FDA Adverse Event Malfunction Summary report: N

INTERA 3000

MDR report key: 20091876 · Received August 28, 2024

Report

Report Number
3015537318-2024-00072
Event Type
Malfunction
Date Received
August 28, 2024
Date of Event
August 2, 2024
Report Date
January 27, 2025
Manufacturer
INTERA ONCOLOGY, INC
Product Code
LKK
UDI-DI
00850014110147
PMA / PMN Number
P890055
Product Problem
Yes
Report Source
Manufacturer report
Reporter Location
PA, US
Reporter Occupation
PHYSICIAN
Health Professional
Yes

Narratives

Additional Manufacturer Narrative · 0

ADDITIONAL FOLLOW UP INVESTIGATION DETERMINED THAT THE ROOT CAUSE WAS LIKELY RELATED TO ALIGNMENT OF THE CATHETER CONNECTION. UPDATED DEVICE COMPONENT CODE.

Additional Manufacturer Narrative · 0

THE DEVICE HAS BEEN REQUESTED BUT HAS NOT YET BEEN RETURNED TO INTERA FOR EVALUATION. WHEN THE DEVICE IS RECEIVED, EVALUATED AND INVESTIGATION COMPLETED, A SUPPLEMENT REPORT WILL BE FILED. BLANK FIELDS IN THE MDR FORM REPRESENT UNKNOWN INFORMATION AT THE TIME OF THIS REPORT.

Additional Manufacturer Narrative · 0

PATIENT INFORMATION ADDED. THE DEVICE WAS TESTED ON THE BENCH UNDER PROTOCOL AND DID NOT INITIALLY FLOW AS EXPECTED. AFTER MANIPULATION OF THE INTERNAL FLOW PATH, FLOW WAS OBSERVED AS EXPECTED. ITHE EXACT ROOT CAUSE IS UNDERTERMINED BUT LIKELY LINKED TO AN ISSUE WITH COMPONENT ALIGNMENT.

Description of Event or Problem · 0

IT WAS REPORTED THAT AN INTERA 3000 HEPATIC ARTERY INFUSION PUMP WAS NOT FLOWING AFTER IMPLANT. THE DEVICE WAS IMPLANTED ON (B)(6) 2024. THE PATIENT PRESENTED TO INFUSION SUITE ON (B)(6) 2024 FOR THEIR INITIAL REFILL. THE SURGEON REPORTED THAT PUMP RETURNED 29 ML INTO COLLECTION SYRINGE. THE SURGEON WAS ABLE TO FLUSH THE CATHETER USING SPECIAL BOLUS NEEDLE AND REPORTED NO RESISTANCE TO FLOW. PATIENT SENT HOME AFTER FILLING PUMP WITH HIGH-DOSE HEPARINIZED SALINE, AS PER PROTOCOL AND REQUESTED THAT PATIENT APPLY HEAT OVER PUMP IMPLANTATION SITE AND RETURN ON (B)(6) 2024 TO RE-ATTEMPT REFILL. ON (B)(6) 2024, THE HEALTHCARE PROVIDER ATTEMPTED TO REFILL PUMP: 30 ML OF HIGH-DOSE HEPARIN RETURNED TO COLLECTING SYRINGE. THE SURGEON ORDERED CT SCAN AND INTRODUCED TPA INTO THE CATHETER ON (B)(6) 2024. THE PUMP WAS EXPLANTED AND REPLACED ON (B)(6) 2024. INTRAOPERATIVELY, THE SURGEON EMPTIED THE PUMP TO DETERMINE IF THE TPA INSTILLED INTO THE CATHETER HAD REINSTATED FLOW. THE PUMP EMPTIED 12 ML. THE SURGEON INDICATED THAT HE HAD IN "AROUND 18-20 ML" ON (B)(6) 2024, WHICH INDICATES THAT THE PUMP WAS FLOWING AND HAD FLOWED APPROXIMATELY 6-8 ML OVER THE 6 DAY PERIOD. NEXT REFILL IS PENDING AND THEREFORE THE DATA ARE NOT AVAILABLE AT THE TIME OF THIS REPORT. HAPS SCAN POST IMPLANT SHOWED NO EXTRAHEPATIC FLOW.

