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It was reported that the procedure was to treat a moderately calcified and moderately tortuous lad.During advancement of the 3.50x12mm trek balloon dilatation catheter (bdc) through an unspecified guideliner, resistance was met due to the guideliner and did not cross.Upon removal, resistance was met due to the guideliner and more force was needed to remove the bdc.The shaft of the bdc was noted to separate and simply withdrawn by removing the guideliner and trek bdc as one unit.A new trek bdc and guideliner were used to complete the procedure.There were no adverse patient effects and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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The device was not returned for analysis.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 information provided, a definitive cause for the reported difficulty advancing and removing the device could not be determined; however, the separation appears to be related to user error/operational context.It was reported by the account that force was required in the attempt to remove the device from the guiding catheter which likely resulted in the reported separation.It should be noted that the coronary dilatation catheters (cdc), trek and mini trek rx, global, instruction for use (ifu) states: if resistance is felt, determine the cause before proceeding.Continuing to advance or retract the catheter while under resistance may result in damage to the vessels and / or damage / separation of the catheter.In this case, it is likely that the violation of the ifu contributed to the reported shaft separation.Possible factors which may contribute to resistance with the guiding catheter during advancement include, but are not limited to, manufacturing, damage to the guiding catheter, or procedural technique (devices not properly supported or coaxially aligned).Possible factors that can contribute to difficulties to remove/resistance with the guiding catheter include, but are not limited to, guiding catheter lumen obstructions, kinks, bends or procedural technique.Additionally, as difficulty was reported during the removal, force was required in the attempts to remove the device and the shaft 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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