MAUDE MDR 4811818

MDR report key
4811818
Report number
1820334-2015-00336
Event key
0
Event type
3
Date of event
2015-04-28
Date received
2015-05-29
Adverse event
3
Product problem
3
Patients in event
0
Reporter occupation
1
Health professional
3
Initial report to FDA
3
Event location
3

Manufacturer Contact#

Contact
MR. LARRY POOL
Address
750 DANIELS WAY BLOOMINGTON IN 47404 US
Phone
812-812-8123
Report source
M
Manufacturer link flag
Y

Devices#

Seq, Brand, Generic table
SeqBrandGenericManufacturerProduct codeModelCatalogLotPMA510(k)ImplantEvaluatedAvailability
1INDY OTW VASCULAR RETRIEVERGAE SNARE, SURGICALCOOK INCGAEN/AINDY-8.0-35-55-404927862R N

Patients#

Sequence, Received, Treatment table
SequenceReceivedTreatmentOutcome
12015-05-2901. R

Event Narratives#

D

Patient 1

DURING A AAA+ZBIS PROCEDURE ON AN (B)(6) MALE PATIENT, THE VASCULAR RETRIEVER BROKE 3 CENTIMETERS BEFORE THE DISTAL TIP AFTER CAPTURE OF THE HYDROPHILLIC WIRE GUIDE. AN ATTEMPT WAS MADE TO RETRIEVE THE SEPARATED PORTION WITH A FLEXOR 12 FR; HOWEVER, THE TIP AND SNARES REMAINED IN THE FEMORAL ARTERY. ALL WERE IMMEDIATELY RETRIEVED WITH A FOGARTY DEVICE WITHOUT HARM TO THE PATIENT. ACCORDING TO THE INITIAL REPORTER, THE PATIENT DID NOT EXPERIENCE ANY ADVERSE EFFECTS DUE TO THIS OCCURRENCE.

N

Patient 1

(B)(4).

N

Patient 1

(B)(4). EVENT EVALUATION: A REVIEW OF COMPLAINT HISTORY, DEVICE HISTORY RECORD, DOCUMENTATION, AND QUALITY CONTROL WAS CONDUCTED DURING THE INVESTIGATION. THE PRODUCT WAS NOT RETURNED FOR EVALUATION. THE DEVICE HISTORY RECORD WAS REVIEWED. OTHER DOCUMENTATION REGARDING THE MANUFACTURE OF THIS DEVICE WAS REVIEWED. THERE IS NO EVIDENCE TO SUGGEST THAT THE PRODUCT WAS NOT MANUFACTURED TO THE CORRECT SPECIFICATIONS. WITHOUT ADDITIONAL INFORMATION OR THE COMPLAINT DEVICE, NO CONCLUSION CAN BE DRAWN FOR THE CAUSE OF THIS COMPLAINT. BASED ON QUALITY ENGINEERING RISK ASSESSMENT, NO ADDITIONAL ACTIONS ARE REQUIRED AT THIS TIME. THE APPROPRIATE INTERNAL PERSONNEL WILL BE NOTIFIED AND WE WILL CONTINUE TO MONITOR FOR SIMILAR COMPLAINTS.

D

Patient 1

DURING A AAA+ZBIS PROCEDURE ON AN (B)(6) YEAR OLD MALE PATIENT, THE VASCULAR RETRIEVER BROKE 3 CENTIMETERS BEFORE THE DISTAL TIP AFTER CAPTURE OF THE HYDROPHILIC WIRE GUIDE. AN ATTEMPT WAS MADE TO RETRIEVE THE SEPARATED PORTION WITH A FLEXOR 12 FR; HOWEVER, THE TIP AND SNARES REMAINED IN THE FEMORAL ARTERY. ALL WERE IMMEDIATELY RETRIEVED WITH A FOGARTY DEVICE WITHOUT HARM TO THE PATIENT. ACCORDING TO THE INITIAL REPORTER, THE PATIENT DID NOT EXPERIENCE ANY ADVERSE EFFECTS DUE TO THIS OCCURRENCE.