(b)(4).The customer returned multiple components from a cvc kit.The guide wire will be analyzed as part of this complaint investigation.Signs-of-use in the form of biological material was observed on the guide wire tubing.Visual analysis revealed that the guide wire contained one slight kink/bend near the distal end.This resulted in the distal j-bend to be slightly misshapen.Microscopic examination confirmed the kink and revealed that the distal and proximal welds were secure and intact.The kink in the guide wire measured 55mm from the distal weld.The guide wire total length measured 603mm , which is within the specification limits of 596mm-604mm per the guide wire graphic.The guide wire outer diameter measured.794mm, which is within the specification limits of.788mm-.826mm per the guide wire graphic.The guide wire was passed through the returned catheter.Little to no resistance was observed.A manual tug test confirmed that the distal and proximal welds were secure and intact.A device history record review was performed, and no relevant findings were identified.The ifu provided with the kit informs the user, "although the incidence of spring-wire guide failure is extremely low, practitioner should be aware of the potential for breakage if undue force is applied to the wire".The ifu also states, "although the incidence of spring-wire guide failure is extremely low, practitioner should be aware of the potential for breakage if undue force is applied to the wire guide".The report of a kinked guide wire was confirmed through complaint investigation.Visual analysis revealed that the guide wire was kinked near the distal end.Despite this, the guide wire met all relevant dimensional and functional requirements, and a device history record review was performed with no relevant findings.Based on the customer report and the sample received, unintentional user error likely caused or contributed to this event.Teleflex will continue to monitor and trend for reports of this nature.
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