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Device Problem Adverse Event Without Identified Device or Use Problem (2993)
Patient Problems Infarction, Cerebral (1771); Intracranial Hemorrhage (1891); Ischemia (1942); Nerve Damage (1979); Neurological Deficit/Dysfunction (1982); Loss of Vision (2139); Therapeutic Response, Decreased (2271); Thromboembolism (2654)
Event Date 08/24/2017
Event Type  Injury  
Manufacturer Narrative
Brasiliense lbc, aguilar-salinas p, miller da, tawk rg, sauvageau ea, hanel ra, analysis of predictors and probability of aneurysm occlusion in the ica after treatment with pipeline embolization device, world neurosurgery (2017), doi: 10.1016/j.Wneu.2017.08.099.The pipeline devices will not be returned for evaluation as they remain implanted in the patients.Based on the provided information, there does not appear to have been any defect of the device during use.The events occurred in the patients post-procedure and the causes could not be conclusively determined from the provided information.Mdrs related to this article: 2029214-2017-01193 2029214-2017-01194.
Event Description
Medtronic literature review found reports of adverse events after pipeline implantation.The purpose of this study was to investigate predictors and rate of occlusion for aneurysms along the internal carotid artery (ica).The authors analyzed the results of 83 patients with 117 aneurysms who underwent treatment with the pipeline embolization device (ped); a total of 106 peds were deployed.The patients¿ mean age was 61.2 years; 75 of the patients were female.The article states that major stroke (ischemic or hemorrhagic stroke resulting in mrs 3, 4, or 5) was observed in two patients ((b)(6) female and (b)(6) female): - one patient experienced stroke eight days after ped placement after discontinuing ticagrelor in another facility.The patient subsequently experienced acute occlusion of the ped.The patient was known to be resistant to clopidogrel.The patient reportedly remains severely disabled on latest assessment (mrs of 5).- one patient experienced major stroke five days after ped placement.The patient had undergone ped treatment of a giant, ophthalmic segment aneurysm.Five days after the procedure the patient was found unresponsive at home.Imaging studies revealed a subarachnoid hemorrhage and significant flow inside the aneurysm.The aneurysm was treated with two additional overlapping devices.After two months, the patient had partially recovered, with persistent right hemiparesis, predominantly in the lower limb, and left inferior quadrantanopia (mrs of 3).Angiography performed 10 months after the second treatment showed complete occlusion of the aneurysm.The article also states that one patient ((b)(6) female) experienced neurological death.The article notes the following minor complications: - two patients ((b)(6) female, (b)(6)female) experienced small intracranial hemorrhages after discharge.One of the patients was intact at latest follow-up and the second patient had worsening of double vision (mrs of 2).- two patients ((b)(6) female, (b)(6) female) experienced mass effect after ped treatment: one patient with multiple adjacent aneurysms developed double vision from a partial sixth cranial nerve palsy days after treatment.The symptoms were completely resolved after 7 months.One patient with a giant posterior communicating aneurysm had acute monocular vision loss five days after the ped was placed.Computed tomography showed significant thrombosis of the aneurysm.A second ped was deployed to avoid the risk of aneurysm rupture.The second procedure caused worsening of visual symptoms and the patient was emergently taken to the operating room to decompress the aneurysm and optic apparatus followed by clip ligation of the device and ica, described elsewhere.Five months after surgery the visual symptoms had improved although perception of objects remained limited (mrs of 2).- one patient ((b)(6) female) experienced thromboembolic events, which caused retinal infarcts.The patient recovered with partial loss of central vision (mrs of 1).
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Brand Name
Type of Device
Manufacturer (Section D)
9775 toledo way
irvine CA 92618
Manufacturer (Section G)
9775 toledo way
irvine CA 92618
Manufacturer Contact
tricha miles
9775 toledo way
irvine, CA 92618
MDR Report Key6986254
MDR Text Key90512139
Report Number2029214-2017-01193
Device Sequence Number1
Product Code OUT
Combination Product (y/n)N
Reporter Country CodeUS
PMA/PMN Number
Number of Events Reported1
Summary Report (Y/N)N
Report Source Manufacturer
Source Type health professional,literatur
Reporter Occupation Physician
Type of Report Initial
Report Date 10/29/2017
1 Device was Involved in the Event
1 Patient was Involved in the Event
Date FDA Received10/30/2017
Is this an Adverse Event Report? Yes
Is this a Product Problem Report? No
Device Operator Health Professional
Was Device Available for Evaluation? No
Is the Reporter a Health Professional? Yes
Date Manufacturer Received10/03/2017
Is the Device Single Use? Yes
Is This a Reprocessed and Reused Single-Use Device? No
Type of Device Usage Initial
Patient Sequence Number1
Patient Outcome(s) Other; Required Intervention;