It was reported that during a peripheral orbital atherectomy procedure, a csi saline infusion pump malfunctioned and the csi orbital atherectomy system could not be used.Subsequently, additional unplanned intervention was required to treat the patient.The physician was treating a lesion in the superficial femoral artery (sfa) with a csi orbital atherectomy device (oad) when the pump started to malfunction.It was discovered that when the pump transitioned from high flow rate to low flow rate, it switched to stand-by.The physician was unable to complete treatment using the csi device and completed the intervention using by placing an unplanned stent.Three requests for additional information have been made, but none has been received.
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The saline pump was returned with the original power cord.The initial visual examination did not reveal any damage or abnormalities that would have contributed to the reported event.Further examination revealed that the power cord remained intact and undamaged.The saline pump was plugged in and activated (powered on).The primer button was pressed and the pump increased to high speed as intended, then reverted back to slow speed and continued to run as intended.The pump motor was then tested using an in-house test fixture that simulates the electrical load of an orbital atherectomy device (oad).The high speed switch to the test fixture was turned on and the pump increased to high speed as intended.Once the test fixture was shut off (simulating turning off the oad) the motor reverted back to slow speed without any issues.The pump motor was then run at high speed for approximately fifteen minutes and retested after resting for one minute.The high speed switch to the test fixture was turned on and the pump increased to high speed and functioned as intended.Once the test fixture was shut off (simulating turning off the oad) the motor then reverted back to slow speed and continued to run as intended.The pump motor was then run at high speed for an additional fifteen minutes and retested.The high speed switch to the test fixture was turned on and the pump increased to high speed as intended.Once the test fixture was shut off (simulating turning off the oad) the motor reverted back to slow speed and the pump switched to stand-by (indicated by a yellow led), rather than continuing to run at low speed.The pump motor was diagnostically tested and found to have a fast running pump motor.At the conclusion of the failure analysis investigation, the reported event was confirmed and the root cause isolated.The root cause of the reported event was an out of specification saline pump.Corrective actions have been implemented to address this issue.(b)(4).
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