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It was reported that the procedure performed was to treat a calcified, mildly tortuous, left coronary diagonal artery that is 70% stenosed with a previously implanted vessel.During advancement of the 1.20x12mm mini trek balloon dilatation catheter (bdc) inside a guideliner resistance was met with the guideliner and the shaft of the mini trek bdc kinked and broke into two pieces inside the guideliner.The mini trek bdc never made it out of the guideliner and was removed as one unit.A new trek balloon was used to complete the procedure.There were no adverse patient effects and no clinically significant delay in the procedure.No additional information was provided.
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Visual inspection was performed on the returned device.The reported kink and separation were confirmed.The reported difficulty advancing the device could not be replicated in a testing environment due to the condition of the returned device.Production record and corrective and preventative actions (capa) reviews were performed and revealed no indication of a product quality issue.Additionally, a review of the complaint history identified no other similar complaints from this lot.Based on the reported information and the observations from the returned analysis, a definitive cause for the reported difficulty advancing the device could not be determined; however, the reported kink and separation appear to be related to circumstances of the procedure.Possible factors which may contribute to resistance with the guiding catheter include, but are not limited to, manufacturing, damage to the guiding catheter, or procedural technique (devices not properly supported or coaxially aligned).A conclusive cause for the reported difficulty could not be determined.Additionally, it is likely that the bdc became kinked during advancement, as difficulty was encountered, and further manipulation of the device resulted in the shaft ultimately separating.There is no indication of a product quality issue with respect to the design, manufacture, or labeling of the device.
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