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

Model Number	9010
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Code	Reocclusion (1985)
Date of Event	01/02/2019
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 there is no similar reocclusion complaints 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 returned for evaluation.The dhr found nothing to indicate a manufacturing related cause for this event.The investigator assessed both events of reocclusion were possibly related to the study device and definitely related to the av access circuit, but not related to the 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 post market approval study during the index procedure, a lutonix percutaneous transluminal drug coated balloon (dcb) dilatation catheter was used to treat the target lesion in the cephalic arch in the left upper arm av fistula.Approximately 3 months after the index procedure, reportedly the patient had elevated venous pressures due to reocclusion of the target lesion.A clinically driven revascularization involving a fistulogram with angioplasty was performed and the health care professional (hcp) deemed it was successful.Approximately two weeks after the reintervention, the proximal segment of the cephalic vein (not target lesion) was occluded.The hcp performed a swing down procedure and it was deemed successful.The investigator assessed both events were possibly related to the study device and definitely related to the av access circuit, but not related to the procedure.The sample was discarded by the user facility and is not available for evaluation.No adverse patient effects were reported.
Additional Manufacturer Narrative
The event description had the following sentence changed "the investigator assessed both events were possibly related to the study device and definitely related to the av access circuit, but not related to the procedure" to "the investigator assessed both events were not related to the study device or to the procedure, but definitely related to the av access circuit." the eval code & desc - method code, 213, was added.Analysis: the sample was not returned from the user facility; therefore, a device evaluation is unable to be performed.A lot history review revealed there is no similar reocclusion complaints 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 returned for evaluation.The dhr found nothing to indicate a manufacturing related cause for this event.The investigator assessed both events of reocclusion were not related to the study device or to the procedure, but definitely related to the 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.
Event or Problem Description
It was reported through a post market approval study during the index procedure, a lutonix percutaneous transluminal drug coated balloon (dcb) dilatation catheter was used to treat the target lesion in the cephalic arch in the left upper arm av fistula.Approximately 3 months after the index procedure, reportedly the patient had elevated venous pressures due to reocclusion of the target lesion.A clinically driven revascularization involving a fistulogram with angioplasty was performed and the health care professional (hcp) deemed it was successful.Approximately two weeks after the reintervention, the proximal segment of the cephalic vein (not target lesion) was occluded.The hcp performed a swing down procedure and it was deemed successful.The investigator assessed both events were not related to the study device or to the procedure, but definitely related to the av access circuit.The sample was discarded by the user facility and is not available for evaluation.No adverse patient effects were reported.

• Brand Name: LUTONIX 035AV 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: 8289546
• Report Number: 3006513822-2019-00010
• Device Sequence Number: 1911612
• Product Code: PRC
• UDI-Device Identifier: 00801741135521
• UDI-Public: (01)00801741135521
• Combination Product (Y/N): N
• Initial Reporter State: AL
• Initial Reporter Country: US
• PMA/510(K) Number: P170003
• 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): 02/21/2019

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: 03/12/2020
• Device Model Number: 9010
• Device Catalogue Number: LX35751060V
• Device Lot Number: GFCQ0734
• Was Device Available for Evaluation?: No
• Event Location: Hospital
• Initial Date Received by Manufacturer: 01/09/2019
• Supplement Date Received by Manufacturer: 02/14/2019
• Initial Report FDA Received Date: 01/30/2019
• Supplement Report FDA Received Date: 02/21/2019
• 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: 93