BEUDAMED
    FDA Adverse Event Injury Summary report: N

    EDWARDS EXPANDABLE INTRODUCER SET, 23MM

    MDR report key: 4171314 · Received October 14, 2014

    Report

    Report Number
    2015691-2014-02418
    Event Type
    Injury
    Date Received
    October 14, 2014
    Date of Event
    September 22, 2014
    Report Date
    September 22, 2014
    Manufacturer
    EDWARDS LIFESCIENCES
    Product Code
    NPT
    PMA / PMN Number
    P130009
    Adverse Event
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    OH, 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. IN THIS CASE, VESSEL CHARACTERISTICS (SEVERE TORTUOSITY) MAY HAVE CONTRIBUTED TO THE EVENT. NO OTHER PATIENT FACTORS WERE DISCLOSED. 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 (B)(4) BASIS, AND ANY EXCURSIONS ABOVE THE CONTROL LIMITS ARE ASSESSED AND DOCUMENTED AS PART OF THIS (B)(4) REVIEW. NO CORRECTIVE OR PREVENTATIVE ACTIONS ARE REQUIRED AT THIS TIME.

    Description of Event or Problem · 1

    UPON REMOVAL OF A 16FR ESHEATH, THE PATIENT¿S BLOOD PRESSURE BEGAN TO FALL AND ANGIOGRAPHY DEMONSTRATED A RIGHT EXTERNAL ILIAC RUPTURE APPROXIMATELY 2CM BELOW THE BIFURCATION OF THE INTERNAL AND EXTERNAL ILIAC ARTERIES. A 14FR LONG SHEATH REPLACED THE ESHEATH AND A CODA BALLOON WAS ADVANCED AND EXPANDED IN THE ABDOMINAL AORTA. THE BLOOD PRESSURE STABILIZED. A 10MM X 5CM VIABAHN COVERED STENT AND A 7MM X 59 MM ATRIUM STENT WERE DEPLOYED, COVERING THE RUPTURE. THE PATIENT LEFT THE OPERATING ROOM IN STABLE CONDITION. TWO DAYS POST PROCEDURE THE PATIENT WAS ¿DOING GREAT¿. AS REPORTED, NO DILATORS WERE USED TO PRE-DILATE THE ACCESS VESSEL. WHILE ADVANCING 16FR ESHEATH, THE PATIENT DISPLAYED SIGNIFICANT DISCOMFORT. THE SHEATH SEEMED TO ADVANCE SMOOTHLY TO LEVEL OF THE RENAL ARTERIES. THE VALVE WAS PLACED WITHOUT COMPLICATIONS. UPON REMOVAL OF THE SHEATH THE PATIENT AGAIN DISPLAYED SIGNIFICANT DISCOMFORT. TWO UNITS OF BLOOD WERE TRANSFUSED DURING THE PROCEDURE. IT WAS UNCLEAR IF THE DISSECTION OCCURRED DURING SHEATH INSERTION OR REMOVAL. THE VESSEL WAS REPORTED AS SEVERELY TORTUOUS; HOWEVER, THE MINIMUM LUMINAL DIAMETER (MLD) AND DEGREE OF CALCIFICATION WERE NOT REPORTED. THE HOSPITAL WOULD NOT RELEASE ADDITIONAL INFORMATION.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    650582 EDWARDS EXPANDABLE INTRODUCER SET, 23MM AORTIC VALVE, PROSTHESIS, PERCUTANEOUSLY DELIVERED NPT EDWARDS LIFESCIENCES 916ES23 59838634

    Patients

    Seq Age Sex Outcome Treatment
    1 81 YR Required Intervention