MAUDE Adverse Event Report: C.R. BARD, INC. (GFO) LUTONIX 035 DRUG COATED BALLOON PTA CATHETER

Model Number	9004
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Code	Reocclusion (1985)
Date of Event	08/31/2016
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Analysis: the sample was not returned from the user facility; therefore, a device evaluation is unable to be performed.A lot history review revealed 2 additional reocclusion complaints were associated with the same lot.A review of the device history record (dhr) indicates the lot was manufactured to specification.Conclusion: the actual sample was not received for evaluation.The dhr found nothing to indicate a manufacturing related cause for this event.The investigator assessed the event was not related to the study device or procedure.Based on the instructions for use (ifu), the occurrence of reocclusion is an inherent risk of any pta procedure, and has been reported in clinical trials of drug coated balloons.If additional information becomes known to the manufacturer, a supplemental report will be provided with all relevant information.The information provided by bard represents all of the known information at this time.Despite good faith efforts to obtain additional information, the complainant / reporter was unable or unwilling to provide any further patient, product, or procedural details to bard.
Event or Problem Description
It was reported through a clinical registry that during the index procedure, a lutonix percutaneous transluminal drug coated balloon (dcb) dilatation catheter was used to treat the target lesion located in the right popliteal artery.Approximately 7 months after the index procedure, the patient¿s right popliteal vessel was reportedly reoccluded.A revascularization was performed and the hcp deemed it was successful.The investigator assessed that the event was not related to the study device or procedure.The sample was discarded by the user facility and is not available for evaluation.No adverse patient effects were reported.
Event or Problem Description
It was reported through a clinical registry that during the index procedure, a lutonix percutaneous transluminal drug coated balloon (dcb) dilatation catheter was used to treat the target lesion located in the right popliteal artery.Approximately 7 months after the index procedure, the patient¿s right popliteal vessel was reportedly reoccluded.A revascularization was attempted with an unknown device and the health care professional (hcp) deemed it was not successful.Approximately 27 months after the index procedure, the hcp performed a revascularization and it was deemed successful.The investigator assessed that the event was not related to the study device or procedure.The sample was discarded by the user facility and is not available for evaluation.No adverse patient effects were reported.
Additional Manufacturer Narrative
Additional information: b.5 the event description had the following sentence added because it was discovered the first revascularization attempt was unsuccessful, "approximately 27 months after the index procedure, the hcp performed a revascularization and it was deemed successful." b.6 the relevant tests and lab data had the following sentence added, "on (b)(6) 2018, reintervention was performed on the target lesion two lesions in a non-target vessel." h.6 the results code, 213, was added in the eval code and desc results section.Corrected data: b.5 the event description had the following sentence changed from "a revascularization was performed and the hcp deemed it was successful." to "a revascularization was attempted with an unknown device and the health care professional (hcp) deemed it was not successful." b.6 the relevant tests and lab data had the following sentence changed from "on (b)(6) 2016, reintervention was performed on target lesion and lesion in a non-target vessel." to "on (b)(6) 2016, an unsuccessful reintervention was performed on the target lesion and a lesion in a non-target vessel." g.1 the mdr contact person and email address were changed from (b)(6), respectively.G.2 the phone number was changed from " (b)(6)." h.6 the eval codes and desc were changed to align with guidance received from us fda effective on july 6th, 2017.The method codes "3263 and 3317" were changed to "4115,3331, and 4110." the conclusion code "92 "was changed to "4310." h3 analysis: the sample was not returned from the user facility; therefore, a device evaluation is unable to be performed.A lot history review revealed 2 additional reocclusion complaints were associated with this lot.A review of the device history record (dhr) indicates the lot was manufactured to specification.Conclusion: the actual sample was not received for evaluation.The dhr found nothing to indicate a manufacturing related cause for this event.The investigator assessed the event was not related to the study device or procedure.Based on the instructions for use (ifu), the occurrence of reocclusion is an inherent risk of any pta procedure, and has been reported in clinical trials of drug coated balloons.If additional information becomes known to the manufacturer, a supplemental report will be provided with all relevant information.

• Brand Name: LUTONIX 035 DRUG COATED BALLOON PTA CATHETER
• Common Device Name: DRUG COATED BALLOON PTA CATHETER
• Manufacturer (Section D): C.R. BARD, INC. (GFO); 289 bay road; queensbury NY 12804
• MDR Report Key: 7521767
• Report Number: 3006513822-2018-00118
• Device Sequence Number: 11096114
• Product Code: ONU
• UDI-Device Identifier: 00801741088759
• UDI-Public: (01)00801741088759
• Combination Product (Y/N): N
• Initial Reporter State: NC
• Initial Reporter Country: US
• PMA/510(K) Number: P130024
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: health professional,other,stu
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 12/28/2018

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?: No
• Operator of Device: Health Professional
• Device Expiration Date: 10/08/2017
• Device Model Number: 9004
• Device Catalogue Number: LX351305150
• Device Lot Number: GFZJ1371
• Was Device Available for Evaluation?: No
• Event Location: Hospital
• Initial Date Received by Manufacturer: Not provided
• Supplement Date Received by Manufacturer: 12/27/2018
• Initial Report FDA Received Date: 05/17/2018
• Supplement Report FDA Received Date: 12/28/2018
• 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
• Patient Age: 68 YR
• Patient Weight: 65