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| Model Number |
P5455K |
| Medical Device Problem Codes |
Fracture (1260); Detachment of Device or Device Component (2907)
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| Health Effect - Clinical Code |
Failure of Implant (1924)
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| Date of Event |
02/01/2021
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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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On or about (b)(6) 2018, plaintiff underwent placement of an angiodynamics vortex titanium port system, with model number p54565k, and lot number 5218796.The device was implanted by dr.(b)(6), m.D., (b)(6), for chemotherapy treatment.On or about (b)(6) 2021, plaintiff presented to (b)(6), for preoperative workup and testing prior to undergoing a colonoscopy, which included a chest x-ray, that revealed the catheter portion of the vortex had fractured and migrated.Based on the x-ray findings, on or about (b)(6) 2021, plaintiff presented to (b)(6), to undergo removal of the vortex port and the fractured catheter.This removal procedure was performed by dr.(b)(6), m.D.
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Additional Manufacturer Narrative
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The device is not available to be returned to the manufacturer for evaluation.An investigation into the root cause for the event is currently in progress.The results of the investigation will be sent via a follow up medwatch.Reference (b)(4).
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Additional Manufacturer Narrative
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The customer's reported complaint description of 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.Device history record review of the packaging/catheter lots revealed no quality related issues or manufacturing deficiencies at the time of manufacture.There have been no other reported complaints for the indicated packaging/catheter lots for similar catheter fractured/detached issue.The catheter and locking connector are provided as separate components within the port assembly kit.The end user attaches the catheter tubing to the port (and secures junction with the locking connector) during the implantation procedure.Since the port was in situ for more than 35 months and event description states catheter was fractured and detached - indicates that pinch-off syndrome is potential root cause for the catheter tubing fracture/detachment.This is cautioned against in the port directions for use (dfu).Labeling review: the directions for use (dfu) that is supplied with this device, contains the following statements: 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.After implantation and during system use: each access to the vortex® mp port system should be performed using aseptic technique.Use only non-coring needles with the vortex® mp port system.The noncoring needle design helps maintain the self-sealing septum.Under qualified procedures the vortex® mp port system allows up to 2,000 punctures with an angiodynamics® 22 gauge noncoring needle, when tested at 10 psi.This pressure exceeds the typical levels experienced in clinical practice.Do not use a syringe smaller than 10 ml.Smaller syringes may create an over-pressurized condition in the system.Warning: for chest placement, avoid medial catheter placement.Instructions for implantation of the vortex® mp port 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 to the subclavian vein.Note: a port placed too deeply may be difficult to palpate and access.Potential complications: use of the system involves potential risks associated with any implanted device or indwelling catheter.They include, but are not limited to: infection, occlusion, drug extravasation (leakage), catheter pinch-off, fibrin sheath, thromboembolism.A review of the angiodynamics complaint system noted no adverse trends for this complaint type and product family.This type of complaint continues to be monitored for trends.Reference (b)(4).
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Search Alerts/Recalls
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