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

Catalog Number	1074225-28
Health Effect - Clinical Code	Stenosis (2263)
Date of Event	07/01/2016
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
(b)(4).During processing of this complaint, attempts were made to obtain complete event, patient and device information.There was no reported device malfunction and the product was not returned.A review of the lot history record identified no manufacturing nonconformities issued to the reported lot that would have contributed to this event.The reported patient effect of stenosis is listed in the xience xpedition everolimus eluting coronary stent system instructions for use (ifu) as a known patient effect of coronary stenting procedures.A conclusive cause for the reported patient effect and the relationship to the product, if any, cannot be determined and 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 on (b)(6) 2014, three xience xpedition stents (2.25x28mm, 2.5x38mm, 3.0x18mm) were successfully implanted in the chronic total occlusion (cto) located in the proximal to distal right coronary artery (rca) lesion.On (b)(6) 2015, it was confirmed there was no issue with any stent and the patient was compliant with dual antiplatelet therapy (dapt).On (b)(6) 2015, it was confirmed there was no issue with any device and the patient had stopped taking clopidogrel.On (b)(6) 2016, target lesion restenosis of the mid rca, 2.25x28mm xience xpedition stent, was noted.Clopidogrel was prescribed again.On (b)(6) 2016, balloon angioplasty was performed as treatment and the condition improved.Per physician, the restenosis was possibly related to the device and not related to the stent procedure and not related to the dapt medications.There was no additional information provided regarding this device issue.

• Brand Name: XIENCE XPEDITION 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: 6491011
• Report Number: 2024168-2017-03143
• Device Sequence Number: 18985672
• Product Code: NIQ
• UDI-Device Identifier: 08717648162060
• UDI-Public: (01)08717648162060(17)160707(10)4063042
• Combination Product (Y/N): N
• Initial Reporter Country: JA
• PMA/510(K) Number: P110019
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2014
• Reporter Type: Manufacturer
• Report Source: company representative,foreig
• Initial Reporter Occupation: Health Professional
• Remedial Action: Other
• Type of Report: Initial
• Report Date (Section B): 04/13/2017

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: 07/07/2016
• Device Catalogue Number: 1074225-28
• Device Lot Number: 4063042
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 03/21/2017
• Initial Report FDA Received Date: 04/13/2017
• 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: STENT: XIENCE XPEDITION 2.5X38, 3.0X18ASPIRIN
• Outcome Attributed to Adverse Event: Hospitalization; Required Intervention
• Patient Age: 47 YR
• Patient Weight: 57