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

Model Number	M001361640
Medical Device Problem Codes	Premature Activation (1484); Failure to Advance (2524); Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	03/17/2025
Type of Reportable Event	Malfunction
Event or Problem Description
Reportable based on device analysis completed on 29may2025.It was reported that the coil could not be pushed out.The patient's blood vessel was twisted, and the splenic artery aneurysm was about 2cm in diameter.After placing two coils, this 14mm x 30cm interlock coil was advanced for 0.5cm.However, it could no longer be pushed out of the microcatheter.It was suspected that the coil was released from catheter.The coil and the delivery catheter were withdrawn from the patient.The procedure was completed with another of the same device.There was no patient complications noted as a result of this event, and patient condition following procedure was stable.However, returned device analysis revealed the arm coil was detached.
Additional Manufacturer Narrative
E1 initial reporter facility name: (b)(6).Device evaluation by manufacturer: the device was returned for analysis.Visual and microscopic inspection observed that only the main coil was returned.The main coil was bent and stretched at the coil arm and primary coil section, moreover the arm coil was detached.Dimensional inspection was performed, and the main coil's max zap tip outer diameter (od) and primary coil od passed the specification test.

• Brand Name: INTERLOCK
• 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: 22341530
• Report Number: 2124215-2025-38977
• Device Sequence Number: 13010451
• Product Code: KRD
• UDI-Device Identifier: 08714729765073
• UDI-Public: (01)08714729765073(17)270128(10)33521498
• Combination Product (Y/N): N
• Initial Reporter Country: CH
• PMA/510(K) Number: K132578
• 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
• Report Date (Section B): 06/26/2025

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: M001361640
• Device Catalogue Number: M001361640
• Device Lot Number: 0033521498
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 04/22/2025
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 05/29/2025
• Initial Report FDA Received Date: 06/26/2025
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 02/28/2024
• 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: 65 YR
• Patient Sex: Female
• Patient Weight: 65 KG