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

Model Number	24700
Medical Device Problem Codes	Break (1069); Material Rupture (1546)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Date of Event	03/17/2020
Type of Reportable Event	Malfunction
Event or Problem Description
It was reported that balloon broke.A 4.0mmx20mmx135cm (4f) sterling balloon catheter was advanced for dilation in the internal and common carotid arteries.During deflation, there was a different sensation and it felt like negative pressure was releasing on the syringe.When attempting to inflate the balloon, the balloon broke.There were no patient complications reported.
Event or Problem Description
It was reported that balloon broke.A 4.0mmx20mmx135cm (4f) sterling balloon catheter was advanced for dilation in the internal and common carotid arteries.During deflation, there was a different sensation and it felt like negative pressure was releasing on the syringe.When attempting to inflate the balloon, the balloon broke.There were no patient complications reported.It was further reported that when removing air from the device, negative pressure was felt escaping from the syringe.The balloon was noticed to be torn/ruptured/damaged during air removal.The procedure was completed with a different balloon catheter.The patient's condition was good.

• Brand Name: STERLING
• Common Device Name: CATHETER, PERCUTANEOUS
• Manufacturer (Section D): BOSTON SCIENTIFIC CORPORATION; two scimed place; maple grove MN 55311
• MDR Report Key: 9874027
• Report Number: 2134265-2020-03788
• Device Sequence Number: 2910664
• Product Code: DQY
• UDI-Device Identifier: 08714729123521
• UDI-Public: 08714729123521
• 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): 04/15/2020

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: 05/02/2022
• Device Model Number: 24700
• Device Catalogue Number: 24700
• Device Lot Number: 0023736564
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 03/17/2020
• Supplement Date Received by Manufacturer: 04/07/2020
• Initial Report FDA Received Date: 03/24/2020
• Supplement Report FDA Received Date: 04/15/2020
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Patient Age: 18 YR