Customer reported "using trerotola device on an avf (arteriovenous fistula), we were working on the outflow, took the device out to get the clot off and when we took our image we noticed a perforation.Examined the device and the tip of the catheter was missing.We used a stent to cover up the perforation." it was reported the user had taken the device out to clean it and noticed the tip was off.A picture was taken using digital subtraction angiography and revealed a perforation.A stent was placed over the tip and perforation.The patient was reported to be well and did not have any additional complications.
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Qn# (b)(4).The customer provided three photos for evaluation.The photos displayed the presumed pebax tip separated inside of a patient.A stent also appeared to be present, which confirms the customer report.The customer also returned one 5fr ptd catheter for evaluation.Visual examination revealed the pebax tip was fully separated from the ptd basket and not returned for evaluation.Microscopic examination confirmed the basket wires were fully welded.The returned ptd basket was able to be retracted and advanced from the ptd catheter.The returned ptd catheter was assembled with a lab inventory rotator.When the rotator button was depressed, the ptd catheter performed as expected.A device history record review was performed with no relevant findings.The instructions-for-use provided with this kit warns the user, "potential fatigue failure of ptd torque cable and fragmentation basket may occur with prolonged activation of ptd device.When using the ptd within the apex of a forearm loop graft, limit operation to 3 minutes or less to reduce the potential for basket failure.A rapid withdrawal rate of 1-2 cm/second is recommended when sharp radii are encountered (i.E., radius of loop graft, radii < 3 cm)." the customer report of a separated ptd tip was confirmed by complaint investigation of the returned sample.The ptd pebax tip was completely separated from the basket and was not returned for evaluation.A device history record review was performed with no relevant findings.A capa has previously been initiated to further investigate this issue.The root cause has been determined to be a manufacturing (molding) issue.Corrective actions have not yet been implemented.
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Customer reported "using trerotola device on an avf (arteriovenous fistula), we were working on the outflow, took the device out to get the clot off and when we took our image we noticed a perforation.Examined the device and the tip of the catheter was missing.We used a stent to cover up the perforation." it was reported the user had taken the device out to clean it and noticed the tip was off.A picture was taken using digital subtraction angiography and revealed a perforation.A stent was placed over the tip and perforation.The patient was reported to be well and did not have any additional complications.
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