The FDA wants to make health care providers aware of the possibility that hydrophilic and/or hydrophobic coatings may separate (e.g., peel, flake, shed, delaminate, slough off) from medical devices such as intravascular catheters, guidewires, balloon angioplasty catheters, delivery sheaths, and implant delivery systems and potentially cause serious injuries to patients. Medical devices such as these are commonly used during minimally invasive procedures in the cerebrovascular, cardiovascular and peripheral vascular systems, and have been used for more than 20 years on millions of patients.
These devices often have hydrophilic and/or hydrophobic lubricious coatings (e.g., polyvinylpyrrolidone (PVP), polytetrafluoroethylene (PTFE), silicone, etc.) to reduce friction between the device(s) and blood vessels. These coatings offer physicians greater maneuverability, and may result in less trauma to blood vessels and reduced thrombogenicity for patients.
Coating separation can be caused by a number of factors, ranging from the difficulty of the procedure and the patient’s anatomy to practitioner technique or using the wrong device for the procedure, to improper preconditioning of the device and improper storage conditions as well as issues with device design or manufacturing processes. Based on current information, the FDA believes the overall benefits of these devices continue to outweigh the risks. However, health care providers should be aware of potential problems and consider certain actions prior to use.
Since January 1, 2010, there have been 11 recalls from various manufacturers associated with these coatings peeling or flaking off of medical devices. The majority of the recalls were associated with guidewires, but there have also been recalls for other types of devices including sheaths, retrieval devices, and embolization device delivery wires used in the vasculature.
In addition, since January 1, 2014, the FDA has received approximately 500 Medical Device Reports (MDRs) describing separation of hydrophilic and/or hydrophobic coatings on medical devices such as guidewires, catheters, and introducers that had been used for cerebrovascular, cardiovascular and peripheral vascular procedures. The majority of the reports were submitted for vascular guidewires and over 75% of the reports describe device malfunctions.
Serious adverse events reported in these MDRs and in the scientific literature include pulmonary embolism, pulmonary infarction, myocardial embolism, myocardial infarction, embolic stroke, tissue necrosis, and death. Serious injuries associated with the peeling of coatings reported in MDRs included the persistence of coating fragments in patients, requiring surgical intervention to mitigate the consequences, adverse tissue reactions, and thrombosis. Eleven MDRs described patient deaths, two of which were not attributed to the device coating. The remaining nine death reports were also described in the published literature. In these cases, occlusion of blood vessels reportedly occurred due to embolization of coating particles from devices during heart and brain catheterization procedures contributing to clinical adverse events such as heart attack and bleeding inside the brain. It may be difficult for clinicians to associate these adverse events with malfunction of the coating; instead, they may mistakenly attribute the adverse events to other procedural complications or patient co-morbidities.
The FDA has not concluded that any specific manufacturer or brand of these devices is Based on current understanding of the benefits and risks of devices with these coatings, the FDA believes that the overall benefits of these devices continue to outweigh the risks. However, health care providers should consider the following information and actions to reduce the potential of serious adverse events:
- Be aware that many devices are designed, labeled, and indicated for specific uses. For example, the coating and performance of a device meant to be used in the peripheral vasculature may be different from a device meant to be used in the cerebral vasculature.
- Follow manufacturer’s instructions for proper device storage (e.g., shelf life, temperature, exposure to light, etc.) as improper storage can impact the integrity of the coating.
- When using two devices together (e.g., catheter and introducer sheath), ensure there is sufficient room for one to pass safely within the other, taking into consideration the features of the device (e.g., curved tip), and that some coatings may swell during use. For example, consider using a slightly larger French size for the introducer sheath than the catheter so there is sufficient room between the devices. Review the device labeling or consult the device manufacturer for further information.
- Follow the manufacturer’s recommended preconditioning steps (if applicable) for the device. Preconditioning activates the lubricious properties of some device coatings for optimal use.
- During preconditioning of the coating, use only the recommended solution (e.g., normal saline, heparinized saline, sterile water, etc.). Solutions may not be interchangeable and may affect the hydrophilic and/or hydrophobic coatings differently.
- Avoid using alcohol, antiseptic solutions, or other solvents to pre-treat the device because this may cause unpredictable changes in the coating, which could affect the device safety and performance.
- Avoid pre-soaking devices for longer than instructed, as this may impact the coating performance.
- Avoid wiping the device with dry gauze as this may damage the device coating.
- Use caution when manipulating, advancing and/or withdrawing these devices through needles, metal cannulas, stents, or other devices with sharp edges, or through tortuous or calcified blood vessels. Manipulation, advancement and/or withdrawal past sharp or beveled edges may result in destruction and/or separation of the outer coating which may lead to clinical adverse events.
- Be aware that attempting to alter the shape of devices by bending, twisting, or similar methods may compromise the coating integrity and that damage to the coating may not always be noticeable to the naked eye.
- Consider replacing a device if it does not move freely, is visibly kinked or otherwise damaged, or does not perform as expected.
The FDA will continue to work with stakeholders in an effort to develop non-clinical test methodologies to better characterize coating performance, establish performance criteria for evaluating coating integrity, and identify gaps in current national and international device standards. The Agency will also continue to work with device manufacturers to ensure accurate labeling that includes clear user instructions on how to minimize the occurrence of these issues.
See the FDA Safety Alert
See the FDA Safety Communication
See also Medical Law Perspectives, February 2015 Report: Mending a Broken Heart: Malpractice Risks in Diagnosing and Treating Heart Disease
See also Medical Law Perspectives, February 2014 Report: Congenital Heart Conditions: How Infants, Adults, and Healthcare Providers Handle the Risks
See also Medical Law Perspectives, December 2013 Report: Thicker Than Water: Liability When Blood Clots Cause Injury or Death
See also Medical Law Perspectives, November 2013 Report: Diagnosis and Treatment of Heart Attacks: Liability Issues