MAUDE Adverse Event Report: BOSTON SCIENTIFIC - MAPLE GROVE EMERGE¿; CATHETERS, TRANSLUMINAL CORONARY ANGIOPLASTY, PERCUTANEOUS

Model Number	H7493918920200
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Code	Death (1802)
Date of Event	12/13/2016
Type of Reportable Event	Death
Additional Manufacturer Narrative
Device evaluated by mfr: it is indicated that the device will not be returned for evaluation.A review of the batch history, historical trending, and similar complaint trending review for the product family will be conducted.If there is any further relevant information from that review, a supplemental medwatch will be filed.(b)(4).
Event or Problem Description
Same case as mdr id: 2134265-2016-12259, 2134265-2016-12261, 2134265-2016-12260, 2134265-2016-12257, 2134265-2016-12256.It was reported that the patient died.Several days prior to this percutaneous coronary intervention (pci), this patient had a repeat thoracic endovascular aneurysm repair (tevar) for a dissection in the aorta.A stent graft was placed at that time.Open surgery was not an option for this pci due to the patient¿s condition.Vascular access was obtained via the femoral artery.The target lesions were located in the distal left main to proximal left anterior descending (lad) and mid lad arteries; the disease was noted to be complex.During the procedure an opticross¿ imaging catheter, a samurai guidewire, a 2.00mmx20mm emerge¿ balloon catheter and a 8mmx4.00mm nc quantum apex¿ balloon catheter were used.A 2.25x28 synergy ii drug-eluting stent (des) was deployed in the mid lad and a 3.50 x 16 synergy ii des was deployed in the distal left main to proximal lad.The procedure went very well.However, as staff was undraping the patient and preparing to transfer, the patient began to bleed internally through his chest tube.Surgery and anesthesia were called and they worked on him, but they could not stop the bleeding and he expired within 10-15 minutes of that time.The physician believes that the patient¿s aorta ruptured and they likely bled out due to that and the anticoagulants.Angiomax was used during the procedure.

• Brand Name: EMERGE¿
• Common Device Name: CATHETERS, TRANSLUMINAL CORONARY ANGIOPLASTY, PERCUTANEOUS
• Manufacturer (Section D): BOSTON SCIENTIFIC - MAPLE GROVE; one scimed place; maple grove MN 55311
• MDR Report Key: 6243926
• Report Number: 2134265-2016-12258
• Device Sequence Number: 955677
• Product Code: LOX
• UDI-Device Identifier: 08714729806301
• UDI-Public: (01)08714729806301(17)20190531(10)19770218
• Combination Product (Y/N): N
• Initial Reporter State: VA
• Initial Reporter Country: US
• PMA/510(K) Number: K113220
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: company representative,health
• Initial Reporter Occupation: Physician
• Type of Report: Initial
• Report Date (Section B): 12/13/2016

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?: No
• Operator of Device: Health Professional
• Device Expiration Date: 05/31/2019
• Device Model Number: H7493918920200
• Device Catalogue Number: 39189-2020
• Device Lot Number: 19770218
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 12/13/2016
• Initial Report FDA Received Date: 01/11/2017
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Concomitant Medical Products and Therapy/Usage Dates: BALLOON: NC QUANTUM APEX 8MM X 4.00MM; GUIDEWIRE: SAMURAI 190CM, STRAIGHT TIP; STENT: SYNERGY II 2.25 X 28; STENT: SYNERGY II 3.50 X 16; ULTRASOUND CATHETER: OPTICROSS
• Outcome Attributed to Adverse Event: Death
• Patient Age: 79 YR