H6: medical device problem code: 2017 - use after damage.A visual inspection was performed on the returned device and the reported separation was confirmed.The inner member and the outer member were noted to be separated from the side arm luer.A review of the lot history record identified no manufacturing nonconformities issued to the reported lot that would have contributed to this event.Based on the review of similar incidents there is no indication of a lot specific product quality issue.There was no damage noted to the balloon catheter during the inspection prior to preparation which suggests a product quality issue with respect to manufacture, design or labeling did not contribute to the reported difficulties.It should be noted that the armada 14, global, ce, instructions for use (ifu) states: carefully inspect the catheter prior to use to verify that it has not been damaged during shipment and that its size, shape and condition are suitable for the procedure for which it is to be used.Do not inflate the pta catheter during preparation of the device.In this case, the reported ifu violation of used after damage was noted and inflated before use does not appear to have caused the reported separation.The investigation determined the reported separation appears to be related to operational circumstances of the procedure.Based on the reported information, during device preparation, the device was wiped with a wet gauze likely stretching the proximal shaft causing the inner and outer member separation from the hub.The device was then inflated and deflated outside the anatomy to identify additional issues with the balloon.The device was then used as a support catheter.The noted damages to the inner, outer members and balloon likely occurred during retraction of the devices.There is no indication of a product quality issue with respect to manufacture, design or labeling; therefore, no corrective action is required.H6: patient code 2645 - removed.
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Subsequent to the initial report, additional information was which indicated that the side arm separated during device preparation and the device was pressurized outside the patient anatomy.The device was used in the anatomy as a support catheter; however, no attempt was made to pressurize the balloon inside the patient anatomy.No additional information was provided.
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