MAUDE MDR 2967834

MDR report key
2967834
Report number
3008089360-2013-00001
Event key
0
Event type
3
Date of event
2012-12-21
Date received
2013-01-25
Adverse event
3
Product problem
3
Patients in event
0
Reporter occupation
1
Health professional
3
Initial report to FDA
3
Event location
0

Manufacturer Contact#

Contact
SHIVA ARDAKANI
Address
7060 KOLL CENTER PARKWAY SUITE 300 PLEASANTON CA 94566 US
Phone
925-925-9259
Report source
M
Manufacturer link flag
Y

Devices#

Seq, Brand, Generic table
SeqBrandGenericManufacturerProduct codeModelCatalogLotPMA510(k)ImplantEvaluatedAvailability
1GLIDER PTCA BALLOON CATHETER 2.5X12MMPTCA BALLOON CATHETERTRIREME MEDICAL INC.LOX4100A-2512FC120423003R N

Patients#

Sequence, Received, Treatment table
SequenceReceivedTreatmentOutcome
12013-01-2501. D

Event Narratives#

D

Patient 1

AN EVENT OCCURRED THAT WAS REPORTED AS A PERFORATION AT THE OSTIUM OF THE DIAGONAL BRANCH IN A CASE WHERE GLIDER PTCA AND SEVERAL OTHER MEDICAL DEVICES WERE USED. THERE WAS SOME RESISTANCE FELT DURING CROSSING TO THE DIAGONAL BRANCH. THE GLIDER DEVICE WAS INFLATED TWICE. THE FIRST INFLATION OF THE GLIDER WAS AT THE OSTIUM OF THE DIAGONAL TO 4 ATMOSPHERES. A SUBSEQUENT ANGIOGRAM REVEALED AN ABNORMAL APPEARANCE TO THE PROXIMAL DIAGONAL. LATER REVIEW OF THE ANGIO DETERMINED THAT THERE WAS A PERFORATION AT THAT POINT. THE GLIDER WAS THEN ADVANCED SLIGHTLY AND RE-INFLATED TO NOMINAL PRESSURE. THE SUBSEQUENT ANGIOGRAM REVEALED A VERY LARGE FREE-FLOWING PERFORATION IN THE VICINITY OF THE PROXIMAL/OSTIAL DIAGONAL. THE EMERGENCY PERICARDIOCENTESIS FOLLOWED, A COVERED STENT WAS PLACED. THE PT DEVELOPED CARDIOGENIC SHOCK AND ULTIMATELY EXPIRED.

N

Patient 1

INSPECTION AND LOT HISTORY RECORDS FOR LOT FC120423003 AND THE SUBASSEMBLIES USED IN ITS MANUFACTURE WERE REVIEWED. NO OUT OF SPECIFICATION FINDINGS WERE OBSERVED. RETURN OF THE DEVICE WAS REQUESTED BUT THE DEVICE HAD BEEN DISPOSED. RELEVANT ANGIOGRAMS WERE REQUESTED BUT HAVE NOT YET ARRIVED. THE INTERNAL INVESTIGATION IS ON-GOING. A F/U MDR WILL BE FILED AFTER RECEIPT AND REVIEW OF THE ANGIOGRAMS AND COMPLETION OF THE INTERNAL INVESTIGATION.