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

Model Number	H7493808008250
Medical Device Problem Code	Break (1069)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Date of Event	04/17/2017
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
(b)(4).
Event or Problem Description
It was reported that shaft break occurred.The 6x2.5mm, 75% stenosed target lesion was located in the moderately tortuous and moderately calcified left anterior descending (lad) artery.A 2.5mm x 8mm quantum¿ maverick¿ balloon catheter was advanced for dilation; however, the shaft was fractured about 20cm from the hub.The device was simply removed and the procedure was completed with another of the same device.No patient harm or complications were reported and the patient's status was stable.
Additional Manufacturer Narrative
Device evaluated by mfr., eval summary attached, method codes, result codes, conclusion codes updated.Device evaluated by mfr: returned product consisted of a quantum maverick balloon catheter in two pieces.The shaft and hypotube were microscopically and visually examined.There was contrast in the inflation lumen.The balloon was tightly folded.There was a complete hypotube separation 58 cm from the strain relief.The hypotube fracture surfaces were ovaled, which suggests the device was kinked prior to separation.Inspection of the remainder of the device, apart from the observed damage, revealed no other damage or irregularities.No other issues were identified during the product analysis.Device analysis determined the condition of the returned device was consistent with the reported information.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).
Event or Problem Description
It was reported that shaft break occurred.The 6 x 2.5 mm, 75% stenosed target lesion was located in the moderately tortuous and moderately calcified left anterior descending (lad) artery.A 2.5 mm x 8 mm quantum¿ maverick¿ balloon catheter was advanced for dilation; however, the shaft was fractured about 20 cm from the hub.The device was simply removed and the procedure was completed with another of the same device.No patient harm or complications were reported and the patient's status was stable.

• Brand Name: QUANTUM¿ MAVERICK¿
• 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: 6544707
• Report Number: 2134265-2017-04390
• Device Sequence Number: 19058915
• Product Code: LOX
• UDI-Device Identifier: 08714729392545
• UDI-Public: (01)08714729392545(17)20190831(10)19556311
• Combination Product (Y/N): N
• Initial Reporter Country: CN
• PMA/510(K) Number: P860019
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: company representative,distri
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 04/17/2017

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: 08/31/2019
• Device Model Number: H7493808008250
• Device Catalogue Number: 38080-0825
• Device Lot Number: 19556311
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 04/27/2017
• Type of Report(Section G): FDA Requested
• Initial Date Received by Manufacturer: 04/17/2017
• Supplement Date Received by Manufacturer: Not provided
• Initial Report FDA Received Date: 05/04/2017
• Supplement Report FDA Received Date: 05/19/2017
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Patient Age: 68 YR
• Patient Weight: 78