| Model Number |
A1040-020 |
| Medical Device Problem Codes |
Difficult to Remove (1528); Material Rupture (1546); Material Separation (1562)
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| Health Effect - Clinical Code |
Device Embedded In Tissue or Plaque (3165)
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| Date of Event |
02/09/2025
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Type of Reportable Event
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Serious Injury
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Event or Problem Description
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It was reported that the procedure was to treat a heavily calcified internal mesenteric artery (ima).A.014 supracore guide wire was placed in the ima.A 3x20mm armada 14 balloon was used to pre-dilated the lesion; however, did not open the lesion enough.The 5.0x18mm herculink stent was attempted to be advanced, but failed to cross due to anatomy.A 4.0x40mm armada 14 balloon was advanced without issue; however, once inflated the balloon ruptured at nominal pressure and removed from the anatomy without issue.A new 4x20mm armada 14 balloon was advanced and once at the target site inflated to nominal pressure; however, ruptured.During removal of the armada 14 balloon resistance was felt with anatomy; however, with gentle tug the device was able to be removed.Under fluoroscopy the distal tip of the balloon was observed on the wire and on removal of the device the tip was noted to remain jailed by the stent.A 3.0x40mm, 4.0x40mm armada 14, other unspecified balloon and with the same 5.0x18mm herculink stent was re-inserted and used to successfully complete the procedure.There was no adverse patient sequela and no clinically significant delay in the procedure.No additional information was provided.
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Additional Manufacturer Narrative
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The device was not returned for analysis.Production record and corrective and preventative actions (capa) reviews were performed and revealed no indication of a product quality issue.Additionally, a review of the complaint history identified no other similar complaints from this lot.The investigation determined the reported complaints appear to be related to operational context.There was no damage noted to the bdc during inspection prior to use or leak noted during preparation, which suggests a product quality issue did not contribute to the reported difficulties.Based on the reported information, it is likely that the balloon interaction with the heavily calcified anatomy such that the balloon ruptured during inflation.Additionally, it is likely that the device interacted with the patient¿s challenging anatomy resulting in the reported difficulty removing the device and subsequently as the physician tugged on the device, the device ultimately separated.Additional treatment was performed to remove the departed portion of the device and the tip was noted to remain jailed by the stent.There is no indication of a product quality issue with respect to the design, manufacture, or labeling of the device.The additional devices referenced in b5 are filed under separate medwatch report numbers.
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Search Alerts/Recalls
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