inforMED
InjuryPOL

TREVO NXT 4MM X 41MM - US

Received May 31, 2023 · Event occurred May 8, 2023

Report 3012931345-2023-00106 · MDR key 17028737

Device

Generic name

Neurovascular Mechanical Thrombectomy Device For Acute Ischemic Stroke Treatment

Model number

90314

Catalog number

90314

Lot number

0000210830

Product problems

  • Fracture
  • Fracture

Patient

Unknown

  • Perforation of Vessels
  • Foreign Body In Patient
  • Perforation of Vessels
  • Foreign Body In Patient

Narrative

Description of Event or Problem

IT WAS REPORTED THAT DURING AN ENDOVASCULAR PROCEDURE AT BASILAR ARTERY IN A STROKE PATIENT, THE SUBJECT STENT RETRIEVER GOT STUCK IN THE CATHETER AND THE CORE WIRE OF THE SUBJECT STENT RETRIEVER FRACTURED INSIDE THE PATIENT VASCULATURE. THE FRACTURED FRAGMENT WAS TRIED TO BE RETRIEVED USING A SNARE DEVICE BUT RUPTURED THE VESSEL SO THE PHYSICIAN HAD TO TAKE DOWN THE VERTEBRAL ARTERY WITH COILS. IT WAS REPORTED THAT THE RUPTURE OF THE VESSEL WAS CAUSED BY THE SNARE DEVICE. THE PATIENT WAS STABLE AFTER THE PROCEDURE. PATIENT'S ANATOMY WAS VERY TORTUOUS AND THE PHYSICIAN FEELS THAT THIS ANATOMY MAY HAVE CONTRIBUTED TO THE REPORTED EVENT.

Additional Manufacturer Narrative

H4 MANUFACTURING DATE ¿ ADDED. D4 EXPIRATION DATE - ADDED. THERE ARE CONTROLS IN THE MANUFACTURING PROCESS TO ENSURE THE PRODUCT MET SPECIFICATIONS UPON RELEASE. THE SUBJECT DEVICE IS NOT AVAILABLE; THEREFORE, VISUAL TESTING AS WELL AS FUNCTIONAL TESTING CANNOT BE PERFORMED. THE REPORTED EVENT IS COVERED IN THE DEVICE DIRECTIONS FOR USE (DFU). AS WELL, THE RISK OF THE REPORTED EVENT IS DOCUMENTED IN THE RISK DOCUMENTATION AND THERE ARE CURRENT CONTROLS TO MITIGATE THE RISK OF THE AS REPORTED EVENT. THE REPORTED COMPLAINT COULD NOT BE CONFIRMED, AND IT COULD NOT BE DEFINITIVELY DETERMINED IF THE DEVICE FAILED TO MEET SPECIFICATIONS BECAUSE THE PRODUCT WAS NOT RETURNED. IT WAS REPORTED THAT THE SUBJECT DEVICE GOT STUCK IN THE NON-STRYKER CATHETER AND FRACTURED IN THE PATIENT. THEY TRIED TO SNARE AND CAPTURE THE DEVICE BUT RUPTURED THE VESSEL SO HE HAD TO TAKE DOWN THE VERTEBRAL ARTERY WITH COILS. AS PER THE ADDITIONAL INFORMATION, THE DEVICE WAS PREPARED AS PER THE DFU, THE ANATOMY WAS VERY TORTUOUS, CONTINUOUS FLUSH WAS MAINTAINED THROUGHOUT THE PROCEDURE, RESISTANCE WAS ENCOUNTERED DURING THE EXTRACTION OF THE CLOT. IT IS PROBABLE THAT THE RETRIEVER EXPERIENCE DIFFICULTIES IN PULLING THE RETRIEVER/ CLOT BACK TO THE DISTAL END OF THE NON-STRYKER CATHETER, CAUSING THE DISTAL END OF THE RETRIEVER TO SEPARATE FROM ITS CORE WIRE, HOWEVER AS THE DEVICE WAS NOT RETURNED FOR ANALYSIS, THIS CANNOT BE DEFINITIVELY DETERMINED, THEREFORE AN ASSIGNABLE CAUSE OF UNDETERMINABLE WILL BE ASSIGNED TO THIS COMPLAINT.

Additional Manufacturer Narrative

H3 OTHER TEXT : THE DEVICE IS NOT AVAILABLE TO THE MANUFACTURER.

Description of Event or Problem

IT WAS REPORTED THAT DURING AN ENDOVASCULAR PROCEDURE AT BASILAR ARTERY IN A STROKE PATIENT, THE SUBJECT STENT RETRIEVER GOT STUCK IN THE CATHETER AND THE CORE WIRE OF THE SUBJECT STENT RETRIEVER FRACTURED INSIDE THE PATIENT VASCULATURE. THE FRACTURED FRAGMENT WAS TRIED TO BE RETRIEVED USING A SNARE DEVICE BUT RUPTURED THE VESSEL SO THE PHYSICIAN HAD TO TAKE DOWN THE VERTEBRAL ARTERY WITH COILS. IT WAS REPORTED THAT THE RUPTURE OF THE VESSEL WAS CAUSED BY THE SNARE DEVICE. THE PATIENT WAS STABLE AFTER THE PROCEDURE. PATIENT'S ANATOMY WAS VERY TORTUOUS AND THE PHYSICIAN FEELS THAT THIS ANATOMY MAY HAVE CONTRIBUTED TO THE REPORTED EVENT.