• Decrease font size
  • Return font size to normal
  • Increase font size
U.S. Department of Health and Human Services


  • Print
  • Share
  • E-mail
Super Search Devices@FDA
510(k) | DeNovo | Registration & Listing | Adverse Events | Recalls | PMA | HDE | Classification | Standards
CFR Title 21 | Radiation-Emitting Products | X-Ray Assembler | Medsun Reports | CLIA | TPLC

Catalog Number CB1413540120OTW
Device Problems Inflation Problem (1310); Material Twisted/Bent (2981)
Patient Problem No Clinical Signs, Symptoms or Conditions (4582)
Event Date 03/29/2021
Event Type  malfunction  
Manufacturer Narrative
If information is provided in the future, a supplemental report will be issued.
Event Description
Physician was attempting to use chocolate pta balloon along with non-medtronic sheath and guidewire during procedure to treat a mode rately calcified plaque lesion in the left mid superficial femoral artery (sfa) with 70% stenosis.The vessel was none tortuous.The vessel diameter and lesion length are 4mm and 15mm respectively.A non-medtronic inflation device was used.There was no damage noted to packaging.There was no issue noted when removing device from hoop/tray.The device was prepped per ifu with no issues identified.It was reported that when the balloon expanded in the blood vessel, the middle part of the balloon could not be opened normally.The device did not pass through a previously deployed stent.There was no resistance encountered when advancing the device.Physician replaced with a new chocolate balloon and the procedure was completed.There was no patient injury.
Manufacturer Narrative
Device evaluation the balloon returned in its post inflated state with no damage evident to the balloon or catheter.Under a microscope both marker bands are visible and intact, and no damage noted to the balloon or balloon cage.The device was flushed with no issues and a 0.014¿ guidewire from the lab was front loaded via the tip and exited out of the gw port with no difficulties.The device was connected to an indeflator and inflated the balloon to nominal pressure (9atm) and rated burst pressure (14atm) and no issues noted.No twist visible on the balloon and the balloon deflated with no difficulties.Medtronic is submitting this report to comply with fda reporting regulations under 21 cfr parts 4 and 803.This report is based upon information obtained by medtronic, which the company may not have been able to fully investigate or verify prior to the date the report was required by the fda.Medtronic has made reasonable efforts to obtain more complete information and has provided as much relevant information as is available to the company as of the submission date of this report.This report does not constitute an admission or a conclusion by fda, medtronic, or its employees that the device, medtronic, or its employee caused or contributed to the event described in the report.In particular, this report does not constitute an admission by anyone that the product described in this report has any ¿defects¿ or has ¿malfunctioned¿.These words are included in the fda 3500a form and are fixed items for selection created by the fda to categorize the type of event solely for the purpose of regulatory reporting.Medtronic objects to the use of these words and others like them because of the lack of definition and the connotations implied by these terms.This statement should be included with any information or report disclosed to the public under the freedom of information act.Any required fields that are unpopulated are blank because the information is currently unknown or unavailable.A good faith effort will be made to obtain the applicable information relevant to the report.If information is provided in the future, a supplemental report will be issued.
Search Alerts/Recalls

  New Search  |  Submit an Adverse Event Report

Brand Name
Type of Device
Manufacturer (Section D)
4600 nathan lane north
plymouth MN 55442
MDR Report Key11602543
MDR Text Key243777861
Report Number2183870-2021-00123
Device Sequence Number1
Product Code LIT
Combination Product (y/n)N
PMA/PMN Number
Number of Events Reported1
Summary Report (Y/N)N
Report Source Manufacturer
Source Type company representative,foreig
Type of Report Initial,Followup
Report Date 06/22/2021
1 Device was Involved in the Event
1 Patient was Involved in the Event
Date FDA Received04/01/2021
Is this an Adverse Event Report? No
Is this a Product Problem Report? Yes
Device Operator Health Professional
Device Expiration Date11/30/2023
Device Catalogue NumberCB1413540120OTW
Device Lot NumberB4233
Was Device Available for Evaluation? Device Returned to Manufacturer
Date Returned to Manufacturer06/02/2021
Date Manufacturer Received06/14/2021
Is This a Reprocessed and Reused Single-Use Device? No
Patient Sequence Number1
Patient Age69 YR