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	03/27/2017
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.The device was not returned for evaluation.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 systems instructions for use 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 manufacture, design or labeling.
Event or Problem Description
It was reported that on (b)(6) 2014, the patient was hospitalized with asymptomatic ischemia.On (b)(4)2014, coronary intervention was performed.Balloon angioplasty was performed and a 2.25 x 28 mm xience xpedition stent and a 2.75 x 8 mm xience xpedition stent were implanted in the proximal to mid left anterior descending (lad) coronary artery.Balloon angioplasty was performed in the first diagonal branch of the lad.The patient was discharged on (b)(6) 2014.Re-stenosis was noted on (b)(6) 2017, in the 2.25 x 28 mm xience xpedition stent and in a non-target vessel.Revascularization was performed on (b)(6) 2017, and a drug eluting stent was implanted at the target lesion.Balloon angioplasty was performed in the non-target vessel.The patient condition resolved on (b)(6) 2017.No additional information was provided.

• 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: 7184633
• Report Number: 2024168-2018-00322
• Device Sequence Number: 10781338
• Product Code: NIQ
• UDI-Device Identifier: 08717648162060
• UDI-Public: 08717648162060
• 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): 01/11/2018

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: 06/15/2016
• Device Catalogue Number: 1074225-28
• Device Lot Number: 4061141
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 09/29/2017
• Initial Report FDA Received Date: 01/11/2018
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Hospitalization; Required Intervention
• Patient Age: 85 YR
• Patient Weight: 49