|
H11: manufacturing review: the lot history records of this lot were reviewed with special attention to the manufacturing and inspection of this product and the product was found to have met specifications prior to shipment.Investigation summary: the stent delivery system sample was returned for evaluation and the outer sheath was separated from the white swivel nut.The investigation leads to confirmed result for joint failure and subsequent deployment failure.There was no indication of manufacturing deficiencies.Potential factors which may have caused or contributed to the reported issue have been considered.Therefore, previous investigations of similar complaints have been reviewed.Challenging placement site / difficult patient anatomy may lead to high friction during deployment.Insufficient flushing of the device before use or inadequate accessories may be contributing factors to the reported issue.Additionally the proximal end of the stent graft should be placed in a straight section of the lumen prior to deployment.A detachment of the outer sheath from the swivel nut probably resulted from high deployment forces.The chamfer at the proximal end of the outer sheath is still in place, the issue was not considered a process related issue.Based on the available information and the evaluation of the returned sample, the investigation is closed with confirmed results for material separation and failure to deployed is considered a cascading event.A definite root cause for the reported event could not be determined.Labeling review: in reviewing the relevant labeling, it was found that the instructions for use (ifu) sufficiently address the potential risks.Regarding precautions, the instruction for use states "if unusual resistance or high deployment force is encountered during stent graft deployment, abort the procedure, remove the delivery system and use an alternative device".With regards to warnings, the instruction for use state: "examine the packaging and endovascular system to determine if there is any damage, defects or if the sterile barrier is compromised.Do not use the device if any of these conditions are observed".Regarding preparation of the device the instruction for use state that "prior to loading the vascular system over a guide wire, both ports must be flushed with sterile saline.Flushing these lumens will also facilitate stent graft deployment".Regarding the anatomy of the placement site the instruction for use states: "prior to stent graft deployment, ensure that the proximal stent graft end is positioned in a straight section of the lumen to reduce the risk of increased deployment forces and possible failure to deploy".Regarding accessories the instruction for use states: "prepare a stiff 0.035" guidewire per its instructions for use and advance the guidewire under fluoroscopy to the target location.The use of an appropriately sized introducer sheath is recommended".The packaging pictograms indicate an introducer size of 9f and a 0.035" guidewire.Section a through f - the information provided by bd represents all of the known information at this time.Despite good faith efforts to obtain additional information, the complainant / reporter was unable or unwilling to provide any further patient, product, or procedural details to bd.
|