MAUDE Adverse Event Report: BARD PERIPHERAL VASCULAR, INC. ATLAS GOLD PTA DILATATION BALLOON CATHETER; PTA BALLOON DILATATION CATHETER

Model Number	ATG80224
Medical Device Problem Codes	Deflation Problem (1149); Detachment of Device or Device Component (2907)
Health Effect - Clinical Codes	Needle Stick/Puncture (2462); Device Embedded In Tissue or Plaque (3165)
Date of Event	12/10/2019
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
As the lot number for the device was provided, a manufacturing review will be performed.The sample was not returned to the manufacturer for inspection/evaluation.Therefore, the investigation of the reported event is inconclusive.Based upon the available information, the definitive root cause for this event is unknown.The instructions for use (ifu) is adequate for the reported device/patient code(s) and provides general instructions for use, as well as warnings, precautions and potential complications associated with the device.Upon receipt of new or additional information, a follow-up report will be submitted as applicable.(expiry date: 12/2021).
Event or Problem Description
It was reported that during an angioplasty procedure in the iliac vein, the pta balloon allegedly detached from the catheter and remained inflated.It was further reported that the catheter was pulled out but the balloon remained inside the patient.Reportedly the balloon had to be punctured with a needle in order to be deflated.The physician then used a 12fr sheath to snare the balloon out and complete the procedure.There was no reported complications to the patient.

• Brand Name: ATLAS GOLD PTA DILATATION BALLOON CATHETER
• Common Device Name: PTA BALLOON DILATATION CATHETER
• Manufacturer (Section D): BARD PERIPHERAL VASCULAR, INC.; 1625 w 3rd st.; tempe AZ 85281
• MDR Report Key: 9564606
• Report Number: 2020394-2019-05910
• Device Sequence Number: 19414685
• Product Code: LIT
• UDI-Device Identifier: 00801741060977
• UDI-Public: (01)00801741060977
• Combination Product (Y/N): N
• Initial Reporter State: FL
• Initial Reporter Country: US
• PMA/510(K) Number: K181323
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: company representative,health
• Initial Reporter Occupation: Physician
• Type of Report: Initial
• Report Date (Section B): 01/08/2020

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: ATG80224
• Device Catalogue Number: ATG80224
• Device Lot Number: 93ZA0090
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 12/12/2019
• Initial Report FDA Received Date: 01/08/2020
• 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: 39 YR