A diamondback 360 coronary orbital atherectomy device (oad) was used for treatment of a highly calcified, 99% stenosed, 3.5mm lesion in the proximal right coronary artery (rca) via retrograde femoral access.The proximal lesion was treated with three low speed treatments.Glideassist was used to advance the crown to the mid rca prior to engaging and treating the mid rca lesion.Two oad low-speed treatments were performed.Cine cardiac imaging did not show extravasation.After the third low-speed treatment, the patient felt chest discomfort.An angiogram revealed a large extravasation to pericardium.Several sizes of balloons were used in an attempt to prevent the cardiac tamponade.Interventions to resolve the adverse event were unsuccessful, and the patient expired.
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H6 investigation conclusion code 22: the diamondback 360® coronary orbital atherectomy system instructions for use manual states that vessel perforation is a potential adverse event that may occur and/or require intervention with use of the system.The oad was returned for analysis.There was no damage or abnormalities observed with the drvieshaft or handle assembly that would have contributed to the reported event.The driveshaft crown was measured and met drawing specifications.Review of the device data log did not identify any events that could have contributed to the reported event.When tested, the oad functioned as intended.The device history record for this oad lot number has been reviewed.No issues or discrepancies were noted during this review that would have contributed to the reported event.The device met material, assembly, and quality control requirements.Csi id: (b)(4).
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