MAUDE Adverse Event Report: C.R. BARD, INC. (BASD) -3006260740 POWERPORT MRI ISP W/ SP, ATTACH 9.6 FR. SIL S/L CATHETER; PORT & CATHETER, IMPLANTED, SUBCUTANEOUS, INTRAVASCULAR

Model Number 1809660

Device Problems Misassembled (1398); Suction Problem (2170); Device Dislodged or Dislocated (2923)

Patient Problem Thrombosis/Thrombus (4440)

Event Date 10/20/2020

Event Type  Injury  

Manufacturer Narrative

As the lot number for the device was provided, a manufacturing review will be performed.The sample was not returned to the manufacturer for inspection/evaluation.Therefore, the investigation of the reported event is inconclusive.Based upon the available information, the definitive root cause for this event is unknown.The instructions for use (ifu) is adequate for the reported device/patient code(s) and provides general instructions for use, as well as warnings, precautions and potential complications associated with the device.Upon receipt of new or additional information, a follow-up report will be submitted as applicable.(expiry date: 12/2021).

Event Description

It was reported that sometime post port placement, the port allegedly had no blood return.It was further reported that portogram showed interim repositioning of the infuse-a-port with the tip of the catheter projecting cephalad at the superior aspect of the superior vena cava.Reportedly a thrombus was found in the tip of the catheter.The patient current status was unknown.

Event Description

It was reported that sometimes post port placement, the port allegedly had no blood return.It was further reported that portogram showed interim repositioning of the infuse-a-port with the tip of the catheter projecting cephalad at the superior aspect of the superior vena cava.Reportedly a thrombus was found in the tip of the catheter.The patient current status was unknown.

Manufacturer Narrative

H10: manufacturing review: the device history record review was performed for the reported lot number and this lot meets all release criteria.The manufacturing review did not indicate any possible manufacturing issue that could be related to the reported event.Investigation summary: the device was not returned for evaluation.Therefore, the investigation is inconclusive for the reported device dislocated or dislodged, thrombus and suction issue.A definitive root cause could not be determined based upon the available information.Labeling review: a review of product labeling documentation (e.G.Procedural instructions, indications, warnings, precautions, cautions, possible complications, contraindications, nursing guide, and unit label) did not find any product labeling inadequacy.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.H3 other text : device not returned.

• Brand Name: POWERPORT MRI ISP W/ SP, ATTACH 9.6 FR. SIL S/L CATHETER
• Type of Device: PORT & CATHETER, IMPLANTED, SUBCUTANEOUS, INTRAVASCULAR
• Manufacturer (Section D): C.R. BARD, INC. (BASD) -3006260740; 605 north 5600 west; salt lake city 84116
• MDR Report Key: 10842067
• MDR Text Key: 216308496
• Report Number: 3006260740-2020-20540
• Device Sequence Number: 1
• Product Code: LJT
• UDI-Device Identifier: 00801741027154
• UDI-Public: (01)00801741027154
• Combination Product (y/n): N
• PMA/PMN Number: K073423
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: company representative,health
• Type of Report: Initial,Followup
• Report Date: 06/07/2021

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 11/16/2020
• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Model Number: 1809660
• Device Catalogue Number: 1809660
• Device Lot Number: REEQ4173
• Was Device Available for Evaluation?: No
• Date Manufacturer Received: 06/11/2021
• Is This a Reprocessed and Reused Single-Use Device?: No
• Patient Sequence Number: 1
• Patient Outcome(s): Other
• Patient Age: 73 YR
• Patient Weight: 71