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It was reported this was a procedure to treat a heavily calcified, heavily tortuous, and 98% stenosed superficial femoral artery.A supera 5.0x120 was inserted and placed at the target lesion.However, after the stent was released and the delivery system was withdrawn from the body, the distal tip was found detached and trapped on the guide wire.It was noted the thumb slide was not fully retracted, and the system lock and deployment lock were not rotated into the locked position.A snare was inserted to retrieve the detached fragment.No additional information 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 handling database identified no other incidents from this lot.Reportedly, after the supera was released at the target lesion and the delivery system was withdrawn from the body, the distal tip of the stent was found detached and trapped on the guide wire.It was noted the thumb slide was not fully retracted, and the lock and the deployment lock were not rotated into the locked position.It should be noted that the supera peripheral stent system instructions for use (ifu) states: following confirmed implantation of the supera stent, retract the thumb slide in a single motion to the starting position on the handle and rotate the system lock and deployment lock into the locked position, in line with the thumb slide.The investigation determined the reported difficulties appear to be related to deviation of the ifu and subsequent circumstances of the procedure as it is likely that failing to rotate the system lock and deployment lock into the locked position resulted in the tip of the supera to not be fully retracted back into the distal sheath, resulting in the tip of the device to be caught on the deployed stent struts; thus inadvertently detaching the distal tip from the delivery system and becoming trapped on the guide wire during withdrawal from the body, ultimately resulting in the reported material separation.As reported, a snare was inserted to retrieve the detached fragment.Based on the reported information and 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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