It was reported that the procedure was to treat a moderately calcified and mildly tortuous left anterior descending coronary artery (lad).A 3.0x15mm xience skypoint stent delivery system (sds) was advanced into the guide liner (guide extension 5f) however, the delivery system became stuck.When attempting to pull out the sds, resistance was met and force was applied.The shaft broke and at a point outside of the y-connector; therefore, everything was removed together.Another 2.5x15mm skypoint was used to complete the procedure.There were no adverse patient effects and no clinically significant delay in the procedure.No additional information was provided.
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The device was returned for analysis.The reported shaft separation was confirmed.The reported difficulty to advance and difficulty to remove could not be replicated in a testing environment as it was related to operational context of the procedure.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 similar incidents from this lot.It was reported that when attempting to pull out the sds, resistance was met and force was applied.The shaft broke and at a point outside of the y-connector; therefore, everything was removed together.It should be noted that the xience skypoint everolimus eluting coronary stent system instruction for use states: if unusual resistance is felt before the stent exits the guiding catheter, do not force passage.Maintain guide wire placement across the lesion and remove the delivery system and guiding catheter as a single unit.In this case, the instructions for use deviation related to the use of force does not appear to have caused the reported difficulties.The investigation determined the reported difficulties appear to be related to circumstances of the procedure.There is no indication of a product quality issue with respect to manufacture, design or labeling.
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