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It was reported that the procedure was to treat a 90% stenosed lesion in the left anterior descending (lad) artery with moderate calcification and mild tortuosity.For post dilatation, the 3.25x12mm nc trek neo balloon dilatation catheter (bdc) was advanced to the target lesion and the balloon was inflated; however, the balloon ruptured during the first inflation at 18 atmospheres (atm).Therefore, the bdc was removed from the patient.There was no adverse patient effect and no clinically significant delay reported in the procedure.A 3.5mm nc trek neo balloon was used to continue the procedure.No additional information was provided.
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The device was not returned for evaluation.Production record and corrective and preventive actions (capa) reviews were performed and revealed no indication of a product quality issue.Additionally, a review of the complaint history of the reported lot did not indicate a lot specific quality issue.The investigation determined that the reported balloon rupture appears to be related to operational context.There was no leak noted during preparation, which suggests a product quality issue did not contribute to the reported difficulties.In this case, it is likely that the balloon interacted with the moderately calcified and mildly tortuous anatomy such that the balloon became damaged and subsequently ruptured during inflation.Based on the reported information, there is no indication of a product quality issue with respect to the design, manufacture, or labeling of the device.
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