MAUDE Adverse Event Report: ARROW INTERNATIONAL LLC ARROW ACCESSORY KIT; INTRODUCER, CATHETER

Catalog Number	SA-09847
Medical Device Problem Code	Fluid/Blood Leak (1250)
Health Effect - Clinical Code	Fluid Discharge (2686)
Date of Event	08/28/2024
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Qn# (b)(4).
Event or Problem Description
It was reported "transvenous pacer lines were intact before and after repositioning patient.Post repositioning, blood and saline filled the contamination shield on the pacer wire and leaking from the distal part of the line.Ttvp wire was removed by cath lab nurse and appropriate sized obturator cap was applied." there was no patient harm or injury.No medical intervention required.The patient's current condition is reported as "fine.".
Additional Manufacturer Narrative
Qn#(b)(4).Complaint verification testing could not be performed as it was reported that the sample is not available for return.A device history record review was performed and no relevant findings were identified.Without the device to evaluate the complaint could not be confirmed and the probable cause could not be determined from the available information.Teleflex will continue to monitor and trend for reports of this nature.
Event or Problem Description
It was reported "transvenous pacer lines were intact before and after repositioning patient.Post repositioning, blood and saline filled the contamination shield on the pacer wire and leaking from the distal part of the line.Ttvp wire was removed by cath lab nurse and appropriate sized obturator cap was applied." there was no patient harm or injury.No medical intervention required.The patient's current condition is reported as "fine".

• Brand Name: ARROW ACCESSORY KIT
• Common Device Name: INTRODUCER, CATHETER
• Manufacturer (Section D): ARROW INTERNATIONAL LLC; morrisville NC
• Manufacturer (Section G): ARROW INTERNATIONAL DE MEXICO S.A. DE C.V.; ave. washington 3701; colonia panamericana, chihuahua; chihuahua 31200 ; MX 31200
• Manufacturer Contact: katharine tarpley ; 3015 carrington mill blvd; morrisville, NC 27560
• MDR Report Key: 20384160
• Report Number: 9680794-2024-00987
• Device Sequence Number: 15090332
• Product Code: DYB
• UDI-Device Identifier: 00801902026149
• UDI-Public: (01)00801902026149(11)230517(17)280430(10)33F23E0220(21)
• Combination Product (Y/N): N
• Initial Reporter Country: CA
• PMA/510(K) Number: K122854
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Foreign,User Facility,Distributor
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 09/12/2024

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 Catalogue Number: SA-09847
• Device Lot Number: 33F23E0220
• 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: 09/12/2024
• Supplement Date Received by Manufacturer: 11/01/2024
• Initial Report FDA Received Date: 10/07/2024
• Supplement Report FDA Received Date: 11/01/2024
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• Date Device Manufactured: 05/17/2023
• 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
• Concomitant Medical Products and Therapy/Usage Dates: NONE REPORTED; NONE REPORTED
• Patient Sex: Unknown