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	03/12/2018
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 1 additional reocclusion complaint was 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 that the event was possibly related to the device, procedure, and av access circuit.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 a reintervention, a lutonix percutaneous transluminal drug coated balloon (dcb) dilatation catheter was used to treat the target lesion located in the left cephalic vein outflow.Approximately 1 month after the reintervention procedure, the patient¿s vessel containing the target lesion was reportedly reoccluded.A revascularization was performed via shunt revision and implementation of a new shunt.The hcp deemed the creation of the new fistula successful.The investigator assessed that the event was possibly related to the device, procedure, and av access circuit.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 a reintervention, a lutonix percutaneous transluminal drug coated balloon (dcb) dilatation catheter was used to treat the target lesion located in the left cephalic vein outflow.Approximately 1 month after the reintervention procedure, the patient¿s vessel containing the target lesion was reportedly reoccluded.A revascularization was performed via shunt revision.The investigator assessed that the event was not related to the study device, but possibly related to the procedure and av access circuit.The sample was discarded by the user facility and is not available for evaluation.No adverse patient effects were reported.
Additional Manufacturer Narrative
Corrected data: the event description had the following sentences changed from "a revascularization was performed via shunt revision and implementation of a new shunt.The hcp deemed the creation of the new fistula successful.The investigator assessed that the event was possibly related to the device, procedure, and av access circuit." to "a revascularization was performed via shunt revision.The investigator assessed that the event was not related to the study device, but possibly related to the procedure and av access circuit." conclusion the conclusion had the following sentence changed from "the investigator assessed that the event was possibly related to the device, procedure, and av access circuit." to "the investigator assessed that the event was not related to the study device, but possibly related to the procedure and av access circuit." the sample was not returned from the user facility; therefore, a device evaluation is unable to be performed.A lot history review revealed 1 additional reocclusion complaint was 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 that the event was not related to the study device, but possibly related to the procedure and av access circuit.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: 7542551
• Report Number: 3006513822-2018-00128
• Device Sequence Number: 19436110
• Product Code: ONU
• UDI-Device Identifier: 00801741122804
• UDI-Public: (01)00801741122804
• Combination Product (Y/N): N
• Initial Reporter Country: AU
• PMA/510(K) Number: P130024
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: foreign,health professional,o
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 06/17/2018

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: 01/31/2020
• Device Model Number: 9004
• Device Catalogue Number: 9090475500040
• Device Lot Number: GFAZ2192
• Was Device Available for Evaluation?: No
• Event Location: Hospital
• Initial Date Received by Manufacturer: Not provided
• Supplement Date Received by Manufacturer: 05/29/2018
• Initial Report FDA Received Date: 05/24/2018
• Supplement Report FDA Received Date: 06/17/2018
• 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: 50 YR
• Patient Weight: 93