Description of Event or Problem · 1
IT WAS REPORTED THIS BALLOON RUPTURED AT 12 ATMOSPHERES, FOLLOWING THE FIRST INFLATION, DURING AN ILIAC ANGIOPLASTY PROCEDURE OF A STENOTIC AND BRITTLE ARTERY. ANOTHER BALLOON CATHETER WAS THEN USED WHICH ALSO RUPTURED. THE PHYSICIAN DETEMINED ADEQUATE DILATATION WAS ACHIEVED AND A THIRD BALLOON WAS NOT USED. A COMPLETION ANGIOGRAM WAS DONE AND SLIGHT EXTRAVASATION OUT OF THE ARTERY WAS NOTED, HOWEVER, NO TREATMENT WAS ADMINISTERED. A SCHEDULED FEMORAL-POPLITEAL BY-PASS PROCEDURE WAS THEN SUCCESSFULLY PERFORMED. THREE TO FOUR HOURS POST BY-PASS PROCEDURE IT WAS NOTICED THE PT'S BLOOD PRESSURE WAS DROPPING. FOUR UNITS OF BLOOD AND 2 UNITS OF PLASMA WERE ADMINISTERED. LATER THAT EVENING, A PATCH ANGIOPLASTY PROCEDURE WAS PERFORMED TO SUCCESSFULLY REPAIR THE ARTERY. THE PATIENT'S CONDITION IS GOOD. THE DEVICE WAS DESTROYED BY THE USER FACILITY. THEREFORE, NO FAILURE ANALYSIS WILL BE AVAILABLE. BALLOON RUPTURE OR BALLOON LEAKAGE IS AN ANTICIPATED EVENT OF PERCUTANEOUS ANGIOPLASTY WHICH HAS BEEN ASSOCIATED WITH OVERPRESSURIZATION OR USE IN A CALCIFIED LESION. CO'S FOLLOW UP REVEALED THE ARTERY WAS STENTIC AND BRITTLE WHICH CO FEELS MAY HAVE CONTRIBUTED TO THIS EVENT. HOWEVER, CO IS UNABLE TO DETERMINE THE EXACT CAUSE FOR THIS EVENT. CO'S DIRECTIONS FOR USE STATE: "THE MINIMAL DILATING FORCE REQUIRED TO DILATE SHOULD BE APPLIED, MINIMIZING THE RISKS OF BALLOON OVER-INFLATION OR RUPTURE... IF LOSS OF PRESSURE WITHIN THE BALLOON OCCURS DURING INFLATION OR IF BALLOON RUPTURES DURING DILATATION, IMMEDIATELY DISCONTINUE THE PROCEDURE. DEFLATE THE BALLOON, DO NOT REINFLATE AND REMOVE CAREFULLY. SAME CASE AS MFR REPORT# 6000036-1999-00106.