MAUDE Adverse Event Report: ASAHI INTECC GAIA THIRD; GUIDE WIRE

Model Number	AHW14R311P
Medical Device Problem Code	Material Separation (1562)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	10/06/2022
Type of Reportable Event	Malfunction
Event or Problem Description
Tip of gaia third separated and detached while attempting to cross cto of om.The tip became stuck behind a stent strut and detached.

• Brand Name: GAIA THIRD
• Common Device Name: GUIDE WIRE
• Manufacturer (Section D): ASAHI INTECC; 3-100 akatsuki-cho; seto, aichi 489-0 071; JA 489-0071
• MDR Report Key: 15651805
• Report Number: 3004718255-2022-00276
• Device Sequence Number: 14067257
• Product Code: DQX
• UDI-Device Identifier: 04547327094795
• UDI-Public: (01)04547327094795(17)240630(10)210722A401
• Combination Product (Y/N): N
• Initial Reporter State: FL
• Initial Reporter Country: US
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Importer
• Initial Reporter Occupation: Physician
• Type of Report: Initial
• Report Date (Section B): 10/21/2022
• Report Date (Section F): 10/21/2022

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: 06/30/2024
• Device Model Number: AHW14R311P
• Device Catalogue Number: AHW14R311P
• Device Lot Number: 210722A401
• Was Device Available for Evaluation?: Yes
• Is the Reporter a Health Professional?: Yes
• Was the Report Sent to FDA?: Yes
• Distributor Facility Aware Date: 10/07/2022
• Device Age: 14 MO
• Event Location: Hospital
• Date Report to Manufacturer: 10/21/2022
• Initial Date Received by Manufacturer: Not provided
• Initial Report FDA Received Date: 10/21/2022
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Patient Age: 75 YR
• Patient Sex: Male
• Patient Weight: 86 KG
• Date Report Sent to FDA: 10/21/2022