MAUDE Adverse Event Report: BOSTON SCIENTIFIC CORPORATION INTERLOCK-35; DEVICE, VASCULAR, FOR PROMOTING EMBOLIZATION

Model Number	83786
Medical Device Problem Code	Difficult to Insert (1316)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	09/15/2023
Type of Reportable Event	Malfunction
Event or Problem Description
Reportable based on device analysis completed on 18dec2023.It was reported that the coil could not be inserted into the catheter.A 10mm x 40cm interlock-35 was selected for use for embolization of an ovarian vein.Intermittent flushing of the interlock-35 coil was performed.While inserting the interlock-35 coil into a non-bsc catheter, resistance was noted at the proximal end of the catheter.The interlock-35 coil was withdrawn and removed from the catheter.The procedure was completed with a new device, same model.No complications were reported, and patient was stable post procedure.However, device analysis revealed that the main coil was detached at the coil arm section.
Additional Manufacturer Narrative
Device evaluated by mfr: the device was returned for evaluation.It was observed that the main coil was returned with a non-boston scientific (bsc) catheter.The main coil was bent and stretched at the primary coil and the coil arm section was detached.A portion of the original pouch was returned, and it was observed that the pouch information matches with the complaint information.No further damages were observed.Functional testing could not be performed due to the main coil and the pusher wire were not interlocking.Dimensional inspection of the main coil revealed the components which could be measured were within specifications.No other issues were identified during the product analysis.

• Brand Name: INTERLOCK-35
• Common Device Name: DEVICE, VASCULAR, FOR PROMOTING EMBOLIZATION
• Manufacturer (Section D): BOSTON SCIENTIFIC CORPORATION; 300 boston scientific way; marlborough MA 01752
• Manufacturer (Section G): BOSTON SCIENTIFIC CORPORATION; model farm road; cork T12 Y K88; EI T12 YK88
• Manufacturer Contact: rachel shields ; 4100 hamline ave n; arden hills, MN 55112 ; 6512422111
• MDR Report Key: 18376949
• Report Number: 2124215-2023-72299
• Device Sequence Number: 7797600
• Product Code: KRD
• UDI-Device Identifier: 08714729793168
• UDI-Public: 08714729793168
• Combination Product (Y/N): N
• Initial Reporter Country: SZ
• PMA/510(K) Number: K133208
• 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
• Report Date (Section B): 12/21/2023

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: 03/14/2026
• Device Model Number: 83786
• Device Catalogue Number: 83786
• Device Lot Number: 0031235866
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 11/27/2023
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 12/18/2023
• Initial Report FDA Received Date: 12/21/2023
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 03/15/2023
• 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
• Patient Sex: Unknown