Catalog Number S-70-060-120-P6 |
Device Problems
Difficult to Remove (1528); Material Separation (1562); Improper or Incorrect Procedure or Method (2017)
|
Patient Problem
No Clinical Signs, Symptoms or Conditions (4582)
|
Event Date 02/09/2024 |
Event Type
malfunction
|
Manufacturer Narrative
|
H6: medical device problem code 2017 - failure to follow steps / instructions.The device was not returned for analysis.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 physician did not put the thumbslide back to the starting position.The tip seemed to tear when there was resistance at the tip of the sheath when the sess was removed.It should be noted that the supera peripheral stent system instructions for use (ifu) states: following confirmed implantation of the supera stent, retract the thumb slide in a single motion to the starting position on the handle and rotate the system lock and deployment lock into the locked position, in line with the thumb slide.The investigation determined the reported difficulties appear to be related to deviation of the instructions for use and subsequent circumstances of the procedure as it is likely that failure to retract the thumbslide back to the starting position, in addition to interaction with the tip of the sheath and post dilatation balloon resulted in the reported difficult to remove.Manipulation of the compromised device ultimately resulted in the reported tip separation.There is no indication of a product quality issue with respect to manufacture, design or labeling.
|
|
Event Description
|
It was reported that the procedure was to treat the restenosed, 7.0 mm right superficial femoral artery (sfa) with moderate calcification, moderate tortuosity and 100% stenosis.The vessel was prepared with a 4x20 mm non-abbott balloon at 12 atmospheres for 60 seconds, twice, and atherectomy was not used.There was a vascular occlusion caused by the fracture of a non-abbott stent that had been implanted in the root of the right sfa.Pre-dilatation was performed and the 7x60 mm supera self expanding stent system (sess) was advanced to the lesion without resistance.The stent was implanted but there was resistance in the sheath during advancement of a balloon for post dilatation.It was noted that the tip of the supera sess had torn and this was confirmed when the tip came out of the sheath when the balloon was advanced further.The sheath which was already inside the anatomy was then advanced to the torn tip and it was retrieved.Reportedly, the physician did not put the thumbslide back to the starting position.The tip seemed to tear when there was resistance at the tip of the sheath when the sess was removed.There were no adverse patient effects and there was no clinically significant delay in the procedure.No additional information was provided.
|
|
Search Alerts/Recalls
|
|