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It was reported that the procedure was to treat a common iliac artery.A non-abbott guide wire and guide catheter were advanced to the external iliac artery on the right and significant stenosis was present in the common femoral artery therefore, the wire was exchanged to a.018 command guide wire.Laser atherectomy was preformed 3 times with angio showing significant improvement flow.A 10x39mm omnilink elite stent was advanced over the wire into the distal aorta and deployed; however the balloon on the delivery system ruptured at 6 atmospheres not allowing the stent to fully expand.A 12x40mm armada 35 balloon dilatation catheter was attempted to be used for post dilatation; however, ruptured at 6 atmospheres.(bdc).During removal resistance was felt when pulling into the sheath and the bdc separated in half and the distal marker still on the wire just outside the sheath.An attempt was made to pull in the separated portion into the sheath when aspirating; however was unsuccessful as the balloon continued to get stuck on the arterial wall.A hemostat was used to pull the separated portion of the balloon from the arteriotomy all separated portions were removed.A perclose was used in attempt to close the left femoral artery; however, the artery was enlarged; therefore, direct pressure was held and access to the contralateral right side was gained.Angio revealed significant extravasation of contrast and a 10x5 non-abbott stent was implanted, post dilatated with 9x40mm unspecified balloon.However, angiogram showed some slight continued extravasation and a 8x39 non abbott was implanted and post dilatated with a 9x40mm unspecified balloon.The right femoral arteriotomy was closed with a perclose device.There was no adverse patient sequela and clinically significant delay was noted.No additional information was provided.
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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; however, the reported difficulty removing the device, separation, unexpected medical intervention and delay to treatment/therapy appear to be related to circumstances of the procedure.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, or insufficient preparation prior to use.In this case, a conclusive cause for the reported balloon rupture could not be determined since the device was not returned for analysis.In addition, the ruptured balloon material likely interacted with the introducer sheath during removal, resulting in the reported difficulty removing the device and upon further manipulation, the device ultimately separated.There is no indication of a product quality issue with respect to the design, manufacture, or labeling of the device.
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