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	11/29/2016
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Analysis: the samples were discarded by the user facility; therefore, device evaluations are unable to be performed.A lot history review revealed 3 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 samples were 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 devices 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.
Event or Problem Description
It was reported through a clinical registry that during the index procedure, two lutonix percutaneous transluminal drug coated balloon (dcb) dilatation catheters were used to treat the target lesion located in the left mid-distal superficial femoral artery (sfa).Approximately 12 months after the index procedure, the patient¿s left sfa vasculature was reportedly reoccluded via duplex ultrasound (dus) imaging.A revascularization was performed and the health care professional (hcp) deemed it was successful.The investigator assessed that the event was not related to the study devices or procedure.The samples were discarded by the user facility and are not available for evaluation.No adverse patient effects were reported.This is one of two products involved with the reported event and the associated manufacturer¿s report number is 3006513822-2018-00282.
Event or Problem Description
It was reported through a clinical registry that during the index procedure, two lutonix percutaneous transluminal drug coated balloon (dcb) dilatation catheters were used to treat the target lesion located in the left mid-distal superficial femoral artery (sfa).Approximately 12 months after the index procedure, the patient¿s left sfa vasculature was reportedly reoccluded via duplex ultrasound (dus) imaging.A revascularization was performed and the health care professional (hcp) deemed it was successful.The investigator assessed that the event was not related to the study devices or procedure.The samples were discarded by the user facility and are not available for evaluation.No adverse patient effects were reported.This is one of two products involved with the reported event and the associated manufacturer¿s report number is 3006513822-2018-00281.
Additional Manufacturer Narrative
Corrected data: b.5 the event description had the following number "282" changed to "281." h3 analysis: the samples were discarded by the user facility; therefore, device evaluations are unable to be performed.A lot history review revealed 3 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 samples were 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 devices 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: 8144100
• Report Number: 3006513822-2018-00282
• Device Sequence Number: 16616212
• Product Code: ONU
• UDI-Device Identifier: 00801741088568
• UDI-Public: (01)00801741088568
• Combination Product (Y/N): N
• Initial Reporter State: IL
• 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): 12/12/2018

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: 07/16/2017
• Device Model Number: 9004
• Device Catalogue Number: LX35130640
• Device Lot Number: GFZG1973
• Was Device Available for Evaluation?: No
• Event Location: Hospital
• Initial Date Received by Manufacturer: 11/15/2018
• Supplement Date Received by Manufacturer: 12/11/2018
• Initial Report FDA Received Date: 12/07/2018
• Supplement Report FDA Received Date: 12/12/2018
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Concomitant Medical Products and Therapy/Usage Dates: BOSTON SCIENTIFIC CHARGER 5X100; BOSTON SCIENTIFIC CHARGER 5X100; BOSTON SCIENTIFIC CHARGER 5X25; BOSTON SCIENTIFIC CHARGER 5X25; LX351306120 LOT# LUZE0022; LX351306120 LOT# LUZE0022; TACK ENDOVASCULAR SYSTEM; TACK ENDOVASCULAR SYSTEM
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 42 YR
• Patient Weight: 119