MAUDE Adverse Event Report: IMPRESS®; CATHETER, INTRAVASCULAR, DIAGNOSTIC

Model Number	00884450035948
Medical Device Problem Codes	Fracture (1260); Material Separation (1562)
Health Effect - Clinical Code	Foreign Body In Patient (2687)
Date of Event	06/07/2021
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
While gaining arterial access for a nephrostomy, the impress catheter detached when inserting a guide wire into the catheter while the catheter was in-vivo.A snare was needed to retrieve the catheter fragment.A standard 150cm straight tip guidewire was used for the procedure.No tortuous, diseased, or calcified anatomy to report.No patient injury.
Additional Manufacturer Narrative
The suspect device was not returned for evaluation.Pictures were provided by the account confirming a break at the tip and body junction.The root cause could not be determined.The device history record was reviewed, and no exception documents were found.A search of the complaint database was performed and 1 similar complaint for this lot number was identified.Should the device be returned at a later date, the investigation will be re-opened.

• Brand Name: IMPRESS®
• Common Device Name: CATHETER, INTRAVASCULAR, DIAGNOSTIC
• MDR Report Key: 12009804
• Report Number: 3010665433-2021-00043
• Device Sequence Number: 11823045
• Product Code: DQO
• UDI-Device Identifier: 00884450035948
• UDI-Public: 00884450035948
• Combination Product (Y/N): N
• Initial Reporter Country: SP
• 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: foreign,user facility
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 06/07/2021

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: 01/26/2024
• Device Model Number: 00884450035948
• Device Catalogue Number: 56538BER
• Device Lot Number: E2045874
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 06/07/2021
• Supplement Date Received by Manufacturer: 07/28/2021
• Initial Report FDA Received Date: 06/16/2021
• Supplement Report FDA Received Date: 08/03/2021
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• Date Device Manufactured: 03/04/2021
• 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
• Outcome Attributed to Adverse Event: Required Intervention