inforMED
InjuryMAL

HEMASHIELD PLATINIUM WOVEN DOUBLE VELOUR

Received Sep 19, 2019 · Event occurred Aug 22, 2019

Report 1640201-2019-00047 · MDR key 9087559

Device

Generic name

Graft, Vascular, Synthetic/biologic Composite

Manufacturer

Intervascular Sas

Model number

M00202175430P0

Catalog number

M00202175430P0

Lot number

19D24

Product problems

  • Material Frayed
  • Material Frayed

Patient

Not reported

  • No Information
  • No Information

Narrative

Additional Manufacturer Narrative

(10/213) THE INVOLVED DEVICE WAS RETURNED TO INTERVASCULAR FOR EXAMINATION AND WAS INSPECTED BY OUR QUALITY ASSURANCE (QA) SUPERVISOR FOR DIMENSION EVALUATION. HIS OBSERVATIONS ARE AS FOLLOWS: "THE PROSTHESIS ARRIVED IN A BIOHAZARD PACKAGE IN THE ORIGINAL BOX WITH THE INSTRUCTIONS AND PART OF THE PATIENT SET, AND WITH THE GRAFT SIZER WITH ITS INSTRUCTIONS. THERE IS NO SHELL OR LID. THE PRODUCT HAS BEEN CUT, IT MEASURES 16.5CM INSTEAD OF 30CM THE PRODUCT IS FRAYED AT THE CUTTING AREA. AS THE PRODUCT HAS BEEN CUT, IT IS NOT POSSIBLE TO RULE ON THE CONFORMITY OF THE PRODUCT. HOWEVER IT SEEMS THAT THE TOOL USED FOR CUTTING IS A PROBABLE CAUSE OF FRAYING, AS SOME WIRES HAVE NOT EVEN BEEN CUT." "NO DEFECT REGARDING THE PRODUCT DURING THE INSPECTION WAS IDENTIFIED." (67) THE CONDUCTED INVESTIGATION SUGGESTS THAT THE PRODUCT WAS NOT DEFECTIVE AT THE TIME OF MANUFACTURING. (61) DUE TO THEIR INTRINSIC WEAVING PATTERN, WOVEN GRAFTS ARE PRONE TO FRAYING WHEN CUT WITH SCISSORS. AS INDICATED IN THE PRODUCT INSTRUCTIONS FOR USE, A LOW-TEMPERATURE DISPOSABLE CAUTERY SHOULD BE USED TO MINIMIZE FRAYING WHEN CUTTING THIS GRAFT.

Description of Event or Problem

THE GRAFT WAS VERIFIED BEFORE USE AND IT WAS FOUND TO BE UNRAVELING. CUSTOMER USED A DIFFERENT UNIT TO COMPLETE THE PROCEDURE. SURGERY WAS PROLONGED.

Additional Manufacturer Narrative

WE DON'T KNOW IF THE DELAY OF SURGERY HAD ANY IMPACT ON THE PATIENT STABILITY. 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, INDICATED THAT THE GRAFT WAS PROCESSED AND INSPECTED ACCORDING TO ESTABLISHED PROCEDURES AND WAS THEREFORE RELEASED FOLLOWING ACCEPTABLE QUALITY INSPECTIONS AND TESTS, INCLUDING A 100% VISUAL INSPECTION. SPECIFICALLY, NO ANOMALY WAS EVIDENCED IN THE TEXTILE RECORDS. 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 GRAFT WAS VERIFIED BEFORE USE AND IT WAS FOUND TO BE UNRAVELLING. CUSTOMER USED A DIFFERENT UNIT TO COMPLETE THE PROCEDURE. SURGERY WAS PROLONGED.