MAUDE Adverse Event Report: COOK IRELAND LTD ZIMMON BILIARY STENT SET; FGE CATHETER, BILIARY, DIAGNOSTIC

Model Number	G21526
Medical Device Problem Codes	Break (1069); Kinked (1339)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Date of Event	05/16/2018
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Cook ireland ltd (manufacturer) is submitting this report on behalf of cook medical incorporated (cmi)(importer).Exemption number: e2016031.Information pertaining to section g.1 as follows: importer site contact and address: (b)(4) cook medical incorporated (cmi) 1025 acuff road p.O box 4195 bloomington indiana 47402-4195.Importer site establishment registration number: 3005580113.Investigation is still pending.A follow up mdr will be submitted to include the investigation conclusions.
Event or Problem Description
The user straightened the pig tail of the stent using the straightener and attempted to advance it over a wire guide (olympus' visiglide angled 0.025 inch) that was placed in the hepatic portal region.But the wire guide would not be inserted into the stent lumen due to a kink of the pig tail.He replaced it with another zebd-7-12 to complete the procedure.
Additional Manufacturer Narrative
(b)(4).Exemption number: e2016031.(b)(4).Problem statement: the customer reported the following complaint issue: "the user straightened the pig tail of the stent using the straightener and attempted to advance it over a wire guide (olympus' visiglide angled 0.025inch) that was placed in the hepatic portal region but the wire guide would not be inserted into the stent lumen due to a kink of the pig tail.He replaced it with another zebd-7-12 to complete the procedure." lab evaluation: 1 x zebd-7-12 device of lot # c1429443 was returned to cirl for evaluation.A lab evaluation was held on 07 jun 2018.Upon evaluation of the returned device, it was noted that the stent was returned with the pigtail straightener.The white pushing catheter was also returned.During the lab evaluation, a kink was confirmed at sideport # 3 at the ductal end.A 0.035 inch wire guide would not pass through the stent.No side or backwall damage was observed.No other defects were noted.Root cause: a definitive root cause for the customer complaint could not be determined as the exact operational conditions of use could not be replicated in the laboratory setting.However, a possible cause of this complaint is that the stent may have been kinked while straightening the pigtails with the pigtail straightener.A precaution included in instructions for use states "care must be exercised when straightening the pigtail curls* in order to avoid kinking or breaking the stent." the complaint is confirmed as the failure was verified in the laboratory and the stent was found to be kinked.Documents review: a review of the manufacturing records for the zebd device of lot # c1429443 did not reveal any discrepancy related to the complaint issue.There is no evidence to suggest that this issue affects the entire lot # c1429443.Upon review of complaints this failure mode has not occurred previously with this lot # c1429443.Prd/fqc/pkg review: prior to distribution, all devices are subjected to 100% inspection to ensure device integrity.These inspections and functional checks are outlined in internal procedures in place at cirl.There is 100% inspection on all stents for kinks and a check that the appropriate size wire guide moves smoothly and freely when inserted into both ends of the stent.There is also a visual inspection of the product and packaging at packaging, packaging qc, and post sterile qc, "complete a 100% visual inspection of the packaged unit (tyvek pouched) while held at a comfortable arm¿s length from the unaided eye at normal lighting conditions." ifu review: it may be noted that according to the instructions for use the user is instructed to: ¿visually inspect with particular attention to kinks, bends and breaks.If any abnormality is detected that would prohibit proper working condition, do not use¿.Summary: the complaint is confirmed as the failure was verified in the laboratory and the stent was found to be kinked.Complaints of this nature will continue to be monitored for potential emerging trends.
Event or Problem Description
Report is being submitted under the precedence for this device family for the issue of ¿stent kinked/bent¿.The user straightened the pig tail of the stent using the straightener and attempted to advance it over a wire guide (olympus' visiglide angled 0.025inch) that was placed in the hepatic portal region.But the wire guide would not be inserted into the stent lumen due to a kink of the pig tail.He replaced it with another zebd-7-12 to complete the procedure.

• Brand Name: ZIMMON BILIARY STENT SET
• Common Device Name: FGE CATHETER, BILIARY, DIAGNOSTIC
• Manufacturer (Section D): COOK IRELAND LTD; o halloran road; limerick
• MDR Report Key: 7600740
• Report Number: 3001845648-2018-00272
• Device Sequence Number: 19178413
• Product Code: FGE
• UDI-Device Identifier: 00827002215269
• UDI-Public: (01)00827002215269(17)201205(10)C1429443
• Combination Product (Y/N): N
• PMA/510(K) Number: K851962
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: company representative,health
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 06/14/2018

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Operator of Device: Health Professional
• Device Expiration Date: 12/05/2020
• Device Model Number: G21526
• Device Catalogue Number: ZEBD-7-12
• Device Lot Number: C1429443
• Was Device Available for Evaluation?: Yes
• Was the Report Sent to FDA?: No
• Distributor Facility Aware Date: 06/13/2018
• Event Location: Hospital
• Initial Date Received by Manufacturer: 05/21/2018
• Supplement Date Received by Manufacturer: 05/21/2018
• Initial Report FDA Received Date: 06/14/2018
• Supplement Report FDA Received Date: 07/12/2018
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1