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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 advanced with unspecified resistance noted and then when removed, the guide wire was unraveled.Additionally the shape retention of the wire was not normal as when the wire was taken out of the anatomy, it was in a "u" shape.A snare was used to remove the guide wire as there was unspecified resistance during removal.An unspecified guide wire was used to complete the procedure.There were no adverse patient sequela and there was no reported clinically significant delay in the procedure.No additional information was provided.
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A visual inspection was performed on the returned device.The reported break was confirmed.The reported stretched coils were confirmed.The reported product quality problem (shape), difficult to remove and difficult to advance could not be tested due to the device condition.The electronic lot history record (elhr) / device history record (dhr) and exception review were performed and revealed no indication of a product quality issue.Additionally, a query of the complaint handling database for the reported lot revealed no indication of a lot specific issue.The investigation was unable to determine a conclusive cause for the reported difficulties; however, the subsequent treatment was likely due to operational context.In this case, analysis of the returned device noted stretched coils, bends, a core break, and a shaping ribbon break on the guide wire¿s distal end.This type of damage is consistent with manipulation 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 damage.Damage to the guide wire would impact its maneuverability within the anatomy, possibly contributing to the reported difficulty during removal.Additionally, analysis of the returned device noted a core and shaping ribbon break on the distal end.It is possible that the core/shaping ribbon break 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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