MAUDE Adverse Event Report: MICRO THERAPEUTICS, INC. DBA EV3 PIPELINE FLEX EMBOLIZATION DEVICE; INTRACRANIAL ANEURYSM FLOW DIVERTER

Model Number	PED-475-25
Medical Device Problem Codes	Break (1069); Unintended Ejection (1234); Physical Resistance/Sticking (4012)
Health Effect - Clinical Code	No Known Impact Or Consequence To Patient (2692)
Date of Event	09/10/2019
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
Physician continued pushing until the resistance suddenly disappeared, so they removed the device during which it was found that the pipeline had disengaged from the pusher while inside the microcatheter.Damage was seen on the central part of the pushwire and it seemed the microcatheter was in an accordion shape.The patient was undergoing surgery for an unruptured, saccular left internal carotid artery aneurysm with a max diameter of 16mm and a neck diameter of 6mm.It is unknown if dual antiplatelet therapy was performed.There were no related patient symptoms.The patient's vessel tortuosity was severe, the devices were prepared as indicated per the ifu, a continuous flush was used.There was no damage to the delivery pusher.
Additional Manufacturer Narrative
H6: codes updated h10: correction upon further review found that regarding the pipeline had disengaged from the pushwire while inside the microcatheter means pipeline braid opens prematurely inside the microcatheter.There was not any pipeline pushwire broke/separation issue.This would not meet the criteria for a reportable event as this pipeline braid opens prematurely inside the catheter during delivery.Medtronic is submitting this report to comply with fda reporting regulations under 21 cfr parts 4 and 803.This report is based upon information obtained by medtronic, which the company may not have been able to fully investigate or verify prior to the date the report was required by the fda.Medtronic has made reasonable efforts to obtain more complete information and has provided as much relevant information as is available to the company as of the submission date of this report.This report does not constitute an admission or a conclusion by fda, medtronic, or its employees that the device, medtronic, or its employee caused or contributed to the event described in the report.In particular, this report does not constitute an admission by anyone that the product described in this report has any ¿defects¿ or has ¿malfunctioned¿.These words are included in the fda 3500a form and are fixed items for selection created by the fda to categorize the type of event solely for the purpose of regulatory reporting.Medtronic objects to the use of these words and others like them because of the lack of definition and the connotations implied by these terms.This statement should be included with any information or report disclosed to the public under the freedom of information act.Any required fields that are unpopulated are blank because the information is currently unknown or unavailable.A good faith effort will be made to obtain the applicable information relevant to the report.If information is provided in the future, a supplemental report will be issued.

• Brand Name: PIPELINE FLEX EMBOLIZATION DEVICE
• Common Device Name: INTRACRANIAL ANEURYSM FLOW DIVERTER
• Manufacturer (Section D): MICRO THERAPEUTICS, INC. DBA EV3; 9775 toledo way; irvine CA 92618
• MDR Report Key: 9009321
• Report Number: 2029214-2019-00916
• Device Sequence Number: 11375088
• Product Code: OUT
• UDI-Device Identifier: 00836462015883
• UDI-Public: 00836462015883
• Combination Product (Y/N): N
• Initial Reporter Country: JA
• PMA/510(K) Number: P100018.S004
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: company representative,foreig
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 05/29/2020

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 Model Number: PED-475-25
• Device Catalogue Number: PED-475-25
• Device Lot Number: A376137
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 09/10/2019
• Supplement Date Received by Manufacturer: 05/22/2020
• Initial Report FDA Received Date: 09/12/2019
• Supplement Report FDA Received Date: 05/29/2020
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1