ENDOSURE AAA PRESSURE SENSOR/DELIVERY SYSTEM

Description of Event or Problem

PHYSICIAN DEPLOYED THE ENDOSURE SENSOR TOO HIGH IN THE AAA SAC. THE PHYSICIAN COULD NOT REACH THE SENSOR TO PULL IT INTO A SHEATH FOR REMOVAL. WHILE MANIPULATING THE SHEATH, THE SENSOR GOT CAUGHT ON THE FIXATION ANCHORS OF THE GORE STENT GRAFT, WHICH PREVENTED THE STENT GRAFT FROM BEING POSITIONED PROPERLY. THE PATIENT WAS CONVERTED TO AN OPEN REPAIR PROCEDURE, THE SENSOR WAS REMOVED AND THE PT WAS DISCHARGED WITHOUT FURTHER INCIDENT.