FDA Adverse Event Injury Summary report: N

BLUE MAX BALLOON DILATATION CATHETER

MDR report key: 232463 · Received July 20, 1999

Report

Report Number
6000036-1999-00105
Event Type
Injury
Date Received
July 20, 1999
Date of Event
June 22, 1999
Report Date
June 22, 1999
Manufacturer
MEDI-TECH A DIV OF BOSTON SCIENTIFIC CORP.
Product Code
LIT
Adverse Event
Yes
Product Problem
Yes
Report Source
Manufacturer report
Reporter Location
IL, US
Reporter Occupation
PHYSICIAN

Narratives

Description of Event or Problem · 1

IT WAS REPORTED THIS BALLOON RUPTURED AT 12 ATMOSPHERES, FOLLOWING THE FIRST INFLATION, DURING AN ILIAC ANGIOPLASTY PROCEDURE OF A STENOTIC AND BRITTLE ARTERY. ANOTHER BALLOON CATHETER WAS THEN USED WHICH ALSO RUPTURED. THE PHYSICIAN DETEMINED ADEQUATE DILATATION WAS ACHIEVED AND A THIRD BALLOON WAS NOT USED. A COMPLETION ANGIOGRAM WAS DONE AND SLIGHT EXTRAVASATION OUT OF THE ARTERY WAS NOTED, HOWEVER, NO TREATMENT WAS ADMINISTERED. A SCHEDULED FEMORAL-POPLITEAL BY-PASS PROCEDURE WAS THEN SUCCESSFULLY PERFORMED. THREE TO FOUR HOURS POST BY-PASS PROCEDURE IT WAS NOTICED THE PT'S BLOOD PRESSURE WAS DROPPING. FOUR UNITS OF BLOOD AND 2 UNITS OF PLASMA WERE ADMINISTERED. LATER THAT EVENING, A PATCH ANGIOPLASTY PROCEDURE WAS PERFORMED TO SUCCESSFULLY REPAIR THE ARTERY. THE PATIENT'S CONDITION IS GOOD. THE DEVICE WAS DESTROYED BY THE USER FACILITY. THEREFORE, NO FAILURE ANALYSIS WILL BE AVAILABLE. BALLOON RUPTURE OR BALLOON LEAKAGE IS AN ANTICIPATED EVENT OF PERCUTANEOUS ANGIOPLASTY WHICH HAS BEEN ASSOCIATED WITH OVERPRESSURIZATION OR USE IN A CALCIFIED LESION. CO'S FOLLOW UP REVEALED THE ARTERY WAS STENTIC AND BRITTLE WHICH CO FEELS MAY HAVE CONTRIBUTED TO THIS EVENT. HOWEVER, CO IS UNABLE TO DETERMINE THE EXACT CAUSE FOR THIS EVENT. CO'S DIRECTIONS FOR USE STATE: "THE MINIMAL DILATING FORCE REQUIRED TO DILATE SHOULD BE APPLIED, MINIMIZING THE RISKS OF BALLOON OVER-INFLATION OR RUPTURE... IF LOSS OF PRESSURE WITHIN THE BALLOON OCCURS DURING INFLATION OR IF BALLOON RUPTURES DURING DILATATION, IMMEDIATELY DISCONTINUE THE PROCEDURE. DEFLATE THE BALLOON, DO NOT REINFLATE AND REMOVE CAREFULLY. SAME CASE AS MFR REPORT# 6000036-1999-00106.

Devices

Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
1 BLUE MAX BALLOON DILATATION CATHETER PTA BALLOON DIL CATHETER LIT MEDI-TECH A DIV OF BOSTON SCIENTIFIC CORP. NA UNK

Patients

Seq Age Sex Outcome Treatment
1 UNKNOWN Required Intervention