Catalog Number 1804250-08 |
Device Problems
Entrapment of Device (1212); Failure to Advance (2524); Device Dislodged or Dislocated (2923); Material Deformation (2976)
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Patient Problem
No Clinical Signs, Symptoms or Conditions (4582)
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Event Date 10/19/2023 |
Event Type
Injury
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Event Description
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It was reported that the procedure was to treat a heavily calcified, heavily tortuous left main into ostial left circumflex (lcx) artery.Two unspecified stents were implanted and a third 2.5x08mm xience skypoint stent delivery system (sds) was attempted to advance.However, it was stent had a tough time pushing it around the left main bend into the lcx.The struts at the proximal end of the stent fished scaled off the edge of the balloon due to the severe angle and the sds could not be pulled back.Therefore, the guideliner was brought up to the edge of the stent and was pulled out as a whole, jammed on the edge of the guideliner.Another xience skypoint stent was used to successfully complete the procedure.There was no adverse patient sequela and no clinically significant delay in the procedure.No additional information was provided.
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Manufacturer Narrative
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Manufacturer's investigation is still pending at this time.Results and conclusions will be provided in the final report.
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Manufacturer Narrative
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The device was returned for analysis.The reported material deformation was confirmed.The reported failure to advance and entrapment with the vessel could not be replicated in a testing environment as it was related to operational context of the procedure.A review of the lot history record identified no manufacturing nonconformities issued to the reported lot that would have contributed to this event.Additionally, a review of the complaint history identified no similar incidents from this lot.The investigation determined the reported difficulties and treatment appear to be related to circumstances of the procedure.There is no indication of a product quality issue with respect to manufacture, design or labeling.H6: medical device problem code 2923 removed, 2976 added.
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Event Description
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Subsequently, after the initial report was filed, return device analysis and follow up with the account confirmed that the stent remained on the delivery system the stent did not dislodge; however, the stent strut was flared.No additional information was provided.
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Search Alerts/Recalls
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