MAUDE Adverse Event Report: MEDCOMP 4FX20CM SGL CT MID LINE; CT MIDLINE

Model Number	MLCT4S20FN
Medical Device Problem Codes	Knotted (1340); Device Handling Problem (3265)
Health Effect - Clinical Code	No Known Impact Or Consequence To Patient (2692)
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
An investigation has been initiated.When the investigation is complete a final report will be submitted.
Event or Problem Description
Upon insertion of the wire, resistance was met.The wire was retracted.An second attempt to reinsert the wire, it wouldn't go through and then was hard to retract fully.Another try to pull it out was made and the wire came out coiled and knotted at the tip.
Additional Manufacturer Narrative
Based on the investigation performed, it was determined that the product was manufactured to specifications at this time.The knot at the tip of the guidewire was confirmed, but we are unable to determine the cause or factors that contributed to this event.Previous investigations by the device manufacturer stated that possible contributing factors to the event may have been resistance in the guidewire during insertion and/or the patient's anatomy.The instructions for use state "do not advance the guidewire or catheter if unusual resistance is encountered".

• Brand Name: 4FX20CM SGL CT MID LINE
• Common Device Name: CT MIDLINE
• Manufacturer (Section D): MEDCOMP; 1499 delp drive; harleysville PA 19438
• MDR Report Key: 7161411
• Report Number: 2518902-2017-00069
• Device Sequence Number: 73325
• Product Code: LJS
• UDI-Device Identifier: 00884908113631
• UDI-Public: 884908113631
• Combination Product (Y/N): N
• Initial Reporter State: FL
• Initial Reporter Country: US
• PMA/510(K) Number: K170770
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: company representative
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 05/09/2018

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: Other
• Device Expiration Date: 03/01/2019
• Device Model Number: MLCT4S20FN
• Device Catalogue Number: MLCT4S20FN
• Device Lot Number: MCBC530
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 12/07/2017
• Initial Date Received by Manufacturer: 12/07/2017
• Supplement Date Received by Manufacturer: 12/07/2017
• Initial Report FDA Received Date: 01/03/2018
• Supplement Report FDA Received Date: 05/09/2018
• 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