MAUDE Adverse Event Report: ABBOTT VASCULAR MINI TREK RX OTW BALLOON DILATATION CATHETER; CORONARY DILATATION CATHETER

Model Number	1012403-08A
Medical Device Problem Code	Material Rupture (1546)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Date of Event	04/27/2020
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
The device was not returned for evaluation.A review of the lot history record identified no manufacturing nonconformities issued to the reported lot that would have contributed to this event.Additionally, a review of the complaint history identified no other similar incidents and/or complaints from this lot.The investigation determined the reported balloon rupture appears to be related to operational context.There is no indication of a product quality issue with respects to the design, manufacture, or labeling of the device.
Event or Problem Description
It was reported that the procedure was to treat a de novo lesion in the mildly tortuous and mildly calcified right coronary artery.The mini trek balloon was advanced without issue to the lesion and ruptured during the first inflation at 8 atmospheres.The device was removed without issue.There was no reported adverse patient effect or a clinically significant delay in the procedure.A non-abbott balloon dilatation catheter was used to complete the procedure.No additional information was provided.

• Brand Name: MINI TREK RX OTW BALLOON DILATATION CATHETER
• Common Device Name: CORONARY DILATATION CATHETER
• Manufacturer (Section D): ABBOTT VASCULAR; 26531 ynez rd.; temecula CA 92591 4628
• MDR Report Key: 10067932
• Report Number: 2024168-2020-04366
• Device Sequence Number: 16335089
• Product Code: LOX
• UDI-Device Identifier: 08717648180866
• UDI-Public: 08717648180866
• Combination Product (Y/N): N
• Initial Reporter Country: JA
• PMA/510(K) Number: K110617
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: company representative,distri
• Initial Reporter Occupation: Physician
• Type of Report: Initial
• Report Date (Section B): 05/18/2020

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
• Operator of Device: Health Professional
• Device Expiration Date: 11/30/2022
• Device Model Number: 1012403-08A
• Device Catalogue Number: 1012403-08A
• Device Lot Number: 91213G1
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 04/28/2020
• Initial Report FDA Received Date: 05/18/2020
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1