MAUDE Adverse Event Report: MERIT MEDICAL SYSTEMS INC. CORVOCET.COAXIAL BUNDLE..18G.20.0 CM.COAX BUNDLE.14.5 CM.; GASTROENTEROLOGY-UROLOGY BIOPSY INSTRUMENT

Catalog Number	CORCA1820B/A
Medical Device Problem Code	Fracture (1260)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	02/01/2021
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 a biopsy procedure, the outer cylinder of a coaxial introducer detached within the patient.The foreign body was successfully removed by extending the puncture site.No other complications to report.
Additional Manufacturer Narrative
The suspect device was returned for evaluation.The complaint was confirmed and the root cause is attributed to clinical use.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: CORVOCET.COAXIAL BUNDLE..18G.20.0 CM.COAX BUNDLE.14.5 CM.
• Common Device Name: GASTROENTEROLOGY-UROLOGY BIOPSY INSTRUMENT
• Manufacturer (Section D): MERIT MEDICAL SYSTEMS INC.; 1600 merit parkway; south jordan UT 84095
• MDR Report Key: 11373578
• Report Number: 1721504-2021-00009
• Device Sequence Number: 16828555
• Product Code: KNW
• UDI-Device Identifier: 00884450316641
• UDI-Public: 884450316641
• Combination Product (Y/N): N
• Initial Reporter Country: JA
• PMA/510(K) Number: K180450
• 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: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 02/01/2021

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: 03/27/2023
• Device Catalogue Number: CORCA1820B/A
• Device Lot Number: H1807721
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 02/23/2021
• Initial Date Received by Manufacturer: 02/01/2021
• Supplement Date Received by Manufacturer: 05/21/2021
• Initial Report FDA Received Date: 02/24/2021
• Supplement Report FDA Received Date: 06/01/2021
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention