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As reported, two 6f multipurpose (mp) a2 100cm infiniti thrulumen diagnostic catheter broke during shaping.The strain relief portion of the device broke during shaping, resulting in a fracture and separation into multiple pieces.The surgeon immediately stopped using the catheters and replaced them with another non-cordis catheter to continue the procedure.There was no reported patient injury.The event occurred during a patent ductus arteriosus (pda) surgical procedure after an unknown guidewire had been removed.The device was stored and prepared according to the instructions for use (ifu).Shaping was performed outside of the patient, and the breakage also occurred outside of the patient.The devices will be returned for evaluation.The hospital reported this case as a serious injury adverse event to the china nmpa.Addendum: both devices were returned with separations at the distal tip and the strain reliefs fully intact.
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Complaint conclusion: as reported, two 6f multipurpose (mp) a2 100cm infiniti thrulumen diagnostic catheter broke during shaping.The strain relief portion of the device broke during shaping, resulting in a fracture and separation into multiple pieces.The surgeon immediately stopped using the catheters and replaced them with another non-cordis catheter to continue the procedure.There was no reported patient injury.The event occurred during a patent ductus arteriosus (pda) surgical procedure after an unknown guidewire had been removed.The device was stored and prepared according to the instructions for use (ifu).Shaping was performed outside of the patient, and the breakage also occurred outside of the patient.Both catheters were returned for evaluation.A non-sterile cath f6inf tl mp a2 100cm 2sh unit was received coiled inside a clear plastic bag and unpacked for evaluation.Two units were received; one device was evaluated under this complaint and the other under a separate complaint.Visual inspection identified a separation at the brite tip/distal tip; however, the separated portion was not returned for evaluation.No other damage or anomalies were observed with the naked eye on the returned device components.Due to the condition found, amplified images of the unit were taken.Analysis of the separated area showed evidence of elongation and plastic deformation, findings commonly associated with tensile overload, indicating the material was subjected to a force beyond its yield strength prior to the observed damage.The fusion between the components showed no anomalies.Dimensional analysis of the inner diameter and outer diameter was performed near the damaged area and the results were within specification.Based on the available information and analysis, there is no evidence to suggest the reported failure is related to the manufacturing process, and no corrective or preventive actions will be taken at this time.The reported ¿brite tip/distal tip ¿ separated¿ seen during the product evaluation of both devices.The exact cause of the reported event cannot be determined.Evaluation results showed signs of tensile overload therefore, use related factors cannot be excluded.The instructions for use do not provide specific guidance regarding manual shaping or deformation of the catheter prior to insertion.The device is intended for use by trained healthcare professionals experienced in catheterization procedures, who are responsible for device handling and technique selection based on clinical judgment.Manual shaping is not defined as a device-specific instruction, requirement, or limitation within the ifu and is therefore considered an operator-dependent technique rather than a manufacturer-directed use condition.Based on the available information, there is no indication that this specific event is related to device design or the manufacturing process.Therefore, no further actions will be taken.
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