MAUDE Adverse Event Report: COOK INC FLEXOR INTRODUCER SHEATH; DYB INTRODUCER, CATHETER

Model Number G09908

Device Problem Nonstandard Device (1420)

Patient Problem No Clinical Signs, Symptoms or Conditions (4582)

Event Type  malfunction  

Manufacturer Narrative

Customer name and address= phone: (b)(6).This report includes information known at this time.A follow-up report will be submitted should additional relevant information become available.

Event Description

Reportedly, during a percutaneous transluminal angioplasty, the radiopaque band was not visible on a flexor introducer sheath.A section of the device did not remain inside the patient¿s body.The patient did not require any additional procedures due to this occurrence.According to the initial reporter, the patient did not experience any adverse effects due to this occurrence.

Manufacturer Narrative

The event is currently under investigation.A follow-up report will be submitted upon receipt of additional information or completion of the investigation.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.

Event Description

No new patient or event information since the last report was submitted.

Event Description

No new patient or event information to report.

Manufacturer Narrative

Description of event: reportedly, during a percutaneous transluminal angioplasty, the radiopaque band was not visible on a flexor introducer sheath.Investigation ¿ evaluation: a visual inspection and functional testing of the returned unused devices was conducted.A document based investigation was also performed including a review of complaint history, device history record, drawings, the instructions for use, manufacturing instructions, and quality control data.Although the used complaint device was not received, the user facility returned (b)(4)unused devices from the complaint lot, reported in 1820334-2021-01526, to cook for investigation.Physical examination of the returned unused devices confirmed no presence of the radiopaque band at the distal end all complaint devices.During tabletop testing, the caps were disassembled from check-flo valves, which showed that the radiopaque band was present just below the flares.Per the device drawing, the radiopaque marker should be 2-3mm from the distal tip of the sheath.Results from the device failure analysis are evidence that the devices were manufactured out of specification.A review of the device history record found no non-conformances related to the reported failure mode.A database search for complaints on the reported lot found 11 additional complaints from the field that were reported for the same failure mode (reported under manufacturer report # 1820334-2021-01506, 1820334-2021-01515, 1820334-2021-01516, 1820334-2021-01517, 1820334-2021-01518, 1820334-2021-01512, 1820334-2021-01513, 1820334-2021-01514, 1820334-2021-01519, 1820334-2021-01520, and 1820334-2021-01526).At this time, cook concluded that complaint device is non-conforming and that additional non-conforming product from this lot exists in the field.Cook also reviewed product labeling.The product ifu does not provide information related to the reported failure mode.A device master record (dmr) review was performed, and device drawings, manufacturing instructions, and quality control procedures associated with the complaint were identified.As a new quality control inspection step was implemented via a previously opened capa after the complaint device lot was manufactured, cook has concluded that sufficient inspection activities are now in place to identify this failure mode prior to distribution.Based on the available information, cook has concluded that a manufacturing deficiency contributed to this incident.The investigation determined that two lots were manufactured incorrectly.A recall-removal was initiated for the two affected lots.Investigation into complaint and nonconformance history found no evidence of additional affected lots.The failure mode is highly detectable by end users, and a new inspection step was implemented 01jun2021.The complaint lots were manufactured prior to implementation of the inspection step.The operator responsible for nonconforming devices was retrained to applicable procedures.Cook will continue monitoring of similar complaints and has notified the appropriate personnel of this event.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.

• Brand Name: FLEXOR INTRODUCER SHEATH
• Type of Device: DYB INTRODUCER, CATHETER
• Manufacturer (Section D): COOK INC; 750 daniels way; bloomington IN 47404
• MDR Report Key: 12011899
• MDR Text Key: 258617614
• Report Number: 1820334-2021-01521
• Device Sequence Number: 1
• Product Code: DYB
• UDI-Device Identifier: 00827002099081
• UDI-Public: (01)00827002099081(17)240331(10)13861362
• Combination Product (y/n): N
• PMA/PMN Number: K142829
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: company representative,foreig
• Type of Report: Initial,Followup,Followup
• Report Date: 10/06/2021

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 06/16/2021
• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Expiration Date: 03/31/2024
• Device Model Number: G09908
• Device Catalogue Number: KCFW-6.0-35-45-RB
• Device Lot Number: 13861362
• Was Device Available for Evaluation?: No
• Date Manufacturer Received: 10/04/2021
• Is This a Reprocessed and Reused Single-Use Device?: No
• Patient Sequence Number: 1
• Treatment: TERUMO WIRE, MUSTANG PTA