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ABBOTT VASCULAR INC. MINI TREK¿; CATHETERS, TRANSLUMINAL CORONARY ANGIOPLASTY, PERCUTANEOUS
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| Model Number |
1012270-12 |
| Medical Device Problem Codes |
Material Rupture (1546); Improper or Incorrect Procedure or Method (2017)
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| Health Effect - Clinical Code |
No Clinical Signs, Symptoms or Conditions (4582)
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| Date of Event |
05/15/2025
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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 procedure performed was to treat a de novo, mildly calcified, mildly tortuous left anterior descending coronary artery.A 2.00x12mm mini trek balloon dilatation catheter (bdc) was not soaked nor prepped outside the anatomy prior to use.Once at the lesion, an attempt was made to inflate the mini trek balloon, however a leak was noted in the balloon and the mini trek bdc was quickly pulled out.An unspecified balloon was used to complete the procedure.There were no adverse patient effects and no clinically significant delay in the procedure.No additional information was provided.
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Additional Manufacturer Narrative
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Manufacturer's investigation is still pending at this time.Results and conclusions will be provided in the final report.H6 medical device problem code: 2017 - incorrect prep.
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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.Based on the information provided, a definitive cause for the reported balloon rupture could not be determined.It was reported that the device was not soaked prior to use.It should be noted that the coronary dilatation catheters (cdc), trek rx and mini trek rx, global instructions for use (ifu) states: submerge the balloon in sterile heparinized normal saline during balloon preparation, to activate the coating.In this case, it is unknown if the ifu violation caused or contributed to the reported complaint.Additionally, it was reported that the device was not prepared (air aspiration) outside the anatomy.It should be noted that the coronary dilatation catheters (cdc), trek rx and mini trek rx, global, ifu specifies: all air must be removed from the balloon and displaced with contrast prior to inserting into the body, otherwise, complications may occur.In this case, it is unknown if the ifu violation caused or contributed to the reported complaint.Possible factors that could contribute to balloon material ruptures include, but are not limited to, balloon damage during processing of the balloon material, inflation technique, interactions with other devices or patient anatomy.In this case, a conclusive cause for the reported balloon rupture could not be determined since the device was not returned for analysis.There is no indication of a product quality issue with respect to the design, manufacture, or labeling of the device.
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Additional Manufacturer Narrative
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Visual inspection and functional testing were performed on the returned device.The reported balloon rupture was confirmed.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.It was reported that the device was not soaked prior to use.It should be noted that the coronary dilatation catheters (cdc), trek rx and mini trek rx, global instructions for use (ifu,) states: submerge the balloon in sterile heparinized normal saline during balloon preparation, to activate the coating.In this case, it is unknown if the instructions for use (ifu) violation caused or contributed to the reported complaint.Additionally, it was reported that the device was not prepared (air aspiration) outside the anatomy.It should be noted that the coronary dilatation catheters (cdc), trek rx and mini trek rx, global ifu specifies: all air must be removed from the balloon and displaced with contrast prior to inserting into the body, otherwise, complications may occur.In this case, it is unknown if the ifu violation caused or contributed to the reported complaint.Based on the information provided, a definitive cause for the reported balloon rupture could not be determined.Possible factors that could contribute to balloon material ruptures include, but are not limited to, balloon damage during processing of the balloon material, inflation technique, interactions with other devices or patient anatomy.There is no indication of a product quality issue with respect to the design, manufacture, or labeling of the device.
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