MAUDE data represents reports of adverse events involving medical devices. This maude entry was filed from a 04,05,06 report with the FDA on 2012-03-05 for HYPERGLIDE OCCLUSION BALLOON SYSTEM 104-4108 manufactured by Ev3 Neurovascular.
[2553078]
It was reported the balloon inflate without the guidewire passed the distal tip during preparation. The device was not used in the patient.
Patient Sequence No: 1, Text Type: D, B5
[9608487]
The catheter has been evaluated. The evaluation showed that the guidewire broke into two segments inside the catheter lumen and one of the segments remained inside the catheter. Catheter lumen. (b)(4).
Patient Sequence No: 1, Text Type: N, H10
| Report Number | 2029214-2012-00100 |
| MDR Report Key | 2478076 |
| Report Source | 04,05,06 |
| Date Received | 2012-03-05 |
| Date of Report | 2012-02-06 |
| Date Mfgr Received | 2012-02-06 |
| Device Manufacturer Date | 2011-10-25 |
| Date Added to Maude | 2012-08-27 |
| Event Key | 0 |
| Report Source Code | Manufacturer report |
| Manufacturer Link | Y |
| Number of Patients in Event | 0 |
| Adverse Event Flag | 3 |
| Product Problem Flag | 3 |
| Reprocessed and Reused Flag | 3 |
| Health Professional | 3 |
| Initial Report to FDA | 3 |
| Report to FDA | 0 |
| Event Location | 0 |
| Manufacturer Contact | HENRY TO |
| Manufacturer Street | 9775 TOLEDO WAY |
| Manufacturer City | IRVINE CA 92618 |
| Manufacturer Country | US |
| Manufacturer Postal | 92618 |
| Manufacturer Phone | 9498601335 |
| Single Use | 3 |
| Previous Use Code | 3 |
| Event Type | 3 |
| Type of Report | 3 |
| Brand Name | HYPERGLIDE OCCLUSION BALLOON SYSTEM |
| Generic Name | OCCLUSION BALLOON CATHETER |
| Product Code | NUF |
| Date Received | 2012-03-05 |
| Returned To Mfg | 2012-02-15 |
| Model Number | 104-4108 |
| Lot Number | 9506627 |
| Device Expiration Date | 2014-08-01 |
| Operator | PHYSICIAN |
| Device Availability | R |
| Device Eval'ed by Mfgr | Y |
| Device Sequence No | 1 |
| Device Event Key | 0 |
| Manufacturer | EV3 NEUROVASCULAR |
| Manufacturer Address | 9775 TOLEDO WAY IRVINE CA 92618 US 92618 |
| Patient Number | Treatment | Outcome | Date |
|---|---|---|---|
| 1 | 0 | 2012-03-05 |