MAUDE Adverse Event Report: MEDLINE INDUSTRIES LP; ANGIOGRAPHY PACK II

Catalog Number	DYNJ17218U
Medical Device Problem Code	Crack (1135)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	03/06/2025
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
According to the facility, on (b)(6) at the beginning of a lower extremity arteriogram, "he was injecting into a sheath or catheter for first imaging after confirming fluid to fluid connection.When he injected, it sprayed all over the room".This occurred 3 times and the syringes were cracked.The staff put the syringes in a bag and finished the procedure with other syringes.The facility stated there was no patient involvement, no patient impact, and that the procedure was completed each time.The facility stated the patient was not harmed or affected.A sample is available for evaluation.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.
Event or Problem Description
According to the facility, on (b)(6) at the beginning of a lower extremity arteriogram, "he was injecting into a sheath or catheter for first imaging after confirming fluid to fluid connection.When he injected, it sprayed all over the room".This occurred 3 times and the syringes were cracked.

• Common Device Name: ANGIOGRAPHY PACK II
• Manufacturer (Section D): MEDLINE INDUSTRIES LP; three lakes drive; northfield IL 60093 2753
• Manufacturer Contact: alex mathew ; three lakes drive; northfield, IL 60093-2753 ; 2249317042
• MDR Report Key: 21767095
• Report Number: 1423395-2025-00028
• Device Sequence Number: 18265418
• Product Code: OES
• UDI-Device Identifier: 10198459162947
• UDI-Public: 10198459162947
• Combination Product (Y/N): N
• Initial Reporter State: IA
• 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): 04/03/2025

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: DYNJ17218U
• Device Lot Number: 24JMI423
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 03/13/2025
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 03/06/2025
• Initial Report FDA Received Date: 04/03/2025
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• 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 Age: 44 YR
• Patient Sex: Male