SMART PORT CT
Report
- Report Number
- 1317056-2025-00250
- Event Type
- Death
- Date Received
- September 17, 2025
- Date of Event
- September 22, 2023
- Report Date
- September 29, 2025
- Manufacturer
- ANGIODYNAMICS, INC
- Product Code
- LJT
- UDI-DI
- 15051684018142
- PMA / PMN Number
- K062414
- Adverse Event
- Yes
- Report Source
- Manufacturer report
- Reporter Location
- IL, US
- Reporter Occupation
- 003
Narratives
THE DEVICE IS NOT AVAILABLE TO BE RETURNED TO THE MANUFACTURER FOR EVALUATION. AN INVESTIGATION INTO THE ROOT CAUSE FOR THE EVENT IS CURRENTLY IN PROGRESS. THE RESULTS OF THE INVESTIGATION WILL BE SENT VIA A FOLLOW UP MEDWATCH. REFERENCE: (B)(4).
THE CUSTOMER'S REPORTED COMPLAINT DESCRIPTION OF PATIENT INFECTION CANNOT BE CONFIRMED GIVEN THE PATIENT CENTRIC NATURE OF THIS SERIOUS ADVERSE EVENT (SAE). NO PORT DEVICE WAS RETURNED FOR EVALUATION SINCE THERE WAS NO REPORT OF PORT DEVICE MALFUNCTION, DAMAGE OR PERFORMANCE ISSUE DURING IN SITU USE/TREATMENT. A DEVICE HISTORY RECORD (DHR) REVIEW OF THE INDICATED PACKAGING LOT REVEALED NO QUALITY RELATED ISSUES OR MANUFACTURING DEFICIENCIES AT THE TIME OF MANUFACTURE. STERILIZATION LOAD RELEASE RECORDS WERE REVIEWED FOR THE PACKAGING LOT IN QUESTION; NO ISSUES WERE OBSERVED. THE PORT WAS IMPLANTED INTO THE PATIENT 39 DAYS PRIOR TO THE PATIENT'S INFECTION. THERE WAS NO REPORT OF PORT DEVICE MALFUNCTION OR PERFORMANCE ISSUE DURING USE. IF THE MANUFACTURING/PACKAGING/STERILIZATION OF THE PORT DEVICE IN QUESTION WAS TO CONTRIBUTE TO AN INFECTION IN THE PATIENT IT WOULD HAVE LIKELY OCCURRED SHORTLY AFTER THE IMPLANT DATE AND NOT 39 DAYS LATER. DEVICE DIRECTIONS FOR USE (DFU) CAUTIONS THAT EACH ACCESS OF THE PORT SHOULD BE PERFORMED USING ASEPTIC TECHNIQUE, FOLLOWING THE INSTITUTIONS UNIVERSAL PRECAUTIONS. THERE IS NO INDICATION FROM THE REPORTED COMPLAINT THAT THE MANUFACTURING/PACKAGING/STERILIZATION OF THE PORT DEVICE COULD HAVE CONTRIBUTED TO THE PATIENT'S INFECTION. INFECTION IS CAUTIONED IN THE DEVICE DFU AS A POTENTIAL COMPLICATION OF PORT SYSTEM USE. LABELING REVIEW: THE DIRECTIONS FOR USE (DFU) THAT IS PROVIDED WITH THE PORT DEVICE CONTAINS THE FOLLOWING STATEMENTS: WARNINGS: · THE DEVICE IS TO BE IMPLANTED, USED, MAINTAINED, AND REMOVED IN STRICT ACCORDANCE WITH INSTITUTIONAL AND OR CENTERS FOR DISEASE CONTROL (CDC) GUIDELINES OR POLICIES. · REUSE OF SINGLE-USE DEVICES CREATES A POTENTIAL RISK OF PATIENT OR USER INFECTIONS. CONTAMINATION OF THE DEVICE MAY LEAD TO