MAUDE Adverse Event Report: MICROVENTION, INC. SCEPTER C OCCLUSION BALLOON (4X10MM); BALLOON CATHETER

Model Number	BC0410C
Medical Device Problem Code	Material Rupture (1546)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Date of Event	08/17/2018
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
The lot number was provided.A review of the approved device history records indicated the lot met all release criteria.A lot history trending review was performed and there were no similar complaints for this lot number.The balloon was returned for evaluation and the reported balloon rupture was confirmed.A pinhole was identified in the balloon material at the distal balloon marker band.It is unknown if the application of pressure to the balloon at prep could have contributed to the balloon rupture.The root cause cannot be determined.The device was used during the same procedure as was reported in mfr report# 2032493-2018-00188.
Event or Problem Description
It was reported that the balloon ruptured in the patient during the first inflation attempt.The balloon had been pinched to prevent inflation during preparation for use.There was no reported patient injury or intervention.The patient was reported to be doing well post procedure.

• Brand Name: SCEPTER C OCCLUSION BALLOON (4X10MM)
• Common Device Name: BALLOON CATHETER
• Manufacturer (Section D): MICROVENTION, INC.; 35 enterprise drive; aliso viejo CA 92656
• MDR Report Key: 7885996
• Report Number: 2032493-2018-00187
• Device Sequence Number: 11202006
• Product Code: MJN
• UDI-Device Identifier: 00842636020539
• UDI-Public: (01)00842636020539(11)180118(17)201231(10)18011854Y
• Combination Product (Y/N): N
• Initial Reporter Country: AS
• PMA/510(K) Number: K110741
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: distributor,foreign,health pr
• Initial Reporter Occupation: Physician
• Type of Report: Initial
• Report Date (Section B): 08/20/2018

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: Other
• Device Expiration Date: 12/31/2020
• Device Model Number: BC0410C
• Device Lot Number: 18011854Y
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 08/28/2018
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 08/20/2018
• Initial Report FDA Received Date: 09/18/2018
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Patient Age: 42 YR