MAUDE Adverse Event Report: AV-TEMECULA-CT HI-TORQUE PILOT GUIDE WIRE

Catalog Number	1010480-H
Health Effect - Clinical Code	Perforation (2001)
Date of Event	05/01/2018
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 analysis.A review of the lot history record 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 incidents from this lot.It should be noted that the reported patient effect(s) of perforation is listed in the hi-torque guide wires instructions for use (ifu) as a known patient effect of coronary stenting procedures.The investigation determined the reported failure to advance appears to be related to circumstances of the procedure as it is likely that as the guide wire was advanced resistance was met with the moderately calcified anatomy resulting in the reported failure to advance.A conclusive cause for the reported perforation, and the relationship to the product, if any, cannot be determined.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 balance middle weight (bmw) guide wire was placed in the left anterior descending (lad).Using a buddy wire technique, a hi-torque pilot guide wire was advanced to the bmw without issue, however, the device failed to cross the moderately calcified lesion as a perforation occurred at the ht pilot lad site.The device was removed without reported issue and balloon angioplasty was performed for 2 minutes as treatment.The perforation was resolved.No additional information was provided.

• Brand Name: HI-TORQUE PILOT GUIDE WIRE
• Common Device Name: GUIDE WIRE
• Manufacturer (Section D): AV-TEMECULA-CT; abbott vascular; 26531 ynez road; temecula CA 92591 4628
• MDR Report Key: 7507724
• Report Number: 2024168-2018-03498
• Device Sequence Number: 1645479
• Product Code: DQX
• UDI-Device Identifier: 08717648073854
• UDI-Public: 08717648073854
• Combination Product (Y/N): N
• Initial Reporter State: MI
• Initial Reporter Country: US
• PMA/510(K) Number: K060449
• 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): 05/11/2018

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?: Yes
• Operator of Device: Health Professional
• Device Expiration Date: 12/31/2019
• Device Catalogue Number: 1010480-H
• Device Lot Number: 8011571
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 05/01/2018
• Initial Report FDA Received Date: 05/11/2018
• 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: BALANCE MIDDLE WEIGHT (BMW) GUIDE WIRE
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Weight: 95