BOSTON SCIENTIFIC CORPORATION ULTRAFLEX TRACHEOBRONCHIAL; PROSTHESIS, TRACHEAL, EXPANDABLE
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Model Number M00564770 |
Device Problems
Positioning Problem (3009); Activation Failure (3270)
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Patient Problem
No Consequences Or Impact To Patient (2199)
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Event Date 05/07/2019 |
Event Type
Injury
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Manufacturer Narrative
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(b)(4).The device has not been received for analysis.Upon receipt and completion of the failure analysis of the complaint device, if there is any further relevant information from that review, a supplemental mdr will be filed.
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Event Description
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It was reported to boston scientific corporation on (b)(4) 2019 that an ultraflex tracheobronchial covered distal release stent was to be used to treat a stenosis in the left main bronchus due to lung cancer during a tracheal stent placement procedure performed on (b)(6) 2019.Reportedly, the patient's anatomy was tortuous and was dilated prior to stent placement.According to the complainant, during the procedure, the stent was able to be deployed; however, the stent failed to expand and moved to the distal end of bronchus.The stent was removed with forceps and the procedure was completed with another ultraflex tracheobronchial stent.There were no patient complications as a result of this event.The patient's condition at the conclusion of the procedure was reported to be stable.
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Manufacturer Narrative
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Problem code 3270 captures the reportable event of stent failed to expand.Problem code 3009 captures the reportable event of stent positioning issue.An ultraflex tracheobronchial covered stent was received for analysis; the delivery system was not returned.Visual examination of the returned device found the stent was received fully deployed off the delivery system and expanded.The stent was measured to be within specifications.No other issues were noted to the stent.The stent was received deployed and expanded.As there was no issue with the device visual test during product analysis, the stent failure to expand complaint cannot be confirmed.The investigation concluded that the reported events were likely due to anatomical or procedural factors, such as characteristics of the lesion, the handling of the device, the technique used by the user, and normal procedural difficulties encountered during the procedure which may have limited the performance of the device.Therefore, the most probable root cause is adverse event related to the procedure.A review of the device history record (dhr) was performed and confirmed that this device met all material, assembly, and performance specifications at the time of release for distribution.
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Event Description
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It was reported to boston scientific corporation on (b)(6) 2019 that an ultraflex tracheobronchial covered distal release stent was to be used to treat a stenosis in the left main bronchus due to lung cancer during a tracheal stent placement procedure performed on (b)(6) 2019.Reportedly, the patient's anatomy was tortuous and was dilated prior to stent placement.According to the complainant, during the procedure, the stent was able to be deployed; however, the stent failed to expand and moved to the distal end of bronchus.The stent was removed with forceps and the procedure was completed with another ultraflex tracheobronchial stent.There were no patient complications as a result of this event.The patient's condition at the conclusion of the procedure was reported to be stable.
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Search Alerts/Recalls
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