MAUDE Adverse Event Report: ARROW INTERNATIONAL LLC ULTRAFLEX IAB: 7.5FR 40CC; SYSTEM, BALLOON, INTRA-AORTIC

Catalog Number IAB-06840-U

Device Problem Fluid/Blood Leak (1250)

Patient Problem No Clinical Signs, Symptoms or Conditions (4582)

Event Date 10/19/2023

Event Type  malfunction  

Manufacturer Narrative

(b)(4).Other remarks: n/a.Corrected data: n/a.

Event Description

It was reported that "the patient used intra-aortic balloon counter pulsation therapy, and underwent coronary intervention for acute myocardial infarction.When preparing to return to the ward after surgery, the patient experienced restlessness, forceful struggle, and limb bending, causing blood to enter the iab helium pipeline.Subsequently, the iab catheter was replaced in a timely manner, but due to proper handling, no harm was caused to the patient".The 2nd iab was inserted at the same insertion site.No patient harm or injury.The patient status is reported a "fine".

Manufacturer Narrative

Qn(b)(4).The reported complaint of iab blood in helium pathway was confirmed upon investigation of the returned sample.The customer returned a 40cc 7.5fr ultraflex intra-aortic balloon catheter (iabc) without the original packaging for investigation.The sample was returned in a cardboard box and was in a plastic bag (inp-1, inp-2).Upon return, the teflon sheath hub was noted at approximately 26.5cm from the iabc luer (inp-4).The one-way valve was tethered to the short driveline tubing (inp-5).The bladder was fully unwrapped (inp-6).The iabc central lumen within the flex-tip assembly area was noted damaged; the wire round/polyimide (part of the flex tip assembly) was noted no longer attached and separated from the inner cannula (iabc central lumen) at approximately 6.5cm from the iabc distal tip (inp-7, inp-8).Multiple bends to the iabc central lumen were noted at approximately 20.5cm, 53.8cm and 66.4cm from the iabc luer (inp-9 through inp-11).Dried blood was noted on the exterior surfaces of the returned sample.Dried blood was also noted within the iabc helium pathway.No other damage or abnormalities were noted to the returned sample.The one-way valve was tested and passed.A vacuum was pulled on the one-way valve, and it held for at least 1 minute and then 30 seconds five separate times in accordance with quality system document.An attempt to aspirate and flush the iabc central lumen using a 60cc lab-inventory syringe was unable to be successfully completed.Upon aspiration, water was unable to be consistently pulled into the syringe.The attempt to flush resulted in bladder inflation.The results are consistent with the previously noted damaged central lumen.The iabc was leak tested in accordance with testing methods from manufacturing procedure.A leak was immediately detected from the iabc distal tip and iabc luer end (anp-1, anp-2).The leak from the iabc distal tip and iabc luer end are consistent with the previously confirmed damaged/separated central lumen (inp-7, inp-8).The iabc was leak tested again with the iabc distal tip and iabc luer end blocked off; no other leaks were detected.A lab inventory 0.025in guidewire was back loaded through the iabc distal tip.The guidewire exited the central lumen and entered the bladder at the location of the flex-tip assembly separation.No blood or debris was noted.The guidewire was front loaded through the iabc luer.Resistance was noted at approximately 20.5cm, 54cm and 66.7cm from the iabc luer, which are the locations of the previously noted bends.Then the guidewire exited the central lumen and entered the bladder at the location of the inner cannula separation.Some blood was noted.Based on a review of the device history record (dhr), the product met speci fication upon release; however, the specifications were not met during the complaint investigation due to the damaged central lumen.The root cause of the complaint was undetermined.Further investigation has been initiated under teleflex's quality system by the manufacturing site to further investigate this issue.Teleflex will continue to monitor and trend for reports of this nature.Other remarks: n/a.Corrected data: n/a.

Event Description

It was reported that "the patient used intra-aortic balloon counter pulsation therapy, and underwent coronary intervention for acute myocardial infarction.When preparing to return to the ward after surgery, the patient experienced restlessness, forceful struggle, and limb bending, causing blood to enter the iab helium pipeline.Subsequently, the iab catheter was replaced in a timely manner, but due to proper handling, no harm was caused to the patient".The 2nd iab was inserted at the same insertion site.No patient harm or injury.The patient status is reported a "fine".

• Brand Name: ULTRAFLEX IAB: 7.5FR 40CC
• Type of Device: SYSTEM, BALLOON, INTRA-AORTIC
• Manufacturer (Section D): ARROW INTERNATIONAL LLC; morrisville NC
• Manufacturer (Section G): ARROW INTERNATIONAL INC.; 16 elizabeth drive; chelmsford MA 01824
• Manufacturer Contact: kevin don bosco ; 3015 carrington mill blvd; morrisville 27560
• MDR Report Key: 18218443
• MDR Text Key: 329141370
• Report Number: 3010532612-2023-00665
• Device Sequence Number: 1
• Product Code: DSP
• UDI-Device Identifier: 00801902026804
• UDI-Public: 00801902026804
• Combination Product (y/n): N
• Reporter Country Code: CH
• PMA/PMN Number: K000729
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: Foreign,Health Professional,User Facility,Company Representative
• Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date: 11/15/2023

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 11/28/2023
• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Catalogue Number: IAB-06840-U
• Device Lot Number: 18F23F0003
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Is the Reporter a Health Professional?: No
• Date Manufacturer Received: 01/04/2024
• Was Device Evaluated by Manufacturer?: Yes
• Date Device Manufactured: 06/02/2023
• Is the Device Single Use?: Yes
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Initial
• Patient Sequence Number: 1
• Patient Sex: Male