MAUDE Adverse Event Report: BOSTON SCIENTIFIC CORPORATION MUSTANG; CATHETER, BILIARY, DIAGNOSTIC

Model Number	24674
Medical Device Problem Code	Material Rupture (1546)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Date of Event	11/30/2020
Type of Reportable Event	Malfunction
Event or Problem Description
It was reported that balloon rupture occurred.The chronic totally occluded target lesion was located in the severely calcified and severely tortuous right common femoral artery.A 4.0 x 20, 75cm mustang balloon catheter was advanced for dilatation.However, during third inflation at 15 atmospheres for 2 seconds, the balloon ruptured.The device was removed and there were no patient complications nor injuries reported.
Event or Problem Description
It was reported that balloon rupture occurred.The chronic totally occluded target lesion was located in the severely calcified and severely tortuous right common femoral artery.A 4.0 x 20, 75cm mustang balloon catheter was advanced for dilatation.However, during third inflation at 15 atmospheres for 2 seconds, the balloon ruptured.The device was removed and there were no patient complications nor injuries reported.It was further reported that the procedure was completed with another of the same device.

• Brand Name: MUSTANG
• Common Device Name: CATHETER, BILIARY, DIAGNOSTIC
• Manufacturer (Section D): BOSTON SCIENTIFIC CORPORATION; two scimed place; maple grove MN 55311
• MDR Report Key: 10994245
• Report Number: 2134265-2020-17420
• Device Sequence Number: 3737922
• Product Code: FGE
• UDI-Device Identifier: 08714729793496
• UDI-Public: 08714729793496
• Combination Product (Y/N): N
• Initial Reporter Country: JA
• PMA/510(K) Number: K103751
• 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,Followup
• Report Date (Section B): 01/08/2021

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: 11/25/2022
• Device Model Number: 24674
• Device Catalogue Number: 24674
• Device Lot Number: 0024832054
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 11/30/2020
• Supplement Date Received by Manufacturer: 12/22/2020
• Initial Report FDA Received Date: 12/11/2020
• Supplement Report FDA Received Date: 01/08/2021
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1