inforMED
MalfunctionDWQ

TRIVEX SYSTEM RESECTOR HANDPIECE

Received May 9, 2019 · Event occurred Apr 10, 2019

Report 1220948-2019-00055 · MDR key 8597023

Device

Generic name

Varicose Vein Albation System

Catalog number

7210387F

Lot number

YB02177

Product problems

  • No Device Output
  • No Device Output

Patient

Not reported

  • No Known Impact Or Consequence To Patient
  • No Known Impact Or Consequence To Patient

Narrative

Additional Manufacturer Narrative

WE HAVE RECEIVED THE COMPLAINT DEVICE FOR EVALUATION AND WE HAVE CONFIRMED THE REPORTED INCIDENT. THE HANDPIECE CABLE AND POWER CABLE WERE INSPECTED AND WERE FOUND TO BE ACCEPTABLE. HANDPIECE WAS THEN CONNECTED INTO THE CONTROL UNIT. WHEN EITHER THE RUN OR THE WINDOW LOCK BUTTON WAS PRESSED, THE INDICATOR LIGHT ON THE CONTROL UNIT FLASHED ORANGE INDICATING AN ISSUE WITH THE HANDPIECE AND THE DRIVE SHAFT WOULD NOT TURN . UPON DISASSEMBLY, WE DID NOT OBSERVE ANY COMPONENT FAILURE. HOWEVER, THE SEAL HOUSING WAS OBSERVED TO HAVE HEAT DISCOLORATION. THE LIKELY ROOT CAUSE OF THIS ISSUE IS A SEIZED BALL BEARING. OVER TIME, PARTICULATES AND WATER COULD ENTER INTO THE BALL BEARING ASSEMBLY SINCE IT IS NOT A HERMATICALLY SEALED COMPONENT. WE HAVE ALREADY IMPLEMENTED A CORRECTIVE AND PREVENTIVE ACTION (CAPA) TO RESOLVE THIS ISSUE BY REPLACING THE BALL BEARINGS WITH SLIP BEARINGS WHICH BETTER PREVENT THE BEARINGS FROM CORROSION AND FROM SEIZING. THIS DEVICE WAS MANUFACTURED PRIOR TO THE IMPLEMENTATION OF THESE CHANGES. THERE WAS NO HARM TO THE PATIENT AS THE RESULT OF THIS INCIDENT. THE PROCEDURE WAS COMPLETED USING A DIFFERENT HANDPIECE.

Description of Event or Problem

THE RESECTOR FAILED TO ROTATE DURING PRE-USE CHECK.