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It was reported that the procedure was to treat a heavily calcified, mildly tortuous popliteal artery lesion with 80% restenosis.A 6.5 x 150 mm supera self-expanding stent was implanted.However, the thumbslide was not retracted, and levers were not locked.Therefore, the stent became extremely elongated, and the nose cone was separated from the delivery system after removing the device from sheath.A snare was used to remove the separated tip from the distal popliteal artery.An additional device was used to complete the procedure.There were no adverse patient effects and there was no clinically significant delay in the procedure.No additional information was provided.
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The device was returned for analysis.The reported material separation was able to be confirmed.The reported stretched stent was unable to be replicated in a testing environment due to the condition of the returned device (stent previously deployed and not returned).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 handling database identified no other incidents from this lot.Reportedly, after the supera self-expanding stent was implanted, the thumbslide was not retracted, and levers were not locked.It should be noted that the supera peripheral stent system instructions for use (ifu) states: prior to removal of the delivery system, ensure the supera stent is completely deployed, the thumb slide is retracted the system lock and deployment lock are locked (in the path of the thumb slide).The investigation determined the reported difficulties appear to be related to deviation of the ifu and subsequent circumstances of the procedure as it is likely that failing to retract the thumbslide and re-lock the levers resulted in the tip of the supera to not be fully retracted back into the distal sheath, resulting in the tip of the device to be caught on the deployed stent during removal; thus inadvertently elongating the stent and separating the nose cone from the delivery system, ultimately resulting in the reported stretched stent and reported/noted material separation.Manipulation of the compromised device during removal likely resulted in the noted device damages (bunched and kinked tip jacket, bent tip).Based on the reported information and results of the complaint investigation there is no indication of a product quality issue with respect to the design, manufacture, or labeling of the device.H6: medical device problem code 2017 - failure to follow steps / instructions.
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