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U.S. Department of Health and Human Services

MAUDE Adverse Event Report: ARROW INTERNATIONAL INC. ARROW CVC SET: 2-LUMEN 8 FR X 20 CM CATHETER,INTRAVASCULAR,THERAP

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ARROW INTERNATIONAL INC. ARROW CVC SET: 2-LUMEN 8 FR X 20 CM CATHETER,INTRAVASCULAR,THERAP Back to Search Results
Catalog Number CS-25802-E
Device Problems Unraveled Material (1664); Physical Resistance (2578)
Patient Problem No Consequences Or Impact To Patient (2199)
Event Date 01/22/2018
Event Type  malfunction  
Event Description
The customer alleges resistance was met when inserting the swg (spring wire guide) through the ars (syringe). The swg unraveled after withdrawing from the introducer needle.
 
Manufacturer Narrative
(b)(4). Corrected data: describe event or problem - corrected to "the swg unraveled after withdrawing from the introducer needle. " the customer returned a used unraveled spring wire guide (swg). The introducer needle was not returned. Visual examination of the swg revealed the guide wire is unraveled from the proximal weld. The distal end of the core wire was undamaged and retained its j shape. The guide wire body also had multiple bends and stretched coils. Microscopic examination of the guide wire confirmed the core wire was broken adjacent to the proximal weld and that the weld was present at the end of the coil wire. The proximal core wire protruding is rounded and pinched. The distal weld was still intact. Both the proximal and distal welds appeared full and spherical. The broken core wire measured 601mm in length, which met specification; therefore, no pieces appear to be missing. The outside diameter of the guide wire was also found to be within specification. A manual tug test confirmed that the distal weld was intact. Additional testing of the introducer needle could not be performed as the needle was not returned. A device history record review was performed and no relevant findings were identified. (con't) other remarks: the instructions for use (ifu) provided with the kit describes suggested techniques to minimize the likelihood of guide wire damage during use. It states that if resistance is encountered when attempting to remove the guide wire after catheter placement, the guide wire may be kinked about the tip of the catheter within the vessel. In this case it is recommended to withdraw the catheter relative to the guide wire about 2-3cm and then attempt to remove the guide wire. The instructions caution that withdrawing the guide wire against the needle bevel or use of excessive force during removal could damage or break the wire. The report that the guide wire was unraveled was confirmed through examination of the returned sample. The guide wire core wire was broken adjacent to the proximal weld. Dimensional inspection and a device history record review did not reveal any evidence of a manufacturing related issue. Arrow guide wires of this size are designed and manufactured to withstand a tensile force of 2. 75 pounds force. This internal specification is higher than the bs en iso 11070:2014 standard of 2. 2 pounds force for this size wire. The selected insertion site and patient anatomy may present a tortuous path that could contribute to the possibility of guide wire kinking. Guide wire breakage may occur if a force greater than the design specification is applied during removal. Based on these circumstances, it was determined that operational context likely contributed to this event, however, the probable cause of guide wire and introducer needle resistance could not be determined based upon the information provided and without the introducer needle being returned. Teleflex will continue to monitor and trend for reports of this nature.
 
Manufacturer Narrative
(b)(4).
 
Event Description
The customer alleges resistance was met when inserting the swg (spring wire guide) through the ars (syringe). The swg unraveled after withdrawing with catheter.
 
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Brand NameARROW CVC SET: 2-LUMEN 8 FR X 20 CM
Type of DeviceCATHETER,INTRAVASCULAR,THERAP
Manufacturer (Section D)
ARROW INTERNATIONAL INC.
reading PA
MDR Report Key7237473
MDR Text Key287251531
Report Number3006425876-2018-00073
Device Sequence Number1
Product Code FOZ
Combination Product (y/n)N
PMA/PMN Number
K900263
Number of Events Reported1
Summary Report (Y/N)N
Report Source Manufacturer
Source Type distributor,foreign,health pr
Type of Report Initial,Followup
Report Date 01/23/2018
1 Device was Involved in the Event
0 Patients were Involved in the Event:
Date FDA Received02/02/2018
Is this an Adverse Event Report? No
Is this a Product Problem Report? Yes
Device Operator
Device Expiration Date04/30/2019
Device Catalogue NumberCS-25802-E
Device Lot Number23F17F0591
Was Device Available for Evaluation? Device Returned to Manufacturer
Date Returned to Manufacturer01/29/2018
Was the Report Sent to FDA?
Event Location No Information
Date Manufacturer Received03/14/2018
Is This a Reprocessed and Reused Single-Use Device? No

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