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U.S. Department of Health and Human Services

MAUDE Adverse Event Report: CLEARSTREAM TECHNOLOGIES LTD. HALO ONE THIN-WALLED GUIDING SHEATH

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CLEARSTREAM TECHNOLOGIES LTD. HALO ONE THIN-WALLED GUIDING SHEATH Back to Search Results
Model Number HLO54535
Device Problem Device Contamination with Chemical or Other Material (2944)
Patient Problem No Clinical Signs, Symptoms or Conditions (4582)
Event Date 06/11/2021
Event Type  malfunction  
Manufacturer Narrative
As the lot number for the device was provided, a review of the device history records is currently being performed.The return of the sample is pending.The investigation of the reported event is currently underway.(expiry date: 09/2022).
 
Event Description
It was reported that during preparation for the procedure, a viscous substance in the device was allegedly adhered to the physician's glove which made the shaft seemed uneven.It was further reported that the substance was wiped clean and the device seemed less uneven.It was further reported that another similar device was opened which also had the same viscous substance, so the physician completed the procedure using a different product.There was no patient contact.
 
Manufacturer Narrative
H10: manufacturing review: a complaint history review was performed.This is the fifth complaint reported for this lot number.The device history records were reviewed and there was nothing found to indicate there was a manufacturing related cause for these reports.Investigation summary: the sample was returned for evaluation and it was clean with no evidence of contamination.The device exhibited areas which were dull in appearance indicating some absence of hydrophilic coating.It was reported that the substance was wiped from the device.The result of the investigation is unconfirmed for the reported contamination issue.The definitive root cause for the reported contamination issue could not be determined based upon the available information.Labeling review: instructions for use for the halo one thin-walled guiding sheath was reviewed and the following sections are applicable: precautions: 6.Carefully inspect the sheath prior to use to verify that the sheath 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 use if product damage is evident.Directions for use: equipment required: ¿ sterile saline solution (heparinized), ¿ sterile saline solution (heparinized) / contrast medium (2:1 ratio recommended), ¿ luer lock syringe/inflation device with manometer (10 ml or larger), ¿ 0.035" (0.89 mm) guidewire or 0.018" (0.46 mm) guidewire as labeled per device halo one thin-walled guiding sheath preparation.1.Verify the french size is suitable for the procedure and can accommodate the required procedural devices as labeled (figure 3).Remove sheath and dilator from package.2.Prior to use, the air in the sheath and dilator should be removed.To facilitate purging, the device is packaged with the dilator inside the sheath in a reverse direction allowing both to be flushed simultaneously.Select a syringe or inflation device with a 10 ml or larger capacity and fill approximately half of it with sterile saline solution.Prepare the lumen by connecting the syringe or inflation device containing the solution into the stopcock on the side-port of the sheath and flush with the sterile heparinized saline solution (figure 4).Close the stopcock to maintain the air tightness following flushing.3.Prior to use the reverse loaded dilator must be removed from the distal end of the sheath.If not already completed at step 2, the air in the dilator lumen should be removed.To facilitate purging, select a syringe or inflation device with a 10 ml or larger capacity and fill approximately half of it with sterile saline solution.Prepare the lumen by connecting the syringe or inflation device containing the solution into the luer connector of the dilator hub and flushing with the sterile heparinized saline solution (figure 7).4.Insert the provided vessel dilator through the hemostatic valve and click the dilator hub into place in the valve housing (figures 5 and 6).5.In order to activate the hydrophilic coating, where labeled, it is recommended to wet the halo one thin-walled guiding sheath with sterile saline solution immediately prior to its insertion in the body.H10: d4 (expiry date: 09/2022).H11:section a through f - the information provided by bd represents all of the known information at this time.Despite good faith efforts to obtain additional information, the complainant / reporter was unable or unwilling to provide any further patient, product, or procedural details to bd.H3 other text: see h10.
 
Event Description
It was reported that during preparation for the procedure, a viscous substance in the device was allegedly adhered to the physician's glove which made the shaft seemed uneven.It was further reported that the substance was wiped clean and the device seemed less uneven.It was further reported that another similar device was opened which also had the same viscous substance, so the physician completed the procedure using a different product.There was no patient contact.
 
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Brand Name
HALO ONE THIN-WALLED GUIDING SHEATH
Type of Device
GUIDING SHEATH
Manufacturer (Section D)
CLEARSTREAM TECHNOLOGIES LTD.
moyne upper
enniscorthy, co. wexford N A
EI  N A
MDR Report Key12134466
MDR Text Key261240560
Report Number9616666-2021-00101
Device Sequence Number1
Product Code DYB
UDI-Device Identifier00801741161926
UDI-Public(01)00801741161926
Combination Product (y/n)N
PMA/PMN Number
K192313
Number of Events Reported1
Summary Report (Y/N)N
Report Source Manufacturer
Source Type company representative,foreig
Type of Report Initial,Followup
Report Date 10/04/2021
1 Device was Involved in the Event
1 Patient was Involved in the Event
Is this an Adverse Event Report? No
Is this a Product Problem Report? Yes
Device Operator Health Professional
Device Model NumberHLO54535
Device Catalogue NumberHLO54535
Device Lot NumberCMEX0368
Was Device Available for Evaluation? Device Returned to Manufacturer
Date Returned to Manufacturer07/21/2021
Initial Date Manufacturer Received 06/11/2021
Initial Date FDA Received07/08/2021
Supplement Dates Manufacturer Received11/02/2021
Supplement Dates FDA Received11/03/2021
Is This a Reprocessed and Reused Single-Use Device? No
Patient Sequence Number1
Patient Outcome(s) Other;
Patient Age75 YR
Patient Weight70
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