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SPECTRANETICS CORPORATION GLIDELIGHT LASER SHEATH; DEVICE, REMOVAL, PACEMAKER ELECTRODE, PERCUTANEOUS
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| Model Number |
500-302 |
| Medical Device Problem Code |
Adverse Event Without Identified Device or Use Problem (2993)
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| Health Effect - Clinical Codes |
Great Vessel Perforation (2152); Cardiac Perforation (2513); Pericardial Effusion (3271)
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| Date of Event |
03/13/2025
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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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A lead extraction procedure commenced to remove a right ventricular (rv) and a right atrial (ra) lead due to needing a tricuspid valve replacement.Spectranetics lld lead locking devices (llds) were inserted into each lead to provide traction.Beginning with a spectranetics 14f glidelight laser sheath on the ra lead, progress was made to the subclavian and stalled.Switching to the rv lead with the same glidelight, advancement was made to the superior vena cava (svc)/ra junction and progress stalled.As the glidelight was being removed to target the ra lead, the patient's blood pressure dropped.A pericardial effusion was detected, and rescue efforts began, including pericardiocentesis and sternotomy.An svc/ra junction perforation was discovered and repaired.The leads were removed post-sternotomy, and the tricuspid valve was replaced.The patient survived the procedure.This report captures the 14f glidelight in use when the perforation occurred, requiring intervention.There was no alleged malfunction of the spectranetics devices in use during the procedure.
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Additional Manufacturer Narrative
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A2) patient date of birth - not available from facility.B6) relevant tests/laboratory data - not available from facility.D4) device serial number - not available from facility.H3) the glidelight was discarded, thus no returned product investigation was performed.H6) great vessel and cardiac perforation are known risks of complication with use of the glidelight device.Submission of this report does not, in itself, represent a conclusion by the manufacturer and/or authorized representative or the national competent authority that the content of this report is complete or accurate, that the medical device(s) listed failed in any manner and/or that the medical device(s) caused or contributed to an alleged death or deterioration in the state of the health of any person.
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