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It was reported that unstable speed occurred.The stenosed target lesion was located in the left anterior descending artery.A rotalink advancer was selected for use.During test outside the patient, everything was normal.However, during the procedure the burr could not be pushed into the guiding catheter, resulting in stalling and stuttering.The device exceeded the set operational speed of 150k rpm as it reached 160k rpm during normal mode.The procedure was completed with another of the same device.There were no patient complications reported post procedure.
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E1.Initial reporter phone: (b)(6).Device analysis results.Device technical analysis:
the device was not returned for analysis; therefore, a technical analysis could not be performed.Device history review:
it was confirmed that this device met manufacturing specification prior to distribution and there are no manufacturing deviations which could have contributed to the reported event.Labeling review:
review of the instructions for use (ifu) confirmed there was relevant content and sufficient guidance with respect to the circumstances described within this complaint.No updates are required to the ifu as a result of this event.Risk review:
a risk review was performed and confirmed that the event was defined in the risk documentation.This event type has been accounted for during product risk analysis to support acceptable risk benefit for the product.Investigation conclusion:
based on a thorough review of the reported complaint, the most probable cause for this complaint was considered adverse event related to procedure.The reported event indicated that during the procedure the burr could not be pushed into the guiding catheter, resulting in stalling and stuttering.The device was not returned for analysis, and the reported events could not be confirmed using the available information.A review of the device history record "[dhr]" indicates that the device was manufactured per specification.The instructions for use include testing of the device before usage within the body and state that use of the device is to be discontinued if evidence of a failure or damage is present.As the reported events do not indicate any device damages or failures during unpackaging, preparation, or testing, it was considered likely that the reported events were attributable to factors encountered during the procedure.
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