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Catalog Number DV15-05150RG
Device Problems Material Separation (1562); Use of Device Problem (1670); Device Handling Problem (3265)
Patient Problem Device Embedded In Tissue or Plaque (3165)
Event Date 06/09/2020
Event Type  Injury  
Manufacturer Narrative
The actual device concerned was not returned, the device history records (dhr) of the device concerned was reviewed. The production lot, to which the device concerned belongs, passed all in-process inspections including the shaft-pressurized test and the balloon-wrapping test for every product, and the finished product inspections including the shaft tensile strength test and the repetitive balloon inflation/deflation test on representative samples based on sampling plan. No nonconformity or abnormality in the manufacturing processes of the device concerned was found. Probable cause(s) and our comment: the balloon may have damaged by the calcified lesion and should have been ruptured when the balloon was inflated. While removing it from the patient, the bulky portion of the ruptured balloon was caught on the sheath and could not be pulled back any more. Further attempts to forcibly pull back the device resulted in breakage of the balloon and the tip, and the broken pieces remained in the patient's blood vessel.
Event Description
Diva is a rapid-exchange type semi-compliant pta balloon catheter compatible with 0. 014 or 0. 018 inch guidewire. Diva has no approval in usa. However, we intend to report this case as the event occurred on the similar device for "metacross rx" (rx type pta balloon dilatation catheter,0. 035" guidewire compatible) in us under 510(k)# k150865. " " crosstella rx" (rx type pta balloon dilatation catheter,0. 018" guidewire compatible) in us under 510(k)#k152873. "" crosperio rx" (rx type pta balloon dilatation catheter,0. 014" guidewire compatible) in us under 510(k)# k152887. " when diva was inserted into the calcified lesion(r-sfa), the balloon was inflated, the balloon burst. When i pulled it out, the tip of the catheter broke. The broken catheter tip was crimped to the blood vessel wall with a stent.
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Brand NameDIVA
Type of DeviceDIVA
Manufacturer (Section D)
osaka, 530-8 288,
JA 530-8288,
Manufacturer Contact
tokyo, 107-6-028
MDR Report Key10238464
MDR Text Key204546600
Report Number3002808904-2020-00013
Device Sequence Number1
Product Code LIT
Combination Product (y/n)N
Reporter Country CodeJA
Number of Events Reported1
Summary Report (Y/N)N
Report Source Manufacturer
Source Type foreign,health professional
Reporter Occupation
Type of Report Initial
Report Date 06/09/2020
1 Device was Involved in the Event
1 Patient was Involved in the Event
Date FDA Received07/07/2020
Is this an Adverse Event Report? Yes
Is this a Product Problem Report? Yes
Device Operator
Device Catalogue NumberDV15-05150RG
Device Lot NumberSP129396
Was Device Available for Evaluation? No
Is the Reporter a Health Professional? Yes
Was the Report Sent to FDA?
Event Location No Information
Date Manufacturer Received06/11/2020
Was Device Evaluated by Manufacturer? Device Not Returned to Manufacturer
Date Device Manufactured12/07/2019
Is the Device Single Use? Yes
Is This a Reprocessed and Reused Single-Use Device? No
Type of Device Usage Initial

Patient Treatment Data
Date Received: 07/07/2020 Patient Sequence Number: 1