ABBOTT MEDICAL AMPLATZER VASCULAR PLUG II; DEVICE, VASCULAR, FOR PROMOTING EMBOLIZATION
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Model Number 9-AVP2-008 |
Device Problems
Difficult to Fold, Unfold or Collapse (1254); Fracture (1260)
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Patient Problem
No Clinical Signs, Symptoms or Conditions (4582)
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Event Date 03/13/2023 |
Event Type
malfunction
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Manufacturer Narrative
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Investigation is not yet complete.A follow-up report will be submitted with all additional relevant information.
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Event Description
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It was reported that on (b)(6) 2023, an 8mm amplatzer vascular plug ii was chosen for implant using a non-abbott delivery system.The goal of the procedure was persistent ductus arteriosus occlusion.The device was prepared per the instructions for use (ifu) and washed with saline solution.While attempting to position the plug, it was retracted and redeployed three times due to the instability of the central disc, which caused difficulty positioning the device.The device remained attached to the delivery cable and was removed from the patient.After removal, it was observed that there was a hole through the nitinol mesh in the central disc of the device.A 10mm amplatzer vascular plug ii was then chosen for implant to replace the 8mm device.The replacement device was successfully implanted, and the procedure was concluded.The patient remained hemodynamically stable throughout the procedure and there was no clinically significant delay.The patient was reported as stable.
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Manufacturer Narrative
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An event of difficulty positioning of the device, device not taking proper shape and a hole in nitinol mesh in the central disc of device was reported.The investigation confirmed the device met functional and visual 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.Images from field appeared to show an avp device connected to the delivery cable.A hole was seen in the central disc of the plug in one of the images.The cause of the reported event of hole in device is the result of the manufacturing process and is consistent with a forming hole which is considered to be a normal and acceptable characteristic of the device.There is no indication of a product quality issue with respect to labeling design or manufacturing of the device.
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Event Description
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It was reported that on 13 march 2023, an 8mm amplatzer vascular plug ii was chosen for implant using a non-abbott delivery system.The goal of the procedure was persistent ductus arteriosus occlusion.The device was prepared per the instructions for use (ifu) and washed with saline solution.While attempting to position the plug, it was retracted and redeployed three times due to the instability of the central disc, which caused difficulty positioning the device.The device remained attached to the delivery cable and was removed from the patient.After removal, it was observed that there was a hole through the nitinol mesh in the central disc of the device.A 10mm amplatzer vascular plug ii was then chosen for implant to replace the 8mm device.The replacement device was successfully implanted, and the procedure was concluded.The patient remained hemodynamically stable throughout the procedure and there was no clinically significant delay.The patient was reported as stable.Subsequent to the initially filed report, the following information was received that the device was checked prior to implant.When attempting to implant the device, the central disc was not taking the correct shape.
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Search Alerts/Recalls
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