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The device was not returned for analysis.Production record and corrective and preventative 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 device was not soaked prior to use.It should be noted that the coronary dilatation catheters (cdc), nc trek neo, instruction for use (ifu) states: submerge the balloon in sterile heparinized normal saline during balloon preparation, to activate the coating.In this case, it is unknown if the instructions for use (ifu) violation caused or contributed to the reported complaint.Based on the information received, the investigation determined that the reported balloon rupture appears to be related to operational context.In this case, it is unknown if the instructions for use (ifu) violation caused or contributed to the reported complaint.There was no leak noted to the balloon during preparation or during the first two inflation, which suggests a product quality issue did not contribute to the reported difficulties.In this case, it is likely that the balloon interacted with the previously implanted stent and/or the heavily tortuous and moderately calcified anatomy resulting in the reported balloon rupture during the third inflation.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: incorrect prep.
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It was reported that the procedure was performed to treat a moderately calcified and heavily tortuous lesion in the mid right coronary artery (mrca).Following the deployment of the 4.0x12mm xience drug-eluting stent, a 5.0x8mm nc trek neo balloon dilatation catheter (bdc) was attempted to be used for post-dilatation; however, was noted to rupture at 12atms during the third inflation.Therefore a new 4.5x8mm balloon catheter was used and the procedure was completed.It was noted that the xience delivery system was not soaked prior to prep.There were no adverse patent effects nor clinical delay reported.No additional information was provided.
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