|
There are controls in the manufacturing process to ensure the product met specifications upon release.During visual inspection, the guidewire mid-section was seen to be kinked.The guidewire distal end was seen to be eroded (indicative of prolonged exposure to saline during the return process) and fractured along the nitinol tubing in two locations from 191cm.A functional test was unable to be performed due to defects.The reported event of 'guidewire difficult to advance' could not be replicated; however, the analysis results are consistent with the reported event.The device failed to meet specification when returned, based on the damage noted.The reported event is covered in the device directions for use (dfu).As well, the risk of the reported event is documented in the risk documentation and there are current controls to mitigate the risk of the as reported event.It was reported that the wire was removed from the hoop and hydrated in the bowl with heparinized saline.It was inserted into a flushed the microcatheter and the wire would not advance through the catheter.It was removed and taken off the table and kept to be returned as a complaint to stryker.Additional information received indicates that no anomalies were noted to device after removal from packaging or prior to prep, the device was prepped per dfu by an experienced tech, the device was not recognized to be in bad condition prior to use, continuous flush is used during the procedure.The device was returned and there was a kink noted to the mid-section of the guidewire; there was some fracturing noted to the nitinol tubing towards the distal end of the guidewire.A functional test was unable to be performed, however the damage noted to the device is consistent with the reported difficulty to advance the guidewire.It is probable that there were procedural factors present during use causing the reported difficulty to advance and fracturing to the distal end of the guidewire, it is likely that the guidewire was also kinked and fractured due to the difficulty experienced during advancing the guidewire.Based on review of all available information an assignable cause of procedural factors will be assigned to the reported event of 'guidewire difficult to advance' and to the analysed 'guidewire distal tip broken/fractured during use' and 'guidewire mid-section kinked/bent', as the issue is associated with a product that meets stryker design and manufacture specifications and was used in according with the dfu but due to procedural and/or anatomical factors during use, the product performance was limited.
|