|
As reported, a 6f.070-inch extra backup (xb) 3 100cm vista brite tip guiding catheter had a hole in it when it was removed from the packaging.Another vista brite catheter was used to complete the intended procedure which was reported to be a left coronary percutaneous coronary intervention (pci).There was no reported patient injury.The device was stored and handled according to the instructions for use (ifu), with no damage observed prior to opening the package.It was prepared per ifu, and there was no difficulty removing it from the sterile packaging.No unusual force was applied during the procedure.It is unknown whether the device was pulled or torqued by the hub.The non-sterile 6f.070 xb 3100cm device was returned for evaluation.Visual inspection of the received unit did not identify any obvious abnormalities on unaided eye inspection.A shape-comparison assessment identified that the distal end was not aligned with the expected curved design; because the unit was not returned in original packaging, handling cannot be completely excluded as a contributing factor, although the following observations indicate an underlying manufacturing defect.A flushing evaluation could not be completed due to a crack on the luer hub.High-magnification evaluation of the luer hub surface revealed a crack extending from the proximal end to the mid-portion in a "j" pattern, with striation patterns on the crack border that are typically associated with tensile overload propagation; taken together with the distal end misalignment, these features are consistent with a manufacturing-related defect affecting the component geometry and structural integrity.The reported "catheter (body/shaft) ¿ puncture/cut" was not seen during the product evaluation.Visual inspection of the unit received did not identify any obvious abnormalities on unaided eye inspection.Additionally, the distal tip was found out of shape.Handling factors cannot be excluded as a potential root cause as determined by the product evaluation team.However, the malfunction, "luer hub ¿ cracked" was observed during the photo evaluation.It is assumed that the hub material was induced to a tensile force that exceeded the hub material yield strength prior to cracking.Users are trained to inspect for signs of damage prior to and during use.Any product with damage is not to be used.Information about safety is provided in the products labeling with the intent to make the user aware of the risks.According to the instructions for use (ifu), although not intended as a mitigation of risk, "store in a cool, dark, dry place.Do not use open or damaged packages.Inspect the guiding catheter before use to verify that its size, shape, and condition are suitable for the specific procedure.Inspect the guiding catheter upon removal from packaging to verify that it is undamaged.Warning: do not use a guiding catheter that has been damaged in any way.If damage is detected, replace with an undamaged guiding catheter." based on the available information and product analysis, the cause of the luer hub crack could not be determined; however, it could be related to the manufacturing process of the unit.Therefore, an investigation has been initiated to further review the potential causes.No further action will be taken at this time.
|