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It was reported that during a carotid stent procedure, a zoom 88 support catheter became kinked approximately 14 cm from the distal tip while positioned in the iliac artery.During the first pass, resistance was encountered during advancement at which time the kink at 14cm was observed.Resistance was also encountered during retraction while attempting to exchange the catheter for a new zoom 88 support.As the physician attempted to withdraw the catheter, it fractured approximately 14 cm from the distal tip.A goose neck snare was used in an attempt to retrieve the detached catheter segment; however, retrieval was unsuccessful, and the fragment remained in the common iliac artery without limiting blood flow.Open surgical intervention was subsequently performed to access the iliac artery and retrieve the distal catheter fragment.The catheter segment was successfully retrieved, and the patient was reported to be alive following the procedure.
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The zoom 88 support catheter was not returned for investigation.The manufacturing records reviewed for the product met the design and manufacturing specifications.Zoom ifu provides the following warning related to retraction against resistance."exercise care when manipulating the device through tortuous anatomy.Do not advance or withdraw the catheters or accessory/adjunctive devices against resistance without careful assessment of the cause under fluoroscopy.If the cause cannot be determined, withdraw all devices as a single unit.Excessive manipulation or torquing the device against resistance may result in damage to the vasculature or the device."
based on the information available, the exact root cause for the shaft break could not be determined.
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