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It was reported this was a procedure to treat a moderately calcified and moderately tortuous left av fistula.An armada 35 7mm/60mm was inserted and advanced to the target lesion.However, upon the first inflation, a balloon rupture occurred at 13atm.Part of the balloon and balloon markers came off and wrapped around the non-abbott guide wire that as inside the patient.The devices were unable to be removed, and the physician cut parts of the wire that was exposed, and the patient was sent into surgery to have it removed.All parts of the of the device was successfully removed.There was 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 balloon rupture and separation were confirmed.The reported entrapment of the device could not be replicated in a testing environment as it was based on operational context.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.Based on the reported information and the observations from the returned analysis, the investigation determined that the reported balloon rupture, separation, entrapment of device and surgical intervention appear to be related to operational context.There was no leak noted to the balloon during preparation, which suggests a product quality issue did not contribute to the reported difficulties.In this case, it is likely that the balloon interacted with the moderately tortuous and moderately calcified anatomy such that the balloon became damaged and subsequently ruptured during the inflation.Additionally, it is likely that as a result of the balloon rupture, the device became entrapped in the patient anatomy and upon further manipulation to remove it, the balloon ultimately separated.There is no indication of a product quality issue with respect to the design, manufacture, or labeling of the device.
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