MAUDE Adverse Event Report: EDWARDS LIFESCIENCES PR FOGARTY ARTERIAL EMBOLECTOMY CATHETER

Model Number	120805FP
Medical Device Problem Code	Material Fragmentation (1261)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	11/07/2022
Type of Reportable Event	Malfunction
Event or Problem Description
It was reported that a fogarty catheter model 120805fp, lot 63724804, malfunctioned before insertion.The balloon had inflation difficulties.There was no injury to the patient.
Additional Manufacturer Narrative
Our product evaluation lab received one model 120805f catheter.The balloon latex appeared deteriorated and discolored with multiple cracks and a tear evident on the balloon.Leakage was observed through the tear on the balloon.Both balloon windings were intact.The balloon latex was released from the proximal windings to check the balloon edges at the tear, which did not appear to match.Latex deterioration is a condition usually caused by age, excessive exposure to light, atmosphere, or ozone.Appears on the balloon surface as a maze of fine cracks or crazing.The condition may occur in a small area or cover the entire balloon.No other visible damage was observed from the catheter body.A device history record review was completed and documented that the device met all specifications upon distribution.The customer report of a balloon malfunction was confirmed on evaluation.An engineering evaluation was initiated to assess for any manufacturing-related processes which could be correlated to the complaint.A pra addresses balloons with fragmentations for embolectomy catheters, and a capa to address this issue is currently in ongoing.As part of the manufacturing process controls, 100 percent of the units go through a balloon winding and visual inspection.The units should not have bends, wrinkles, cuts, contamination, stains, deterioration, discoloration, or ripples.The storage conditions for these catheters are specified in the ifu.Complaint histories for all reported events are reviewed against trending control limits, and any excursions above the control limits are assessed and documented as part of this monthly review.

• Brand Name: FOGARTY ARTERIAL EMBOLECTOMY CATHETER
• Common Device Name: FOGARTY ARTERIAL EMBOLECTOMY CATHETER
• Manufacturer (Section D): EDWARDS LIFESCIENCES PR; state rd indus pk 402 km 1.4; anasco PR 00610
• Manufacturer (Section G): EDWARDS LIFESCIENCES PR; state rd indus pk 402 km 1.4; anasco PR 00610
• Manufacturer Contact: jessica atallah ; 1 edwards way; irvine, CA 92614 ; 9492500294
• MDR Report Key: 15920310
• Report Number: 2015691-2022-09686
• Device Sequence Number: 4702332
• Product Code: DXE
• UDI-Device Identifier: 00690103205220
• UDI-Public: (01)00690103205220(17)230628(11)210329(10)63724804
• Combination Product (Y/N): N
• Initial Reporter State: GA
• Initial Reporter Country: US
• PMA/510(K) Number: PREAMENDMENT
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Health Professional,User Facility,Company Representative
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial
• Report Date (Section B): 12/05/2022

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: 06/28/2023
• Device Model Number: 120805FP
• Device Catalogue Number: 120805FP
• Device Lot Number: 63724804
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 11/21/2022
• Is the Reporter a Health Professional?: Yes
• Was the Report Sent to FDA?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 11/23/2022
• Initial Report FDA Received Date: 12/05/2022
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 03/29/2021
• 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
• If action reported to FDA under 21 USC 360i(g), list FDA-assigned Recall Number or include a statement: FCA 90905
• Patient Sequence Number: 1
• Patient Sex: Unknown