FLUENCY PLUS ENDOVASCULAR STENT GRAFT
Report
- Report Number
- 2020394-2025-01195
- Event Type
- Malfunction
- Date Received
- August 7, 2025
- Date of Event
- July 10, 2025
- Report Date
- October 16, 2025
- Manufacturer
- BARD PERIPHERAL VASCULAR, INC.
- Product Code
- PFV
- UDI-DI
- 04049519008653
- PMA / PMN Number
- P130029
- Product Problem
- Yes
- Report Source
- Manufacturer report
- Reporter Location
- NC, US
- Reporter Occupation
- PHYSICIAN
- Health Professional
- Yes
Narratives
H11: AS THE LOT NUMBER FOR THE DEVICE WAS PROVIDED, A REVIEW OF THE DEVICE HISTORY RECORDS IS CURRENTLY BEING PERFORMED. THE RETURN OF THE SAMPLE IS PENDING. THE INVESTIGATION OF THE REPORTED EVENT IS CURRENTLY UNDERWAY. SECTION A THROUGH F ¿ THE INFORMATION PROVIDE BY BD REPRESENTS ALL THE KNOWN INFORMATION AT THIS TIME. DESPITE GOOD FAITH EFFORTS TO OBTAIN ADDITIONAL INFORMATION, THE COMPLAINANT/REPORTER WAS UNABLE OR UNWILLING TO PROVIDE ANY FURTHER PATIENT, PRODUCT, OR PROCEDURAL DETAILS TO BD.
H11: MANUFACTURING REVIEW: BASED ON THE INFORMATION AVAILABLE IT IS NOT REASONABLY SUGGESTED THAT A MANUFACTURING PROCESS MAY HAVE CAUSED OR CONTRIBUTED TO THE REPORTED ISSUE. HOWEVER, THE LOT HISTORY RECORDS OF THIS LOT WERE REVIEWED WITH SPECIAL ATTENTION TO THE MANUFACTURING AND INSPECTION OF THIS PRODUCT AND THE PRODUCT WAS FOUND TO HAVE MET THE SPECIFICATION PRIOR TO SHIPMENT. INVESTIGATION SUMMARY: THE STENT GRAFT DELIVERY SYSTEM SAMPLE WAS RETURNED FOR EVALUATION WITH AN ELONGATED OUTER SHEATH, THE STENT SHEATH WAS KINKED JUST PROXIMAL TO THE PROXIMAL END OF THE LOADED STENT AND DEPLOYMENT ATTEMPTS FAILED DURING TESTING LEADING TO FURTHER ELONGATION OF THE OUTER SHEATH. THE INVESTIGATION LEADS TO CONFIRMED RESULTS FOR DEPLOYMENT FAILURE AND MATERIAL DEFORMATION. THERE WAS NO INDICATION OF MANUFACTURING DEFICIENCY. IT WAS REPORTED THAT AN 8F INTRODUCER WAS USED AND THEN SWITCHED TO 10F FOR DEPLOYMENT WITH A 0.035" GUIDEWIRE FOR ACCESS, THE TRACKING VESSEL WAS NEITHER TORTUOUS NOR CALCIFIED, THE LESION WAS PRE-DILATED AND THE DEVICE WAS PROPERLY FLUSHED BEFORE USE. BASED ON THE PROVIDED INFORMATION AND THE EVALUATION OF THE RETURN SAMPLE, THE INVESTIGATION IS CLOSED WITH CONFIRMED RESULTS FOR FAILURE TO DEPLOY AND MATERIAL DEFORMATION. A DEFINITE ROOT CAUSE FOR THE REPORTED EVENT COULD NOT BE DETERMINED. LABELING REVIEW: IN REVIEWING THE RELEVANT LABELING, IT WAS FOUND THAT THE INSTRUCTIONS FOR USE (IFU) SUFFICIENTLY ADDRESS THE POTENTIAL RISKS. THE IFU STATE: 'IF UNUSUAL RESISTANCE OR HIGH DEPLOYMENT FORCE IS ENCOUNTERED DURING STENT GRAFT DEPLOYMENT, ABORT THE PROCEDURE, REMOVE THE DELIVERY SYSTEM AND USE AN ALTERNATIVE DEVICE.' REGARDING PREPARATION OF THE DEVICE THE IFU STATE THAT "PRIOR TO LOADING THE VASCULAR