FDA Adverse Event Malfunction Summary report: N

466FXXXX

MDR report key: 8038151 · Received November 5, 2018

Report

Report Number
1016427-2018-02213
Event Type
Malfunction
Date Received
November 5, 2018
Date of Event
August 14, 2018
Report Date
November 5, 2018
Manufacturer
CORDIS CASHEL
Product Code
DTK
Product Problem
Yes
Report Source
Manufacturer report
Reporter Location
JA
Reporter Occupation
OTHER HEALTH CARE PROFESSIONAL

Narratives

Additional Manufacturer Narrative · 1

THIS ARTICLE WAS FOUND DURING A RECENT CLINICAL EVALUATION REVIEW/LITERATURE SEARCH OF THIS DEVICE. PLEASE NOTE THAT PATIENT SPECIFIC DETAILS (MEDICAL HISTORY AND REASON FOR INTERVENTION) ARE NOT AVAILABLE. THE DEVICE IS AN OPTEASE INFERIOR VENA CAVA FILTER BUT THE CATALOG AND LOT NUMBER ARE NOT AVAILABLE. KOIZUMI, J., HARA, T., SEKIGUCHI, T., ICHIKAWA, T., TAJIMA, H., TAKENOSHITA, N., SHIRATO, K. (2018). MULTICENTER INVESTIGATION OF THE INCIDENCE OF INFERIOR VENA CAVA FILTER FRACTURE. JAPANESE JOURNAL OF RADIOLOGY, 36(11), 661-668. DOI:10.1007/S11604-018-0764-X AS NOTED IN THE PUBLICATION BY KOIZUMI ET AL., MULTICENTER INVESTIGATION OF THE INCIDENCE OF INFERIOR VENA CAVA FILTER FRACTURE; JPN J RADIOL. 2018 AUG 14. DOI: 10.1007/S11604-018-0764-X; REPORTS ONE CASE OPTEASE FILTER FRACTURE 1853 DAYS POST IMPLANTATION. THE FRACTURED STRUT IS LOCATED IN THE SPINE/SUPERIOR. NO MIGRATION OF THE FRACTURED STRUT HAS OCCURRED. THE FILTER WAS IMPLANTED IN THE INFRARENAL POSITION. THE PRODUCT WAS NOT RETURNED FOR ANALYSIS AND THE STERILE LOT NUMBER HAS NOT BEEN PROVIDED; THEREFORE, NO DEVICE ANALYSIS NOR DEVICE HISTORY RECORD REVIEW COULD BE PERFORMED. THE INFERIOR VENA CAVA (IVC) FILTER IS INDICATED FOR USE IN THE PREVENTION OF RECURRENT PULMONARY EMBOLISM (PE) VIA PERCUTANEOUS PLACEMENT IN THE VENA CAVA FOR PATIENTS IN WHICH ANTICOAGULANTS ARE CONTRAINDICATED, ANTICOAGULANT THERAPY FOR THROMBOEMBOLIC DISEASE HAS FAILED, EMERGENCY TREATMENT FOLLOWING MASSIVE PULMONARY EMBOLISM WHERE ANTICIPATED BENEFITS OF CONVENTIONAL THERAPY ARE REDUCED OR FOR CHRONIC, RECURRENT PULMONARY EMBOLISM WHERE ANTICOAGULANT THERAPY HAS FAILED, OR IS CONTRAINDICATED. THE PURPOSE OF A VENA CAVA FILTER IS TO CATCH THROMBUS FROM THE LOWER EXTREMITIES AS IT TRAVELS ALONG NORMAL BLOOD FLOW PATTERNS UP TOWARDS THE HEART. WITHOUT THE LIMITED INFORMATION PROVIDED, THE EXACT CAUSE OF THE REPORTED ¿FILTER- FRACTURED- IN PATIENT¿ COULD NOT BE DETERMINED. THE INSTRUCTIONS FOR USE (IFU) STATES FILTER FRACTURE IS A POTENTIAL COMPLICATION OF VENA CAVA FILTERS. ANATOMIC LOCATIONS THAT CREATE CONCENTRATED STRESS POINTS FROM FILTER DEFORMATION (FOR EXAMPLE, DEPLOYMENT AT APEX OF SCOLIOSIS, OVERLAPPING OF EITHER OF THE RENAL OSTIA, OR PLACEMENT ADJACENT TO A VERTEBRAL OSTEOPHYTE) MAY CONTRIBUTE TO FRACTURE OF A PARTICULAR FILTER STRUT. ALSO, WITH THE LIMITED INFORMATION AVAILABLE FOR REVIEW AT THIS TIME, THERE IS NOTHING TO SUGGEST THAT THE REPORTED EVENT IS RELATED TO THE DESIGN AND/OR MANUFACTURING PROCESS OF THE DEVICE; THEREFORE NO CORRECTIVE ACTION WILL BE TAKEN. SHOULD ADDITIONAL INFORMATION BECOME AVAILABLE, THE FILE WILL BE UPDATED ACCORDINGLY.

Description of Event or Problem · 1

AS NOTED IN THE PUBLICATION BY KOIZUMI ET AL., MULTICENTER INVESTIGATION OF THE INCIDENCE OF INFERIOR VENA CAVA FILTER FRACTURE; JPN J RADIOL. 2018 AUG 14. DOI: 10.1007/S11604-018-0764-X; REPORTS ONE CASE OPTEASE FILTER FRACTURE 1853 DAYS POST IMPLANTATION. THE FRACTURED STRUT IS LOCATED IN THE SPINE/SUPERIOR. NO MIGRATION OF THE FRACTURED STRUT HAS OCCURRED. THE FILTER WAS IMPLANTED IN THE INFRARENAL POSITION.

Devices

Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
880472 466FXXXX FILTER, INTRAVASCULAR, CARDIOVASCULAR DTK CORDIS CASHEL UNK

Patients

Seq Age Sex Outcome Treatment
1 75 YR