Neither the complaint instrument nor the angiographic material was returned for analysis.Therefore, no technical investigation on the subject could be performed.The product release documentation was reviewed to establish whether a deviation from the manufacturing process could be the cause for the reported event.One photograph taken from the angiogram was provided for analysis.The photograph with a rather poor quality shows a dislodged stent at the distal end of the guiding catheter up to the previously implanted stent whereas the stent appears severely deformed.Review of the product release documentation confirmed that the instrument was manufactured according to specifications and passed all in-process and final inspections.As a part of final inspection every stent system undergoes visual inspection to ensure correct embedding and homogeneous crimping of the stent.Further, the stent outer diameter and the stent retention force of a defined number of samples is tested from every lot.Based on the conducted investigations of the device being subject to this complaint, no material or manufacturing related root cause could be determined.The root cause for the complaint event is most likely related to the patients anatomy (i.E.Previously implanted stent).It should be noted that, according to the ifu, when treating multiple lesions, the distal lesion should be initially stented followed by stenting of the proximal lesion.In addition, during slow pull back of the stent system the user is advised to perform fluoroscopic control upon entry of the stent into the guiding catheter to avoid dislodgement of the stent from its position on the delivery system balloon.
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