MAUDE Adverse Event Report: BARD PERIPHERAL VASCULAR, INC. DORADO PTA DILATATION CATHETER; PTA BALLOON DILATATION CATHETER

Model Number	DR80104
Medical Device Problem Codes	Break (1069); Difficult to Remove (1528); Detachment of Device or Device Component (2907); Material Deformation (2976)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
For the reported event, lot number was provided, and lot history review being performed.The sample was returned for evaluation.The company is still investigating the issue at this time.The device is labeled for single use.".
Event or Problem Description
This report summarizes one malfunction.A review of the reported information indicates that model dr80104 pta balloon dilatation catheter allegedly experienced detachment of device component, material deformation and difficult to remove.The information was received from one source.One patient was involved with no reported patient injury.The female patient is (b)(6) years old and weighs (b)(6) pounds.
Additional Manufacturer Narrative
For the reported malfunction, lot number was provided and a lot history review was performed.The sample was returned for evaluation.The investigation was confirmed for the reported retraction issue, balloon shaft joint break and unconfirmed for the reported device detachment.Based upon the available information, the definitive root cause for this malfunction was unknown.The device was labeled for single use.H11:section a through f - the information provided by bd represents all of 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.
Event or Problem Description
This report summarizes one malfunction.A review of the reported information indicates that model dr80104 pta balloon dilatation catheter allegedly experienced detachment of device component, material deformation and difficult to remove.The information was received from one source.One patient was involved with no reported patient injury.The female patient is 84 years old and weighs 116 pounds.

• Brand Name: DORADO PTA DILATATION CATHETER
• Common Device Name: PTA BALLOON DILATATION CATHETER
• Manufacturer (Section D): BARD PERIPHERAL VASCULAR, INC.; 1625 w 3rd st.; tempe AZ 85281
• MDR Report Key: 10286805
• Report Number: 2020394-2020-04551
• Device Sequence Number: 18961637
• Product Code: DQY
• UDI-Device Identifier: 00801741059544
• UDI-Public: (01)00801741059544
• Combination Product (Y/N): N
• Initial Reporter State: AZ
• Initial Reporter Country: US
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 10/13/2020

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: No Information
• Device Model Number: DR80104
• Device Catalogue Number: DR80104
• Device Lot Number: 93NE0036
• Initial Date Received by Manufacturer: 06/30/2020
• Supplement Date Received by Manufacturer: 09/30/2020
• Initial Report FDA Received Date: 07/16/2020
• Supplement Report FDA Received Date: 10/13/2020
• Patient Sequence Number: 1