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

Model Number	CQ5068
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 for the malfunction was provided and a lot history review was performed.The device has not been returned for evaluation.Since no sample was returned and no objective evidence was provided the investigation will remain inconclusive for the reported material rupture.The catalog number identified has not been cleared in the us, but is similar to the conquest pta dilatation balloon products that are cleared in the us.The pro code for the conquest pta dilatation balloon products are identified.Based on the information provided, the definitive root cause is unknown.The device is labeled for single use.
Event or Problem Description
This report summarizes one malfunction.A review of the reported information indicated that model cq5068j pta balloon dilatation catheter allegedly experienced material rupture.This information was received from one source.This malfunction involved a patient with no consequences.The female patient's age and weight were not provided.

• Brand Name: CONQUEST PTA DILATATION 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: 9967775
• Report Number: 2020394-2020-02827
• Device Sequence Number: 17102746
• Product Code: DQY
• UDI-Device Identifier: 00801741062889
• UDI-Public: (01)00801741062889
• 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
• Report Date (Section B): 04/16/2020

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: CQ5068
• Device Catalogue Number: CQ5068J
• Device Lot Number: REDX1631
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 03/31/2020
• Initial Report FDA Received Date: 04/16/2020
• Patient Sequence Number: 1