Catalog Number 1012530-60 |
Device Problems
Premature Activation (1484); Difficult to Remove (1528); Deformation Due to Compressive Stress (2889)
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Patient Problem
No Clinical Signs, Symptoms or Conditions (4582)
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Event Date 10/26/2023 |
Event Type
malfunction
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Manufacturer Narrative
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B3, b6: dates are estimated.Manufacturer's investigation is still pending at this time.Results and conclusions will be provided in the final report.
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Event Description
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It was reported that during the procedure, the guide wire was in the target lesion and the prepared absolute pro self-expanding stent system (sess) was being advanced over the guide wire, when the stent became exposed [started to deploy] prior to entering the introducer sheath.The sess was then attempted to be removed from the guide wire, however resistance was met and the outer sheath of the sess was noted as bunched up.They decided to deploy the stent on the guide wire in order to remove it.A new absolute pro stent was used successfully for the procedure.There were no reported adverse patient effects and no clinically significant delays in the procedure.No additional information was provided.
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Manufacturer Narrative
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The device was returned for analysis.The reported deformation due to compressive stress was able to be confirmed.The reported premature activation and the reported difficult to remove were unable to be replicated in a testing environment due to the condition of the returned device.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.As there was no damage noted to the device during the inspection prior to use, the investigation determined the reported difficulties appear to be related to circumstances of the procedure as it is likely that during advancement onto the guide wire inadvertent mishandling resulted in the reported bunched outer sheath/noted wrinkled sheath, the noted kinked/bunched inner member and the noted smashed/torn tip; thus compromising the device resulting in the reported premature activation and the reported difficult to remove.There is no indication of a product quality issue with respect to manufacture, design or labeling.
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Search Alerts/Recalls
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