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	02/16/2019
Type of Reportable Event	Serious Injury
Event or Problem Description
It was reported a perforation and tilt occurred.On (b)(6) 2005, the patient underwent placement of a greenfield vena cava filter.On (b)(6) 2019, a computed tomography (ct) scan confirmed a tilt and mesenteric perforation.The inferior vena cava (ivc) filter is tilted to the left and nose is within the wall of the ivc at about 1:00.The legs protrude beyond the wall of the ivc.Two of the legs are beneath aortic bifurcation.
Event or Problem Description
It was reported a perforation and tilt occurred.On (b)(6) 2005, the patient underwent placement of a greenfield vena cava filter.On (b)(6) 2019, a computed tomography (ct) scan confirmed a tilt and mesenteric perforation.The inferior vena cava (ivc) filter is tilted to the left and nose is within the wall of the ivc at about 1:00.The legs protrude beyond the wall of the ivc.Two of the legs are beneath aortic bifurcation.

• 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: 9948316
• Report Number: 2134265-2020-04926
• Device Sequence Number: 3296542
• Product Code: DTK
• UDI-Device Identifier: 08714729114666
• UDI-Public: 08714729114666
• 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: 2005
• Reporter Type: Manufacturer
• Report Source: consumer,other
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 07/28/2020

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: 11/18/2007
• Device Model Number: 43175
• Device Catalogue Number: 43175
• Device Lot Number: 0007157532
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 03/24/2020
• Supplement Date Received by Manufacturer: 07/13/2020
• Initial Report FDA Received Date: 04/10/2020
• Supplement Report FDA Received Date: 07/28/2020
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Other
• Patient Age: 74 YR