MAUDE Adverse Event Report: BOSTON SCIENTIFIC CORPORATION COYOTE; CATHETER, ANGIOPLASTY, PERIPHERAL, TRANSLUMINAL

Model Number	H74939185252210
Medical Device Problem Code	Material Rupture (1546)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	12/06/2023
Type of Reportable Event	Malfunction
Event or Problem Description
It was reported that a balloon rupture occurred.The 99% stenosed target lesion was located in the moderately tortuous and moderately calcified vessel below the knee.A 2.5mm x 220mm x 150cm coyote balloon was advanced for dilation.During the procedure, the balloon ruptured upon first inflation at 7 atmospheres within 3 seconds.The balloon was removed from the patient's body without any problem using the normal method and the procedure was completed with another of the same device.No complications were reported, and the patient was in good condition after the procedure.
Additional Manufacturer Narrative
This report is being filed to correct the model number and unique identifier (udi) # in response to an fda request.
Event or Problem Description
It was reported that a balloon rupture occurred.The 99% stenosed target lesion was located in the moderately tortuous and moderately calcified vessel below the knee.A 2.5mm x 220mm x 150cm coyote balloon was advanced for dilation.During the procedure, the balloon ruptured upon first inflation at 7 atmospheres within 3 seconds.The balloon was removed from the patient's body without any problem using the normal method and the procedure was completed with another of the same device.No complications were reported, and the patient was in good condition after the procedure.

• Brand Name: COYOTE
• Common Device Name: CATHETER, ANGIOPLASTY, PERIPHERAL, TRANSLUMINAL
• Manufacturer (Section D): BOSTON SCIENTIFIC CORPORATION; 300 boston scientific way; marlborough MA 01752
• Manufacturer (Section G): BOSTON SCIENTIFIC CORPORATION; two scimed place; maple grove MN 55311
• Manufacturer Contact: rachel shields ; 4100 hamline ave n; arden hills, MN 55112 ; 6512422111
• MDR Report Key: 18308012
• Report Number: 2124215-2023-70179
• Device Sequence Number: 17838655
• Product Code: DQY
• UDI-Device Identifier: 08714729796893
• UDI-Public: (01)08714729796893(17)260515(10)31625562
• Combination Product (Y/N): N
• Initial Reporter Country: JA
• PMA/510(K) Number: K111295
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Other,Foreign,Health Professional,Company Representative
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 07/03/2024

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: 05/15/2026
• Device Model Number: H74939185252210
• Device Catalogue Number: 24699
• Device Lot Number: 0031625562
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 12/06/2023
• Supplement Date Received by Manufacturer: 06/12/2024
• Initial Report FDA Received Date: 12/11/2023
• Supplement Report FDA Received Date: 07/03/2024
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• Date Device Manufactured: 05/16/2023
• 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: GUIDEWIRE - JUPITER; GUIDEWIRE - JUPITER; INFLATION DEVICE - NIPRO; INFLATION DEVICE - NIPRO; INTRODUCER SHEATH - PARENT SELECT; INTRODUCER SHEATH - PARENT SELECT; MICRO CATHETER - ZIZAI; MICRO CATHETER - ZIZAI
• Patient Sex: Unknown