MAUDE Adverse Event Report: INTACT VASCULAR, INC. TACK ENDOVASCULAR SYSTEM (4F, 1.5-4.5MM); SCAFFOLD, DISSECTION REPAIR

Model Number	154150041
Medical Device Problem Code	Entrapment of Device (1212)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	11/17/2021
Type of Reportable Event	Malfunction
Event or Problem Description
The tack endovascular system (tes) was used in a peripheral procedure.During use, the tes was able to advance well and 3 of the 4 tacks were deployed successfully.However, during removal, the tes got stuck halfway out, and had to pull the tes and guidewire as a unit.A new guide wire was inserted to complete the procedure.No patient injury reported.This product problem is being submitted due to removal as a system.There is potential for harm if it were to recur.
Additional Manufacturer Narrative
The patient's dob or age at time of event, sex, gender, weight, ethnicity, and race are unknown.Patient information regarding relevant tests/laboratory data or medical history are unknown.The tes catheter was returned intact to an 0.014" non-philips guidewire.Visual inspection of the catheter found the stainless-steel pusher shaft separated from the catheter.Visual inspection of the guidewire found several kinks with missing coating observed in multiple areas.During functional testing, the outer sheath was flushed with no occlusions noted.An attempt was made to remove the guidewire with slight movement felt, but was unable to release even with extreme force applied.However, the force applied to attempt removal, damaged the inner core which prevented the guidewire compatibility testing.A probable root cause may be due to the damaged observed on the non-philips guidewire; however, the cause could not be established.Submission of this report does not, in itself, represent a conclusion by the manufacturer and/or authorized representative or the national competent authority that the content of this report is complete or accurate, that the medical device(s) listed failed in any manner and/or that the medical device(s) caused or contributed to an alleged death or deterioration in the state of the health of any person.

• Brand Name: TACK ENDOVASCULAR SYSTEM (4F, 1.5-4.5MM)
• Common Device Name: SCAFFOLD, DISSECTION REPAIR
• Manufacturer (Section D): INTACT VASCULAR, INC.; 5905 nathan lane north; plymouth MN 55442
• Manufacturer (Section G): INTACT VASCULAR, INC.; 5905 nathan lane north; plymouth MN 55442
• Manufacturer Contact: ana tan ; 5905 nathan lane north; plymouth, MN 55442 ; 858720-4037
• MDR Report Key: 19671540
• Report Number: 3012608866-2024-00016
• Device Sequence Number: 3211926
• Product Code: QCT
• UDI-Device Identifier: 00863328000196
• UDI-Public: (01)00863328000196
• Combination Product (Y/N): N
• Initial Reporter Country: US
• PMA/510(K) Number: P190027
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Company Representative
• Initial Reporter Occupation: Physician
• Type of Report: Initial
• Report Date (Section B): 07/03/2024

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: 06/10/2023
• Device Model Number: 154150041
• Device Catalogue Number: 154150041
• Device Lot Number: 258492
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 11/30/2021
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 06/10/2024
• Initial Report FDA Received Date: 07/03/2024
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 06/10/2021
• 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: UNK MFG AND SIZE: GUIDE CATHETER; UNK MFG AND SIZE: GUIDE WIRE; UNK MFG AND SIZE: INTRODUCER SHEATH
• Patient Sex: Unknown