It was reported that the procedure was to treat a fistula in the cephalic arch.Pre-dilatation was performed with a 6mm balloon.The 7.0x40mm armada 35 balloon dilatation catheter (bdc) was not prepared per instructions for use (ifu) and was advanced without resistance, however, the balloon burst during the first inflation at 18 atmospheres (atms).There was resistance during removal with the anatomy and force was applied then separated in the anatomy upon removal.The separated material remained on the guide wire and was snared from the anatomy.There was no adverse patient sequelae and there was no clinically significant delay in the procedure.No additional information was provided.
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A visual inspection was performed on the returned device.The reported balloon rupture and separation were confirmed.The reported difficulty to remove could not be replicated in a testing environment as it was based on operational circumstances.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 similar incidents and/or complaints from this lot.It was reported by the account that the device was not prepared per instructions for use (ifu).It should be noted that the percutaneous transluminal angioplasty catheter (pta), armada 35/ armada 35ll global, ce, instructions for use (ifu) states: perform the following steps to remove all air and verify the integrity of the pta catheter.The user must perform the seven steps listed.In this case, it is unknown if the ifu violation caused or contributed to the reported complaints.Additionally, extra force was applied to remove the device, as difficulty was encountered and the bdc separated.It should be noted that the percutaneous transluminal angioplasty catheter (pta), armada 35/ armada 35ll global, ce, instructions for use (ifu) states: maintaining a vacuum in the balloon, withdraw the catheter.Note: gentle counterclockwise twisting motion of the balloon may ease withdrawal through the sheath or from the percutaneous entry site.If the balloon cannot be withdrawn through the sheath, withdraw the catheter and sheath as one unit.In this case, the physician did not follow the instructions for use.Instead of using gentle counterclockwise twisting motion to remove the device, force was applied resulting in the reported separation.The investigation was unable to determine a conclusive cause for the reported balloon rupture; however, the reported difficulty removing the device and unexpected medical intervention appear to be related to circumstances of the procedure.The reported separation appears to be related to use error/operational context.Balloon material ruptures can be affected by numerous factors including, but not limited to, balloon damage during processing of the balloon material, materials, inflation technique, and interactions with other devices or lesion calcification.A conclusive cause for the reported balloon rupture could not be determined since limited anatomical information was provided.Additionally, the difficulty reported during removal was likely the result of the ruptured balloon material catching on the patient anatomy during removal.Force was used in an attempt to remove the device, as difficulty was encountered, and the bdc ultimately separated.Additional treatment with a snare was performed to remove the separated portion.There is no indication of a product quality issue with respect to design, manufacture or labeling of the device.
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