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It was reported that the procedure was to treat a lesion in mid left anterior descending (lad) artery.The 2.5x15mm trek balloon dilatation catheter (bdc) was prepared with 100% contrast mix.Then the bdc was advanced to the target lesion; however, the balloon would not deflate.Therefore, the balloon had to be cut and removed from the wire.Another same size trek balloon was used to continue the procedure.No additional information was provided.
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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 review of the complaint history identified no other similar complaints from this lot.Based on the information received, the investigation determined that the reported failure to deflate appears to be related to user error; however, the reported unexpected medical intervention appears to be related to circumstances of the procedure.It was reported that the contrast ratio used in the procedure was 100% contrast.It should be noted that the coronary dilatation catheters (cdc), trek/mini trek rx, instructions for use specified that the contrast is 60% contrast medium diluted 1:1 with normal saline.Contrast that is more concentrated can lead to slower inflation and deflation times.In this case, it is likely that the concentrated contrast solution contributed to the reported failure to deflate.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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