Brand Name | JETSTREAM XC |
Type of Device | CATHETER, PERIPHERAL, ATHERECTOMY |
Manufacturer (Section D) |
BOSTON SCIENTIFIC CORPORATION |
300 boston scientific way |
marlborough MA 01752 |
|
Manufacturer (Section G) |
BOSTON SCIENTIFIC CORPORATION |
model farm road |
|
cork T12 Y K88 |
EI
T12 YK88
|
|
Manufacturer Contact |
rachel
shields
|
4100 hamline ave n |
arden hills, MN 55112
|
6512422111
|
|
MDR Report Key | 18996940 |
MDR Text Key | 339147436 |
Report Number | 2124215-2024-18566 |
Device Sequence Number | 1 |
Product Code |
MCW
|
UDI-Device Identifier | 08714729889892 |
UDI-Public | 08714729889892 |
Combination Product (y/n) | N |
Reporter Country Code | US |
PMA/PMN Number | K133023 |
Number of Events Reported | 1 |
Summary Report (Y/N) | N |
Report Source |
Manufacturer
|
Source Type |
Health Professional,Company Representative |
Reporter Occupation |
Physician
|
Type of Report
| Initial |
Report Date |
03/28/2024 |
1 Device was Involved in the Event |
|
1 Patient was Involved in the Event |
|
Is this an Adverse Event Report? |
No
|
Is this a Product Problem Report? |
Yes
|
Device Operator |
Health Professional
|
Device Model Number | 45007 |
Device Catalogue Number | 45007 |
Device Lot Number | 0032670737 |
Was Device Available for Evaluation? |
Device Returned to Manufacturer
|
Date Returned to Manufacturer | 03/13/2024 |
Is the Reporter a Health Professional? |
Yes
|
Initial Date Manufacturer Received |
03/04/2024
|
Initial Date FDA Received | 03/28/2024 |
Was Device Evaluated by Manufacturer? |
Yes
|
Date Device Manufactured | 10/19/2023 |
Is the Device Single Use? |
Yes
|
Type of Device Usage |
Initial
|
Patient Sequence Number | 1 |
Patient Age | 70 YR |
Patient Sex | Female |
Patient Race | Black Or African American |