MAUDE Adverse Event Report: MEDLINE INDUSTRIES, LP; LHK TRICITY SURGICAL CENTERS

Catalog Number	VASC1380A
Medical Device Problem Code	Connection Problem (2900)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	02/05/2025
Type of Reportable Event	Malfunction
Event or Problem Description
According to the customer, the control syringe was no staying attached to the manifold during the procedure.It was stated that no injury occurred.
Additional Manufacturer Narrative
According to the customer, the control syringe was no staying attached to the manifold during the procedure.It was stated that no injury occurred.There was no further information.To date, no information has been received to indicate that a user or a patient experienced a death, serious injury, medical intervention, follow-up care, or other adverse health impact associated with the reported problem/issue.In an abundance of caution, and in response to an fda 483 issued for cfn 1417592 on 22-jan-2024, this medwatch is being filed for the reported problem/issue.If additional relevant information becomes available a supplemental medwatch will be filed.

• Common Device Name: LHK TRICITY SURGICAL CENTERS
• Manufacturer (Section D): MEDLINE INDUSTRIES, LP; 10 glens falls technical park; glens falls NY 12801 3864
• Manufacturer Contact: alex mathew ; three lakes drive; northfield, IL 60093-2753 ; 2249317042
• MDR Report Key: 21519375
• Report Number: 3015910259-2025-00016
• Device Sequence Number: 9695722
• Product Code: OES
• UDI-Device Identifier: 10195327466077
• UDI-Public: 10195327466077
• Combination Product (Y/N): N
• Initial Reporter State: AZ
• Initial Reporter Country: US
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Health Professional
• Initial Reporter Occupation: Other
• Type of Report: Initial
• Report Date (Section B): 03/04/2025

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
• Device Catalogue Number: VASC1380A
• Device Lot Number: 24JBC751
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 02/05/2025
• Initial Report FDA Received Date: 03/04/2025
• Was Device Evaluated by Manufacturer? (Y/N): No
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Usage of Device: Unknown
• Patient Sequence Number: 1
• Patient Sex: Unknown