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Model Number 9-PDA-006 |
Device Problem
Material Deformation (2976)
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Patient Problem
No Consequences Or Impact To Patient (2199)
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Event Type
Injury
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Event Description
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On (b)(6) 2019, 5mm amplatzer duct occluder was selected for use and positioned at the patient's defect, but deemed unsuitable due to size, so the device was re-sheathed and removed.A 6mm amplatzer duct occluder was then selected for implant.After the 6mm device was re-positioned three times, on the third attempt, the device released from the cable prematurely and embolized.The device was snared via the femoral artery and the patient is reported to be discharged.Additional information has been requested.
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Event Description
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On (b)(6) 2019, 8/6 amplatzer duct occluder (pda) was selected for use and positioned at the patient's defect, but deemed unsuitable due to size, so the device was resheathed and removed.Another 10/8 pda and delivery sheath were selected for implant.After the pda was re-positioned three times, on the third attempt, the device prematurely released from the cable and embolized.The device was snared via the femoral artery and the defect was then successfully closed with a 6/7 mvsd.The patient is reported to be discharged.
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Manufacturer Narrative
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An event of premature release and embolization was reported.The investigation confirmed the device met functional and dimensional specifications when analyzed at abbott.The device history record was reviewed to ensure that each manufacturing and inspection operation was performed and the product met all specifications at the time of commercialization.The cause of the reported incident could not be conclusively determined.According to instructions for use, 600207-008 revision b " do not release the amplatzer duct occluder from the delivery cable if the device does not conform to its original configuration or if the device position is unstable.Recapture the device and redeploy.If still unsatisfactory, recapture the device and replace with a new device".
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Search Alerts/Recalls
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