MAUDE Adverse Event Report: ABBOTT VASCULAR XIENCE SKYPOINT DRUG ELUTING CORONARY STENT DELIVERY SYSTEM

Model Number	1804250-12
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Codes	Angina (1710); Myocardial Infarction (1969)
Date of Event	03/12/2022
Type of Reportable Event	Serious Injury
Event or Problem Description
It was reported that the patient has a history of st elevated myocardial infarction (stemi) and on (b)(6) 2022 a 2.5x12 mm and a 3.0x38 mm xience skypoint stent were implanted.On (b)(6) 2022 the patient was re admitted to the hospital due to tietze syndrome [chest pain] and acute myocardial infarction.Surgery and cardiac "sanpl" were performed.There were no reported adverse patient sequela.No additional information was provided.
Additional Manufacturer Narrative
The stent remains in patient.The device will not be returned for evaluation.Investigation is not yet complete.A follow-up report will be submitted with all additional relevant information.
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.The reported patient effects of angina and myocardial infarction are listed in the xience skypoint, everolimus eluting coronary stent system (eecss), electronic instructions for use as known patient effects of coronary stenting procedures.Based on the information reviewed, there is no indication of a product quality issue.A conclusive cause for the reported patient effects, and the relationship to the product, if any, cannot be determined; however, the reported treatment appears to be related to the operational context of the procedure.There is no indication of a product quality issue with respect to manufacture, design or labeling.
Event or Problem Description
It was reported that the patient has a history of st elevated myocardial infarction (stemi) and on (b)(6) 2022 a 2.5x12 mm and a 3.0x38 mm xience skypoint stent were implanted.On (b)(6) 2022 the patient was re admitted to the hospital due to tietze syndrome [chest pain] and acute myocardial infarction.Surgery and cardiac "sanpl" were performed.There were no reported adverse patient sequela.Subsequent to the initially filed report, the following information was provided: the patient was discharged from initial procedure on (b)(6) 2022 and discharged again on (b)(6) 2022 after readmission.Measure of cardiac sample and pressure were performed via percutaneous approach.No additional information was provided.

• Brand Name: XIENCE SKYPOINT DRUG ELUTING CORONARY STENT DELIVERY SYSTEM
• Common Device Name: DRUG ELUTING CORONARY STENT DELIVERY SYSTEM
• Manufacturer (Section D): ABBOTT VASCULAR; 26531 ynez rd.; temecula CA 92591 4628
• Manufacturer (Section G): ABBOTT VASCULAR, REG # 3005718570 (P099); cashel road; clonmel tipperary ; EI
• Manufacturer Contact: lindsey bell ; 26531 ynez rd.; temecula, CA 92591-4628 ; 9519143996
• MDR Report Key: 15043417
• Report Number: 2024168-2022-07828
• Device Sequence Number: 17872448
• Product Code: NIQ
• UDI-Device Identifier: 08717648233067
• UDI-Public: 08717648233067
• Combination Product (Y/N): Y
• Initial Reporter State: IL
• Initial Reporter Country: US
• PMA/510(K) Number: P110019
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2022
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Health Professional,Company Representative
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 08/15/2022

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?: No
• Operator of Device: Health Professional
• Device Expiration Date: 08/16/2023
• Device Model Number: 1804250-12
• Device Catalogue Number: 1804250-12
• Device Lot Number: 1080941
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 06/27/2022
• Supplement Date Received by Manufacturer: 07/26/2022
• Initial Report FDA Received Date: 07/18/2022
• Supplement Report FDA Received Date: 08/15/2022
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• Date Device Manufactured: 08/17/2021
• Is the Device Labeled for Single Use? (Y/N): Yes
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Usage of Device: Initial
• Patient Sequence Number: 1
• Concomitant Medical Products and Therapy/Usage Dates: 3.0X38 MM XIENCE SKYPOINT.
• Outcome Attributed to Adverse Event: Required Intervention; Hospitalization; Disability
• Patient Age: 74 YR
• Patient Sex: Female
• Patient Weight: 93 KG