inforMED
InjuryNYT

DYNAMIC Y STENT

Received Jun 3, 2014 · Event occurred May 12, 2014

Report 3005099803-2014-02144 · MDR key 3845094

Device

Generic name

Prosthesis, Tracheal, Expandable, Polymeric

Manufacturer

Willy Ruesch Gmbh

Model number

M00570680

Product problems

  • Difficult to Remove
  • Positioning Problem

Patient

51 YR

  • No Code Available

Narrative

Additional Manufacturer Narrative

THE COMPLAINANT WAS UNABLE TO REPORT THE LOT NUMBER; THEREFORE, THE MANUFACTURE DATE AND EXPIRATION DATE ARE UNKNOWN. HOWEVER, THE COMPLAINANT STATED THAT THE DEVICE WAS USED PRIOR TO THE EXPIRATION DATE (B)(6). TRACHEOTOMY SURGERY PERFORMED. REPORTED EVENT OF STENT POSITIONING PROBLEM. REPORTED EVENT OF STENT DIFFICULT TO REMOVE. THE COMPLAINANT INDICATED THAT THE DEVICE WAS DISPOSED AND WILL NOT BE RETURNED FOR EVALUATION; THEREFORE, A FAILURE ANALYSIS OF THE COMPLAINT DEVICE COULD NOT BE COMPLETED. IF ANY FURTHER RELEVANT INFORMATION IS IDENTIFIED, A SUPPLEMENTAL MEDWATCH WILL BE FILED.

Description of Event or Problem

IT WAS REPORTED TO BOSTON SCIENTIFIC CORPORATION THAT A DYNAMIC Y STENT WAS USED IN THE TRACHEA DURING A STENT PLACEMENT PROCEDURE PERFORMED ON (B)(6) 2014. ACCORDING TO THE COMPLAINANT, THE STENT WAS IMPLANTED TO TREAT A MALIGNANT LESION AND AN ULCER IN THE LEFT MAIN STEM BRONCHUS. REPORTEDLY, THE PATIENT¿S ANATOMY WAS TORTUOUS AND WAS NOT DILATED PRIOR TO STENT PLACEMENT. DURING THE PROCEDURE, THE PHYSICIAN WAS ABLE TO DEPLOY THE STENT. THE PHYSICIAN NOTED THAT THE PATIENT WAS GETTING AIR AROUND THE STENT BUT NOT THROUGH IT. FOLLOWING DEPLOYMENT, THE ULCER STARTED BLEEDING IN THE DISTAL TRACHEA AND BLOOD STARTED TO FILL UP AROUND THE BOTTOM OF THE STENT BLOCKING THE AIR FLOW. THE PHYSICIAN PERFORMED SUCTION TO THE BLEED AND THEN CHOSE TO REMOVE THE STENT. THE PHYSICIAN WAS UNABLE TO REMOVE THE STENT WITH BOTH RIGID AND FLEXIBLE GRASPERS .THE PHYSICIAN PERFORMED A TRACHEOTOMY TO REMOVE THE STENT AND REFINE THE AIRWAY TO REESTABLISH NORMAL AIRFLOW. FOLLOWING THE PROCEDURE, THE PATIENT WAS IN THE INTENSIVE CARE UNIT WITH CLOSE MONITORING. REPORTEDLY, THE BLEEDING HAS BEEN RESOLVED.