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| Model Number |
C408645 |
| Medical Device Problem Codes |
Poor Quality Image (1408); Failure to Advance (2524); Material Split, Cut or Torn (4008)
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| Health Effect - Clinical Code |
No Clinical Signs, Symptoms or Conditions (4582)
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| Date of Event |
11/26/2024
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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 the dragonfly optis imaging catheter was intended to be used in the left circumflex artery (lcx) lesion.However, the imaging catheter failed to cross the lesion.The imaging catheter displayed poor images.Therefore, the imaging catheter was removed from the patient, and the procedure was completed with another dragonfly optis.There were no adverse patient effects and no clinically significant delay in the procedure.No additional information was provided.Returned device analysis found the window tube and torquewire assembly were kinked 159 centimeters (cm) distal from the proximal end of the inner shell.There was a hole in the window tube material at the noted kink.
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Additional Manufacturer Narrative
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A visual inspection and additional testing methods were performed on the returned device.The reported failure to advance and poor image quality were not able to be confirmed.Production record and corrective and preventative actions (capa) reviews were performed and revealed no indication of a product quality issue.Additionally, a query of the complaint handling database for the reported lot revealed there is no indication of a lot specific issue.Based on the reported information and the observations from the returned analysis, the investigation determined that the reported failure to advance and poor image quality appears to be related to circumstances of the procedure.The catheter was noted to be damaged (kinked and torn sheath with optical fiber break) which was the cause for the reported failure to advance and poor imaging results.In this case, it is likely that the catheter damage was caused by the use techniques employed or the patient anatomical conditions.Based on the results of the complaint investigation there is no indication of a product quality issue with respect to the design, manufacture, or labeling of the device.
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Search Alerts/Recalls
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