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The device was not returned for analysis.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.It was reported that the omnilink elite stent delivery system (sds) was attempted to be delivered onto a 0.014 inch guide wire.It should be noted that the omnilink elite electronic instructions for use (ifu) specifies to use a 0.035¿ guide wire of appropriate length.In this case, it is unknown if the ifu deviation contributed to the reported event.A conclusive cause for the reported difficulties could not be determined; however, the subsequent unexpected medical intervention appears to be related to the operational context of the procedure.Factors that could contribute to failure to advance include, but are not limited to, patient anatomical morphology, inner lumen obstruction, patient disease state, pre-dilatation strategy, device placement technique, interaction with previously placed stents or accessory devices.Factors that may contribute to stent dislodgment include, but are not limited to, negative pressure during sheath removal, forced sheath removal, mishandling during product preparation for use, interaction with accessory devices, previously placed stents and/or patient disease state.In this case, it is possible that the device may have interacted with the tortuous celiac artery with 90% stenosis during advancement, causing the reported failure to advance.Further interaction with the challenging anatomy during advancement/positioning of the device may have contributed to the reported stent dislodgement; however, this cannot be confirmed.A snare device was used to retrieve the stent, and everything was pulled out of the body together.Access was lost and the procedure was aborted.Based on the 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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