MAUDE Adverse Event Report: LEMAITRE VASCULAR, INC. PRUITT F3-S POLYURETHANE CAROTID SHUNT

Catalog Number 2014-10

Device Problem Material Puncture/Hole (1504)

Patient Problem No Clinical Signs, Symptoms or Conditions (4582)

Event Date 02/18/2024

Event Type  malfunction  

Manufacturer Narrative

We have not received the device for investigation as it was discarded.Hence, we could not conclusively determine the root cause of the reported incident.We have conducted a lot history review and did not find any issues noted in the manufacturing or packaging process that could be related to this issue.All qc tests passed their requirements.Further, we have not received any other complaints of a similar nature for devices from this lot.

Event Description

It was reported that the pruitt f3-s shunt had a hole in the balloon and couldn't be used for surgery.It wasn't used on the patient and no injury was reported.

• Brand Name: PRUITT F3-S POLYURETHANE CAROTID SHUNT
• Type of Device: POLYURETHANE CAROTID SHUNT
• Manufacturer (Section D): LEMAITRE VASCULAR, INC.; 63 second ave; burlington MA 01803
• Manufacturer (Section G): LEMAITRE VASCULAR, INC; 63 second ave; burlington MA 01803
• Manufacturer Contact: peter song ; 63 second ave; burlington, MA 01803 ; 7814251683
• MDR Report Key: 18941185
• MDR Text Key: 338367011
• Report Number: 1220948-2024-00065
• Device Sequence Number: 1
• Product Code: MJN
• UDI-Device Identifier: 00840663108367
• UDI-Public: (01)00840663108367
• Combination Product (y/n): N
• Reporter Country Code: US
• PMA/PMN Number: K152833
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: Company Representative
• Reporter Occupation: Administrator/Supervisor
• Type of Report: Initial
• Report Date: 03/20/2024

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 03/20/2024
• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Catalogue Number: 2014-10
• Device Lot Number: PFP1151
• Was Device Available for Evaluation?: No
• Date Manufacturer Received: 02/19/2024
• Was Device Evaluated by Manufacturer?: No
• Date Device Manufactured: 06/09/2023
• 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