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

Model Number	CQ5074
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, therefore, 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.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 cq5074 pta balloon dilatation catheter allegedly experienced material rupture.This information was received from one source.The malfunction involved one patient with no patient consequences.The patient was reportedly a (b)(6) year old male weighing (b)(6) kgs.
Event or Problem Description
This report summarizes one malfunction.A review of the reported information indicated that model cq5074 pta balloon dilatation catheter allegedly experienced material rupture.This information was received from one source.The malfunction involved one patient with no patient consequences.The patient was reportedly a 57 year old male weighing 59kgs.
Additional Manufacturer Narrative
H10: the lot number for the malfunction was provided and a lot history review was performed.The device has not been returned for evaluation, although one video was provided for review.Based on the video review, balloon rupture can be confirmed.The definitive root cause for the reported balloon rupture could not be determined based upon available information.The device is labeled for single use.

• 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: 9967779
• Report Number: 2020394-2020-02828
• Device Sequence Number: 3835883
• Product Code: DQY
• UDI-Device Identifier: 00801741062957
• UDI-Public: (01)00801741062957
• 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): 07/13/2020

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: CQ5074
• Device Catalogue Number: CQ5074
• Device Lot Number: REDT0366
• Initial Date Received by Manufacturer: 03/31/2020
• Supplement Date Received by Manufacturer: 06/25/2020
• Initial Report FDA Received Date: 04/16/2020
• Supplement Report FDA Received Date: 07/13/2020
• Patient Sequence Number: 1