inforMED
MalfunctionMAL

GELSOFT

Received Jun 26, 2019 · Event occurred May 2, 2019

Report 9612515-2019-00010 · MDR key 8734316

Device

Generic name

Gelsoft Bifurcate

Manufacturer

Vascutek Ltd

Catalog number

631407

Lot number

375738 8500

Product problems

  • Stretched
  • Stretched

Patient

Not reported

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

Narrative

Additional Manufacturer Narrative

PATIENT CODE: 2692 - NO KNOWN IMPACT OR CONSEQUENCE TO PATIENT. DEVICE CODE: 1601 - STRETCHED (PROBLEM ASSOCIATED WITH AN INCREASE OR ELONGATION IN A MATERIAL DIMENSION). METHOD CODE: 4109 - HISTORICAL DATA ANALYSIS. 4110 - TREND ANALYSIS. 4114 - DEVICE NOT RETURNED. 3331 - ANALYSIS OF PRODUCTION RECORDS. RESULT CODE: 4247 - APPROPRIATE TERM / CODE NO AVAILABLE. CONCLUSION CODE: 22 - KNOWN INHERENT RISK OF DEVICE. A REVIEW OF MANUFACTURING AND QC RECORDS CONFIRMED THAT THE DEVICE WAS MANUFACTURED TO SPECIFICATION. WITHOUT THE RETURN OF THE GRAFT FOR ANALYSIS VASCUTEK LTD ARE UNABLE TO DETERMINE A ROOT CAUSE FOR THIS EVENT. HOWEVER FROM A REVIEW OF CLINICAL PAPERS AND THE DEVICE IFU IT HAS BEEN NOTED THAT DILATATION IS A KNOWN AND EXPECTED COMPLICATION OF THIS TYPE OF PROCEDURE DUE TO THE KNITTED STRUCTURE OF THE GRAFT. THE PERCENTAGE OF DILATATION VARIES SIGNIFICANTLY THROUGHOUT LITERATURE. (B)(4). ON THIS BASIS VASCUTEK NOW CONSIDERS THIS COMPLAINT CLOSED. HOWEVER THIS ISSUE WILL BE TRACKED AND TRENDED AS PART OF THE ROUTINE COMPLAINTS MONITORING AND REPORTING PROCESS. IF AN ADVERSE TREND DEVELOPS ACTIONS WILL BE TAKEN AT THAT TIME.

Description of Event or Problem

THE EVENT, WHICH OCCURRED IN (B)(6) HOSPITAL, GERMANY WAS REPORTED TO VASCUTEK LTD AS FOLLOWS: THE PATIENT RECEIVED 3 BIFURCATED GRAFTS CREATING A SO-CALLED OCTOPUS GRAFT. DURING CT FOLLOW UP THE PHYSICIAN OBSERVED AN INCREASE OF THE DIAMETER OF THE MAIN GRAFT BODY TO 19.5MM. THIS COMPLAINT IS RELATED TO COMPLAINTS (B)(4) (MFR # 9612515-2019-00013) AND (B)(4) (MFR # 9612515-2019-000009). THIS REPORT WAS UPDATED TO REFLECT CORRECT MFR NUMBER FOR COMPLAINT (B)(4).

Additional Manufacturer Narrative

(B)(4). A REVIEW OF MANUFACTURING AND QC RECORDS CONFIRMED THAT THE DEVICE WAS MANUFACTURED TO SPECIFICATION. WITHOUT THE RETURN OF THE GRAFT FOR ANALYSIS VASCUTEK LTD ARE UNABLE TO DETERMINE A ROOT CAUSE FOR THIS EVENT. HOWEVER FROM A REVIEW OF CLINICAL PAPERS AND THE DEVICE IFU IT HAS BEEN NOTED THAT DILATATION IS A KNOWN AND EXPECTED COMPLICATION OF THIS TYPE OF PROCEDURE DUE TO THE KNITTED STRUCTURE OF THE GRAFT. THE PERCENTAGE OF DILATATION VARIES SIGNIFICANTLY THROUGHOUT LITERATURE. IN THE LAST FIVE YEARS FROM 2014 TO 2019 VASCUTEK LTD HAS RECEIVED A TOTAL OF 8 COMPLAINTS, FOR KNITTED GRAFTS WHERE DILATATION OF THE GRAFT HAS BEEN REPORTED AS AN ISSUE. SALES FOR THIS PERIOD AND GRAFT TYPE IS (B)(4) UNITS. THIS GIVES A VERY LOW INCIDENT RATE OF (B)(4). AS DILATATION OF KNITTED GRAFTS IS INHERENT AND EXPECTED THERE IS NO COMMON INDUSTRY INCIDENT RATE FOR COMPARISON. ON THIS BASIS VASCUTEK NOW CONSIDERS THIS COMPLAINT CLOSED. HOWEVER THIS ISSUE WILL BE TRACKED AND TRENDED AS PART OF THE ROUTINE COMPLAINTS MONITORING AND REPORTING PROCESS. IF AN ADVERSE TREND DEVELOPS ACTIONS WILL BE TAKEN AT THAT TIME.

Description of Event or Problem

THE EVENT, WHICH OCCURRED IN (B)(6) WAS REPORTED TO VASCUTEK LTD AS FOLLOWS: THE PATIENT RECEIVED 3 BIFURCATED GRAFTS CREATING A SO-CALLED OCTOPUS GRAFT. DURING CT FOLLOW UP THE PHYSICIAN OBSERVED AN INCREASE OF THE DIAMETER OF THE MAIN GRAFT BODY TO 19.5MM. THIS COMPLAINT IS RELATED TO COMPLAINTS (B)(4) (MFR # 9612515-2019-00008) AND (B)(4) (MFR # 9612515-2019-000009).