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

Model Number	M001361760
Medical Device Problem Codes	Stretched (1601); 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	04/06/2025
Type of Reportable Event	Malfunction
Event or Problem Description
Reportable based on device analysis completed on 06-jun-2025.It was reported that coil unable to advance and stretched occurred.The target lesion was located in the coronary artery.A bsc microcatheter and 2/5mm x 5.8cm interlock was used for treatment.During the procedure, the physician utilized a bsc microcatheter to deploy the coil; however, the coil was unable to be pushed out of the catheter.Following multiple attempts, the physician retracted the coil, and it was noted that the coil had become stretched.The procedure was completed with another of the same device.There were no patient complications as a result of this event.However, returned device analysis revealed pusher wire was detached.
Additional Manufacturer Narrative
Device evaluated by mfr: the interlock device was returned for analysis.Upon inspection, it was noted that the main coil, introducer sheath, and pusher wire were included in the return.Observations revealed that the main coil was bent in the primary coil section, resulting in a loss of its original form due to deformation.Additionally, the pusher wire exhibited bending, stretching, and detachment at the coil section.

• 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: 22388029
• Report Number: 2124215-2025-43610
• Device Sequence Number: 12936686
• Product Code: KRD
• UDI-Device Identifier: 08714729765103
• UDI-Public: (01)08714729765103(17)251010(10)30516790
• 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): 07/02/2025

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 Expiration Date: 10/10/2025
• Device Model Number: M001361760
• Device Catalogue Number: M001361760
• Device Lot Number: 0030516790
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 05/08/2025
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 06/06/2025
• Initial Report FDA Received Date: 07/02/2025
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 11/10/2022
• 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: 57 YR
• Patient Sex: Male
• Patient Weight: 69 KG