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It was reported that during preparation, upon unsheathing a 9.0 x 29 mm omnilink elite vascular balloon-expandable stent (bes) system, the stent was noted to have completely come off the delivery system.A new 9.0 x 29 mm omnilink elite vascular bes was used to complete the procedure.There was no device use or patient involvement, and no clinically significant delay in the procedure.No additional information was provided.
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A visual inspection was performed on the returned device.The reported stent dislodgement was confirmed.Production record and corrective and preventative actions (capa) reviews were performed and revealed no indication of a product quality issue.Additionally, a query of the complaint handling database for the reported lot revealed there is no indication of a lot specific issue.A conclusive cause for the reported stent dislodgement could not be determined; however, factors that may contribute to stent dislodgment include, but are not limited to, negative pressure during sheath removal, forced sheath removal, mishandling during product preparation for use, interaction with accessory devices, previously placed stents and/or patient disease state.In this case, it is possible that inadvertent mishandling may have occurred during sheath/stylet removal or preparation of the device, causing the reported stent dislodgement; however, this cannot be confirmed.Based on the results of the complaint investigation, there is no indication of a product quality issue with respect to the design, manufacture, or labeling of the device.
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