MAUDE Adverse Event Report: ARROW INTERNATIONAL LLC ARROW CVC SET: 14 GA X 6IN (16 CM); CATHETER PERCUTANEOUS

Catalog Number	ES-04706
Medical Device Problem Code	Dull, Blunt (2407)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	09/23/2024
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
(b)(4).
Event or Problem Description
It was reported "on (b)(6) 2024, the doctor found the swg kinked when swg insertion into ars, dilator tip was found blunt during use on the patient.They changed to a new one." there was no medical intervention required.The patient's current condition is reported as "fine".Associated mdr includes:3006425876-2024-01084.
Additional Manufacturer Narrative
(b)(4).The customer returned one, opened cvc kit containing multiple components.No obvious signs of use were observed.Visual analysis revealed that the dilator tip was uneven and slightly frayed.Microscopic examination confirmed the damage.Visual analysis also revealed kinking on the guide wire.The dilator length from the hub to the distal tip measured 99mm, which is within the specification limits of 95.2mm-108mm per the dilator product drawing.The dilator inner diameter at the distal tip measured 0.9398mm, which is within the specification limits of 0.09144mm-0.09652mm per the dilator extrusion product drawing.The outer diameter of the distal tip measured 1.33mm, which is within the specification limits of 1.27mm-1.37mm per the dilator product drawing.The tip inner diameter and outer diameter measurements indicates that the dilator is not blunt.The returned guide wire was inserted through the dilator tip.No resistance was encountered at the tip.The guide wire was able to pass.Performed per ifu statement, "use tissue dilator to enlarge tissue tract to the vein as required.Follow the angle of the guidewire slowly through the skin".R & d and manufacturing have been consulted regarding investigations of this nature.They stated that various factors could contribute to the observed damage to the dilator tip, including the manufacturing process and/or undue force applied unintentionally by the user during an attempted insertion.A device history record review was performed, and no relevant findings were identified.The ifu provided with the kit informs the user, "do not use excessive force when introducing guidewire or tissue dilator as this can lead to vessel perforation, bleeding, or component damage".The report of a damaged dilator tip was confirmed through complaint investigation.Visual analysis revealed that the dilator tip was uneven and frayed.Despite the damage, all relevant dimensional and functional requirements were met, and a device history record review did not reveal any relevant findings.Based on the customer report that the defect occurred during use and the appearance of the damage to the tip, the root cause appears consistent with damage due to undue force when inserting the dilator over the guide wire; however, the root cause cannot be determined as it is unknown if the damage occurred before or after the customer handled.Teleflex will continue to monitor and trend for reports of this nature.
Event or Problem Description
It was reported "on (b)(6) 2024, the doctor found the swg kinked when swg insertion into ars, dilator tip was found blunt during use on the patient.They changed to a new one." there was no medical intervention required.The patient's current condition is reported as "fine".Associated mdr includes: 3006425876-2024-01084.

• Brand Name: ARROW CVC SET: 14 GA X 6IN (16 CM)
• Common Device Name: CATHETER PERCUTANEOUS
• Manufacturer (Section D): ARROW INTERNATIONAL LLC; morrisville NC
• Manufacturer (Section G): ARROW INTERNATIONAL CR, A.S.; jamska 2359/47; zdar nad sazavou 591 0 1; EZ 591 01
• Manufacturer Contact: katharine tarpley ; 3015 carrington mill blvd; morrisville, NC 27560
• MDR Report Key: 20641724
• Report Number: 3006425876-2024-01137
• Device Sequence Number: 15309239
• Product Code: DQY
• UDI-Device Identifier: 00801902108418
• UDI-Public: (01)00801902108418(11)230815(17)280731(10)71F23H0798(21)
• Combination Product (Y/N): N
• Initial Reporter Country: CH
• PMA/510(K) Number: K862056
• 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): 10/15/2024

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: ES-04706
• Device Lot Number: 71F23H0798
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 11/06/2024
• Is the Reporter a Health Professional?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 10/15/2024
• Supplement Date Received by Manufacturer: 11/26/2024
• Initial Report FDA Received Date: 11/08/2024
• Supplement Report FDA Received Date: 12/02/2024
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 08/15/2023
• 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