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| Catalog Number |
532598B |
| Medical Device Problem Codes |
Difficult to Remove (1528); Detachment of Device or Device Component (2907)
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| Health Effect - Clinical Code |
No Clinical Signs, Symptoms or Conditions (4582)
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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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As reported, a 5f pigtail (pig) 110cm super torque mb diagnostic catheter became stuck on the guidewire during an aortomonoiliac endograft procedure and during the attempt to remove the device, the catheter broke, leaving approximately one-third at the patient¿s access site.This required partial removal of the guidewire and catheter through the introducer, followed by complete removal of the catheter, which was described as extremely difficult due to tight adhesion to the guidewire.There was a reported patient injury.The device was used for angiography and subsequent measurement of the endograft length required to complete the procedure.The procedure was performed as part of an endovascular aneurysm repair (evar) completion in a patient with an abdominal aortic aneurysm with a right type ib endoleak and a left type iii endoleak, with a rapidly enlarging aneurysm reaching 10 cm in diameter.The device will not be returned for evaluation.
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Additional Manufacturer Narrative
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Additional information is pending and will be submitted within 30 days upon receipt.
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Additional Manufacturer Narrative
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Complaint conclusion: as reported, a 5f pigtail (pig) 110cm super torque mb diagnostic catheter became stuck on the guidewire during an aortomonoiliac endograft procedure and during the attempt to remove the device, the catheter broke, leaving approximately one-third at the patient¿s access site.This required partial removal of the guidewire and catheter through the introducer, followed by complete removal of the catheter, which was described as extremely difficult due to tight adhesion to the guidewire.There was a reported patient injury.The device was used for angiography and subsequent measurement of the endograft length required to complete the procedure.The procedure was performed as part of an endovascular aneurysm repair (evar) completion in a patient with an abdominal aortic aneurysm with a right type ib endoleak and a left type iii endoleak, with a rapidly enlarging aneurysm reaching 10 cm in diameter.Multiple attempts to obtain supplemental information were made; however, additional event details were not provided.The device will not be returned for evaluation.The product was not returned for analysis.A product history record (phr) review of lot 18440172 revealed no anomalies or non-conformances during the manufacturing and inspection processes that can be associated with the reported event.The reported ¿catheter body/shaft ¿ resistance/friction ¿ inner lumen, catheter body/shaft ¿ separated and catheter body/shaft ¿ withdrawal difficulty ¿ through sheath¿ could not be substantiated because the device was not returned and no images or procedural films were provided.This device is contraindicated for evar procedures due to the potential for entrapment of the catheter between endovascular devices and the vessel wall.Therefore, entrapment cannot be ruled out as a potential root cause.Users are trained to inspect for signs of damage prior to and during use.Any product with damage is not to be used.Information for safety is provided in the products labeling with the intent of making the user aware of the risks.According to the instructions for use (ifu), although not intended as a mitigation of risk, ¿contraindications: do not use the super torque mb catheter in procedures where entrapment of the catheter between endovascular devices and the vessel wall may occur, for example endovascular aortic repair (evar) procedures.¿ based on the information available, there is no indication that the event is related to the design or manufacturing process.Therefore, no preventative or corrective actions will be taken at this time.
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Event or Problem Description
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As reported, a 5f pigtail (pig) 110cm super torque mb diagnostic catheter became stuck on the guidewire during an aortomonoiliac endograft procedure and during the attempt to remove the device, the catheter broke, leaving approximately one-third at the patient¿s access site.This required partial removal of the guidewire and catheter through the introducer, followed by complete removal of the catheter, which was described as extremely difficult due to tight adhesion to the guidewire.There was a reported patient injury.The device was used for angiography and subsequent measurement of the endograft length required to complete the procedure.The procedure was performed as part of an endovascular aneurysm repair (evar) completion in a patient with an abdominal aortic aneurysm with a right type ib endoleak and a left type iii endoleak, with a rapidly enlarging aneurysm reaching 10 cm in diameter.Multiple attempts to obtain supplemental information were made; however, additional event details were not provided.The device will not be returned for evaluation.
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Search Alerts/Recalls
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