inforMED
InjuryMAL

HEMASHIELD PLATINUM WOVEN DOUBLE VELOUR

Received Oct 4, 2019 · Event occurred Aug 31, 2019

Report 1640201-2019-00077 · MDR key 9157413

Device

Generic name

Graft, Vascular, Synthetic/biologic Composite

Manufacturer

Intervascular Sas

Model number

M00202175926P0

Catalog number

M00202175926P0

Lot number

18L07

Product problems

  • Manufacturing, Packaging or Shipping Problem
  • Manufacturing, Packaging or Shipping Problem

Patient

Not reported

  • Blood Loss
  • Blood Loss

Narrative

Description of Event or Problem

SEE INITIAL MFR REPORT 1640201-2019-00077. COMPLAINT # (B)(4).

Additional Manufacturer Narrative

DUE TO SIMILARITIES OF THE EVENTS DESCRIBED IN THE MFR REPORTS #1640201- 2018-00019, #1640201- 2018-00020, #1640201-2019-00021 #1640201-2019-00022,AND #1640201-2019-00077, A HEALTH HAZARD EVALUATION HAS BEEN INITIATED IN RELATION WITH THESE FIVE CASES AND ASSESSED BY OUR CORPORATE MEDICAL OFFICER. PROBABILITY AND HEALTH RISK ARE DESCRIBED AS FOLLOWS: "THE MOST LIKELY OCCURRENCE AS A CONSEQUENCE OF THIS HOLE BLEEDING IS A PROCEDURAL DELAY DUE TO THE NECESSITY TO PERFORM AN ADDITIONAL HEMOSTASIS MEASURE. THE DELAY IS EXPECTED TO BE LIMITED AND NOT IMPACTING THE FLOW OF THE OPERATION AND ITS OUTCOME. IN THE EVENT OF INTRAOPERATIVE BLEEDING, IT WOULD, IN MOST CASES, BE CONTROLLED BY COMPRESSION, CLOTTING AGENT APPLICATION OR A SIMPLE SUTURE. THIS HOWEVER, CAN OCCASIONALLY RESULT IN A SERIOUS OR EVEN CRITICAL SITUATIONS FOR EITHER GENERAL OR AT GREATEST RISK POPULATIONS RESPECTIVELY. REOPERATION TO CONTROL POSTOPERATIVE BLEEDING IS A REMOTE POSSIBILITY THAT CAN BE CRITICAL ESPECIALLY FOR THE POPULATION AT GREATEST RISK. HOWEVER THE PRESENCE OF MEDIASTINAL DRAINAGE WILL MITIGATE THE POTENTIAL INCIDENCE OF TAMPONADE AND HELP IN PROMPTLY DETECT AN UNUSUAL BLEEDING. THE CRITICALITY OF THIS EVENT FOR THE HIGH-RISK POPULATION DERIVES FROM THE RE-OPERATION AND THE POTENTIAL IMPACT ON THE ALREADY DELICATE OVERALL CONDITION" FOLLOWING THIS EVALUATION, INTERVASCULAR HAS DECIDED TO WITHDRAW FROM THE MARKET ALL PRODUCTS POTENTIALLY AFFECTED. 1710 DEVICES ARE INVOLVED (RECALL # RC034 INITIATED ON 23-MAR-2020) (25) A CAPA (#281548) HAS BEEN INITIATED IN ORDER TO INVESTIGATE AND TAKE APPROPRIATE CORRECTIVE ACTIONS. THE MOST LIKELY ROOT CAUSE(S) MAY BE A COMBINATION OF CONDITIONS: - LINKED TO THE SLIGHT STRETCHING OF THE WOVEN FABRIC EXPECTED DURING THE SEWING OPERATION, AS EXPLAINED IN INITIAL MFR REPORT #1640201- 2018-00019, #1640201- 2018-00020 (COMPLAINT #(B)(4) AND #(B)(4)). -LINKED TO THE SEWING OPERATOR BEING STRESSED AFTER HAVING BEEN INFORMED ABOUT THE FIRST 2 COMPLAINTS (FOR THE THREE ADDITIONAL SIMILAR EVENTS, SEE INITIAL MFR REPORT #1640201-2019-00021, #1640201-2019-00022 AND #1640201-2019-00077 ; COMPLAINT #(B)(4), #(B)(4) AND #(B)(4)).

Additional Manufacturer Narrative

(B)(4). THE INVESTIGATION IS STILL ONGOING. A FOLLOW-UP REPORT WILL BE SENT UPON COMPLETION OF THE INVESTIGATION. DEVICE IS NOT ACCESSIBLE FOR TESTING AS IT REMAINED IMPLANTED IN THE PATIENT.

Description of Event or Problem

THE DOCTOR DID THE OPERATION ON (B)(6) 2019. DURING THE OPERATION, THEY USED ONE HEMASHIELD 4B GRAFT AND FOUND THE CONNECTION BETWEEN THE GRAFT BODY AND THESE THREE BRANCHES WAS BLEEDING A LOT. AND THEN THEY USED THE AUTOLOGOUS PERICARDIUM TO MEND THE BLEEDING SITE. IT TOOK AROUND 15 HOURS TO DO THIS OPERATION BECAUSE OF THE BLEEDING ISSUE AND THEREFORE THEY DELAYED STERNAL CLOSURE FOR THE EDEMA.

Remedial action

  • Recall