INJURY, ILLNESS OR DEATH OF THE PATIENT. · DO NOT USE SYRINGES SMALLER THAN 10 ML SYRINGE WHEN ACCESSING THE PORT AS SYSTEM DAMAGE CAN OCCUR. FLUSHING OCCLUDED CATHETERS WITH SMALL SYRINGES CAN CREATE EXCESSIVE PRESSURES WITHIN THE PORT SYSTEM. PRECAUTIONS · CAREFULLY READ AND FOLLOW ALL INSTRUCTIONS PRIOR TO USE. · STRICT ASEPTIC TECHNIQUE IS OF PARAMOUNT IMPORTANCE WHEN IMPLANTING ANY DEVICE. · FOR PERIPHERAL PLACEMENT, IRRITATION TO THE VEIN, RESULTING IN POSTOPERATIVE THROMBOPHLEBITIS, HAS BEEN ASSOCIATED WITH GUIDEWIRE AND INTRODUCER INSERTION. · WHEN USING PERCUTANEOUS INTRODUCERS: TO AVOID BLOOD VESSEL DAMAGE, DO NOT ALLOW THE PERCUTANEOUS INTRODUCER SHEATH TO REMAIN INDWELLING IN THE BLOOD VESSEL WITHOUT THE INTERNAL SUPPORT OF A CATHETER OR DILATOR. · IF MORE THAN ONE DRUG IS TO BE ADMINISTERED, BETWEEN THE INDIVIDUAL DRUG APPLICATIONS, FLUSH THE SYSTEM WITH 5 TO 10 ML NORMAL SALINE FOR INJECTION TO PREVENT DRUG INTERACTIONS. · AFTER ANY INFUSION, INJECTION OR BOLUS APPLICATION, THE SYSTEM SHOULD BE FLUSHED WITH NORMAL SALINE FOR INJECTION OR LOCKED WITH A HEPARIN SOLUTION PER INSTITUTIONAL PROTOCOL TO PREVENT THROMBOTIC OCCLUSION OF THE CATHETER. POTENTIAL COMPLICATIONS USE OF AN ANGIODYNAMICS PORT SYSTEM INVOLVES POTENTIAL RISKS NORMALLY ASSOCIATED WITH THE INSERTION OR USE OF ANY IMPLANTED DEVICE OR INDWELLING CATHETER INCLUDING BUT NOT LIMITED TO: AIR EMBOLISM CATHETER DISCONNECTION OR MIGRATION CATHETER EMBOLIZATION CATHETER FRAGMENTATION CATHETER PINCH-OFF CLOT FORMATION DRUG EXTRAVASATION (LEAKAGE) EROSION OF VESSEL AND SKIN IMPLANT REJECTION INFECTION INFLAMMATION THROMBOEMBOLISM THROMBOPHLEBITIS THROMBOSIS NECROSIS OF SCARRING OF SKIN OVER IMPLANT AREA VESSEL TRAUMA POST-OPERATIVE CARE THE INCISION SITE SHOULD BE MONITORED FOR SIGNS OF INFECTION, INFLAMMATION, HEMATOMA, DEVICE ROTATION OR EROSION. ROUTINE WOUND CARE SHOULD BE GIVEN TO THESE SITES. THE SMART PORT CT IMPLANTABLE PORT MAY BE USED IMMEDIATELY AFTER VERIFICATION OF CATHETER PLACEMENT. INSTRUCT PATIENT TO AVOID ANY HEAVY EXERTION OR STRENUOUS ACTIVITY DURING THE FIRST FEW DAYS AFTER SURGERY. GENERAL GUIDELINES · EACH ACCESS OF AN ANGIODYNAMICS SMART PORT CT IMPLANTABLE PORT SHOULD BE PERFORMED USING ASEPTIC TECHNIQUE. · FOLLOW INSTITUTIONAL UNIVERSAL PRECAUTIONS. A REVIEW OF THE ANGIODYNAMICS COMPLAINT SYSTEM NOTED NO ADVERSE TRENDS FOR THIS COMPLAINT TYPE AND PRODUCT FAMILY. THIS TYPE OF COMPLAINT CONTINUES TO BE MONITORED FOR TRENDS. REFERENCE (B)(4).
