BEUDAMED
    FDA Adverse Event Injury Summary report: N

    RETROFLEX 3 INTRODUCER SHEATH SET

    MDR report key: 4132395 · Received October 1, 2014

    Report

    Report Number
    2015691-2014-02287
    Event Type
    Injury
    Date Received
    October 1, 2014
    Date of Event
    May 1, 2014
    Report Date
    September 4, 2014
    Manufacturer
    EDWARDS LIFESCIENCES
    Product Code
    DYB
    PMA / PMN Number
    K093877
    Adverse Event
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    MN, US
    Reporter Occupation
    PHYSICIAN

    Narratives

    Additional Manufacturer Narrative · 1

    ACCORDING TO THE INSTRUCTIONS FOR USE (IFU), CARDIOVASCULAR COMPLICATIONS, INCLUDING PERFORATION OR DISSECTION OF VESSELS WHICH MAY REQUIRE INTERVENTION, ARE POTENTIAL ADVERSE EVENTS ASSOCIATED WITH THE TRANSFEMORAL TRANSCATHETER AORTIC VALVE REPLACEMENT PROCEDURE. ACCORDING TO LITERATURE REVIEW, AND AS DOCUMENTED IN A TECHNICAL SUMMARY WRITTEN BY EDWARDS LIFESCIENCES, VASCULAR COMPLICATIONS ARE A WELL RECOGNIZED COMPLICATION OF THE TRANSFEMORAL TAVR PROCEDURE IN THIS ELDERLY POPULATION WITH MULTIPLE CO-MORBIDITIES. EDWARDS HAS REVIEWED MANY REPORTS, INCLUDING SCREENING DATA RECORDS AND SOURCE DOCUMENTATION OF VASCULAR COMPLICATIONS AND HAS FOUND THAT THE ROOT CAUSE IS TYPICALLY RELATED TO A COMBINATION OF VESSEL SIZE, TORTUOSITY AND CALCIFICATIONS. ALTHOUGH THE INCIDENCE IS DECREASING WITH SMALLER SHEATH/DELIVERY SYSTEM SIZES AND PHYSICIAN EXPERIENCE, THERE WILL CONTINUE TO BE CASES IN WHICH VASCULAR COMPLICATIONS WILL OCCUR. THE THV PHYSICIAN TRAINING MANUALS INSTRUCT ON PROCEDURAL CONSIDERATIONS FOR SHEATH INSERTION WITH REGARDS TO PROPER SCREENING CRITICAL TO REDUCING VASCULAR COMPLICATIONS. THE TRAINING MANUAL INSTRUCTS THE OPERATOR ON PROPER SHEATH INSERTION AND WITHDRAWAL TECHNIQUES, INCLUDING PRE-DILATING THE VESSEL WITH THE EDWARDS DILATORS. IT ALSO NOTES THAT CALCIFICATION MAY REDUCE LUMEN DIAMETER AND LIMIT OR PREVENT TRANSFEMORAL PASSAGE OF THE DEVICES. THE IFU CONTRAINDICATES PATIENTS WITH ILIO-FEMORAL VESSEL CHARACTERISTICS THAT WOULD PRECLUDE SAFE PLACEMENT OF SHEATHS SUCH AS SEVERE OBSTRUCTIVE CALCIFICATION OR SEVERE TORTUOSITY. PRE-PROCEDURE SCREENING AND ASSESSMENT OF THE FEMORAL/ILIAC ARTERY INTERNAL DIAMETERS WILL ENABLE THE CLINICIAN TO DETERMINE IF THE SAPIEN VALVE CAN BE DELIVERED TRANSFEMORALLY. ASSESSMENT OF LOCATION AND AMOUNT OF CIRCUMFERENTIAL CALCIUM WILL AID IN DETERMINING AREAS OF REDUCED VESSEL DIAMETERS. THE OPERATORS ARE TRAINED TO MEASURE MINIMUM VESSEL DIAMETER TAKING CALCIUM INTO ACCOUNT. THE PHYSICIAN TRAINING MANUAL ALSO LISTS THE MINIMUM RECOMMENDED VESSEL SIZE FOR EACH SIZE DEVICE. DESPITE THE BEST SCREENING TOOLS, A SMALL PERCENTAGE OF PATIENTS WILL HAVE FEMORAL/ILIAC VESSELS THAT ARE NOT AMENABLE TO THE TRANS-FEMORAL APPROACH OR WHERE INCREASED RESISTANCE IS ENCOUNTERED DURING INSERTION OF DEVICES. IN MANY CASES, THE VESSEL MINIMUM LUMINAL DIAMETER (MLD) MAY BE BORDERLINE OR BELOW THE INDICATED SIZE. IN ADDITION, SIGNIFICANT CALCIFICATION AND/OR TORTUOSITY, NOT ALWAYS APPRECIABLE ON IMAGING, COULD BE CONTRIBUTING FACTORS TO THE EVENT. THE MINIMUM REQUIRED VESSEL DIAMETER FOR A 24FR RF3 SHEATH IS >8MM. IN THIS CASE, THE PATIENT¿S MLD WAS 9.0MM. THE CAUSE OF THE REPORTED LEFT EXTERNAL ILIAC ARTERY DISSECTION CANNOT BE CONFIRMED. HOWEVER, PER REPORT IT APPEARS TO BE RELATED TO A COMBINATION OF PATIENT FACTORS (ACCESS VESSEL WITH A CALCIFIED POSTERIOR WALL WAS FRAGILE, TYPICAL OF VESSELS EXPOSED TO LONG-TERM STEROID USE) AND PROCEDURAL FACTORS (USE OF LARGE BORE DEVICES). THE IFU AND TRAINING MANUALS HAVE BEEN REVIEWED AND NO INADEQUACIES HAVE BEEN IDENTIFIED WITH REGARDS TO WARNINGS, CONTRAINDICATIONS, AND THE DIRECTIONS/CONDITIONS FOR THE SUCCESSFUL USE OF THE DEVICE. COMPLAINT HISTORIES FOR ALL REPORTED EVENTS ARE REVIEWED AGAINST TRENDING CONTROL LIMITS ON A MONTHLY BASIS, AND ANY EXCURSIONS ABOVE THE CONTROL LIMITS ARE ASSESSED AND DOCUMENTED AS PART OF THIS MONTHLY REVIEW. NO CORRECTIVE OR PREVENTATIVE ACTIONS ARE REQUIRED AT THIS TIME.

