ST. JUDE MEDICAL, COSTA RICA LTDA PRESSUREWIRE¿ X, WIRELESS, RX 175CM; TRANSDUCER, PRESSURE, CATHETER TIP
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Model Number C12059 |
Device Problem
Disconnection (1171)
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Patient Problem
Thrombosis (2100)
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Event Date 04/16/2018 |
Event Type
Injury
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Event Description
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A pressurewire x, wireless could not be equalized and lost signal when advancing past the lesion.The light remained green but no signal was reaching the quantien.A second device was used and could not equalize due to a drift.In the 20 minutes while attempting to do the ffr the patient had a stent thrombosis.This complication required the patient to receive balloon angioplasty and be admitted to the hospital.The patient required a repeat angiogram.The patient is stable now after the physician treated.Patient's information (e.G.Age, weight, gender, patient's initials) cannot be handled by abbott in absence of patient's written consent as required by the personal data protection national legislation.National legislation prevents the recording of such information.A written consent has not been obtained in this case; therefore, this information is not available.Please reference 3008452825-2018-00132 for first device.
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Manufacturer Narrative
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The reported event of a pressure registration issue could not be confirmed.Functional testing could not be performed due to the condition of the returned pressure wire.The presence of a dried salt-like substance inside the covering of the sensor element can affect signal readings, which precludes further signal testing.Electrical testing of the guidewire revealed no anomalies.The transmitter was returned in the ¿on¿ position; no light was visible.Further functional testing with a test battery and guidewire from stock revealed the transmitter had no functional anomalies.The device history record was reviewed to ensure that each manufacturing and inspection operation was performed.Based on the received condition of the device and the information provided, the cause of the reported pressure registration issue remains unknown.The pressure wire aeris instructions for use (ifu) states that potential complications which may be encountered during all catheterization procedures include but are not limited to: vessel dissection or occlusion, perforation, embolus, spasm, local and/or systemic infection, pneumothorax, congestive heart failure, myocardial infarction, hypotension, chest pain, renal insufficiency, serious arrhythmias or death.
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