MAUDE Adverse Event Report: BOSTON SCIENTIFIC CORPORATION STERLING; CATHETER, PERCUTANEOUS

Model Number	24700
Medical Device Problem Codes	Material Rupture (1546); Failure to Advance (2524); Material Integrity Problem (2978)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Date of Event	04/22/2019
Type of Reportable Event	Malfunction
Event or Problem Description
It was reported that balloon rupture occured.A 4.0mmx40mmx135cm (4f) sterling balloon catheter was advanced for dilation.However, during procedure, it was noted that the device failed to cross the lesion and the tip of the balloon was damaged.The procedure was completed with a different device.There were no patient complications nor injuries reported and the patient's status was stable.
Event or Problem Description
It was reported that balloon rupture occured.A 4.0mmx40mmx135cm (4f) sterling balloon catheter was advanced for dilation.However, during procedure, it was noted that the device failed to cross the lesion and the tip of the balloon was damaged.The procedure was completed with a different device.There were no patient complications nor injuries reported and the patient's status was stable.
Additional Manufacturer Narrative
Device evaluated by mfr.: returned product consisted of a sterling balloon catheter.The shaft, hypotube, tip and balloon were microscopically and visually examined.There was contrast in the inflation lumen and balloon.The balloon was loosely folded.Microscopic inspection revealed tip damage/tear.There was a tear at the distal end of the balloon due to the extent of the tip damage.The inner shaft of the balloon was buckled from the distal end to the proximal end of the balloon.Inspection of the remainder of the device presented no other damage or irregularities.

• Brand Name: STERLING
• Common Device Name: CATHETER, PERCUTANEOUS
• Manufacturer (Section D): BOSTON SCIENTIFIC CORPORATION; two scimed place; maple grove MN 55311
• MDR Report Key: 8734997
• Report Number: 2134265-2019-07464
• Device Sequence Number: 11288321
• Product Code: DQY
• UDI-Device Identifier: 08714729123576
• UDI-Public: 08714729123576
• Combination Product (Y/N): N
• Initial Reporter Country: CH
• PMA/510(K) Number: K053116
• 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): 07/26/2019

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: 07/31/2021
• Device Model Number: 24700
• Device Catalogue Number: 24700
• Device Lot Number: 0022453434
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 06/24/2019
• Initial Date Received by Manufacturer: 05/31/2019
• Supplement Date Received by Manufacturer: 07/18/2019
• Initial Report FDA Received Date: 06/26/2019
• Supplement Report FDA Received Date: 07/26/2019
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Patient Age: 62 YR
• Patient Weight: 48