MAUDE Adverse Event Report: COOK INC SLIP-CATH BEACON TIP HYDROPHILIC ANGIOGRAPHIC CATHETER; DQO CATHETER, INTRAVASCULAR, DIAGNOSTIC

Model Number	N/A
Medical Device Problem Code	Material Separation (1562)
Health Effect - Clinical Code	Device Embedded In Tissue or Plaque (3165)
Date of Event	04/12/2016
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
(b)(4).The reported event is currently under investigation.
Event or Problem Description
During an angiography procedure, when advancing the catheter into the carotid artery, the tip broke from the device.To prevent possible tip translocation to the aorta and/or cerebral damage, the doctors intervened.A micro 3fr pfm was utilized to remove the tip.The retrieval process last approximately two hours, the tip was retrieved.The patient remained unharmed.No additional details have been received.
Additional Manufacturer Narrative
Investigation - evaluation: a review of the complaint history, device history record, documentation, instructions for use (ifu), manufacturing instructions, specifications, trends, and quality control of the device was conducted during the investigation.The complaint device was not returned therefore, no physical examinations could be performed; however, a document based investigation evaluation was (also) performed.There is no evidence to suggest the product was not made to specifications.Review of device history record shows no nonconforming events which could contribute to this failure mode.It should be noted this complaint is the second reported complaint associated to this lot number.The device is shipped with an instruction for use (ifu) that describes the intended use; specific items are addressed include precautions: "store in a dark, dry, cool place.Avoid extended exposure to light.Upon removal from package, inspect the product to ensure no damage has occurred." based on the information provided, no product returned and the results of the investigation, the most likely root cause is manufacturing related.Measures are being conducted to address this failure mode.We will continue to monitor for similar complaints.

• Brand Name: SLIP-CATH BEACON TIP HYDROPHILIC ANGIOGRAPHIC CATHETER
• Common Device Name: DQO CATHETER, INTRAVASCULAR, DIAGNOSTIC
• Manufacturer (Section D): COOK INC; 750 daniels way; bloomington IN 47404
• MDR Report Key: 6294659
• Report Number: 1820334-2017-00228
• Device Sequence Number: 919442
• Product Code: DQO
• UDI-Device Identifier: 00827002119925
• UDI-Public: (01)00827002119925(17)180626(10)NS5963200
• Combination Product (Y/N): N
• Initial Reporter Country: VM
• PMA/510(K) Number: K122937
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: distributor,foreign
• Initial Reporter Occupation: Other
• Remedial Action: Recall
• Type of Report: Initial,Followup
• Report Date (Section B): 05/02/2017

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?: No
• Operator of Device: Health Professional
• Device Model Number: N/A
• Device Catalogue Number: SCBR5.0-38-100-P-NS-SIM2
• Was Device Available for Evaluation?: No
• Type of Report(Section G): FDA Requested
• Initial Date Received by Manufacturer: 04/12/2016
• Supplement Date Received by Manufacturer: Not provided
• Initial Report FDA Received Date: 02/01/2017
• Supplement Report FDA Received Date: 05/02/2017
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• If action reported to FDA under 21 USC 360i(g), list FDA-assigned Recall Number or include a statement: Z-2610/2623-2016
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 61 YR