FDA Adverse Event Malfunction Summary report: N

CONTOUR-SE

MDR report key: 585586 · Received March 2, 2005

Report

Report Number
585586
Event Type
Malfunction
Date Received
March 2, 2005
Date of Event
August 3, 2004
Report Date
March 1, 2005
Manufacturer
BOSTON SCIENTIFIC CORP.
Product Code
NAJ
Product Problem
Yes
Report Source
User Facility report
Reporter Location
MA, US

Narratives

Description of Event or Problem · 1

DURING THE PERIOD FROM 8/2003 TO 8/2004, 22 PATIENTS HAD UFE, UTERINE FIBROID EMBOLIZATION, TREATMENTS. FIVE WERE LOST TO FOLLOW-UP BUT OF THE 17 REMAINING, 12 HAD FAILURES FOR FIBROID REDUCTION REQUIRING REPEAT TREATMENT OR HYSTERECTOMY. ADDITIONAL FOLLOW-UP REVEALS: THE SPHERES WERE DESCRIBED AS "CLUMPING." THEY WERE ATTRACTED TO EACH OTHER AND NOT BEING DISPERSED TO ALL THE BLOOD VESSESLS. THROUGHOUT WE WERE TOLD BY THE MANUFACTURER THAT WE WERE THE ONLY ONE HAVING PROBLEMS WITH THE PRODUCT. RECENTLY, WE WERE INFORMED THAT THERE HAD BEEN ISSUES AND A DOCTOR IN FRANCE HAD WORKED ON IMPROVING THE PERFORMANCE OF THE PRODUCT AND THAT NOW BOSTON SCIENTIFIC SUGGESTS TO USE LARGER PARTICLES OF THE PRODUCT. THEY HAD CHOSEN NOT TO INFORM US ABOUT ISSUES WITH THE PRODUCT, WHEN WE ASKED BEFORE, SINCE THEY FIRST WANTED TO KNOW WHAT TO RECOMMEND INSTEAD. ACCORDING TO OUR RESULTS, WE HYPOTHESIZE THAT THE PRODUCT WE USED (500-700 MICRON) TENDS TO CLUMP AND LEAD TO PROXIMAL OCCLUSION (THERE WAS A VERY POOR CORRELATION BETWEEN FIBROID SIZE AND AMOUNT OF PARTICLES USED), THUS USING LARGER PARTICLES WOULD SEEM COUNTERINTUITIVE. WE HAVE SHARED THIS OPINION WITH THE MANUFACTURER. TECHNIQUE WAS RULED OUT AS A POSSIBLE CAUSE. STORAGE OF THE SPHERES IS CONSISTENT WITH THE MANUFACTURERS RECOMMENDATIONS - IN A DRY PLACE AND ONLY FRESH PRODUCT WAS USED.

Devices

Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
1 CONTOUR-SE MICROSPHERES IN FLUID SUSPENSION NAJ BOSTON SCIENTIFIC CORP. M001761370 *

Patients

Seq Age Sex Outcome Treatment
1 *