MAUDE Adverse Event Report: BOSTON SCIENTIFIC - MAPLE GROVE MAVERICK²¿; CATHETERS, TRANSLUMINAL CORONARY ANGIOPLASTY, PERCUTANEOUS

Model Number	H7493892812250
Medical Device Problem Code	Failure to Advance (2524)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Date of Event	04/07/2017
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
(b)(4).Device evaluated by mfr: returned product consisted of a maverick 2 balloon catheter in two pieces.The shafts, balloon, tip and welds were microscopically examined.There was contrast in the inflation lumen.The balloon was tightly folded.Microscopic examination and tactile inspection revealed numerous kinks throughout the hypotube and a complete hypotube separation 43 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 damage or issues were identified during the product analysis.Device analysis determined the condition of the returned device was not consistent with the reported information due to the additional damage found.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
Same case as mdr id: 2134265-2017-05282.Reportable based on device analysis completed on 12may2017.It was reported that crossing difficulties were encountered.The target lesion was located in the left anterior descending artery.After a non-bsc guide wire was placed in the lesion, a 2.50 mm x 12 mm maverick²¿ balloon catheter was advanced for dilatation but failed to cross the lesion.The device was removed and another 2.50 mm x 12 mm maverick²¿ balloon catheter was advanced but also failed to cross.The device was removed and 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 broken.

• Brand Name: MAVERICK²¿
• 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: 6604200
• Report Number: 2134265-2017-05281
• Device Sequence Number: 11015395
• Product Code: LOX
• UDI-Device Identifier: 08714729369981
• UDI-Public: (01)08714729369981(17)20190930(10)19748140
• Combination Product (Y/N): N
• Initial Reporter Country: IN
• 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
• Report Date (Section B): 05/12/2017

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: 09/30/2019
• Device Model Number: H7493892812250
• Device Catalogue Number: 38928-1225
• Device Lot Number: 19748140
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 05/02/2017
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 05/12/2017
• Initial Report FDA Received Date: 06/01/2017
• 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: GUIDE WIRE: FIELDER XT
• Patient Age: 79 YR
• Patient Weight: 88