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On or about (b)(6), 2022, plaintiff underwent right subclavian placement of an angiodynamics smartport product at (b)(6) in (b)(6), michigan, and performed by dr.(b)(6), m.D.On or about (b)(6) 2023, plaintiff presented to (b)(6) health in (b)(6), michigan.Plaintiff's medical team determined that the defective smartport device had fractured and needed to be removed.Dr.(b)(6), m.D.Performed a removal procedure but was only able to remove a portion of the fractured port catheter.The patient did not experience any adverse effects or harm as a result of this incident.
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The customer's reported complaint description of port catheter tubing fractured and detached cannot be confirmed.No port/catheter tubing device was returned for evaluation.Without receiving product for evaluation, we are unable to definitively determine a root cause for this incident.A device history record (dhr) review was not conducted since there was no reported lot number and dhr review of ship history report lots was not performed since packaged good item number is also unknown.Since port was in situ for more than 11 months and event description statement that the catheter [tubing] was placed in subclavian vein and had fractured - indicates that pinch-off syndrome is potential root cause for the catheter tubing fracture.This is cautioned against in the device directions for use (dfu).Labeling review: the directions for use (dfu) that is supplied with the port device, contains the following statements: contraindications: · catheter insertion in the subclavian vein medial to the border of the first rib, an area which is associated with higher rates for pinch-off.Warnings: · do not use syringes smaller than 10 ml when accessing the port as system damage can occur.Flushing occluded catheters with small syringes can create excessive pressures within the port system.· failure to ensure patency of the catheter prior to power injection studies may result in port system failure and patient injury may occur.· do not power inject through a port system that exhibits signs of clavicle-first rib compression or pinch-off as it may result in port system failure and patient injury may occur.· absence of a blood return or a poor blood return can be a sign of a potential complication such as occlusion, kinking, breakage, pinch-off syndrome, fibrin formation, thrombosis or malposition.This should be evaluated prior to device usage.A blood return should be present prior to usage of device for any therapy or testing.· if the patient complains of pain, or there is swelling when the device is flushed or when medication or contrast media is administered, evaluate the device for infiltration, proper needle placement, and potential complications such as occlusion, kinking, breakage, pinch-off syndrome, thrombosis or malposition.Failure to assess these complaints or observations can lead to device failure.Potential complications: use of an angiodynamics port system involves potential risks normally associated with the insertion or use of any implanted device or indwelling catheter including but not limited to: catheter disconnection or migration, catheter embolization, catheter fragmentation, catheter pinch-off, drug extravasation (leakage).Catheter placement considerations: warning: avoid medial catheter placement into subclavian vein through percutaneous technique.This placement could lead to catheter occlusion, damage, rupture, shearing, or fragmentation due to compression of the catheter between the first rib and clavicle.Catheter shearing has been reported when the catheter is inserted via a more medial route in the subclavian vein.Pinch-off syndrome: pinch-off syndrome signs may include difficulty in aspirating blood, resistance to flushing or infusion of medications or fluids that improves with position changes, infraclavicular pain and/or swelling with catheter flushing or infusion palpitations, sudden onset chest pain, cardiac arrhythmias, extra heart sound, chest wall swelling at the port pocket, vein insertion site, pain in shoulder or port area not associated with swelling, cough, paresthesia of arm on side of catheter withdrawal occlusion or swishing sound with catheter flushing.A review of the angiodynamics complaint system noted no adverse trends for this complaint type and product family.This type of complaint will continue to be monitored for trends.Reference (b)(4).
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