| Brand Name | VersaCross Connect Access Solution for FARADRIVE |
| Common Device Name | dilator, vessel, for percutaneous catheterization |
| Manufacturer (Section D) |
| BOSTON SCIENTIFIC CORPORATION |
| 300 boston scientific way |
| marlborough MA 01752 |
|
| Manufacturer (Section G) |
| Boston Scientific Corporation |
| multitenant #2, street #58 zon |
|
| cartago, 03 30106 |
|
CS
30106
|
|
| Manufacturer Contact |
|
mary
crawford
|
| 4100 hamline avenue north |
| dc a330 |
| saint paul, MN 55112
|
|
+1(651)440-0979
|
|
| MDR Report Key | 25796582 |
| Report Number | 2124215-2026-36956 |
| Device Sequence Number | 5852155 |
| Product Code |
DRE
|
| UDI-Device Identifier | 00685447019046 |
| Combination Product (Y/N) | N |
| Initial Reporter State | ON |
| Initial Reporter Country | CA |
| PMA/510(K) Number | K233647 |
| Number of Events Summarized | 1 |
| Summary Report (Y/N) | N |
| Reporter Type |
Manufacturer
|
| Report Source |
Other,Foreign,Health Professional,Company Representative |
| Initial Reporter Occupation |
Physician
|
| Type of Report
| Initial,Followup,Followup |
| Report Date (Section B) |
09/15/2026 |
| 1 Device was Involved in the Event |
|
| 1 Patient was Involved in the Event |
|
| Is this an Adverse Event Report? |
Yes
|
| Is this a Product Problem Report? |
Yes
|
| Operator of Device |
Health Professional
|
| Device Model Number | VXAK0041 |
| Device Catalogue Number | VXAK0041 |
| Device Lot Number | 0038000723 |
| Was Device Available for Evaluation? |
No
|
| Is the Reporter a Health Professional? |
Yes
|
| Was the Report Sent to FDA? |
No
|
| Type of Report(Section G) | Thirty-Day |
| Initial Date Received by Manufacturer | 07/02/2026 |
| Supplement Date Received by Manufacturer | 07/09/2026 08/30/2026
|
| Initial Report FDA Received Date | 07/13/2026 |
| Supplement Report FDA Received Date | 08/06/2026 09/15/2026
|
| Date Device Manufactured | 05/22/2025 |
| 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 |
| Outcome Attributed to Adverse Event |
Hospitalization;
Required Intervention;
|
| Patient Sex | Unknown |