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

Model Number	US35130412
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Codes	Reocclusion (1985); Vascular Dissection (3160)
Date of Event	01/19/2019
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
The lot number for the device was provided.The device history records are currently under review.The sample was not returned to the manufacturer for inspection/evaluation.Upon receipt of new or additional information and completion of the investigation, a follow-up report will be submitted as applicable.Expiration date: 08/2020.
Event or Problem Description
It was reported through the results of a clinical trial, that during an angioplasty procedure in the superial femoral artery and popliteal artery with a focused forced percutaneous transluminal angioplasty (pta) balloon dilatation catheter, following use of the study device, dissection was identified.The target lesion was treated with drug-coated balloon angioplasty followed by stent placement.
Additional Manufacturer Narrative
Manufacturing review: a lot history review was conducted and it was determined that a device history record (dhr) review was not required.Investigation summary: the investigation is inconclusive, as no objective evidence has been provided to confirm any alleged deficiency with the device.Based upon the available information, the definitive root cause is unknown.Label review: the review of the ifu (instructions for use), indications, warnings, precautions, cautions, possible complications, and contraindications showed that the product labeling is adequate.
Event or Problem Description
It was reported through the results of a clinical trial, that during an angioplasty procedure in the superial femoral artery and popliteal artery with a focused forced percutaneous transluminal angioplasty (pta) balloon dilatation catheter, following use of the study device, dissection was identified.The target lesion was treated with drug-coated balloon angioplasty followed by stent placement.New information: it was reported sometime post procedure, patient developed reocclusion in the mid sfa.No other information was received.

• 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: 8731578
• Report Number: 2020394-2019-01204
• Device Sequence Number: 2021899
• Product Code: PNO
• UDI-Device Identifier: 00801741116681
• UDI-Public: (01)00801741116681
• Combination Product (Y/N): N
• Initial Reporter State: TX
• Initial Reporter Country: US
• PMA/510(K) Number: K163420
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: company representative,health
• Initial Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial,Followup
• Report Date (Section B): 09/13/2019

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 Expiration Date: 06/28/2020
• Device Model Number: US35130412
• Device Catalogue Number: US35130520
• Device Lot Number: GFCV2115
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 05/29/2019
• Supplement Date Received by Manufacturer: 09/11/2019
• Initial Report FDA Received Date: 06/25/2019
• Supplement Report FDA Received Date: 09/14/2019
• 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: 72 YR