MAUDE Adverse Event Report: CORDIS CORPORATION SABER RX3MM4CM155; CATHETER, ANGIOPLASTY, PERIPHERAL, TRANSLUMINAL

Model Number 51003004L

Device Problem Burst Container or Vessel (1074)

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

Event Date 04/04/2022

Event Type  malfunction  

Manufacturer Narrative

Additional information is pending and will be submitted within 30 days upon receipt.

Event Description

A 3mm x 4cm 155 saber rx percutaneous transluminal angioplasty (pta) balloon catheter was used for ivus could not cross the lesion and the pressure did not rise above 3 atmospheres (atm) during the initial inflation.Rupture was confirmed on fluoroscopy and it was removed.It was replaced with a new saber (different lot) and it could be inflated without any issues.There was no reported patient injury.The lesion was the left popliteal and back-knee.A contralateral approach was made from the right femoral artery with a 6f non-cordis guiding sheath.A non-cordis guidewire was changed to another guidewire and it crossed the lesion.The device was discarded due to hospital regulation.Additional information was requested; however, the information was not obtained after multiple attempts.

Event Description

A 3mm x 4cm 155 saber rx percutaneous transluminal angioplasty (pta) balloon catheter was used for ivus could not cross the lesion and the pressure did not rise above 3 atmospheres (atm) during the initial inflation.Rupture was confirmed on fluoroscopy and it was removed.It was replaced with a new saber (different lot) and it could be inflated without any issues.There was no reported patient injury.The lesion was the left popliteal and back-knee.A contralateral approach was made from the right femoral artery with a 6f non-cordis guiding sheath.A non-cordis guidewire was changed to another guidewire and it crossed the lesion.The device was discarded due to hospital regulation.Additional information was requested; however, the information was not obtained after multiple attempts.

Manufacturer Narrative

A 3mm x 4cm 155 saber rx percutaneous transluminal angioplasty (pta) balloon catheter was used for ivus could not cross the lesion and the pressure did not rise above three atmospheres (atm) during the initial inflation.Rupture was confirmed on fluoroscopy, and it was removed.It was replaced with a new saber (different lot) and it could be inflated without any issues.There was no reported patient injury.The lesion was the left popliteal and back-knee.A contralateral approach was made from the right femoral artery with a 6f non-cordis guiding sheath.A non-cordis guidewire was changed to another guidewire, and it crossed the lesion.Additional information was requested; however, the information was not obtained after multiple attempts.The product was not returned for analysis as it was discarded due to hospital regulation.A product history record (phr) review of lot 82230535 revealed no anomalies or non-conformances during the manufacturing and inspection processes that can be associated with the reported event.The reported ¿balloon burst-at/below rbp¿ could not be confirmed as the device was not returned for analysis.The exact cause could not be determined.Vessel characteristics, although unknown and procedural factors likely contributed to the reported event.However, with the limited amount of information available regarding lesion characteristics and without the return of the device for analysis it is difficult to draw a clinical conclusion between the device and the event reported.According to the warnings in the safety information in the instructions for use ¿prior to angioplasty, the catheter should be examined to verify functionality and integrity, and ensure that its size and shape are suitable for the specific procedure for which it is to be used.Do not use if product damage is suspected or evident.To reduce the potential for vessel damage or the risk of dislodgement of particles it is very important that the inflated diameter of the balloon should approximate the diameter of the vessel just proximal and distal to the lesion.The balloon dimensions are printed on the product label.The compliance table incorporated with the product shows how balloon diameter increases as pressure increases.Do not exceed the rated burst pressure recommended on the label.The rated burst pressure is based on the results of in vitro testing.At least 99.9% of the balloons (with a 95% confidence) will not burst at or below their rated burst pressure.Use of a pressure monitoring device is recommended to prevent over-pressurization.Pressure in excess of the rated burst pressure can cause balloon rupture and potential inability to withdraw the catheter through the introducer sheath.Balloon rupture can cause vessel damage and the need for additional intervention.Use only the recommended balloon inflation medium (a 50/50 mixture by volume of contrast medium and normal saline).Never use air or any gaseous medium to inflate the balloon.¿ neither the phr nor the information available suggests a design or manufacturing related cause for the reported event.Therefore, no corrective or preventive action will be taken at this time.

• Brand Name: SABER RX3MM4CM155
• Type of Device: CATHETER, ANGIOPLASTY, PERIPHERAL, TRANSLUMINAL
• Manufacturer (Section D): CORDIS CORPORATION; 14201 nw 60 avenue; miami lakes FL 33014
• Manufacturer (Section G): CORDIS CORPORATION; 14201 nw 60 avenue; miami lakes FL 33014
• Manufacturer Contact: karla castro ; 14201 nw 60 avenue; miami lakes, FL 33014 ; 7863138372
• MDR Report Key: 14258675
• MDR Text Key: 291716113
• Report Number: 9616099-2022-05602
• Device Sequence Number: 1
• Product Code: LIT
• UDI-Device Identifier: 20705032075739
• UDI-Public: (01)20705032075739(17)240731(10)82230535
• Combination Product (y/n): N
• Reporter Country Code: JA
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: Foreign,Health Professional,Company Representative
• Reporter Occupation: Other Health Care Professional
• Type of Report: Initial,Followup
• Report Date: 05/24/2022

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: 07/31/2024
• Device Model Number: 51003004L
• Device Catalogue Number: 51003004L
• Device Lot Number: 82230535
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Initial Date Manufacturer Received: 04/05/2022
• Initial Date FDA Received: 05/02/2022
• Supplement Dates Manufacturer Received: 05/04/2022
• Supplement Dates FDA Received: 05/24/2022
• Date Device Manufactured: 08/23/2021
• Is the Device Single Use?: Yes
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Initial
• Patient Sequence Number: 1
• Treatment: GUIDEWIRE (VASSALLO18FLOPPY, ASAHIINTECC).; GUIDING SHEATH (6F, DESTINATION TERUMO).; SABER BALLOON.; UNK GUIDEWIRE (G30).