MAUDE Adverse Event Report: ABBOTT VASCULAR DRAGONFLY¿ OPTIS¿ IMAGING CATHETER; DIAGNOSTIC INTRAVASCULAR CATHETER

Catalog Number C408646

Device Problems Difficult to Remove (1528); Failure to Advance (2524)

Patient Problem Vascular Dissection (3160)

Event Date 08/09/2023

Event Type  Injury  

Manufacturer Narrative

Manufacturer's investigation is still pending at this time.Results and conclusions will be provided in the final report.

Event Description

It was reported optical coherence tomography was to be performed in the distal left anterior descending area, behind an implanted stent.When the dragonfly imaging catheter was pushed through the implanted distal stent, the dragonfly got stuck in the stent, was difficult to remove and caused a dissection.The dissection was treated with two stents.No additional information was provided.

Manufacturer Narrative

The device was not returned for analysis.The lot history record could not be reviewed because the device was not returned, and the lot number was not provided.Additionally, a similar incident record review could not be performed because the device was not returned, and the lot number was not provided.Based on the information provided, the investigation was unable to determine a root cause for the reported failure to advance and difficult to remove.It may be possible that the anatomical conditions of the vessel and/or interaction with the implanted stent affected maneuverability of the device by preventing advancement.Furthermore, while advancing against resistance, the device or accessory device may have damaged and inadvertently caught on the implanted stent resulting in the reported difficult to remove and subsequent dissection.However, without having the device to examine, this could not be confirmed.Additionally, a cause for the reported patient effects of unexpected medical intervention and vascular dissection and the relationship to the product, if any, cannot be determined.There is no indication of a product quality issue with respect to the design, manufacture, or labeling of the device.H6: medical device problem code 4614 was removed and code 4641 was added.

• Brand Name: DRAGONFLY¿ OPTIS¿ IMAGING CATHETER
• Type of Device: DIAGNOSTIC INTRAVASCULAR CATHETER
• Manufacturer (Section D): ABBOTT VASCULAR; 26531 ynez rd.; temecula CA 92591 4628
• Manufacturer (Section G): ABBOTT MEDICAL REG#3009600098; 4 robbins rd; westford MA 01886
• Manufacturer Contact: lindsey bell ; 26531 ynez rd.; temecula, CA 92591-4628 ; 9519143996
• MDR Report Key: 17693969
• MDR Text Key: 322774096
• Report Number: 2024168-2023-09677
• Device Sequence Number: 1
• Product Code: DQO
• UDI-Device Identifier: 00183739000654
• UDI-Public: 00183739000654
• Combination Product (y/n): N
• Reporter Country Code: GM
• PMA/PMN Number: K141769
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: Foreign,Health Professional,Company Representative
• Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date: 09/27/2023

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Catalogue Number: C408646
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Initial Date Manufacturer Received: 08/22/2023
• Initial Date FDA Received: 09/06/2023
• Supplement Dates Manufacturer Received: 09/19/2023
• Supplement Dates FDA Received: 09/27/2023
• Was Device Evaluated by Manufacturer?: Device Not Returned to Manufacturer
• Is the Device Single Use?: Yes
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Initial
• Patient Sequence Number: 1
• Patient Outcome(s): Required Intervention