MAUDE Adverse Event Report: THE SPECTRANETICS CORPORATION SPECTRANETICS TURBO ELITE LASER ATHERECTOMY CATHETER; CATHETER, PERIPHERAL, ATHERECTOMY

Model Number 417-152

Device Problem Break (1069)

Patient Problem Unintended Radiation Exposure (4565)

Event Date 07/29/2021

Event Type  malfunction  

Manufacturer Narrative

The device was not returned for investigation.

Event Description

A peripheral atherectomy procedure commenced to treat a lesion in the proximal superficial femoral artery.The physician chose to use a spectranetics turbo elite laser atherectomy catheter to treat the patient.During the procedure, it was reported that the housing of the catheter was broken; when they inserted the catheter they could see red light emitting through the middle of the catheter.The procedure was completed with a second turbo elite device with no reported patient harm.This report captures the turbo elite which was reported damaged during use and resulted in unintended radiation exposure with potential for harm.

Manufacturer Narrative

The device was returned to the manufacturer on 14 sept 2021.The device investigation was completed on 16 sept 2021.The device was returned and evaluated by a cross functional team.Wrinkles were seen on the device''s outer jacket, 45.75in from the distal tip.Dead fibers and a breach to the outer jacket were seen in the area of the wrinkles.8-9 dead fibers were seen at both the distal tip and the proximal coupler.Likely, the device''s outer jacket became caught on an unknown structure, causing the wrinkles in and a breach to the outer jacket.This failure has been determined to be use related.

• Brand Name: SPECTRANETICS TURBO ELITE LASER ATHERECTOMY CATHETER
• Type of Device: CATHETER, PERIPHERAL, ATHERECTOMY
• Manufacturer (Section D): THE SPECTRANETICS CORPORATION; 9965 federal drive; colorado springs CO 80921
• MDR Report Key: 12339190
• MDR Text Key: 267348268
• Report Number: 1721279-2021-00154
• Device Sequence Number: 1
• Product Code: MCW
• UDI-Device Identifier: 00813132024734
• UDI-Public: (01)00813132024734(17)230512(10)FAZ21E04A
• Combination Product (y/n): Y
• PMA/PMN Number: K170059
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: company representative,health
• Type of Report: Initial,Followup
• Report Date: 07/29/2021

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 Expiration Date: 05/12/2023
• Device Model Number: 417-152
• Device Catalogue Number: 417-152
• Device Lot Number: FAZ21E04A
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 09/14/2021
• Was the Report Sent to FDA?: No
• Initial Date Manufacturer Received: 07/29/2021
• Initial Date FDA Received: 08/18/2021
• Supplement Dates Manufacturer Received: 09/16/2021
• Supplement Dates FDA Received: 09/27/2021
• Is This a Reprocessed and Reused Single-Use Device?: No
• Patient Sequence Number: 1
• Treatment: 2ND TURBO ELITE LASER ATHERECTOMY CATHETER; BOSTON SCIENTIFIC 0.014 GUIDE WIRE; COOK MEDICAL 6F INTRODUCER SHEATH; SPECTRANETICS CVX-300 EXCIMER LASER SYSTEM