MAUDE Adverse Event Report: INTERVASCULAR SAS HEMACAROTID PATCH; VASCULAR GRAFT PROSTHESIS

Model Number	HEK08/75CPUT(1)
Medical Device Problem Code	Manufacturing, Packaging or Shipping Problem (2975)
Health Effect - Clinical Code	Blood Loss (2597)
Date of Event	06/30/2015
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
(b)(4).A review of the complaint device history records, including collagen coating records, indicated that the patch was processed and inspected according to procedures and no anomaly was found.Specifically, the review of the water permeability testing records of products coated on the same day and under the same conditions as the complaint device indicated values well within product specifications.(b)(4).One retention sample coated on the same period and under the same conditions as the complaint device underwent water permeability testing at 120mmhg as per iso 7198.The test result indicated a value well within product specifications.No conclusion can be drawn.However, all available information and the product testing performed would tend to indicate that the device was not defective.
Event or Problem Description
During a surgery performed on (b)(6) 2015, 30 minutes after a thromboendarterectomy intervention of the left carotid with placement of the patch, the wound had to be reopened because of multiple sources of bleeding.This required the use of hemostatic agents, and the surgery was prolonged by an unknown amount of time.The patch remained implanted.

• Brand Name: HEMACAROTID PATCH
• Common Device Name: VASCULAR GRAFT PROSTHESIS
• Manufacturer (Section D): INTERVASCULAR SAS; zi athelia 1; la ciotat cedex, 13705 ; FR 13705
• MDR Report Key: 5418534
• Report Number: 1640201-2016-00003
• Device Sequence Number: 10899843
• Product Code: DSY
• UDI-Device Identifier: 00384401001478
• UDI-Public: 00384401001478
• Combination Product (Y/N): N
• Initial Reporter Country: IT
• PMA/510(K) Number: K983819
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2015
• Reporter Type: Manufacturer
• Report Source: company representative,distri
• Initial Reporter Occupation: Health Professional
• Report Date (Section B): 01/12/2016

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: Yes
• Operator of Device: No Information
• Device Expiration Date: 01/31/2020
• Device Model Number: HEK08/75CPUT(1)
• Device Catalogue Number: HEK08/75CPUT(1)
• Device Lot Number: 15B05
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: Not provided
• Initial Report FDA Received Date: 02/09/2016
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 77 YR