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Block h6: imdrf device code a0401 captures the reportable investigation finding of catheter guide break.Block h11: an advanix biliary stent with naviflex rx delivery system was returned for analysis.Visual examination of the returned device found the push catheter and stent suture hole were torn.Functional testing confirmed that the guide catheter was detached.A destructive test was performed, and it was observed that the hypotube was in good conditions.No other damages were noted to the stent and delivery system.Product analysis confirmed the reported event of stent failure to deploy and as the guide catheter returned detached.The investigation concluded that the reported event and additional observed damages were most likely related to procedural factors, as device handling and the technique used by the physician (including the force applied) could have contributed to the observed problems.Additionally, functional testing determined that the guide catheter was detached.This event was likely due to a quality control deficiency, as it was found that the pull wire had not been assembled deeply enough into the black guide catheter.Boston scientific initiated a non-conforming events prevention (ncep) investigation in june 2024 to further evaluate "catheter guide break" events where the hypotube was not properly bonded to the inside of the guide catheter.The investigation found the guide catheter can slip within the grippers during the bonding cycle after the foot pedal is pushed to begin the cycle.If this is not identified during visual inspection by the operator, this can cause an insufficient bond between hypotube and guide catheter.An immediate action was taken to add a magnification tool to the manufacturing process to improve operator visualization of the bond during the required inspection, and all operators were reminded of the correct method for bond inspections.Although the advanix biliary stent with naviflex rx delivery system continues to perform within anticipated product performance expectations, boston scientific initiated a corrective and preventive action (capa) investigation to further investigate whether any additional corrective actions are warranted.Therefore, a review and analysis of the all the available information indicated that the most probable cause is quality control deficiency.
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