FDA Adverse Event Malfunction Summary report: N

ATLANTIS¿ SR PRO²

MDR report key: 3042101 · Received April 9, 2013

Report

Report Number
2134265-2013-02196
Event Type
Malfunction
Date Received
April 9, 2013
Date of Event
March 8, 2013
Report Date
March 11, 2013
Manufacturer
BOSTON SCIENTIFIC - FREMONT (SUD)
Product Code
DQO
PMA / PMN Number
K063312
Adverse Event
Yes
Product Problem
Yes
Report Source
Manufacturer report
Reporter Occupation
PHYSICIAN

Narratives

Additional Manufacturer Narrative · 1

UPDATED: DEVICE EVALUATED BY MANUFACTURER, EVALUATION SUMMARY ATTACHED, METHOD CODES, RESULT CODES, CONCLUSION CODES. DEVICE EVALUATED BY MANUFACTURER: THE DEVICE WAS RETURNED FOR ANALYSIS. THE IMAGING CORE, TELESCOPE, AND HUB ASSEMBLY WERE MISSING; ONLY THE SHEATH ASSEMBLY WAS RECEIVED. KINKS WERE OBSERVED IN THE SHEATH ASSEMBLY AT 20.1CM, 21.6CM, AND 22.6CM FROM FEMORAL MARKER AT THE PROXIMAL END. THE GUIDEWIRE EXIT PORT WAS LIFTED 1.0MM. A TEST GUIDEWIRE (0.014") WAS INSERTED AND NO INDICATION OF RESISTANCE IN TRACKING THE GUIDEWIRE INTO THE CATHETER WAS NOTED. FULL IMAGE CHARACTERIZATION TESTING CANNOT BE PERFORMED BASED ON THE RETURNED CONDITION OF THE CATHETER. NO OTHER ISSUES OR DEFECTS WERE OBSERVED DURING PRODUCT ANALYSIS OF THE RETURNED DEVICE. THE MANUFACTURING BATCH RECORD REVIEW CONFIRMED THAT THE DEVICE MET ALL MATERIAL, ASSEMBLY AND PERFORMANCE SPECIFICATIONS. A PROBABLE ROOT CAUSE OF OPERATIONAL CONTEXT WAS ASSIGNED TO THE REPORTED COMPLAINT DUE TO PROCEDURAL/ANATOMICAL FACTORS THAT LIMITS ITS PERFORMANCE. (B)(4).

Additional Manufacturer Narrative · 1

(B)(4).

Description of Event or Problem · 1

SAME CASE AS MDR ID# 2134265-2013-02367. IT WAS REPORTED THAT DURING A PERCUTANEOUS CORONARY INTERVENTION, A CATHETER WAS STUCK IN STENT AND THE STENT WAS DEFORMED. THE TARGET LESION WAS LOCATED IN THE MODERATELY TORTUOUS AND MODERATELY CALCIFIED LEFT ANTERIOR DESCENDING ARTERY. A PROMUS ELEMENT STENT WAS IMPLANTED IN THE LESION. THE STENT WAS POST-DILATED WITH AN UNKNOWN BALLOON CATHETER. THEY PERFORMED THE IVUS WITH THE ATLANTIS SR PRO IMAGING CATHETER. THE IMAGING CATHETER BECAME STUCK WITH THE EDGE OF THE STENT AND THE STENT WAS DEFORMED. THE PHYSICIAN THOUGHT THAT THE GUIDEWIRE EXIT PORT OF THIS DEVICE WAS STUCK WITH THE STENT. AN ATTEMPT TO RETRIEVE THE IMAGING CATHETER WAS PERFORMED BY CUTTING THE SHAFT OF THE CATHETER AND REMOVED ITS IMAGING CORE (DRIVE CABLE). THEN THEY ADVANCED THE 0.14 INCH UNKNOWN GUIDEWIRE AND REMOVED THE IMAGING CATHETER FROM THE STENT. TO REPAIR THE DEFORMED STENT, THEY POST-DILATE IT WITH AN UNKNOWN BALLOON CATHETER. THE PROCEDURE WAS COMPLETED WITH THIS DEVICE. THERE WERE NO REPORTED PATIENT COMPLICATIONS AND THE PATIENT STATUS POST PROCEDURE WAS LISTED AS GOOD.

Description of Event or Problem · 1

SAME CASE AS MDR ID# 2134265-2013-02367. IT WAS REPORTED THAT DURING A PERCUTANEOUS CORONARY INTERVENTION, A CATHETER WAS STUCK IN STENT AND THE STENT WAS DEFORMED. THE TARGET LESION WAS LOCATED IN THE MODERATELY TORTUOUS AND MODERATELY CALCIFIED LEFT ANTERIOR DESCENDING ARTERY. A PROMUS ELEMENT STENT WAS IMPLANTED IN THE LESION. THE STENT WAS POST-DILATED WITH AN UNKNOWN BALLOON CATHETER. THEY PERFORMED THE IVUS WITH THE ATLANTIS SR PRO IMAGING CATHETER. THE IMAGING CATHETER BECAME STUCK WITH THE EDGE OF THE STENT AND THE STENT WAS DEFORMED. THE PHYSICIAN THOUGHT THAT THE GUIDEWIRE EXIT PORT OF THIS DEVICE WAS STUCK WITH THE STENT. AN ATTEMPT TO RETRIEVE THE IMAGING CATHETER WAS PERFORMED BY CUTTING THE SHAFT OF THE CATHETER AND REMOVED ITS IMAGING CORE (DRIVE CABLE). THEN THEY ADVANCED THE 0.14 INCH UNKNOWN GUIDEWIRE AND REMOVED THE IMAGING CATHETER FROM THE STENT. TO REPAIR THE DEFORMED STENT, THEY POST-DILATE IT WITH AN UNKNOWN BALLOON CATHETER. THE PROCEDURE WAS COMPLETED WITH THIS DEVICE. THERE WERE NO REPORTED PATIENT COMPLICATIONS AND THE PATIENT STATUS POST PROCEDURE WAS LISTED AS GOOD.

Devices

Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
145333 ATLANTIS¿ SR PRO² CATHETER, INTRAVASCULAR, DIAGNOSTIC DQO BOSTON SCIENTIFIC - FREMONT (SUD) H749390140 15741248

Patients

Seq Age Sex Outcome Treatment
1 Required Intervention