MAUDE Adverse Event Report: ABBOTT VASCULAR XIENCE SIERRA EVEROLIMUS ELUTING CORONARY STENT SYSTEM; DRUG ELUTING CORONARY STENT DELIVERY SYSTEM

Model Number	1550350-08
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Codes	Angina (1710); Dyspnea (1816); Stenosis (2263)
Date of Event	01/23/2020
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
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.It should be noted that the reported patient effects of angina and stenosis are listed in the xience sierra, everolimus eluting coronary stent system instructions for use as known patient effects of coronary stenting procedures.A conclusive cause for the reported patient effect(s), and the relationship to the product, if any, cannot be determined; however, the reported treatment appears to be related to the operational context of the procedure.There is no indication of a product quality issue with respect to manufacture, design or labeling of the device.The 3.0x8mm xience sierra stet mentioned is filed under a separate medwatch report number.
Event or Problem Description
Patient id: (b)(6).It was reported that on (b)(6) 2019, the patient presented with elevated troponin.A 3.0x8mm and 3.5x8mm xience sierra stents were implanted in the ramus coronary artery with acceptable results.On 09/11/2019, the patient presented with chest pain.Per imaging, the left anterior descending (lad) and right coronary artery (rca) had an occlusion.The ramus coronary artery 3.0x8mm xience sierra stent was observed with in-stent restenosis.As treatment, another percutaneous coronary intervention (pci) was performed.The ramus was treated with a high-pressure balloon catheter.The pre-existing coronary artery bypass graft to the lad was patent.The patient was discharged home with continued dual antiplatelet therapy (dapt).There was no device malfunction.No additional information was provided regarding this issue.On (b)(6) 2020, the patient experienced chest pain.Coronary angiography revealed an occluded lad, circumflex and rca arteries.The lima was patent to the lad.Both xience sierra stents implanted in the ramus had restenosed, treated with laser and high pressure balloon.Medications were provided.No additional information was provided regarding this issue.
Additional Manufacturer Narrative
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 dyspnea is listed in the everolimus eluting coronary stent system, instructions for use as known patient effect of coronary stenting procedures.A conclusive cause for the reported patient effect(s), and the relationship to the product, if any, cannot be determined.There is no indication of a product quality issue with respect to manufacture, design or labeling of the device.
Event or Problem Description
Subsequent to the previous medwatch report, the additional information was received: on (b)(6) 2020, the patient presented to the emergency room with chest pain and shortness of breath.Imaging was performed revealing an occluded lad, cx, and rca.The lima to the lad was patent and the ramus had in-stent restenosis treated with balloon angioplasty.The event resolved that same day and the patient was discharged home.

• Brand Name: XIENCE SIERRA EVEROLIMUS ELUTING CORONARY STENT SYSTEM
• Common Device Name: DRUG ELUTING CORONARY STENT DELIVERY SYSTEM
• Manufacturer (Section D): ABBOTT VASCULAR; 26531 ynez rd.; temecula CA 92591 4628
• MDR Report Key: 9826324
• Report Number: 2024168-2020-02375
• Device Sequence Number: 19216870
• Product Code: NIQ
• UDI-Device Identifier: 08717648227394
• UDI-Public: 08717648227394
• Combination Product (Y/N): Y
• Initial Reporter State: NY
• Initial Reporter Country: US
• PMA/510(K) Number: P110019
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2019
• Reporter Type: Manufacturer
• Report Source: health professional,study
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 08/13/2020

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: 09/30/2019
• Device Model Number: 1550350-08
• Device Catalogue Number: 1550350-08
• Device Lot Number: 8092541
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 02/18/2020
• Supplement Date Received by Manufacturer: 07/23/2020
• Initial Report FDA Received Date: 03/12/2020
• Supplement Report FDA Received Date: 08/13/2020
• 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: 3.0X8MM XIENCE SIERRA STENT
• Outcome Attributed to Adverse Event: Hospitalization; Required Intervention
• Patient Age: 66 YR
• Patient Weight: 90