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

Model Number	24700
Medical Device Problem Code	Material Rupture (1546)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Date of Event	03/13/2020
Type of Reportable Event	Malfunction
Event or Problem Description
It was reported that balloon ruptured occurred.A 8.0mmx20mmx80cm (4f) sterling balloon catheter was advanced for dilatation.However, on the first dilatation the balloon ruptured at 4 atmosphere for 5 seconds.The procedure was completed with another of same device.The device was removed without any problem.No patient serious injury or adverse event were reported.
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 and blood in the inflation lumen and balloon, and blood in the guidewire lumen.The balloon was loosely folded.The device was prepped with an inflation device filled with water and connected to the inflation port to inflate the device.There was a hole in the inner shaft 2mm distal from the distal marker band.The device was functionally tested.Inspection of the remainder of the device presented no other damage or irregularities.
Event or Problem Description
It was reported that balloon rupture occurred.A 8.0mmx20mmx80cm (4f) sterling balloon catheter was advanced for dilatation.However, on the first dilatation the balloon ruptured at 4 atmosphere for 5 seconds.The procedure was completed with another of same device.The device was removed without any problem.No patient serious injury or adverse event were reported.

• Brand Name: STERLING
• Common Device Name: CATHETER, PERCUTANEOUS
• Manufacturer (Section D): BOSTON SCIENTIFIC CORPORATION; two scimed place; maple grove MN 55311
• MDR Report Key: 9867983
• Report Number: 2134265-2020-03717
• Device Sequence Number: 468932
• Product Code: DQY
• UDI-Device Identifier: 08714729720645
• UDI-Public: 08714729720645
• Combination Product (Y/N): N
• Initial Reporter Country: JA
• 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): 04/28/2020

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: 04/25/2022
• Device Model Number: 24700
• Device Catalogue Number: 24700
• Device Lot Number: 0023699310
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 03/31/2020
• Initial Date Received by Manufacturer: 03/16/2020
• Supplement Date Received by Manufacturer: 04/25/2020
• Initial Report FDA Received Date: 03/23/2020
• Supplement Report FDA Received Date: 04/28/2020
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1