MAUDE Adverse Event Report: ABBOTT VASCULAR INC. INDEFLATOR; SYRINGE, BALLOON INFLATION

Model Number	1000186-115
Medical Device Problem Code	Leak/Splash (1354)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	09/16/2024
Type of Reportable Event	Malfunction
Event or Problem Description
It was reported that during preparation of the indeflator device air bubbles were noted; therefore, the indeflator device was not used in the procedure.There was no patient involvement and clinically significant delay reported in the procedure.No additional information was reported.
Additional Manufacturer Narrative
The device was returned for analysis.The reported leak was unable to be confirmed.Device history record (dhr) and corrective and preventive actions (capa) reviews were performed and revealed an indication of a product quality issue.Additionally, a review of the complaint handling database identified similar incidents from this lot.The investigation determined the reported difficulties appear to be a potential product quality issue.On oct 24th 2024, abbott vascular determined that a field action was required for specific lots of priority pack 20/30 w/115 rhv product.The product associated with this complaint is from the impacted population.This action is being taken due to an increased potential for a leak in the indeflator under pressure or vacuum due to a gap in the hose snap fitting and o-rings from a specific supplier.B3: date of event estimated.

• Brand Name: INDEFLATOR
• Common Device Name: SYRINGE, BALLOON INFLATION
• Manufacturer (Section D): ABBOTT VASCULAR INC.; 3200 lakeside drive; santa clara CA 95054 2807
• Manufacturer (Section G): ABBOTT VASCULAR, REG # 2024168; 26531 ynez road; temecula CA 92591 4628
• Manufacturer Contact: lindsey bell ; 26531 ynez rd.; temecula, CA 92591-4628 ; 9519143996
• MDR Report Key: 20665913
• Report Number: 2024168-2024-13344
• Device Sequence Number: 20958028
• Product Code: MAV
• UDI-Device Identifier: 08717648015274
• UDI-Public: (01)08717648015274(17)260531(10)60566432
• Combination Product (Y/N): N
• Initial Reporter Country: CA
• PMA/510(K) Number: K991102
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Foreign,Health Professional,Company Representative
• Initial Reporter Occupation: Other
• Remedial Action: Recall
• Type of Report: Initial
• Report Date (Section B): 11/12/2024

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 Expiration Date: 05/31/2026
• Device Model Number: 1000186-115
• Device Catalogue Number: 1000186-115
• Device Lot Number: 60566432
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 11/05/2024
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 10/24/2024
• Initial Report FDA Received Date: 11/12/2024
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 06/10/2024
• 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: UNK
• Patient Sequence Number: 1
• Patient Sex: Unknown