MAUDE Adverse Event Report: BARD PERIPHERAL VASCULAR, INC. ULTRAVERSE 035 PTA CATHETER; PTA BALLOON DILATATION CATHETER

Model Number	U3575106
Medical Device Problem Code	Material Rupture (1546)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
The lot number was provided for the reported malfunction and a lot history review will be performed.The device is pending return.The investigation of the reported malfunction is currently underway.The device is labeled for single use.
Event or Problem Description
This report summarizes one malfunction.The information reviewed indicated that model u3575106 pta balloon dilatation catheter allegedly experienced material rupture.This information was received from one source.The malfunction involved a patient with no reported consequences.Age, weight, and gender were not provided.
Event or Problem Description
This report summarizes one malfunction.The information reviewed indicated that model u3575106 pta balloon dilatation catheter allegedly experienced material rupture.This information was received from one source.The malfunction involved a patient with no reported consequences.Age, weight, and gender were not provided.
Additional Manufacturer Narrative
H10: the lot number was provided for the reported malfunction and a lot history review was performed.The device has not been returned for evaluation, therefore, the investigation is inconclusive for material rupture 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.The device is labeled for single use.H10:g4 h11: h6 (method, results and conclusion) h11:section a through f - 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.

• Brand Name: ULTRAVERSE 035 PTA 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: 9596971
• Report Number: 2020394-2020-00508
• Device Sequence Number: 19451260
• Product Code: LIT
• UDI-Device Identifier: 00801741094590
• UDI-Public: (01)00801741094590
• Combination Product (Y/N): N
• Initial Reporter State: AZ
• Initial Reporter Country: US
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 04/06/2020

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: No Information
• Device Model Number: U3575106
• Device Catalogue Number: U3575106
• Device Lot Number: CMCZ0220
• Initial Date Received by Manufacturer: 12/31/2019
• Supplement Date Received by Manufacturer: 03/26/2020
• Initial Report FDA Received Date: 01/16/2020
• Supplement Report FDA Received Date: 04/06/2020
• Patient Sequence Number: 1