inforMED
MalfunctionMAL

HEMASHIELD GOLD KNITTED MICROVEL DOUBLE VELOUR

Received Apr 12, 2019

Report 1640201-2019-00024 · MDR key 8510183

Device

Generic name

Vascular Polyester Graft

Manufacturer

Intervascular Sas

Model number

M002020852010

Catalog number

M002020852010

Lot number

17K11

Product problems

  • Device Contaminated During Manufacture or Shipping
  • Device Contaminated During Manufacture or Shipping

Patient

Not reported

  • No Patient Involvement
  • No Patient Involvement

Narrative

Additional Manufacturer Narrative

(3331/213) A REVIEW OF THE COMPLAINT DEVICE HISTORY RECORDS, INDICATED THAT THE GRAFT WAS PROCESSED AND INSPECTED ACCORDING TO ESTABLISHED PROCEDURES AND WAS THEREFORE RELEASED FOLLOWING ACCEPTABLE QUALITY INSPECTIONS AND TESTS. THESE TESTS INCLUDE A 100% VISUAL INSPECTION OF THE GRAFT. (11) THE INVESTIGATION IS STILL ONGOING. A FOLLOW-UP REPORT WILL BE SENT UPON COMPLETION OF THE INVESTIGATION.

Additional Manufacturer Narrative

(10/180) THE INVOLVED PRODUCT WAS RETURNED TO INTERVASCULAR AND WAS INSPECTED BY OUR QUALITY ASSURANCE (QA) MANAGER. HIS OBSERVATIONS ARE AS FOLLOWS: "THE PRODUCT HAS BEEN CUT IN HALF. EACH OF THE 2 PIECES OF THE PRODUCT PRESENTS A COLOURED SPOT: - BIFURCATED PART: BROWN SPOT OF UNDETERMINED ORIGIN ; - BODY PART: GREY SPOT OF UNDETERMINED ORIGIN ; THE PRODUCT, AS IT WAS RECEIVED, DOES NOT CONFORM TO THE SPECIFICATION. HOWEVER, IT SHOULD BE NOTED THAT GIVEN THE SIZE OF THE TWO SPOTS, IT SEEMS DIFFICULT THAT THIS TYPE OF DEFECT COULD NOT HAVE BEEN DETECTED BY THE QUALITY CONTROL (QC) TECHNICIAN DURING THE QC PROCESS WITH A BACKLIT TABLE AND A MAGNIFYING GLASS LAMP." (4315) THE CAUSE OF THE EVENT REMAINS UNKNOWN SINCE THE GRAFT HAS BEEN MANIPULATED BY THE USER AND SINCE BOTH STAINS ARE NEAR THE CUTTING LOCATION. HOWEVER, THE CONDUCTED INVESTIGATION SUGGESTS THAT THE PRODUCT WAS NOT DEFECTIVE AT THE TIME OF MANUFACTURING.

Additional Manufacturer Narrative

IT WAS REPORTED THAT THE PRODUCT IS AVAILABLE FOR INVESTIGATION, IT SHOULD BE RETURNED TO INTERVASCULAR FOR EXAMINATION. A REVIEW OF THE COMPLAINT DEVICE HISTORY RECORDS IS ONGOING, RESULTS ARE PENDING. THE REVIEW OF POST-MARKETING HISTORICAL DATA INDICATED THAT NO OTHER SIMILAR COMPLAINT WAS REPORTED FOR THE SAME LOT NUMBER. THE INVESTIGATION IS STILL ONGOING. A FOLLOW-UP REPORT WILL BE SENT UPON COMPLETION OF THE INVESTIGATION.

Description of Event or Problem

THE HOSPITAL REPORTED THAT DURING PREPARATION FOR A PROCEDURE, UPON OPENING THE GRAFT, IT APPEARED TO BE A BROWN SPOT ON THE GRAFT. THE GRAFT WAS NEVER IMPLANTED. A REPLACEMENT DEVICE WAS USED TO COMPLETE THE PROCEDURE. NO PHYSICIAN ASSOCIATED. NO PATIENT INVOLVEMENT. THE DATE OF THE EVENT IS UNKNOWN.