    Additional Manufacturer Narrative · 1

    THIS IS ONE OF TWO REPORTS BEING SUBMITTED FOR THIS CASE. PLEASE REFERENCE MANUFACTURER REPORT NO. 2015691-2014-02288.

    Description of Event or Problem · 1

    MEDICAL RECORDS RECEIVED INDICATE THAT AFTER THE SUCCESSFUL REMOVAL OF THE 24F RETROFLEX 3 (RF3) SHEATH, THE IMAGES REVEALED A NON-FLOW-LIMITING DISSECTION IN THE ¿LEFT EXTERNAL ILIAC ARTERY SECONDARY TO LARGE ACCESS VALVE DELIVERY SHEATH, SUCCESSFULLY REPAIRED WITH OVERLAPPING SELF-EXPANDING STENTS¿. ALTHOUGH THE DISSECTION WAS NON-FLOW-LIMITING, IT WAS DECIDED TO REPAIR THE VESSEL GIVEN THE EXTENT OF THE DISSECTION. THE FINAL ANGIOGRAPHY DEMONSTRATED A RESIDUAL SMALL, NON-FLOW-LIMITING DISSECTION IN THE COMMON FEMORAL WHICH WAS NOT STENTED. THERE WAS GOOD FLOW DOWN THE PROFUNDA FEMORIS ARTERY. THE SUPERFICIAL FEMORAL ARTERY IS CHRONICALLY OCCLUDED AND IS HEAVILY CALCIFIED. THE PATIENT¿S LEFT COMMON FEMORAL ARTERY (LCFA) DIAMETER MEASURED 9MM WITH A CALCIFIED POSTERIOR WALL AND WAS FRAGILE, TYPICAL OF VESSELS EXPOSED TO LONG-TERM STEROID USE. THE PATIENT WAS TRANSFERRED TO THE CCU IN STABLE CONDITION AND WAS EXTUBATED THAT EVENING.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    612743 RETROFLEX 3 INTRODUCER SHEATH SET INTRODUCER, CATHETER DYB EDWARDS LIFESCIENCES 9120S26

    Patients

    Seq Age Sex Outcome Treatment
    1 78 YR Required Intervention