MAUDE Adverse Event Report: BOSTON SCIENTIFIC CORPORATION QUANTUM MAVERICK; CATHETERS TRANSLUMINAL CORONARY ANGIOPLASTY PERCUTANEOUS

Model Number	7005
Medical Device Problem Code	Material Deformation (2976)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Date of Event	10/16/2019
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Device evaluated by mfr.: returned product consisted of a quantum maverick balloon catheter.The balloon was tightly folded.There were numerous hypotube kinks.The hypotube was separated 19.5cm from the hub.The separated ends of the hypotube was ovaled indicating the hypotube was kinked prior to separating.
Event or Problem Description
Reportable based on device analysis completed on 10jan2020.It was reported that shaft kink occurred.The 93% stenosed, 4x10mm target lesion was located in moderately tortuous and moderately calcified left anterior descending artery.A 4.0mm x 8mm quantum maverick balloon catheter was advanced for dilatation.However, during procedure the balloon delivery shaft was kinked.The procedure was completed with different device.No patient complications were reported and the patient's status was stable.However, returned device analysis revealed shaft detached/separation.

• Brand Name: QUANTUM MAVERICK
• Common Device Name: CATHETERS TRANSLUMINAL CORONARY ANGIOPLASTY PERCUTANEOUS
• Manufacturer (Section D): BOSTON SCIENTIFIC CORPORATION; two scimed place; maple grove MN 55311
• MDR Report Key: 9643313
• Report Number: 2134265-2020-00686
• Device Sequence Number: 2179641
• Product Code: LOX
• UDI-Device Identifier: 08714729392606
• UDI-Public: 08714729392606
• Combination Product (Y/N): N
• Initial Reporter Country: CH
• 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): 01/29/2020

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: 03/26/2022
• Device Model Number: 7005
• Device Catalogue Number: 7005
• Device Lot Number: 0023547793
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 12/27/2019
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 01/10/2020
• Initial Report FDA Received Date: 01/29/2020
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Patient Age: 48 YR
• Patient Weight: 78