MAUDE Adverse Event Report: ASAHI INTECC ASAHI INTECC CARAVEL; MICRO CATHETER

Catalog Number	CRV135-19P
Health Effect - Clinical Code	No Known Impact Or Consequence To Patient (2692)
Date of Event	04/29/2020
Type of Reportable Event	Malfunction
Event or Problem Description
Doctor had an in-stent cto and from an antegrade position had a caravel tip come free.States it may have been snagged behind a stent strut, but couldn't be exactly sure how it came free and said device was not torqued.Tip was safely removed with a balloon.

• Brand Name: ASAHI INTECC CARAVEL
• Common Device Name: MICRO CATHETER
• Manufacturer (Section D): ASAHI INTECC; 3-100 akatsuki-cho; seto, aichi 489-0 071; JA 489-0071
• MDR Report Key: 10039201
• Report Number: 3004718255-2020-00141
• Device Sequence Number: 3081844
• Product Code: DQY
• UDI-Device Identifier: 24547327108779
• UDI-Public: (01)24547327108779(17)221130(10)191203K38A
• Combination Product (Y/N): N
• Initial Reporter Country: US
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Importer
• Initial Reporter Occupation: Physician
• Type of Report: Initial
• Report Date (Section B): 04/29/2020
• Report Date (Section F): 05/08/2020

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Operator of Device: Health Professional
• Device Expiration Date: 11/30/2022
• Device Catalogue Number: CRV135-19P
• Device Lot Number: 191203K38A
• Was Device Available for Evaluation?: Yes
• Was the Report Sent to FDA?: Yes
• Distributor Facility Aware Date: 04/29/2020
• Device Age: 5 MO
• Event Location: Hospital
• Date Report to Manufacturer: 05/08/2020
• Initial Date Received by Manufacturer: Not provided
• Initial Report FDA Received Date: 05/08/2020
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Date Report Sent to FDA: 05/08/2020