BOSTON SCIENTIFIC - MAPLE GROVE QUANTUM¿ MAVERICK¿; CATHETERS, TRANSLUMINAL CORONARY ANGIOPLASTY, PERCUTANEOUS
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Model Number H7493808012300 |
Device Problem
Kinked (1339)
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Patient Problem
No Consequences Or Impact To Patient (2199)
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Event Date 09/12/2016 |
Event Type
malfunction
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Manufacturer Narrative
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(b)(4).Age at time of event: 18 years or older.(b)(4).Device evaluated by mfr: returned product consisted of a quantum maverick balloon catheter.The balloon was loosely folded.There was contrast in the inflation lumen.The outer shaft, inner shaft, balloon and tip were microscopically examined.The hypotube shaft was completely separated 78 cm from the hub.The fracture faces were oval as if kinked prior to separation.There were numerous hypotube kinks.There was no evidence of any material or manufacturing deficiencies contributing to the damage.The manufacturing batch record review confirmed that the device met all material, assembly and performance specifications.The most probable root cause is operational context as device performance was limited due to anatomical procedural factors.(b)(4).
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Event Description
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Reportable based on analysis completed on 30-sep-2016.It was reported that shaft kink occurred.The 78% stenosed, 11mm x 3.0mm target lesion was located in the moderately tortuous and moderately calcified left anterior descending artery.A 3.0mmx12mm quantum maverick balloon catheter was advanced for dilation.However, during the delivery of the device, it was noticed that the shaft was kinked.The device was successfully removed from the patient.The procedure was completed with another of the same device.No patient complications were reported and the patient's status was stable.However, returned device analysis revealed hypotube break.
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