BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    PROCOL BIOLOGIC VASCULAR GRAFT

    MDR report key: 9163915 · Received October 7, 2019

    Report

    Report Number
    1220948-2019-00138
    Event Type
    Malfunction
    Date Received
    October 7, 2019
    Date of Event
    September 9, 2019
    Report Date
    October 7, 2019
    Manufacturer
    LEMAITRE VASCULAR, INC.
    Product Code
    LXA
    UDI-DI
    00840663108688
    PMA / PMN Number
    P020049
    Adverse Event
    Yes
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    SC, US
    Reporter Occupation
    PHYSICIAN

    Narratives

    Additional Manufacturer Narrative · 1

    WE HAVE NOT RECEIVED THE GRAFT FOR EVALUATION SINCE THE GRAFT HAS BEEN IMPLANTED. HENCE, WE COULD NOT CONCLUSIVELY DETERMINE THE CAUSE OF THE FAILURE. HOWEVER, WE WERE ABLE TO OBSERVE THE REPORTED INCIDENT BASED ON THE PICTURE THAT WAS PROVIDED TO US. A SECTION OF THE GRAFT NEXT TO THE SUTURE TIE APPEARED TO BE ANEURYSMAL IN THAT PICTURE. PROCOL VACULAR BIOPROSTHESIS IS DERIVED FROM A SINGLE LENGTH OF BOVINE MESENTERIC VEIN THAT IS CHEMICALLY CROSS-LINKED WITH GLUTARALDEHYDE. NATURAL VARIATIONS EVEN IN THE SAME GRAFT IS POSSIBLE. COLLATERAL BRANCHES ARE LIGATED WITH SURGICAL SUTURE AND THE GRAFT IS INSPECTED UNDER PULSATILE FLOW CONDITIONS AT SIMULATED PHYSIOLOGICAL INTERNAL GRAFT PRESSURE. EACH GRAFT IS PRESSURIZED BETWEEN 2.7-4.0 PSI ( 139 - 206 MMHG) DURING THE INSPECTION PROCESS. IF PRESSURE EXCEEDS 4 PSI, THE VESSEL IS REJECTED FOR 'OVERPRESSURIZED' AND DISCARDED. UNDER A PRESSURIZED CONDITION, EACH GRAFT IS INSPECTED BY THE MANUFACTURING OPERATORS FOR ANY PRESENCE OF HOLE, TEAR OR SWELLING. AN OD GAGE IS PASSED OVER THE ENTIRE LENGTH OF THE VESSEL. IF ANY SECTION OF THE GRAFT APPEARED TO BE SWOLLEN OR DID NOT PASS THROUGH THE GAGE SMOOTHLY, THEN THAT SECTION OF THE GRAFT IS REJECTED BY THE TECHNICIAN. EACH GRAFT IS AGAIN INSPECTED BY THE QC TECHNICIAN FOR THESE ATTRIBUTES. WE HAVE CONDUCTED A LOT HISTORY REVIEW AND DID NOT FIND ANY ISSUES NOTED IN THE MANUFACTURING OR PACKAGING PROCESS THAT COULD BE RELATED TO THIS ISSUE. ALL QC TESTS PASSED THEIR REQUIREMENTS. BASED ON OUR INVESTIGATION AND OUR SALES REP'S OBSERVATION, THE GRAFT WAS LIKELY DAMAGED DUE TO OVER-PRESSURIZATION WHEN PREPARING THE LUMEN OF THE GRAFT PRIOR TO THE PROCEDURE AT THE HOSPITAL. HE OBSERVED THE PREP NURSE TO BE PRESSURIZING THE GRAFT WITH A 20CC SYRINGE PRIOR TO HAND OFF. WITH THIS INFORMATION, WE WERE ABLE TO RECREATE A SIMILAR MALFUNCTION WITH A NEW GRAFT USING A PRESSURE GAUGE. WE OBSERVED PRESSURE AS HIGH AS 15 PSI WHICH IS 5 TIMES HIGHER THAN NORMAL HUMAN BLOOD PRESSURE. OUR IFU PROPERLY INSTRUCTS USERS TO USE LIGHT PRESSURE WHEN IRRIGATING THE GRAFT AND NOT TO FLUSH THE GRAFT OPPOSITE THE DIRECTION OF FLOW AS COMPETENT VALVES MAY CAUSE EXCESSIVE PRESSURE AND MAY COMPROMISE THE INTEGRITY OF THE VESSEL. THE IFU ALSO INFORMS USERS NOT TO USE FORCEPS TO GRIP THE GRAFT AS IT MAY DAMAGE THE GRAFT.

    Description of Event or Problem · 1

    SURGEON USED A PROCOL VASCULAR BIOPROSTHESIS FOR CREATING A BRIDGE GRAFT FOR VASCULAR ACCESS TO A DIALYSIS PATIENT. AFTER SURGEON COMPLETED THE ARTERIAL ANASTOMOSIS, UPON PRESSURIZING THE GRAFT, HE OBSERVED AN ANEURYSMAL SPOT ON THE GRAFT. SURGEON REPAIRED THE GRAFT AND CONTINUED WITH THE SURGERY. THERE WAS NO INJURY TO THE PATIENT AS THE RESULT OF THIS INCIDENT.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    958727 PROCOL BIOLOGIC VASCULAR GRAFT VASCULAR GRAFT LXA LEMAITRE VASCULAR, INC. PVB1042 00840663108688

    Patients

    Seq Age Sex Outcome Treatment
    1 Required Intervention