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Catalog Number 0650HYB0605 |
Device Problems
Break (1069); Sticking (1597); Activation, Positioning or Separation Problem (2906)
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Patient Problem
Tissue Damage (2104)
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Event Date 11/03/2015 |
Event Type
Injury
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Manufacturer Narrative
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(b)(4).Concomitant medical products: (b)(6) 2015 gore® hybrid vascular graft lot #13687094.A review of the manufacturing records for the devices verified that the lots met all pre-release specifications.The devices were returned to w.L.Gore & associates for investigation.Submitted in this event was/were 2 incomplete gore® hybrid vascular grafts.The examination found no definitive anomalies attributable to the manufacture of the devices.The returned devices match the reported description of the devices in the event.Information provided reported the use of a ¿12fr.Peel away sheath¿ used for both grafts.Instructions for use (ifu) table 1 recommends use of an 11 fr peal/tear-away sheath size for a labeled nitinol reinforced section diameter of 6mm.Device 1: partial expansion of the proximal end, with the middle of the nitinol reinforced section(nrs) still constrained, along with blunt end fibers, is consistent with attempted deployment of the constraint delivery system(cds) from a proximal to distal direction.Ifu states, ¿deployment of the nitinol reinforced section will occur from the tip of the delivery constraint toward the non-nitinol reinforced section¿ if instructions are followed.Body tape delamination and distal migration is consistent with extraction of an expanded device from a vessel.No major tape delamination, bent or broken struts, or visible interactions/entanglements were observed suggesting the deployment line(dl) was free from any obstructions inhibiting deployment.
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Event Description
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On (b)(6) 2015, a patient was being implanted with two gore hybrid vascular grafts in a debranching procedure in the superior mesenteric artery and the left renal artery.The grafts were both inserted through a 12 fr peel-away sheath.It was reported to gore that as the nitinol portion of the first device was being deployed into the superior mesenteric artery, the deployment line broke.The device was partially deployed.The arteriotomy was extended, the nitinol portion was removed and a regular anastomosis was performed.It was reported to gore that as the nitinol portion of the second device was being deployed into the renal artery, the deployment line got stuck after two-thirds of the device deployed.The procedure was completed by extending the arteriotomy, cutting the nitinol portion off and performing a regular anastomosis.
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Manufacturer Narrative
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Initial reporter: complainant was a distributor.
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Search Alerts/Recalls
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