MAUDE Adverse Event Report: BOSTON SCIENTIFIC CORPORATION NC QUANTUM APEX; CATHETERS, TRANSLUMINAL CORONARY ANGIOPLASTY, PERCUTANEOUS

Model Number	6532
Medical Device Problem Code	Break (1069)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	05/15/2021
Type of Reportable Event	Malfunction
Event or Problem Description
It was reported that shaft break occurred.Vascular access was obtained via femoral artery.The 92% stenosed, 29mm x 2.75mm, concentric, de novo target lesion was located in the moderately tortuous and severely calcified left anterior descending artery.A 15mm x 2.75mm nc quantum apex was used to post-dilate a 32mm x 2.5mm stent.However, during procedure, it was noticed that the balloon shaft was broken.The device was removed and the procedure was completed with a different device.No complications were reported and the patient status was stable.
Event or Problem Description
It was reported that shaft break occurred.Vascular access was obtained via femoral artery.The 92% stenosed, 29mm x 2.75mm, concentric, de novo target lesion was located in the moderately tortuous and severely calcified left anterior descending artery.A 15mm x 2.75mm nc quantum apex was used to post-dilate a 32mm x 2.5mm stent.However, during procedure, it was noticed that the balloon shaft was broken.The device was removed and the procedure was completed with a different device.No complications were reported and the patient status was stable.
Additional Manufacturer Narrative
Device evaluated by mfr.: returned product consisted of an nc quantum apex balloon catheter.The device was microscopically and visually examined.There were numerous hypotube and shaft kinks and bends.There was contrast in the inflation lumen and balloon.There was blood in the guidewire lumen.The balloon was loosely folded.

• Brand Name: NC QUANTUM APEX
• Common Device Name: CATHETERS, TRANSLUMINAL CORONARY ANGIOPLASTY, PERCUTANEOUS
• Manufacturer (Section D): BOSTON SCIENTIFIC CORPORATION; two scimed place; maple grove MN 55311
• MDR Report Key: 12019131
• Report Number: 2134265-2021-07582
• Device Sequence Number: 3425609
• Product Code: LOX
• UDI-Device Identifier: 08714729783367
• UDI-Public: 08714729783367
• Combination Product (Y/N): N
• Initial Reporter Country: IN
• PMA/510(K) Number: K121667
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: company representative,distri
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 08/05/2021

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: 08/06/2022
• Device Model Number: 6532
• Device Catalogue Number: 6532
• Device Lot Number: 0024225934
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 07/01/2021
• Initial Date Received by Manufacturer: 05/30/2021
• Supplement Date Received by Manufacturer: 07/20/2021
• Initial Report FDA Received Date: 06/17/2021
• Supplement Report FDA Received Date: 08/05/2021
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Patient Age: 51 YR