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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.Based on the information received, the investigation determined that the reported issue appears to be related to operational as it is likely the patients bypass graft from a previous procedure resulted in the reported inability to use the appropriate sheath for support causing the reported difficulty to advance and subsequent migration of the device.Additionally, the reported difficulty/delayed positioning appears to be a result of the patients anatomy as clips from a previous procedure were misidentified as the scaffold marker bands causing the scaffold to be deployed in an unintended lesion.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.
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It was reported that the procedure was to treat the popliteal artery with mild calcification and 70% stenosis.The 3.0x38 mm esprit btk system was being delivered without an up and over sheath because the patient had a bypass graft.Where the bypass anastomosis was located, there were clips and it was thought these were the balloon markers.The scaffold was deployed but the image never showed the balloon expand.This is because the esprit was deployed in the graft as the wire and balloon shaft migrated into the aorta because there was not enough support.The scaffold was deployed into the 7 mm graft, and this is assumed because the stent could not be seen floating in the graft.The patient will return for follow up.No additional information was provided.
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