Description of Event or Problem · 0

IT WAS REPORTED THAT AN INTERA 3000 HEPATIC ARTERY INFUSION PUMP WAS NOT FLOWING AFTER IMPLANT. THE DEVICE WAS IMPLANTED ON (B)(6) 2024. THE PATIENT PRESENTED TO INFUSION SUITE ON 02 AUGUST 2024 FOR THEIR INITIAL REFILL. THE SURGEON REPORTED THAT PUMP RETURNED 29 ML INTO COLLECTION SYRINGE. THE SURGEON WAS ABLE TO FLUSH THE CATHETER USING SPECIAL BOLUS NEEDLE AND REPORTED NO RESISTANCE TO FLOW. PATIENT SENT HOME AFTER FILLING PUMP WITH HIGH-DOSE HEPARINIZED SALINE, AS PER PROTOCOL AND REQUESTED THAT PATIENT APPLY HEAT OVER PUMP IMPLANTATION SITE AND RETURN ON 09 AUGUST 2024 TO RE-ATTEMPT REFILL. ON 09 AUGUST 2024, THE HEALTHCARE PROVIDER ATTEMPTED TO REFILL PUMP: 30 ML OF HIGH-DOSE HEPARIN RETURNED TO COLLECTING SYRINGE. THE SURGEON ORDERED CT SCAN AND INTRODUCED TPA INTO THE CATHETER ON 14 AUGUST 2024. THE PUMP WAS EXPLANTED AND REPLACED ON (B)(6) 2024. INTRAOPERATIVELY, THE SURGEON EMPTIED THE PUMP TO DETERMINE IF THE TPA INSTILLED INTO THE CATHETER HAD REINSTATED FLOW. THE PUMP EMPTIED 12 ML. THE SURGEON INDICATED THAT HE HAD IN "AROUND 18-20 ML" ON 14 AUGUST 2024, WHICH INDICATES THAT THE PUMP WAS FLOWING AND HAD FLOWED APPROXIMATELY 6-8 ML OVER THE 6 DAY PERIOD. NEXT REFILL IS PENDING AND THEREFORE THE DATA ARE NOT AVAILABLE AT THE TIME OF THIS REPORT. HAPS SCAN POST IMPLANT SHOWED NO EXTRAHEPATIC FLOW.

Description of Event or Problem · 0

IT WAS REPORTED THAT AN INTERA 3000 HEPATIC ARTERY INFUSION PUMP WAS NOT FLOWING AFTER IMPLANT. THE DEVICE WAS IMPLANTED ON (B)(6) 2024. THE PATIENT PRESENTED TO INFUSION SUITE ON (B)(6) 2024 FOR THEIR INITIAL REFILL. THE SURGEON REPORTED THAT PUMP RETURNED 29 ML INTO COLLECTION SYRINGE. THE SURGEON WAS ABLE TO FLUSH THE CATHETER USING SPECIAL BOLUS NEEDLE AND REPORTED NO RESISTANCE TO FLOW. PATIENT SENT HOME AFTER FILLING PUMP WITH HIGH-DOSE HEPARINIZED SALINE, AS PER PROTOCOL AND REQUESTED THAT PATIENT APPLY HEAT OVER PUMP IMPLANTATION SITE AND RETURN ON (B)(6) 2024 TO RE-ATTEMPT REFILL. ON (B)(6) 2024, THE HEALTHCARE PROVIDER ATTEMPTED TO REFILL PUMP: 30 ML OF HIGH-DOSE HEPARIN RETURNED TO COLLECTING SYRINGE. THE SURGEON ORDERED CT SCAN AND INTRODUCED TPA INTO THE CATHETER ON (B)(6) 2024. THE PUMP WAS EXPLANTED AND REPLACED ON (B)(6) 2024. INTRAOPERATIVELY, THE SURGEON EMPTIED THE PUMP TO DETERMINE IF THE TPA INSTILLED INTO THE CATHETER HAD REINSTATED FLOW. THE PUMP EMPTIED 12 ML. THE SURGEON INDICATED THAT HE HAD IN "AROUND 18-20 ML" ON (B)(6) 2024, WHICH INDICATES THAT THE PUMP WAS FLOWING AND HAD FLOWED APPROXIMATELY 6-8 ML OVER THE 6 DAY PERIOD. NEXT REFILL IS PENDING AND THEREFORE THE DATA ARE NOT AVAILABLE AT THE TIME OF THIS REPORT. HAPS SCAN POST IMPLANT SHOWED NO EXTRAHEPATIC FLOW.

Devices

Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
1521323 INTERA 3000 HEPATIC ARTERY INFUSION PUMP LKK INTERA ONCOLOGY, INC AP03000H 28155410S 00850014110147

Patients

Seq Age Sex Outcome Treatment
1 62 YR Male Required Intervention