MAUDE Adverse Event Report: BARD PERIPHERAL VASCULAR, INC. ULTRASCORE FOCUSED FORCE PTA BALLOON

Model Number	US35130520
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Code	Vascular Dissection (3160)
Date of Event	07/26/2018
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
As the lot number for the device was provided, a review of the device history records is currently being performed.The device has not been returned to the manufacturer for evaluation.The investigation of the reported event is currently underway.The information provided by bd 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 bd.
Event or Problem Description
It was reported through the results of a clinical trial that following an angioplasty procedure in the mid 1/3 of the left superficial femoral artery with a focused force percutaneous transluminal angioplasty (pta) balloon dilatation catheter, dissection was identified.The current status of the patient is unknown.
Additional Manufacturer Narrative
Manufacturing review: the device history records have been reviewed with special attention to the raw materials, subassemblies, manufacturing process, and quality control testing.This lot met all release criteria.There was nothing found to indicate there was a manufacturing related cause for this event.Investigation summary: the device was not returned, however medical records were provided.Based on the medical records, four months after a lower extremity arteriogram and sfa stenting, the patient was admitted to the hospital for lower calf and toe pain.The patient underwent thrombolysis followed by arteriogram, angioplasty and superficial femoral artery stenting and removal of the lysis catheter.Three days later the patient underwent fasciotomy incision and closure.Based on the medical record review, the reported dissection as part of the original angioplasty could not be confirmed.The investigation is inconclusive, as no objective evidence has been provided to confirm an alleged deficiency with the device.Based upon the available information, the definitive root cause is unknown.Labeling review: the review of the ifu (instructions for use), indications, warnings, precautions, cautions, possible complications, and contraindications showed that the product labeling is adequate.(expiry date: 04/2020).
Event or Problem Description
It was reported through the results of a clinical trial that following an angioplasty procedure in the mid 1/3 of the left superficial femoral artery with a focused force percutaneous transluminal angioplasty (pta) balloon dilatation catheter, dissection was identified.The current status of the patient is unknown.New information: it was reported through the result of a clinical trial that approximately 7 months post index procedure, target lesion revascularization was occurred.It was further reported that a stent was placed with following balloon dilatation catheter.The procedure was completed without any issues.
Event or Problem Description
It was reported through the results of a clinical trial that following an angioplasty procedure in the mid 1/3 of the left superficial femoral artery with a focused force percutaneous transluminal angioplasty (pta) balloon dilatation catheter, dissection was identified.The current status of the patient is unknown.New information: it was reported through the result of a clinical trial that approximately 7 months post index procedure, target lesion revascularization was occurred.It was further reported that a stent was placed with following balloon dilatation catheter.The procedure was completed without any issues.New information: it was reported that approximately 12 months post index procedure, duplex ultrasound was performed and identified stenosis.
Additional Manufacturer Narrative
Manufacturing review: the device history records have been reviewed with special attention to the raw materials, subassemblies, manufacturing process, and quality control testing.This lot met all release criteria.There was nothing found to indicate there was a manufacturing related cause for this event.Investigation summary: the device was not returned, however medical records were provided.Based on the medical records, four months after a lower extremity arteriogram and sfa stenting, the patient was admitted to the hospital for lower calf and toe pain.The patient underwent thrombolysis followed by arteriogram, angioplasty and superficial femoral artery stenting and removal of the lysis catheter.Three days later the patient underwent fasciotomy incision and closure.Based on the medical record review, the reported dissection as part of the original angioplasty could not be confirmed.The investigation is inconclusive, as no objective evidence has been provided to confirm an alleged deficiency with the device.Based upon the available information, the definitive root cause is unknown.Labeling review: the review of the ifu (instructions for use), indications, warnings, precautions, cautions, possible complications, and contraindications showed that the product labeling is adequate.

• Brand Name: ULTRASCORE FOCUSED FORCE PTA BALLOON
• Common Device Name: FOCUSED FORCE PTA BALLOON
• Manufacturer (Section D): BARD PERIPHERAL VASCULAR, INC.; 1625 w 3rd st.; tempe AZ 85281
• MDR Report Key: 8397371
• Report Number: 2020394-2019-00174
• Device Sequence Number: 1628795
• Product Code: PNO
• UDI-Device Identifier: 00801741116803
• UDI-Public: (01)00801741116803
• Combination Product (Y/N): N
• Initial Reporter State: TX
• Initial Reporter Country: US
• PMA/510(K) Number: K172571
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: company representative,study
• Initial Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial,Followup,Followup
• Report Date (Section B): 11/06/2019

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?: Yes
• Operator of Device: Health Professional
• Device Model Number: US35130520
• Device Catalogue Number: US35130520
• Device Lot Number: GFCQ1416
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 02/07/2019
• Supplement Date Received by Manufacturer: 05/16/2019; 11/04/2019
• Initial Report FDA Received Date: 03/06/2019
• Supplement Report FDA Received Date: 05/30/2019; 11/06/2019
• 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: CLOPIDOGREL, APIXABAN; CLOPIDOGREL, APIXABAN; CLOPIDOGREL, APIXABAN
• Outcome Attributed to Adverse Event: Other
• Patient Age: 75 YR
• Patient Weight: 69