Catalog Number 1120250-23 |
Device Problems
Failure to Advance (2524); Material Deformation (2976); Activation Failure (3270)
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Patient Problem
No Consequences Or Impact To Patient (2199)
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Event Date 10/15/2019 |
Event Type
malfunction
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Manufacturer Narrative
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Exemption number e2019001.The device was received.Investigation is not yet complete.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 re-stenosed lesion in the heavily calcified, moderately tortuous, 90% stenosed right coronary artery.A 2.5x23mm xience alpine stent delivery system (sds) failed to reach the intended position when the stent struts interacted with an unspecified previously implanted stent.Although the interaction led to flared stent struts, stent deployment was attempted and failed, so the stent was removed and not implanted.A new 2.5x18mm xience xpedition stent was used to successfully complete the procedure.There were no adverse patient effects and no clinically significant delay in the procedure.No additional information was provided.
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Manufacturer Narrative
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The device was returned for analysis.The reported material deformation was confirmed.The reported activation failure (inflation issues) was not confirmed.The reported failure to advance could not be replicated in a testing environment as it was related to operational context of the procedure.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 identified no similar incidents from this lot.The investigation determined the reported failure to advance and material deformation (stent flare) appear to be related to circumstances of the procedure as it is likely the device interacted with the previously implanted stent causing the reported failure to advance and subsequent material deformation (stent flare.The investigation was unable to determine a conclusive cause for the reported activation failure.There is no indication of a product quality issue with respect to manufacture, design or labeling.
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Search Alerts/Recalls
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