MAUDE Adverse Event Report: ANGIODYNAMICS BIOFLO PICC WITH ENDEXO TECHNOLOGY; BIOSTABLE PICC

Model Number	45887
Medical Device Problem Code	Obstruction of Flow (2423)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	03/09/2023
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
It was reported that the device is not available to be returned to the manufacturer for evaluation.The results of the investigation will be sent via a follow up medwatch.Reference (b)(4).
Event or Problem Description
The end user reported that they had a problem with a picc line from a bio-stable 5f dl-55cm ir-145 kit, non-valved with nitinol gwt.After initial placement, the picc work fine, the next day when they tried to infuse, the picc was clogged.The picc was removed and replaced.
Additional Manufacturer Narrative
It was reported that the device is not available to be returned to the manufacturer for evaluation.The results of the investigation will be sent via a follow up medwatch.Reference (b)(4).
Event or Problem Description
New information provided: on (b)(6) 2023, a patient was ordered to have a picc line catheter placed to receive intravenous antibiotics and continue treatment at home, after discharge.The rn placed the picc line in the brachial vein of the right arm, without presenting any problem.After the procedure, a portable x-ray of the thorax was performed.The picc line was running with good flow.On (b)(6) 2023, the nurse followed up on the patient, and was notified by the nurse in charge that the picc line was not working properly.The catheter was not irrigating correctly and the flow decreased slowly or at intervals.The nurse proceeded to reposition the picc line under aseptic techniques, with a wire 0.18, and it was functional.On (b)(6) 2023, the nurse did another follow-up round and the nurse in charge of the patient notified her that the picc line had problems during the administration of medications, it only went down when the intravenous infusion machine was used.On (b)(6) 2023, the picc line was not flowing well and was removed, the nurse inserted another picc line into the brachial vein of the left arm.Currently the patient remains hospitalized receiving intravenous antibiotic therapy.On (b)(6) 2023 the patient was discharged home.
Additional Manufacturer Narrative
As the reported device was not returned, angiodynamics is unable to perform a device evaluation.The customer's reported complaint description of picc device was occluded cannot be confirmed since no complaint sample was returned.Without receiving product for evaluation, we are unable to definitively determine a root cause for this incident.Potential contributing factor for an occluded picc that is in situ is inadequate flushing that results in thrombosis and/or fibrin sheath formation.Prior to being placed in the tray, the catheter is 100% inspected at the top-assembly and sub-assembly levels to ensure lumen patency.Dhr review of the packaging/assembly lots revealed no quality related issues or manufacturing deficiencies at the time of manufacture a review of the device history records was performed for the indicated lots for any deviations related to the reported failure mode of the complaint.  the review confirms that the lots met all material, assembly and performance specifications; i.E.No ncr associated with reported failure mode.Labeling review: the dfu (directions for use) that is supplied with this picc device contains the following directions for catheter care/ maintenance: - flush the catheter after every use, or at least every seven days when not in use, to maintain patency.Use a 10 ml syringe or larger.- flush the catheter with a minimum of 10 ml of sterile normal saline, using a "pulse" or "stop/start" technique.Precaution: if resistance is met when flushing, it is recommended that no further attempts be made.Further flushing may result in catheter rupture.Refer to institutional protocol for clearing occluded catheters.Precaution: never forcibly flush an obstructed lumen.If either lumen develops a thrombus, first attempt to aspirate the clot with a syringe.If aspiration fails, consult institutional protocol for management of thrombosis.Avoid sharp or acute angles during insertion which may compromise catheter functionality.Catheter maintenance it is recommended that institutional protocols be followed for all aspects of catheter care, use and maintenance.The following care, use and maintenance information is not intended as a substitute for institutional protocol, but rather, to describe guidelines and recommendations that can be used successfully with the bioflo picc with endexo and pasv valve technology.General catheter care and use · use aseptic technique during catheter care and use.· use standard and universal precautions during catheter care procedures.· never leave catheter uncapped.· do not use clamps, or instruments with teeth or sharp edges on the catheter, as catheter damage may occur.Potential complications/adverse events catheter occlusion catheter malfunction a review of the angiodynamics complaint system noted no adverse trends for this complaint type and product family.This type of complaint will continue to be monitored for trends.Reference (b)(4).

• Brand Name: BIOFLO PICC WITH ENDEXO TECHNOLOGY
• Common Device Name: BIOSTABLE PICC
• Manufacturer (Section D): ANGIODYNAMICS; 10 glens falls technical park; glens falls NY 12801
• Manufacturer (Section G): ANGIODYNAMICS; 10 glens falls technical park; glens falls NY 12801
• Manufacturer Contact: alexandra invencio ; 26 forest street; marlborough, MA 01752 ; 5086587990
• MDR Report Key: 16662512
• Report Number: 1317056-2023-00033
• Device Sequence Number: 15104928
• Product Code: LJS
• UDI-Device Identifier: H965458870
• UDI-Public: H965458870
• Combination Product (Y/N): N
• Initial Reporter State: PR
• Initial Reporter Country: US
• PMA/510(K) Number: K131038
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2023
• Device Explanted Year: 2023
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: User Facility,Company Representative,Distributor
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup,Followup
• Report Date (Section B): 07/10/2023

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: 12/31/2024
• Device Model Number: 45887
• Device Catalogue Number: 45887
• Device Lot Number: 5770773
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 03/09/2023
• Supplement Date Received by Manufacturer: 04/24/2023; 07/05/2023
• Initial Report FDA Received Date: 04/03/2023
• Supplement Report FDA Received Date: 05/09/2023; 07/10/2023
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• Date Device Manufactured: 02/07/2023
• 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
• Patient Age: 64 YR
• Patient Sex: Male