It was reported, during a tace (transcatheter arterial chemoembolization) procedure, leakage occurred from the stopcock.The physician had attempted to mix contrast medium and anti-cancer agent when the leakage was observed.Another manufacturer's device was used instead and the procedure was completed successfully.No patient adverse effects were reported.
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Blank fields on this form indicate the information is unknown, unavailable, or unchanged.Investigation ¿ evaluation.A review of the complaint history, device history record, documentation, drawing, manufactures instructions, quality control, and a functional test & visual inspection of the returned device were conducted during the investigation.The visual inspection of the returned device confirmed that there was a crack on the body of the device.During the functional test, the device was noted to have leaked through the crack when the stem was in the left position.No leaks were noted from the fitting when tested.However, the thru-hole was verified to be open when using a 0.65 pin gauge.Additionally, a document based investigation evaluation was performed.There is no evidence to suggest the product was not made to specifications.A review of the device history record showed no nonconforming events which could contribute to this failure mode.It should be noted there were no other reported complaints for this lot number.Furthermore, a review of the manufactures instructions and documentation revealed relevant information surrounding the mold used for this device.The material used for this device has the potential to absorb moisture, resulting in an increase in diameter, thus raising the potential for cracking the stopcock body.Based on the information provided, the examination of the returned product, and the results of our investigation, a definitive root cause can be traced to device designed.Measures are being conducted to address this failure mode.We will continue our monitoring of similar complaints and have notified the appropriate personnel of this event.Per the risk assessment no further action is required.This report is required by the fda under 21 cfr part 803.This report is based on unconfirmed information submitted by others.Neither the submission of this report nor any statement made in it is intended to be an admission that any cook device is defective or malfunctioned; that a death or serious injury occurred; or that any cook device caused or contributed to; or is likely to cause or contribute to a death or serious injury if a malfunction occurred.
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