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U.S. Department of Health and Human Services

MAUDE Adverse Event Report: ST. JUDE MEDICAL - NEUROMODULATION (PUERTO RICO, LLC) OCTRODE LEAD KIT, 60CM LENGTH; PERCUTANEOUS LEAD

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ST. JUDE MEDICAL - NEUROMODULATION (PUERTO RICO, LLC) OCTRODE LEAD KIT, 60CM LENGTH; PERCUTANEOUS LEAD Back to Search Results
Model Number 3186
Device Problem Fracture (1260)
Patient Problems Failure of Implant (1924); Inadequate Pain Relief (2388)
Event Date 12/01/2021
Event Type  Injury  
Event Description
Related manufacturer reference number: 3006705815-2021-06189.It was reported the patient experienced ineffective stimulation due to high impedances.X-rays confirmed one lead is fractured.Patient rode in a rally car race that was extremely bumpy.Surgical intervention may take place at a later date.It is unknown which lead is liable, as such both leads are being reported.
 
Manufacturer Narrative
Date of event is estimated.
 
Event Description
Additional information received indicates the lead was explanted and replaced.Effective therapy was established.
 
Manufacturer Narrative
The results of the investigation are inconclusive since the device was not returned for analysis.Based on the information received, the cause of the reported incident could not be conclusively determined.
 
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Brand Name
OCTRODE LEAD KIT, 60CM LENGTH
Type of Device
PERCUTANEOUS LEAD
Manufacturer (Section D)
ST. JUDE MEDICAL - NEUROMODULATION (PUERTO RICO, LLC)
lot a interior - #2 street km 67.5
santana industrial park
arecibo PR 00612
Manufacturer (Section G)
ST. JUDE MEDICAL - NEUROMODULATION (PUERTO RICO, LLC)
lot a interior - #2 street km 67.5
santana industrial park
arecibo PR 00612
Manufacturer Contact
ronnie shalev
6901 preston road
plano, TX 75024
9723098000
MDR Report Key12967588
MDR Text Key281979431
Report Number3006705815-2021-06190
Device Sequence Number1
Product Code LGW
UDI-Device Identifier05415067017246
UDI-Public05415067017246
Combination Product (y/n)N
Reporter Country CodeUS
PMA/PMN Number
P010032
Number of Events Reported1
Summary Report (Y/N)N
Report Source Manufacturer
Source Type Health Professional,Company Representative
Reporter Occupation Physician
Type of Report Initial,Followup
Report Date 03/04/2022
1 Device was Involved in the Event
1 Patient was Involved in the Event
Is this an Adverse Event Report? Yes
Is this a Product Problem Report? Yes
Device Operator Health Professional
Device Expiration Date07/09/2023
Device Model Number3186
Device Catalogue Number3186
Device Lot NumberA000112439
Was Device Available for Evaluation? No
Is the Reporter a Health Professional? Yes
Was the Report Sent to FDA? No
Initial Date Manufacturer Received 12/01/2021
Initial Date FDA Received12/09/2021
Supplement Dates Manufacturer Received02/28/2022
Supplement Dates FDA Received03/04/2022
Was Device Evaluated by Manufacturer? Device Not Returned to Manufacturer
Date Device Manufactured07/09/2021
Is the Device Single Use? Yes
Is This a Reprocessed and Reused Single-Use Device? No
Type of Device Usage Initial
Patient Sequence Number1
Treatment
SCS ANCHORS X 2; SCS IPG
Patient Outcome(s) Other;
Patient Age37 YR
Patient SexFemale
Patient Weight59 KG
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