MAUDE Adverse Event Report: C.R. BARD, INC. (BASD) -3006260740 M.R.I. DUAL-LUMEN IMPLANTABLE PORT WITH ATTACHABLE 9.5F; PORT & CATHETER, IMPLANTED, SUBCUTANEOUS, INTRAVASCULAR

Catalog Number 0605920

Device Problems Fluid/Blood Leak (1250); Difficult to Flush (1251); Device Appears to Trigger Rejection (1524); Suction Problem (2170)

Patient Problems Extravasation (1842); Appropriate Clinical Signs, Symptoms, Conditions Term / Code Not Available (4581)

Event Date 08/01/2023

Event Type  Injury  

Manufacturer Narrative

H10: as the lot number for the device was provided, a review of the device history records will be performed.The sample was not returned to the manufacturer for inspection/evaluation.Therefore, the investigation of the reported event is inconclusive.Based upon the available information, the definitive root cause for this event is unknown.The instructions for use (ifu) is adequate for the reported device/patient code(s) and provides general instructions for use, as well as warnings, precautions and potential complications associated with the device.Upon receipt of new or additional information, a follow-up report will be submitted as applicable.H10: d4 (expiry date: 01/2026).H11: section a through f: the information provided by bd represents all the known information at this time.Despite good faith efforts to obtain additional information, the complainant/reporter was unable or unwilling to provide any further patient, product, or procedural details to bd.H3 other text : device not returned.

Event Description

It was reported that one week four days post port placement procedure, the patient allegedly had extravasation of chemotherapy.It was further reported that catheter of the port had a large fibrin sheath that wrapped around the catheter and extended over the tip.It was also reported that the device allegedly had suction issue and was allegedly difficult to be flushed.The current status of the patient is unknown.

• Brand Name: M.R.I. DUAL-LUMEN IMPLANTABLE PORT WITH ATTACHABLE 9.5F
• Type of Device: PORT & CATHETER, IMPLANTED, SUBCUTANEOUS, INTRAVASCULAR
• Manufacturer (Section D): C.R. BARD, INC. (BASD) -3006260740; 605 north 5600 west; salt lake city 84116
• Manufacturer (Section G): BARD REYNOSA S.A. DE C.V. -9617592; blvd. montebello #1; parque industrial colonial; reynosa, tamaulipas 88780 ; MX 88780
• Manufacturer Contact: brett curtice ; 800 w. rio salado pkwy; tempe, AZ 85281 ; 4803032689
• MDR Report Key: 17681453
• MDR Text Key: 322603511
• Report Number: 3006260740-2023-03892
• Device Sequence Number: 1
• Product Code: LJT
• UDI-Device Identifier: 00801741026027
• UDI-Public: (01)00801741026027
• Combination Product (y/n): N
• Reporter Country Code: AS
• PMA/PMN Number: K912702
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: Other,Foreign,Health Professional,User Facility,Company Representative
• Reporter Occupation: Physician
• Type of Report: Initial
• Report Date: 08/19/2023

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 09/05/2023
• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Catalogue Number: 0605920
• Device Lot Number: REFQ1352
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Date Manufacturer Received: 08/10/2023
• Was Device Evaluated by Manufacturer?: Device Not Returned to Manufacturer
• Is the Device Single Use?: Yes
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Initial
• Patient Sequence Number: 1
• Patient Outcome(s): Required Intervention