MAUDE Adverse Event Report: IMPRESS®.NON-BRAIDED CATHETER; DIAGNOSTIC PERIPHERAL CATHETER

Model Number	00884450022436
Medical Device Problem Codes	Fracture (1260); Material Separation (1562)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	10/20/2020
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
The suspect device is expected to return for evaluation.A follow up will be submitted when the evaluation is complete.
Event or Problem Description
The account alleges that during an angiogram, the pig tail catheter tip detached within the patient.The physician had successfully acquired retrograde arterial access and during a targeted power injection, the tip of the catheter detached within the patient.The physician then successfully retrieved the foreign body from the patient with a vascular snare device.A new catheter was prepped and used to successfully complete the procedure.The patient tolerated the procedure well.No additional consequences to report.
Additional Manufacturer Narrative
The suspect device was not returned for evaluation.The complaint could not be confirmed.The root cause could not be determined.A search of the complaint database was performed and no similar complaints for this lot number were found.The device history record was reviewed, and no exception documents were found.

• Brand Name: IMPRESS®.NON-BRAIDED CATHETER
• Common Device Name: DIAGNOSTIC PERIPHERAL CATHETER
• MDR Report Key: 10742947
• Report Number: 3010665433-2020-00042
• Device Sequence Number: 3195678
• Product Code: DQO
• UDI-Device Identifier: 00884450022436
• UDI-Public: 00884450022436
• Combination Product (Y/N): N
• Initial Reporter Country: GM
• PMA/510(K) Number: K053171
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: company representative,foreig
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 10/22/2020

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: Yes
• Operator of Device: Health Professional
• Device Expiration Date: 06/30/2022
• Device Model Number: 00884450022436
• Device Catalogue Number: 41103510PIG-NB
• Device Lot Number: E1617528
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 10/22/2020
• Supplement Date Received by Manufacturer: 12/22/2020
• Initial Report FDA Received Date: 10/27/2020
• Supplement Report FDA Received Date: 12/22/2020
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• Date Device Manufactured: 06/18/2019
• Is the Device Labeled for Single Use? (Y/N): Yes
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Usage of Device: Initial
• Patient Sequence Number: 1
• Concomitant Medical Products and Therapy/Usage Dates: GUIDEWIRE
• Outcome Attributed to Adverse Event: Required Intervention