Evaluation summary: the visual appearance of the balloon showed slight signs of a twist 4.5 cm from the tip.After the decontamination visual and tactile inspection were performed: it was found unfolded, full of dried contrast medium, with a twist 4.5 cm from the tip.The 0.018¿¿ guide wire was loaded without any issue.During the analysis, negative pressure was applied with a manometric syringe on the balloon: no bubbles emerged in the water column.The balloon was inflated and observed under microscope.At 2 bar it was still showing slight signs of twist.At 7 bar and 14 bar twist was no longer detected.No twist was present on the guide wire lumen.After the balloon deflation it was still possible to see slight wrinkles on the surface in correspondence of the twist.Continued from block evaluation codes: results: operational problem - the root cause is related to the direction of the folding pleats which appear not to be folded parallel to the shaft of the device.Once inside the artery, the folding pleats most likely encounter resistance related to a tight lesion, resulting an incomplete balloon expansion evaluation codes: conclusion: operational context caused or contributed to event - the root cause is related to the direction of the folding pleats which appear not to be folded parallel to the shaft of the device.Once inside the artery, the folding pleats most likely encounter resistance related to a tight lesion, resulting an incomplete balloon.
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