ON OR ABOUT ON (B)(6) 2023, DECEDENT UNDERWENT PLACEMENT OF AN ANGIODYNAMICS SMARTPORT PORT CATHETER PRODUCT, WITH MODEL NUMBER: H787CT80STPAVI1, AND LOT NUMBER: 5766912. THIS SMARTPORT DEVICE WAS COMPRISED OF A PORT BODY AND A POLYURETHANE CATHETER. THE SMARTPORT DEVICE WAS IMPLANTED BY DR. (B)(6), M.D., AT (B)(6), AND THE PURPOSE OF IMPLANTATION OF THE SMARTPORT WAS TO ADMINISTER MEDICATION TO TREAT DECEDENT'S ESOPHAGEAL CANCER. ON OR ABOUT ON (B)(6) 2023, DECEDENT PRESENTED TO (B)(6), WITH COMPLAINTS OF NECK AND LEG PAIN. DECEDENT'S BLOOD WAS DRAWN FROM THE SMARTPORT AND WAS SUBSEQUENTLY CULTURED, REVEALING THAT DECEDENT WAS SUFFERING FROM BACTEREMIA, AND THAT THE SMARTPORT WAS THE SOURCE OF THE INFECTION. THE INFECTION QUICKLY PROGRESSED INTO SEVERE SEPSIS. ON OR ABOUT ON (B)(6) 2023, WHILE STILL HOSPITALIZED AT (B)(6), DECEDENT UNDERWENT REMOVAL OF THE INFECTED SMARTPORT. THIS REMOVAL PROCEDURE WAS PERFORMED BY DR. (B)(6), M.D. DESPITE REMOVAL OF THE INFECTED SMARTPORT AND TREATMENT FOR THE SEVERE SEPSIS AFTER REMOVAL OF THE DEVICE, DECEDENT CONTINUED TO HAVE A FEVER AND OTHER SYMPTOMS SUGGESTIVE OF AN ONGOING INFECTION, REMAINING HOSPITALIZED AT (B)(6) TO UNDERGO CONTINUED TREATMENT. ON OR ABOUT ON (B)(6) 2023, DUE TO DECEDENT'S UNRESOLVED PORT INFECTION, DECEDENT UNDERWENT DEBRIDEMENT OF HIS SEPTIC STERNOCLAVICULAR JOINT AND LEFT LOWER NECK WOUND. PLAINTIFF REMAINED HOSPITALIZED AT (B)(6) FOLLOWING THIS PROCEDURE. ON OR ABOUT ON (B)(6) 2023, DUE TO DECEDENT'S UNRESOLVED PORT INFECTION, DECEDENT UNDERWENT A SECOND DEBRIDEMENT OF HIS STERNOCLAVICULAR JOINT AND LEFT CHEST WOUND. DECEDENT ALSO UNDERWENT PULSAVAC IRRIGATION, AND A WOUND VAC WAS PLACED. DECEDENT REMAINED HOSPITALIZED AT (B)(6). ON OR ABOUT ON (B)(6) 2023, DUE TO DECEDENT'S UNRESOLVED PORT INFECTION, DECEDENT UNDERWENT INCISION AND DRAINAGE OF HIS RIGHT STERNOCLAVICULAR SEPTIC JOINT AND REMAINED HOSPITALIZED AT (B)(6). ON OR ABOUT ON (B)(6) 2023, DECEDENT UNDERWENT A CHEST CT, WHICH REVEALED DECEDENT WAS SUFFERING FROM SEPTIC EMBOLI, WHICH WAS SECONDARY TO THE PORT CATHETER INFECTION CAUSED BY THE DEFECTIVE SMARTPORT. DECEDENT REMAINED HOSPITALIZED AT (B)(6). ON OR ABOUT ON (B)(6) 2023, DUE TO THE DAMAGE CAUSED BY THE PORT INFECTION AND TRAUMA FROM THE DEBRIDEMENT PROCEDURES, DECEDENT UNDERWENT CHEST WALL RECONSTRUCTION, WITH EXCISION OF THE WOUND LEFT BY THE SMARTPORT, ADJACENT TISSUE TRANSFER OF THE CHEST, AND PLACEMENT OF ANOTHER WOUND VAC. DECEDENT REMAINED HOSPITALIZED AT (B)(6). FOLLOWING DECEDENT'S NUMEROUS PROCEDURES TO TREAT SEVERE SEPSIS STEMMING FROM THE INFECTED SMARTPORT, DECEDENT RECEIVED INPATIENT HOSPITAL TREATMENT UNTIL HE WAS DISCHARGED ON (B)(6) 2023. DECEDENT SUBSEQUENTLY PASSED AWAY ON (B)(6) 2023.
Devices
| Seq | Brand | Generic | Product Code | Manufacturer | Model | Lot | UDI-DI |
|---|---|---|---|---|---|---|---|
| 2599386 | SMART PORT CT | PORT & CATHETER, IMPLANTED, SUBCUTANEOUS, INTRAVASCULAR | LJT | ANGIODYNAMICS, INC | H787CT80STPAVI1 | 5766912 | 15051684018142 |
Patients
| Seq | Age | Sex | Outcome | Treatment |
|---|---|---|---|---|
| 1 | NA | Male | Hospitalization| O| D| R| L |