MAUDE Adverse Event Report: MEDTRONIC DOMINICANA 3-WAY CATHETER CONNECTOR; PORT & CATHETER, IMPLANTED, SUBCUTANEOUS, INTR

Model Number	45105
Medical Device Problem Codes	Break (1069); Fracture (1260)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	06/01/2026
Type of Reportable Event	Malfunction

• Brand Name: 3-WAY CATHETER CONNECTOR
• Common Device Name: PORT & CATHETER, IMPLANTED, SUBCUTANEOUS, INTR
• Manufacturer (Section D): MEDTRONIC DOMINICANA; zona franca de san isidro; carretera san isidro, km 17; santo domingo 11500 ; DR 11500
• Manufacturer (Section G): MEDTRONIC DOMINICANA; zona franca de san isidro; carretera san isidro, km 17; santo domingo 11500 ; DR 11500
• Manufacturer Contact: justin ellis ; 4620 n. beach st.; fort worth, TX 76137 ; 7635265677
• MDR Report Key: 25886412
• Report Number: 9612501-2026-02005
• Device Sequence Number: 13266223
• Product Code: LKG
• UDI-Device Identifier: 00763000027735
• UDI-Public: (01)00763000027735(17)300410(10)0231259663
• Combination Product (Y/N): N
• Initial Reporter Country: CH
• PMA/510(K) Number: K874498
• 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: Physician
• Type of Report: Initial
• Report Date (Section B): 07/21/2026

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 Model Number: 45105
• Device Catalogue Number: 45105
• Device Lot Number: 0231259663
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 07/17/2026
• Initial Report FDA Received Date: 07/21/2026
• Date Device Manufactured: 05/06/2025
• 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
• Patient Sex: Unknown