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

Catalog Number	7742-20M100SH
Medical Device Problem Code	Fracture (1260)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	07/22/2021
Type of Reportable Event	Malfunction
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 aortic aneurysm repair procedure, the catheter detached within the patient.The catheter detached at two locations outside the patient's body.The physician was able to successfully remove both pieces of the catheter form the patient by hand.The patient tolerated the procedure well with no additional consequences to report.
Additional Manufacturer Narrative
The suspect device has been returned for evaluation.The complaint is confirmed.The root cause is attributed to the manufacturing process.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: .PERFORMA®.NON-BRAIDED CATHETER
• Common Device Name: DIAGNOSTIC PERIPHERAL CATHETER
• MDR Report Key: 12338990
• Report Number: 3010665433-2021-00067
• Device Sequence Number: 11600606
• Product Code: DQO
• UDI-Device Identifier: 00884450002605
• UDI-Public: 884450002605
• Combination Product (Y/N): N
• Initial Reporter State: OH
• Initial Reporter Country: US
• PMA/510(K) Number: K000659
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: company representative,user f
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 07/26/2021

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Operator of Device: Health Professional
• Device Expiration Date: 03/01/2024
• Device Catalogue Number: 7742-20M100SH
• Device Lot Number: E2061862
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 08/10/2021
• Initial Date Received by Manufacturer: 07/22/2021
• Supplement Date Received by Manufacturer: 09/29/2021
• Initial Report FDA Received Date: 08/18/2021
• Supplement Report FDA Received Date: 10/05/2021
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 03/26/2021
• 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
• Concomitant Medical Products and Therapy/Usage Dates: GUIDEWIRE.; GUIDEWIRE