SYSTEM OVER A GUIDE WIRE, BOTH PORTS MUST BE FLUSHED WITH STERILE SALINE (...). FLUSHING THESE LUMENS WILL ALSO FACILITATE STENT GRAFT DEPLOYMENT" AND "CAREFULLY REMOVE THE ENDOVASCULAR SYSTEM FROM ITS PACKAGING AND INSPECT PACKAGING AND SYSTEM FOR ANY DAMAGE OR DEFECTS. DO NOT USE IF THE STERILE BARRIER IS COMPROMISED". REGARDING THE ANATOMY OF THE PLACEMENT SITE THE IFU STATES: "PRIOR TO STENT GRAFT DEPLOYMENT (...), ENSURE THAT THE PROXIMAL STENT GRAFT END IS POSITIONED IN A STRAIGHT SECTION OF THE LUMEN TO REDUCE THE RISK OF INCREASED DEPLOYMENT FORCES AND POSSIBLE FAILURE TO DEPLOY". REGARDING ACCESSORIES THE IFU STATES: "PREPARE A STIFF 0.035" GUIDEWIRE PER ITS INSTRUCTIONS FOR USE AND ADVANCE THE GUIDEWIRE UNDER FLUOROSCOPY TO THE TARGET LOCATION. THE USE OF AN APPROPRIATELY SIZED INTRODUCER SHEATH IS RECOMMENDED". THE PACKAGING PICTOGRAMS INDICATE AN INTRODUCER SIZE OF 10F AND A 0.035" GUIDEWIRE. BASED ON THE PROVIDED INFORMATION AND THE EVALUATION OF THE RETURN SAMPLE, THE INVESTIGATION IS CLOSED WITH CONFIRMED RESULTS FOR FAILURE TO DEPLOY AND MATERIAL DEFORMATION. A DEFINITE ROOT CAUSE FOR THE REPORTED EVENT COULD NOT BE DETERMINED. G3, H6 (METHOD, RESULT, CONCLUSION). SECTION A THROUGH F: THE INFORMATION PROVIDED BY BD REPRESENTS ALL THE KNOWN INFORMATION AT THIS TIME. DESPITE GOOD FAITH EFFORTS TO OBTAIN ADDITIONAL INFORMATION, THE COMPLAINANT / REPORTER WAS UNABLE OR UNWILLING TO PROVIDE ANY FURTHER PATIENT, PRODUCT, OR PROCEDURAL DETAILS TO BD. THE INVESTIGATION LEADS TO CONFIRMED RESULTS FOR DEPLOYMENT FAILURE AND MATERIAL DEFORMATION.
ON (B)(6) 2025, A PATIENT UNDERWENT A STENT GRAFT PLACEMENT PROCEDURE TARGETING A LEFT BRACHIAL BASILIC FISTULA USING THE FLUENCY PLUS ENDOVASCULAR STENT GRAFT. DURING THE PROCEDURE, THE STENT FAILED TO DEPLOY AS INTENDED. THE STENT DID NOT RELEASE PROPERLY AND APPEARED TO BE KINKED WITHIN THE CATHETER SHEATH. THE PROCEDURE WAS COMPLETED USING ANOTHER DEVICE. THERE WAS NO REPORTED PATIENT INJURY.
ON (B)(6) 2025, A PATIENT UNDERWENT A STENT GRAFT PLACEMENT PROCEDURE TARGETING A LEFT BRACHIAL BASILIC FISTULA USING THE FLUENCY PLUS ENDOVASCULAR STENT GRAFT. DURING THE PROCEDURE, THE STENT FAILED TO DEPLOY AS INTENDED. THE STENT DID NOT RELEASE PROPERLY AND APPEARED TO BE KINKED WITHIN THE CATHETER SHEATH. THE PROCEDURE WAS COMPLETED USING ANOTHER DEVICE. THERE WAS NO REPORTED PATIENT INJURY.
Devices
| Seq | Brand | Generic | Product Code | Manufacturer | Model | Lot | UDI-DI |
|---|---|---|---|---|---|---|---|
| 2219142 | FLUENCY PLUS ENDOVASCULAR STENT GRAFT | ENDOVASCULAR STENT GRAFT | PFV | BARD PERIPHERAL VASCULAR, INC. | ANJX4501 | 04049519008653 |
Patients
| Seq | Age | Sex | Outcome | Treatment |
|---|---|---|---|---|
| 1 | 63 YR | Unknown |