BEUDAMED
    FDA Adverse Event Injury Summary report: N

    PERCLOSE PROGLIDE 6F SUTURE MEDIATED CLOSURE (SMC) SYSTEM

    MDR report key: 1904674 · Received November 22, 2010

    Report

    Report Number
    2953144-2010-02867
    Event Type
    Injury
    Date Received
    November 22, 2010
    Date of Event
    September 13, 2010
    Report Date
    October 26, 2010
    Manufacturer
    AV-REDWOOD CITY
    Product Code
    MGB
    PMA / PMN Number
    P960043
    Adverse Event
    Yes
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    IA, US
    Reporter Occupation
    HEALTH PROFESSIONAL

    Narratives

    Additional Manufacturer Narrative · 1

    (B)(4). THE DEVICE WAS RECEIVED. INVESTIGATION IS NOT YET COMPLETE.(B)(4). DURING PROCESSING OF THIS COMPLAINT, ATTEMPTS WERE MADE TO OBTAIN COMPLETE EVENT, PATIENT AND DEVICE INFORMATION.

    Additional Manufacturer Narrative · 1

    (B)(4). THE PLUNGER, SUTURE, LINK, NEEDLES AND CUFFS WERE NOT RETURNED WHICH LIMITED THE INVESTIGATION. EVALUATION OF THE RETURNED DEVICE COMPONENTS REVEALED NO ABNORMAL OBSERVATIONS THAT COULD CONTRIBUTE TO THE REPORTED NEEDLE-TO-CUFF MISS. DURING LAB TESTING, THE PROXY PLUNGER WAS INSERTED TO TEST THE NEEDLE TRAJECTORY AND PUSH MANDREL TRAVEL AND THE RESULTS WERE ACCEPTABLE. BASED ON THE INVESTIGATION FINDINGS, THE DEVICE PERFORMED ACCORDING TO SPECIFICATION AND A ROOT CAUSE RELATED TO THE REPORTED EVENT COULD NOT BE DETERMINED. THE MOST PROBABLE ROOT CAUSE FOR THE REPORTED CUFF MISS IS POSSIBLY NEEDLE DEFLECTION DURING PLUNGER DEPLOYMENT DUE TO A FAILURE TO MAINTAIN A STABLE POSITION OF THE DEVICE WITH RESPECT TO THE TISSUE TRACT OR/AND THE PATIENT ANATOMY. NO MANUFACTURING OR QUALITY ISSUES WERE DETECTED. REVIEW OF THE DEVICE HISTORY RECORD FOR THIS LOT DID NOT PRODUCE ANY FINDINGS RELEVANT TO THIS REPORT.

    Description of Event or Problem · 1

    PERCUTANEOUS CORONARY INTERVENTION (PCI) WAS PERFORMED IN A LESION WITH MILD CALCIFICATION AND MODERATE TORTUOSITY IN THE LEFT ANTERIOR DESCENDING (LAD) ARTERY. A STENT WAS IMPLANTED AND THE INTRAVASCULAR ULTRASOUND (IVUS) CATHETER WAS USED TO IMAGE STENT PLACEMENT. THE STENT WAS FULLY DEPLOYED AND WELL APPOSED. UPON REMOVAL MILD RESISTANCE WAS FELT AND THE IVUS CATHETER BECAME CAUGHT ON THE STENT. THE PHYSICIAN PULLED THE IVUS CATHETER RELEASING THE IVUS CATHETER WHICH WAS SUCCESSFULLY REMOVED FROM THE PATIENT WITHOUT INCIDENT. THE PROCEDURE WAS COMPLETED WITH ANOTHER IVUS CATHETER. THE PATIENT CONDITION WAS REPORTED AS "GOOD".

    Description of Event or Problem · 1

    IT WAS REPORTED THAT A PHYSICIAN TRAINED IN THE USE OF THE PROGLIDE DEVICE ATTEMPTED ARTERIOTOMY CLOSURE OF THE COMMON FEMORAL ARTERY AFTER AN UNSPECIFIED PROCEDURE. REPORTEDLY, A CUFF MISS OCCURRED AND A SECOND PROGLIDE WAS USED SUCCESSFULLY TO ACHIEVE HEMOSTASIS. ALTHOUGH REQUESTED, NO ADDITIONAL INFORMATION WAS PROVIDED.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 PERCLOSE PROGLIDE 6F SUTURE MEDIATED CLOSURE (SMC) SYSTEM SUTURE MEDIATED CLOSURE MGB AV-REDWOOD CITY 920286H

    Patients

    Seq Age Sex Outcome Treatment
    1 Required Intervention