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It was reported that the procedure was to treat a 90% stenosed lesion in the obtuse marginal artery with moderate calcification.The 2.5x15mm xience skypoint stent delivery system (sds) was advanced to the target lesion, and the stent was attempted to be deployed.However, the balloon failed to inflate, and the device was noted to not be holding pressure.Therefore, the sds was removed from the patient.Another xience skypoint sds was used to continue the procedure.There was no adverse patient effect reported, and no clinically significant delay reported in the procedure.No additional information was provided.
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A visual and functional inspection was performed on the returned device.The reported activation failure was confirmed; however, it is possible the observed split, cut, torn material may have caused the reported activation failure.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.A conclusive cause for the reported activation failure could not be determined.Factors that may contribute to an activation failure including expansion failures include, but are not limited to, inflation technique, contrast concentration, loose connection with the indeflator, anatomical conditions, contamination in the inflation lumen or damage to the device.Potential factors that may contribute to split, cut or torn material include, but are not limited to, interaction with accessory devices, anatomical conditions, mishandling during manufacturing, during receiving/storage at the account, and/or during removal from packaging, preparation of the device and/or protective sheath/stylet removal.There was no damage noted to the stent delivery system (sds) during the inspection prior to use which suggests a product quality issue did not contribute to the reported difficulties.In this case, it is possible that the device may have interacted with the challenging anatomy and/or accessory devices during advancement, causing the observed deformation due to compressive stress (kinked inner member) and torn outer member, ultimately causing the reported activation failure; however, this cannot be confirmed.There is no indication of a product quality issue with respect to manufacture, design, or labeling; therefore, no product-related corrective action will be implemented in this case.
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