MAUDE Adverse Event Report: MEDTRONIC NEUROSURGERY CSF-SHUNT ASMBLY, SM., MED. PRESS. W/ C/P CATH, SM, 90CM; SHUNT, CENTRAL NERVOUS SYSTEM AND COMPONENTS

Model Number	46624
Medical Device Problem Code	Fracture (1260)
Health Effect - Clinical Code	No Known Impact Or Consequence To Patient (2692)
Date of Event	05/02/2019
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
It was reported that during implantation, the peritoneal catheter broke about 30 centimeters from the distal tip during insertion.After reinserting the tunneler, the peritoneal catheter was passed successfully.
Additional Manufacturer Narrative
If information is provided in the future, a supplemental report will be issued.
Event or Problem Description
Additional information received reported there were no environmental/external/patient factors that may have led or contributed to the issue.

• Brand Name: CSF-SHUNT ASMBLY, SM., MED. PRESS. W/ C/P CATH, SM, 90CM
• Common Device Name: SHUNT, CENTRAL NERVOUS SYSTEM AND COMPONENTS
• Manufacturer (Section D): MEDTRONIC NEUROSURGERY; 125 cremona drive; goleta CA 93117
• MDR Report Key: 8592170
• Report Number: 2021898-2019-00174
• Device Sequence Number: 2065681
• Product Code: JXG
• UDI-Device Identifier: 00643169472457
• UDI-Public: 00643169472457
• Combination Product (Y/N): N
• Initial Reporter State: MA
• Initial Reporter Country: US
• PMA/510(K) Number: K841442
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: health professional
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 05/28/2019

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: 02/29/2024
• Device Model Number: 46624
• Device Catalogue Number: 46624
• Device Lot Number: E62949
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 05/03/2019
• Supplement Date Received by Manufacturer: 05/09/2019
• Initial Report FDA Received Date: 05/08/2019
• Supplement Report FDA Received Date: 05/28/2019
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1