BOSTON SCIENTIFIC CORPORATION MAVERICK; CATHETERS, TRANSLUMINAL CORONARY ANGIOPLASTY, PERCUTANEOUS
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Model Number 7580 |
Device Problem
Deflation Problem (1149)
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Patient Problem
Cardiac Enzyme Elevation (1838)
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Event Date 04/01/2020 |
Event Type
Injury
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Manufacturer Narrative
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Age at time of event: 18 years or older.
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Event Description
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It was reported that balloon deflation issues and electrocardiogram (ecg) elevations occurred.The 90% stenosed target lesion was located in the less calcified proximal left anterior descending artery (lad).The 2.50mm x 12mm maverick balloon was advanced to the target lesion and the balloon was inflated.It was noted that inflation was already "jerky" and the balloon opened suddenly at 14 bar.When attempting to deflate the balloon, it was not possible.As the proximal lad was closed, elevations were noted in the ecg.The proximal end of the balloon catheter was then cut and a guideliner was advanced to aid in deflating the balloon.With the help of the guideliner, the balloon could be partially deflated.The maverick balloon and guideliner were then withdrawn together into a non bsc guide catheter and out of the vessel.The proximal lad had been closed for two to three minutes.Upon removal of the devices, the patient's condition became stable again and the procedure was completed.No additional patient complications resulted in relation to this event and the patient was reported to be stable following the procedure.
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Event Description
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It was reported that balloon deflation issues and electrocardiogram (ecg) elevations occurred.The 90% stenosed target lesion was located in the less calcified proximal left anterior descending artery (lad).The 2.50mm x 12mm maverick balloon was advanced to the target lesion and the balloon was inflated.It was noted that inflation was already "jerky" and the balloon opened suddenly at 14 bar.When attempting to deflate the balloon, it was not possible.As the proximal lad was closed, elevations were noted in the ecg.The proximal end of the balloon catheter was then cut and a guideliner was advanced to aid in deflating the balloon.With the help of the guideliner, the balloon could be partially deflated.The maverick balloon and guideliner were then withdrawn together into a non bsc guide catheter and out of the vessel.The proximal lad had been closed for two to three minutes.Upon removal of the devices, the patient's condition became stable again and the procedure was completed.No additional patient complications resulted in relation to this event and the patient was reported to be stable following the procedure.
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Manufacturer Narrative
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Age at time of event: 18 years or older.Device evaluated by mfr: returned product consisted of a maverick 2 balloon catheter.The shaft, hypotube, tip and balloon were microscopically and visually examined.There were numerous kinks.There was a complete separation at 5.6cm distal of the strain relief.There was contrast and blood in the inflation lumen and balloon, and blood in the guidewire lumen.The balloon was loosely folded.Microscopic inspection revealed tip damage.The outer shaft was stretched down for 2mm starting 2mm distal of the exit notch.An unknown guidewire, a guide catheter, and a 6f guide liner were with the device.Inspection of the remainder of the device presented no other damage or irregularities.Product analysis confirmed there would have been difficulty deflating the balloon.
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