inforMED
MalfunctionNQH

CARDIOMEMS ENDOSURE DELIVERY SYSTEM

Received Jul 9, 2007 · Event occurred Jun 22, 2007

Report 3004936110-2007-00008 · MDR key 2971423

Device

Generic name

Intravascular Pressure Sensor

Manufacturer

Cardiomems, Inc.

Catalog number

S2-2080

Product problems

  • Difficult to Remove
  • Separation Failure

Patient

67 YR

  • Vessel Or Plaque, Device Embedded In

Narrative

Description of Event or Problem

THE SENSOR WAS PLACED IN THE AAA AFTER THE MAIN BODY OF THE STENT GRAFT WAS DEPLOYED. THE SENSOR WOULD NOT RELEASE EASILY FROM THE DELIVERY SYSTEM AND WAS PULLED DOWN LOWER THAN THE OPTIMAL POSITION ABOVE THE STENT GRAFT CONTRALATERAL LIMB GATE. AS THE CONTRALATERAL LIMB WAS INSERTED THE SENSOR WAS PUSHED INSIDE OF THE MAIN BODY OF THE STENT GRAFT. THE PHYSICIAN WAS UNABLE TO REMOVE THE SENSOR AT THIS POINT AND AN ADDITIONAL AORTIC CUFF HAD TO BE PLACED INSIDE THE MAIN BODY OF THE STENT GRAFT TO TRAP THE SENSOR.