| Model Number |
SI-1371-S |
| Medical Device Problem Code |
Material Puncture/Hole (1504)
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| Health Effect - Clinical Code |
No Clinical Signs, Symptoms or Conditions (4582)
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| Date of Event |
02/04/2026
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Type of Reportable Event
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Malfunction
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Additional Manufacturer Narrative
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One 13f agilis sheath and dilator were received for investigation.The dilator had been perforated proximal to the distal tip.The dilator and sheath were flushed with fluid and the dilator was inserted into the sheath; no resistance or anomalies were noted.A needle/stylet assembly from current inventory was inserted and advanced through the dilator/sheath assembly; however, the needle could not advance past the location of the perforation.No damage was noted on the returned sheath.The damaged dilator tip was not able to be replicated with dilators from current inventory.The batch record was reviewed to ensure that each manufacturing and inspection operation was performed.The cause of the dilator bend and perforation remains unknown.
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Event or Problem Description
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This report is to advise of a punctured dilator that was noted during analysis.During the atrial fibrillation procedure, the tip of the dilator was bent during the passage of the brk needle.The patient anatomy was unusual and the curvature of the vein complicated access for the transseptal puncture.The sheath was replaced and the procedure was completed with no adverse patient consequences.
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Search Alerts/Recalls
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