Catalog Number B2060-040 |
Device Problems
Leak/Splash (1354); Difficult to Remove (1528); Material Separation (1562)
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Patient Problem
Vessel Or Plaque, Device Embedded In (1204)
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Event Date 02/07/2019 |
Event Type
Injury
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Manufacturer Narrative
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(b)(4).During processing of this complaint, attempts were made to obtain complete event, patient and device information.Concomitant medical products: guide wire: terumo advantage 0.035.Stent: 8x80 covera, begraft.The device is expected to be returned for investigation.It has not yet been received.A follow-up report will be submitted with all additional relevant information.
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Event Description
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It was reported that the procedure was performed to treat a totally occluded lesion in the iliac artery.Following recanalization, a 6x40mm armada 35 balloon catheter was used to pre-dilate the lesion.An 8x80mm non-abbott covered stent failed to cross due to the bifurcation and was removed.The balloon catheter was re-advanced for additional pre-dilatation; however, after dilatation the balloon became stuck with the anatomy and was not able to move forward or backwards.It was noted that the balloon catheter became damaged because blood was noted in the lumen.A puncture on the other groin was made to advance the guide wire into an introducer sheath and remove the catheter from the other side, but the guide wire was also stuck in the balloon catheter.The guide wire was pulled very hard with forceps while the balloon catheter was held down.A jolt was felt and the resistance lessened.The balloon catheter and half of the balloon came out.The remaining part of the balloon stayed in the common iliac.Several attempts were made to snare the separated balloon portion, but were unsuccessful.The balloon was covered with a peripheral stent graft.The patient is doing well.No additional information was provided.
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Manufacturer Narrative
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Internal file number - (b)(4).Evaluation summary: visual analysis was performed on the returned device.The reported separation was confirmed.The difficulty removing was not tested due to the condition of the returned device.A review of the lot history record identified no manufacturing nonconformities issued to the reported lot that would have contributed to this event.Additionally, a review of the complaint history revealed no other incidents.The investigation determined the reported difficulties were likely due to challenging case circumstances.The separation noted to the balloon and inner member on the returned device likely occurred while attempting to advance and retract through the totally occluded lesion.It is likely that the balloon became lodged within the occlusion resulting in separation during the attempt to remove.It was reported that the armada 35 was used for pre-dilatation suggesting that the damage was not pre-existing and occurred during the second advancement attempt for additional pre-dilatation.There is no indication of a product quality issue with respect to the design, manufacture, or labeling of the device.
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Search Alerts/Recalls
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