MAUDE Adverse Event Report: BOSTON SCIENTIFIC CORPORATION MUSTANG; STENTS, DRAINS AND DILATORS FOR THE BILIARY DUCTS

Model Number	H74939171090870
Medical Device Problem Code	Material Rupture (1546)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	01/06/2025
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
D2b: pro code - lit.G4: pma/510(k) # field on 3500a form - k141597.
Event or Problem Description
It was reported balloon rupture occurred.The stenosed target lesion was located in the subclavian vessel.A 9.0 x 80, 75cm mustang balloon catheter was advanced for dilatation.During the procedure, a burst occurred as the pressure was gradually increased to the burst pressure level.The device was removed without any problem, and the procedure was completed with a different device.There were no patient complications reported, and the patient was in good condition after the procedure.
Additional Manufacturer Narrative
D2b: pro code - lit.G4: pma/510(k) # field on 3500a form - k141597.
Event or Problem Description
It vwas reported balloon rupture occurred.The stenosed target lesion was located in the subclavian vessel.A 9.0 x 80, 75cm mustang balloon catheter was advanced for dilatation.During the procedure, a burst occurred as the pressure was gradually increased to the burst pressure level.The device was removed without any problem, and the procedure was completed with a different device.There were no patient complications reported, and the patient was in good condition after the procedure.

• Brand Name: MUSTANG
• Common Device Name: STENTS, DRAINS AND DILATORS FOR THE BILIARY DUCTS
• Manufacturer (Section D): BOSTON SCIENTIFIC CORPORATION; 300 boston scientific way; marlborough MA 01752
• Manufacturer (Section G): BOSTON SCIENTIFIC CORPORATION; pmt 741 persiaran cassia selat; bandarcassia, pulau pinan 14110 ; MY 14110
• Manufacturer Contact: rachel shields ; 4100 hamline ave n; arden hills, MN 55112 ; 6512422111
• MDR Report Key: 21201323
• Report Number: 2124215-2025-02360
• Device Sequence Number: 18032368
• Product Code: FGE
• UDI-Device Identifier: 08714729794868
• UDI-Public: 08714729794868
• Combination Product (Y/N): N
• Initial Reporter Country: KS
• PMA/510(K) Number: K141521
• 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,Distributor
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 03/06/2025

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 Model Number: H74939171090870
• Device Catalogue Number: H74939171090870
• Device Lot Number: 0033371509
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 01/06/2025
• Supplement Date Received by Manufacturer: 02/17/2025
• Initial Report FDA Received Date: 01/21/2025
• Supplement Report FDA Received Date: 03/06/2025
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 02/07/2024
• 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 Age: 60 YR
• Patient Sex: Female