| Catalog Number |
FEM06080 |
| Medical Device Problem Codes |
Break (1069); Fracture (1260); Misfire (2532)
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| Health Effect - Clinical Code |
No Clinical Signs, Symptoms or Conditions (4582)
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| Date of Event |
12/03/2024
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Type of Reportable Event
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Malfunction
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Event or Problem Description
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It was reported that during a stent graft placement procedure, there was mild resistance to deployment at first.After some time approximately one fifth of device deployed.It was further reported that there was significant resistance and the cover sheath of the device that is pulled back to deploy the device broke.The procedure was completed using another device.There was no reported patient injury.
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Additional Manufacturer Narrative
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H10: as the lot number for the device was provided, a review of the device history records is currently being performed.The device has been returned to the manufacturer for evaluation.However.The investigation of the reported event is currently underway.H11: section a through f - the information provided by bd represents all of the known information at this time.Despite good faith efforts to obtain additional information, the complainant / reporter was unable or unwilling to provide any further patient, product, or procedural details to bd.
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Additional Manufacturer Narrative
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H10: manufacturing review: based on the information available it is not reasonably suggested that a manufacturing process may have caused or contributed to the reported issue.However, the lot history records of this lot were reviewed with special attention to the manufacturing and inspection of this product and the product was found to have met the specification prior to shipment.Investigation summary: the sample was returned for evaluation, and the stent graft was partially deployed while the outer sheath was fractured which leads to confirmed results for sheath fracture and misfire.There was no indication of manufacturing deficiencies.Based on the provided information and the evaluation of the returned sample, the investigation is closed with confirmed results for partial deployment and outer sheath fracture.A definite root cause for the reported event could not be determined.Labeling review: in reviewing the relevant labeling, it was found that the instructions for use (ifu) sufficiently address the potential risks.The ifu state: 'if unusual resistance or high deployment force is encountered during stent graft deployment, abort the procedure, remove the delivery system and use an alternative device.' regarding preparation of the device the ifu state that "prior to loading the vascular system over a guide wire, both ports must be flushed with sterile saline (.).Flushing these lumens will also facilitate stent graft deployment".Regarding the anatomy of the placement site the ifu states: "prior to stent graft deployment (.), ensure that the proximal stent graft end is positioned in a straight section of the lumen to reduce the risk of increased deployment forces and possible failure to deploy".Regarding accessories the ifu states: "prepare a stiff 0.035" guidewire per its instructions for use and advance the guidewire under fluoroscopy to the target location.The use of an appropriately sized introducer sheath is recommended".The packaging pictograms indicate an introducer size of 8f and a 0.035" guidewire.H10: g3, h6 (device).H11: h6 (result, conclusion).H11: section a through f - the information provided by bd represents all of the known information at this time.Despite good faith efforts to obtain additional information, the complainant / reporter was unable or unwilling to provide any further patient, product, or procedural details to bd.
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Event or Problem Description
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It was reported that during a stent graft placement procedure, there was mild resistance to deployment at first.After some time approximately one fifth of device deployed.It was further reported that there was significant resistance and the cover sheath of the device that is pulled back to deploy the device broke.The procedure was completed using another device.There was no reported patient injury.
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Search Alerts/Recalls
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