MAUDE Adverse Event Report: COVIDIEN MFG DC BOULDER EVIDENT; ELECTROSURGICAL, CUTTING & COAGULATION & ACCESSORIES

Model Number	VT1737
Medical Device Problem Code	Detachment of Device or Device Component (2907)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Date of Event	06/06/2018
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
If information is provided in the future, a supplemental report will be issued.
Event or Problem Description
According to the reporter, during a procedure, while the antenna was placed into the liver tumor and when the physician repositioned the needle within the liver, the antenna tip broke.All parts of it were completely removed from the patient's body.A new similar antenna was used in order to finish the procedure.There was no patient injury.
Additional Manufacturer Narrative
If information is provided in the future, a supplemental report will be issued.

• Brand Name: EVIDENT
• Common Device Name: ELECTROSURGICAL, CUTTING & COAGULATION & ACCESSORIES
• Manufacturer (Section D): COVIDIEN MFG DC BOULDER; 5920 longbow dr; boulder CO 80301 3299
• MDR Report Key: 7762940
• Report Number: 1717344-2018-01051
• Device Sequence Number: 19162375
• Product Code: GEI
• UDI-Device Identifier: 10884524000671
• UDI-Public: 10884524000671
• Combination Product (Y/N): N
• Initial Reporter Country: GM
• PMA/510(K) Number: K032702
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: company representative,foreig
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 10/02/2018

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?: Yes
• Operator of Device: Health Professional
• Device Expiration Date: 09/05/2022
• Device Model Number: VT1737
• Device Catalogue Number: VT1737
• Device Lot Number: 72490277X
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 07/24/2018
• Supplement Date Received by Manufacturer: 08/08/2018
• Initial Report FDA Received Date: 08/08/2018
• Supplement Report FDA Received Date: 10/02/2018
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Patient Age: 34 YR