COOK INC ULTRATHANE MAC-LOC LOCKING LOOP MULTIPURPOSE DRAINAGE CATHETER; GBO CATHETER, NEPHROSTOMY, GENERAL & PLASTIC SURGERY
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Model Number N/A |
Device Problems
Difficult to Remove (1528); Improper or Incorrect Procedure or Method (2017); Difficult to Advance (2920)
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Patient Problem
No Clinical Signs, Symptoms or Conditions (4582)
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Event Date 10/27/2022 |
Event Type
malfunction
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Manufacturer Narrative
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Blank fields on this form indicate the information is unknown or unavailable.Pma/510(k) #: exempt.This report includes information known at this time.A follow up report will be submitted should additional relevant information become available.This report is required by the fda under 21 cfr part 803.This report is based on unconfirmed information submitted by others.Neither the submission of this report nor any statement made in it is intended to be an admission that any cook device is defective or malfunctioned; that a death or serious injury occurred; or that any cook device caused or contributed to; or is likely to cause or contribute to a death or serious injury if a malfunction occurred.
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Event Description
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It was reported the flexible stiffener in an ultrathane mac-loc locking loop multipurpose drainage catheter set was difficult to remove.The device was required for an ureterostomy procedure on a patient of unspecified gender and age.When the flexible stiffener was advanced into the catheter and over the wire guide, the physician experience difficulty and noted the device was "tight".Attempted removal of the stiffener was also difficult and "tight"; an unknown 0.035 wire guide broke in the process.All of the components were then removed from the patient and the procedure was successfully completed with a competitor's device.Once removed from the patient, the physician attempted to remove the stiffener from the catheter but was unsuccessful.As reported, the patient did not experience any adverse effects or require any additional procedures due to this occurrence.Additional information regarding the event has been requested but is currently unavailable.
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Manufacturer Narrative
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Blank fields on this form indicate the information is unknown, unavailable or unchanged.Correction: d10 additional information: b5, h6 - annex a this report includes information known at this time.A follow-up report will be submitted should additional, relevant information become available.This report is required by the fda under 21 cfr part 803 and is based on unconfirmed information submitted by others.Neither the submission of this report nor any statement contained herein is intended to be an admission that any cook device is defective or malfunctioned, that a death or serious injury occurred, nor that any cook device caused, contributed to, or is likely to cause or contribute to a death or serious injury if a malfunction occurred.
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Event Description
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Additional information was received on (b)(6) 2022 by a cook clinical specialist.When performing the procedure, the customer was cutting the mac-loc off and pulling the string out; then, the customer was placing the drain through a stoma, up the ureter, and into the kidney over a competitor's wire guide.As reported, the patient did not experience any adverse effects or require any additional procedures due to this occurrence.
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Manufacturer Narrative
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Investigation ¿ evaluation: on 28oct2022, cook medical received a complaint from a representative at the (b)(6).During the insertion of an ultrathane mac-loc locking loop multipurpose drainage catheter (rpn: ult10.2-38-45-p-6s-clm-rh, lot: unknown) into the patient, the physician had difficulty threading the flexible stiffener over the wire.When using the plastic stiffener in the multipurpose drainage, tightness was noticed during advancement and removal of the flexible stiffener.While attempting to remove the stiffener, the.035 wire broke in the patient.The physician was able to remove the entire device from the patient, and a competitor¿s device was then used to complete the procedure with no further complications.Attempts to remove the stiffener from the dilator were made by the physician once the device was outside of the patient, and difficulty was still felt.Reviews of the documentation, including the instructions for use (ifu), manufacturing instructions, quality control procedures and specifications of the device, were conducted during the investigation.The complaint device was not returned for evaluation; therefore, a physical examination could not be conducted.However, a document-based investigation evaluation was performed.A review of the device master record (dmr) concluded that inspection activities are currently in place to prevent the release of non-conforming product related to the reported failure mode.The customer did not provide the lot number for the complaint device.Cook reviewed the sales history for this customer and was unable to identify the complaint lot.The device history record could not be reviewed.Cook also reviewed product labeling.Although the lot was not returned, the current attached ifu, t_multi2_rev1, under the heading precautions: it reads, ¿when inserting a stiffening cannula into the catheter with retention suture, hold suture during cannula insertion to avoid bunching or tangling of the suture.¿ from evidence gathered by a review of the dmr and ifu, it was concluded that the device was manufactured to specification.Cook could confirm that there were no nonconforming devices in house or out in the field.Based on the information provided, no returned product, and the results of our investigation, a definitive cause for the failure could be traced to the user, due to an unapproved or contraindicated use.It was stated that the mac-loc adaptor was cut, with the black suture string pulled out, prior to insertion.The appropriate personnel have been notified.Per the risk assessment no further action is required.We will continue to monitor for similar complaints.This report is required by the fda under 21 cfr part 803 and is based on unconfirmed information submitted by others.Neither the submission of this report nor any statement contained herein is intended to be an admission that any cook device is defective or malfunctioned, that a death or serious injury occurred, nor that any cook device caused, contributed to, or is likely to cause or contribute to a death or serious injury if a malfunction occurred.
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Event Description
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No additional information regarding patient and/or event details has been received since the previous medwatch report was sent.
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Search Alerts/Recalls
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