| Catalog Number |
1001780J |
| Medical Device Problem Codes |
Break (1069); Product Quality Problem (1506); Difficult to Remove (1528); Stretched (1601); Difficult to Advance (2920)
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| Health Effect - Clinical Code |
No Clinical Signs, Symptoms or Conditions (4582)
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| Date of Event |
10/11/2023
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Type of Reportable Event
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Malfunction
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Additional Manufacturer Narrative
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Manufacturer's investigation is still pending at this time.Results and conclusions will be provided in the final report.The additional bmw device referenced in b5 is filed under a separate medwatch report number.
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Event or Problem Description
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It was reported that the procedure was to treat the left anterior descending (lad) coronary artery with heavy calcification and mild tortuosity.The balance middleweight (bmw) guide wire was used and then when removed, the guide wire was unraveled.There was unspecified resistance during advancement for both wires.Additionally the shape retention of the wire was not normal as the shape was a "u" when the guide wire was taken out of the anatomy.This occurred with a second bmw guide wire as well.There was unspecified resistance during removal for both wires.Reportedly, a snare was required to pull back one of the wires.An unspecified guide wire was used to complete the procedure.There were no adverse patient sequela.No additional information was provided.
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Additional Manufacturer Narrative
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A visual inspection was performed on the returned device.The reported stretched coils were confirmed.The reported break was not confirmed.The reported difficult to remove and difficult to advance could not be tested due to the device condition.The reported product quality problem (shape) was confirmed as a kink in the shaping ribbon.A review of the lot history record identified no manufacturing nonconformities issued to the reported lot that would have contributed to this event.Additionally, a review of the complaint history of the reported lot did not indicate a lot specific quality issue.The investigation determined the reported difficulties appear to be related to the operational context of the procedure.In this case, analysis of the returned device noted misaligned coils and bends/kinks on the guide wire¿s distal end.This type of damage is consistent with advancement against resistance.It is possible that interaction with the patient¿s heavily calcified and mildly tortuous lesion or an accessory device may have contributed to the reported resistance during advancement and subsequently resulted in the noted coil damage.Damage to the guide wire (bends/kinks) would impact its maneuverability within the anatomy, possibly contributing to the reported difficulty during removal.Additionally, analysis of the returned device noted a kink in the shaping ribbon.It is possible that the kink in the shaping ribbon contributed to the guide wire tip reportedly not retaining its shape.There is no indication of a product quality issue with respect to manufacture, design, or labeling.
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Search Alerts/Recalls
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