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It was reported the 2.75 x 15mm trek rx was to be used in the mid left anterior descending (mlad) lesion with resistance due to the heavy calcification and moderate tortuosity.The trek balloon was used for pre-dilatation, however, the balloon ruptured at 15 atmospheres (atms) which is above the rated burst pressure (rbp) during the second inflation.Therefore, the balloon was removed and another trek rx was used to complete the procedure.There were no adverse patient effects and no clinically significant delay in 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 identified no other similar complaints from this lot.It was reported that the bdc was overinflated to 15 atmospheres (atms) when the balloon ruptured.It should be noted that the coronary dilatation catheters (cdc), trek rx and mini trek rx, global, instruction for use (ifu) states: balloon pressure should not exceed the rated burst pressure (rbp).The rbp for the trek rx device is 14 atm; therefore, rbp was exceeded.In this case, it could not be determined if inflating the balloon slightly over the rated burst pressure contributed to the rupture.The investigation determined that the reported complaints appear to be related to operational context.There was no leak noted during preparation or during the first inflation, which suggests a product quality issue did not contribute to the reported difficulties.It was reported by the account that the balloon dilatation catheter (bdc) interacted with the moderately tortuous and heavily calcified anatomy resulting in the reported difficulty advancing the device and subsequently the balloon became damaged and ruptured during second 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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