MAUDE Adverse Event Report: AV-TEMECULA-CT XIENCE ALPINE OTW EVEROLIMUS ELUTING CORONARY STENT SYSTEM; DRUG ELUTING CORONARY STENT SYSTEM

Catalog Number	1145350-23
Health Effect - Clinical Code	No Patient Involvement (2645)
Date of Event	02/22/2017
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
(b)(4).During processing of this complaint, attempts were made to obtain complete event, patient and device information.Evaluation summary: the device was returned for analysis.Visual inspections were performed on the returned device.The labeling issue was confirmed.A review of the lot history record (lhr) identified no manufacturing nonconformities issued to the reported lot that would have contributed to this event.Additionally, a review of the complaint history identified no other similar incidents from this lot.A review of the lhr for the xience alpine 3.50x23 lot noted that the lot was manufactured and packaged on 23/june/2015, whereas the xience alpine 3.50x18 lot was manufactured and packaged on 11/october/2016.Therefore, this information indicates that the 2 units involved in this complaint never came into contact with one another during production or relabeling.In review of the noted information, this may suggest that a potential mix-up occurred at the hospital.The investigation determined the reported difficulties appear to be related to circumstances of the procedure.There is no indication of a product quality issue with respect to the design, manufacture, or labeling of the device.
Event or Problem Description
It was reported that a 3.5 x 23 mm xience alpine stent delivery system (sds) was to be used for the procedure; however, the device inside the box was a 3.5 x 18 mm xience alpine sds.The device was not used, no patient involvement.There was no clinically significant delay in procedure.No additional information was provided.

• Brand Name: XIENCE ALPINE OTW EVEROLIMUS ELUTING CORONARY STENT SYSTEM
• Common Device Name: DRUG ELUTING CORONARY STENT SYSTEM
• Manufacturer (Section D): AV-TEMECULA-CT; abbott vascular; 26531 ynez road; temecula CA 92591 4628
• MDR Report Key: 6401513
• Report Number: 2024168-2017-02093
• Device Sequence Number: 18992036
• Product Code: NIQ
• UDI-Device Identifier: 08717648200267
• UDI-Public: (01)08717648200267(17)180622(10)5061641
• Combination Product (Y/N): N
• Initial Reporter State: NJ
• Initial Reporter Country: US
• PMA/510(K) Number: P110019
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: company representative,health
• Initial Reporter Occupation: Health Professional
• Remedial Action: Other
• Type of Report: Initial
• Report Date (Section B): 03/13/2017

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: 06/22/2018
• Device Catalogue Number: 1145350-23
• Device Lot Number: 5061641
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 02/24/2017
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 02/22/2017
• Initial Report FDA Received Date: 03/13/2017
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1