FDA Adverse Event Injury Summary report: N

MEDUSA MULTI-COIL

MDR report key: 8662451 · Received May 31, 2019

Report

Report Number
MW5087079
Event Type
Injury
Date Received
May 31, 2019
Date of Event
August 20, 2018
Report Date
May 10, 2019
Manufacturer
ENDOSHAPE INC.
Product Code
HCG
UDI-DI
10857798005017
Adverse Event
Yes
Report Source
Voluntary report
Reporter Location
CO, US
Reporter Occupation
003

Narratives

Description of Event or Problem · 1

REPORTING PHYSICIAN IS DR (B)(6), ASSISTANT PROFESSOR OF MEDICINE, PULMONARY HYPERTENSION PROGRAM, DIVISION OF PULMONARY, CRITICAL CARE, AND SLEEP MEDICINE, UNIVERSITY OF (B)(6). ADDRESS: (B)(6), PHONE: (B)(6), EMAIL: (B)(6). THE DEVICE IS ALLEGED TO HAVE MIGRATED FROM THE LEFT INTERNAL ILIAC VEIN TO THE PULMONARY ARTERY MORE THAN TWO YEARS AFTER IMPLANTATION. TIME OF MIGRATION OCCURRENCE IS ESTIMATED BASED ON ONSET OF PT SYMPTOMS, AND PHYSICIAN REPORTED THE PT HAD IMAGING APPROX ONE YEAR PRIOR WHICH SHOWED THE DEVICE IN THE ORIGINAL IMPLANTED LOCATION. REPORTING PHYSICIAN DID NOT KNOW THE DR OR INSTITUTE FOR ORIGINAL IMPLANTATION, AND DID NOT HAVE IMAGES OF IMPLANTED DEVICE. PT WAS REPORTED AS STABLE AND BEING EVALUATED FOR SURGICAL REMOVAL OF THE DEVICE FROM THE PULMONARY ARTERY. NEW INFO WAS PRESENTED TO MFR IN APRIL 2019 BY LEGAL REP OF PT, INDICATING PT WAS INITIALLY TREATED BY PRIMARY CARE PHYSICIAN IN (B)(6) 2018 FOR CONGESTION, COUGH, AND SHORTNESS OF BREATH. CT SCAN PERFORMED IN (B)(6) 2018 INDICATED "COIL-LIKE METALLIC STRUCTURE IN THE RIGHT BASILAR LOBE PULMONARY ARTERIES." AN ATTEMPT TO REMOVE THE DEVICE WAS PERFORMED AT (B)(6) HOSPITAL ON (B)(6) IN (B)(6) 2018 WITHOUT SUCCESS. PT WAS REFERRED TO DIVISION OF THORACIC AND CARDIOVASCULAR AT THE (B)(6) HOSP. ULTIMATELY THE DEVICE WAS REMOVED BY DR (B)(6) AT (B)(6) HOSP IN (B)(6) 2018. LEGAL REP OF PT CLAIMS TO HAVE POSSESSION OF THE DEVICE. TO DATE, THE MFR HAS NOT BEEN PROVIDED THE DEVICE OR ANY IMAGING FOR REVIEW. IDENTITY OF THE DEVICE HAS NOT BEEN CONFIRMED BY THE MFR. FDA SAFETY REPORT ID# (B)(4).

Devices

Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
453937 MEDUSA MULTI-COIL VASCULAR EMBOLIZATION DEVICE HCG ENDOSHAPE INC. MMC-122 T978 10857798005017

Patients

Seq Age Sex Outcome Treatment
1 57 YR Required Intervention