As reported, a cardiologist reported a case of aortic dissection while using the 5f tempo (5f tempo 0.038 100c bl) brachial left catheter.The intended procedure was a coronary angiogram; the right radial was accessed.The dissection occurred in the rca.It was noted that the coronary angiogram (cag) went smoothly.It was noted that the coronary artery was clean.After the cag, patient experienced pain on the chest and heart frequency dropped.There were no ecg changes.The patient was transported to another facility.At the new facility, the heart frequency changed, and patient was than transported to another facility.At this facility, two stents were placed in the rca.Patient came back for examination.It was noted, the patient experienced shortness of breath; no cause was found but shortness of breath continues.There was no vessel calcification, tortuosity or stenosis.The device was not used for a chronic total occlusion.The device was stored, handled, and prepped per the instructions for use (ifu).There were no visible signs of device/package damage prior to use.There were no anomalies noted when the device was taken out of the package, and no anomalies noted during or after the device was prepped.Unusual force was not used at any time during the procedure; neither resistance met while advancing the device nor torquing required.Another device was used to complete the procedure.The event did not cause a clinically relevant increase in the duration of the procedure.The event caused a condition that required hospitalization or significant prolongation of existing hospitalization.A procedural cd is not available for review.The device will not be returned for evaluation.
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After further review of additional information received the following sections have been updated accordingly: a2, a3, a4, b4, d4, g3, g4, h1, h2, h3 and h6.As reported, a cardiologist reported a case of aortic dissection while using the 5f tempo (5f tempo 0.038 100c bl) brachial left catheter.The intended procedure was a coronary angiogram; the right radial artery was accessed.The dissection occurred in the rca.It was noted that the coronary angiogram (cag) went smoothly.It was noted that the coronary artery was clean.After the cag, patient experienced pain on the chest and heart frequency dropped.There were no ecg changes.The patient was transported to another facility.At the new facility, the heart frequency changed, and patient was then transported to another facility.At this facility, two stents were placed in the rca.Patient came back for examination, and it was noted the patient experienced shortness of breath.No cause was found but shortness of breath continues.There was no vessel calcification, tortuosity, or stenosis.The device was not used for a chronic total occlusion.The device was stored, handled, and prepped per the instructions for use (ifu).There were no visible signs of device/package damage prior to use.There were no anomalies noted when the device was taken out of the package, and no anomalies noted during or after the device was prepped.Unusual force was not used at any time during the procedure; neither resistance met while advancing the device nor torquing required.Another device was used to complete the procedure.The event did not cause a clinically relevant increase in the duration of the procedure.The event caused a condition that required hospitalization or significant prolongation of existing hospitalization.The product was not returned for analysis.A product history record (phr) review of lot 18018751 revealed no anomalies or non-conformances during the manufacturing and inspection processes that can be associated with the reported event.Without the return of the device or images for analysis, the reported customer event ¿aortic dissection¿ could not be confirmed.Patient specific vessel characteristics and/or damaging the catheter tip during removal from the package may have contributed to the reported event.Users are trained to inspect for signs of damage prior to and during use.Any product with damage is not to be used.Information for safety is provided in the products labeling with the intent to make the user aware of the risks.According to the instructions for use (ifu), although not intended as a mitigation of risk, ¿to prevent damage to the catheter tip during removal from the package, grasp the hub and withdraw the catheter.Possible complications include but are not limited to the following: air embolism, hematoma at the puncture site, infection, perforation of the vessel wall¿ based on the information available and the phr review, there is no indication that the event is related to the device design or manufacturing process.Therefore, no preventative or corrective actions will be taken at this time.
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