MAUDE data represents reports of adverse events involving medical devices. This maude entry was filed from a company representative,foreig report with the FDA on 2019-11-08 for ADVANTA V12 COVERED STENT 85364 manufactured by Atrium Medical Corporation.
[173458806]
On completion of the investigation a follow up report will be submitted.
Patient Sequence No: 1, Text Type: N, H10
[173458807]
It was reported that after the stent was deployed the balloon detached from the catheter post deployment. It was retrieved in the sheath.
Patient Sequence No: 1, Text Type: D, B5
| Report Number | 3011175548-2019-01158 |
| MDR Report Key | 9295474 |
| Report Source | COMPANY REPRESENTATIVE,FOREIG |
| Date Received | 2019-11-08 |
| Date of Report | 2019-11-08 |
| Date of Event | 2019-11-01 |
| Date Mfgr Received | 2019-12-10 |
| Device Manufacturer Date | 2019-09-05 |
| Date Added to Maude | 2019-11-08 |
| Event Key | 0 |
| Report Source Code | Manufacturer report |
| Manufacturer Link | Y |
| Number of Patients in Event | 0 |
| Adverse Event Flag | 3 |
| Product Problem Flag | 3 |
| Reprocessed and Reused Flag | 3 |
| Reporter Occupation | OTHER HEALTH CARE PROFESSIONAL |
| Health Professional | 3 |
| Initial Report to FDA | 3 |
| Report to FDA | 3 |
| Event Location | 3 |
| Manufacturer Contact | MS. LYNDA MCLAUGHLIN |
| Manufacturer Street | 40 CONTINENTAL BLVD |
| Manufacturer City | MERRIMACK NH 03054 |
| Manufacturer Country | US |
| Manufacturer Postal | 03054 |
| Manufacturer G1 | ATRIUM MEDICAL CORPORATION |
| Manufacturer Street | 40 CONTINENTAL BLVD |
| Manufacturer City | MERRIMACK NH 03054 |
| Manufacturer Country | US |
| Manufacturer Postal Code | 03054 |
| Single Use | 3 |
| Previous Use Code | 3 |
| Event Type | 3 |
| Type of Report | 3 |
| Brand Name | ADVANTA V12 COVERED STENT |
| Generic Name | STENT, RENAL |
| Product Code | NIN |
| Date Received | 2019-11-08 |
| Model Number | 85364 |
| Catalog Number | 85364 |
| Lot Number | 450599 |
| Operator | HEALTH PROFESSIONAL |
| Device Availability | N |
| Device Age | DA |
| Device Eval'ed by Mfgr | N |
| Device Sequence No | 1 |
| Device Event Key | 0 |
| Manufacturer | ATRIUM MEDICAL CORPORATION |
| Manufacturer Address | 40 CONTINENTAL BLVD MERRIMACK NH 03054 US 03054 |
| Patient Number | Treatment | Outcome | Date |
|---|---|---|---|
| 1 | 0 | 1. Required No Informationntervention | 2019-11-08 |