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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 18 atmospheres (atms) when the balloon ruptured during the second inflation.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 was determined that it was unlikely that 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, heavily calcified and 90% stenosed lesion 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.H6: medical device problem code 2017 clarifier - above rbp.
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It was reported that the procedure was to treat a 90% stenosed de novo lesion in the left anterior descending artery with heavy calcification and moderate tortuosity.The 1.5x12mm mini trek balloon dilatation catheter (bdc) was advanced to target lesion with resistance due to the anatomy and the balloon was inflated; however, the balloon ruptured at 18 atmospheres (atm) during the second inflation.Therefore, the bdc was removed from the patient.Another trek balloon was used to continue the procedure.There was no adverse patient effect and no clinically significant delay reported in the procedure.No additional information was provided.
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