of the tip.It is undetermined if the reported deviation of the instructions for use caused/contributed to the reported difficulties.The investigation determined the reported difficulties appear to be related to circumstances of the procedure as it is likely that during mandrel removal the tip of the device was inadvertently pulled as well; thus resulting in the reported difficult to remove-mandrel and ultimately resulting in the reported premature activation-stent.There is no indication of a product quality issue with respect to manufacture, design or labeling.
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