MAUDE Adverse Event Report: BOSTON SCIENTIFIC CORPORATION GREENFIELD; FILTER, INTRAVASCULAR, CARDIOVASCULAR

Model Number	43175
Medical Device Problem Code	Positioning Problem (3009)
Health Effect - Clinical Code	Perforation (2001)
Date of Event	03/06/2019
Type of Reportable Event	Serious Injury
Event or Problem Description
In (b)(6) 2007 the patient underwent placement of a greenfield vena cava filter.In (b)(6) 2019 a computed tomography (ct) scan revealed a 15 degree leftward tilt and a minimal mesenteric perforation involving the distal inferior filter limbs measuring 2mm.
Event or Problem Description
In (b)(6) 2007 the patient underwent placement of a greenfield vena cava filter.In (b)(6) 2019 a computed tomography (ct) scan revealed a 15 degree leftward tilt and a minimal mesenteric perforation involving the distal inferior filter limbs measuring 2mm.

• Brand Name: GREENFIELD
• Common Device Name: FILTER, INTRAVASCULAR, CARDIOVASCULAR
• Manufacturer (Section D): BOSTON SCIENTIFIC CORPORATION; two scimed place; maple grove MN 55311
• MDR Report Key: 9939152
• Report Number: 2134265-2020-04716
• Device Sequence Number: 3696871
• Product Code: DTK
• UDI-Device Identifier: 08714729114659
• UDI-Public: 08714729114659
• Combination Product (Y/N): N
• Initial Reporter State: TX
• Initial Reporter Country: US
• PMA/510(K) Number: K901659
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2007
• Reporter Type: Manufacturer
• Report Source: company representative,consum
• Initial Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial,Followup
• Report Date (Section B): 08/10/2020

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?: Yes
• Operator of Device: Health Professional
• Device Expiration Date: 09/30/2009
• Device Model Number: 43175
• Device Catalogue Number: 43175
• Device Lot Number: 0009163205
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 03/24/2020
• Supplement Date Received by Manufacturer: 07/23/2020
• Initial Report FDA Received Date: 04/08/2020
• Supplement Report FDA Received Date: 08/10/2020
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Other
• Patient Age: 78 YR