K Number
K072269
Device Name
ANGIOJET ULTRA DVX THROMBECTOMY SET, MODEL: 106552
Date Cleared
2007-09-08

(24 days)

Product Code
Regulation Number
870.5150
AI/MLSaMDIVD (In Vitro Diagnostic)TherapeuticDiagnosticis PCCP Authorized
Intended Use
The AngioJet Ultra DVX Thrombectomy Set is intended for use with the AngioJet Ultra Console to break apart and remove thrombus from upper and lower extremity peripheral arteries ≥3 mm in diameter; break apart and remove thrombus from upper extremity and infra-inguinal lower extremity peripheral veins ≥3 mm in diameter; and for use with the AngioJet Ultra Power Pulse Kit for the control and selective infusion of physician specified fluids, including thrombolytic agents, into the peripheral vascular system.
Device Description
Each AngioJet Ultra DVX Thrombectomy Set is a sterile, single use, disposable set that includes the Thrombectomy Catheter and Pump in one combined unit. The AngioJet Ultra DVX Thrombectomy Set is used with the AngioJet Ultra Console.
More Information

Not Found

No
The document describes a mechanical thrombectomy device and does not mention any AI or ML components in its description, intended use, or performance studies.

Yes
The device is intended to break apart and remove thrombus (blood clots), which is a direct treatment for a medical condition.

No

Explanation: The device is intended for thrombectomy (breaking apart and removing thrombus) and fluid infusion, which are therapeutic interventions, not diagnostic ones. It does not mention analyzing images or data to make a diagnosis.

No

The device description explicitly states it is a "sterile, single use, disposable set that includes the Thrombectomy Catheter and Pump in one combined unit," indicating it is a physical medical device with hardware components.

Based on the provided information, this device is not an IVD (In Vitro Diagnostic).

Here's why:

  • IVD Definition: In vitro diagnostics are tests performed on samples taken from the human body, such as blood, urine, or tissue, to detect diseases, conditions, or infections. They are used outside the body (in vitro).
  • Device Function: The AngioJet Ultra DVX Thrombectomy Set is a device used inside the body (in vivo) to physically break apart and remove thrombus (blood clots) from blood vessels. It is a therapeutic device, not a diagnostic one.
  • Intended Use: The intended use clearly describes a procedure performed within the vascular system, not a laboratory test on a sample.

Therefore, this device falls under the category of a medical device used for treatment, not an in vitro diagnostic.

N/A

Intended Use / Indications for Use

The AngioJet Ultra DVX Thrombectomy Set is intended for use with the AngioJet Ultra Console to break apart and remove thrombus from upper and lower extremity peripheral arteries ≥3 mm in diameter; break apart and remove thrombus from upper extremity and infra-inguinal lower extremity peripheral veins ≥3 mm in diameter, and for use with the AngioJet Ultra Power Pulse Kit for the control and selective infusion of physician specified fluids, including thrombolytic agents, into the peripheral vascular system.

Product codes (comma separated list FDA assigned to the subject device)

QEZ, KRA
DXE, KRA

Device Description

Each AngioJet Ultra DVX Thrombectomy Set is a sterile, single use, disposable set that includes the Thrombectomy Catheter and Pump in one combined unit. The AngioJet Ultra DVX Thrombectomy Set is used with the AngioJet Ultra Console.

Mentions image processing

Not Found

Mentions AI, DNN, or ML

Not Found

Input Imaging Modality

Not Found

Anatomical Site

upper and lower extremity peripheral arteries, upper extremity and infra-inguinal lower extremity peripheral veins

Indicated Patient Age Range

Not Found

Intended User / Care Setting

physician

Description of the training set, sample size, data source, and annotation protocol

Not Found

Description of the test set, sample size, data source, and annotation protocol

Not Found

Summary of Performance Studies (study type, sample size, AUC, MRMC, standalone performance, key results)

Representative samples of the devices underwent bench testing, including but not limited to mechanical testing, biocompatibility, sterility, comparative testing to demonstrate appropriate functional and performance characteristics.

Key Metrics (Sensitivity, Specificity, PPV, NPV, etc.)

Not Found

Predicate Device(s): If the device was cleared using the 510(k) pathway, identify the Predicate Device(s) K/DEN number used to claim substantial equivalence and list them here in a comma separated list exactly as they appear in the text. List the primary predicate first in the list.

K071342 AngioJet Ultra XPEEDIOR Thrombectomy Set, K071514 AngioJet XPEEDIOR® 120 Catheter, K052256, K061951- AngioJet XPEEDIOR® 120 Catheter, K050794 - AngioJet DVX Rheolytic Thrombectomy Catheter

Reference Device(s): Identify the Reference Device(s) K/DEN number and list them here in a comma separated list exactly as they appear in the text.

Not Found

Predetermined Change Control Plan (PCCP) - All Relevant Information for the subject device only (e.g. presence / absence, what scope was granted / cleared under the PCCP, any restrictions, etc).

Not Found

§ 870.5150 Embolectomy catheter.

(a)
Identification. An embolectomy catheter is a balloon-tipped catheter that is used to remove thromboemboli, i.e., blood clots which have migrated in blood vessels from one site in the vascular tree to another.(b)
Classification. Class II (performance standards).

0

Image /page/0/Picture/0 description: The image shows the logo of the U.S. Food and Drug Administration (FDA). The logo consists of two parts: the Department of Health & Human Services seal on the left and the FDA acronym along with the full name of the agency on the right. The FDA part of the logo is in blue, with the acronym in a square and the full name written out below.

September 15, 2021

Possis Medical, Inc. Mike Burnside Sr. Regulatory Affairs Associate 9055 Evergreen Blvd., N.w. Minneapolis, Minnesota 55433-8003

Re: K072269

Trade/Device Name: Angiojet Ultra DVX Thrombectomy Set Regulation Number: 21 CFR 870.5150 Regulation Name: Embolectomy catheter Regulatory Class: Class II Product Code: QEZ, KRA

Dear Mike Burnside:

The Food and Drug Administration (FDA) is sending this letter to notify you of an adminis trative change related to your previous substantial equivalence (SE) determination letter dated September 28, 2007. Specifically, FDA is updating this SE Letter because FDA has created a new product code to better categorize your device technology.

Please note that the 510(k) submission was not re-reviewed. For questions regarding this letter please contact Gregory O'Connell, OHT2: Office of Cardiovascular Devices. (301) 796-6075. Gregory. Oconnell@FDA.HHS.gov.

Sincerely,

Digitally signed by Gregory W. Gregory W. O'connell -S O'connell -S Date: 2021.09.15
10:22:47-04'00'

Gregory O'Connell Assistant Director DHT2C: Division of Coronary and Peripheral Intervention Devices OHT2: Office of Cardiovascular Devices Office of Product Evaluation and Quality Center for Devices and Radiological Health

1

Image /page/1/Picture/1 description: The image shows the logo for the U.S. Department of Health & Human Services. The logo features a stylized caduceus symbol, which is a staff with two snakes coiled around it. The text "DEPARTMENT OF HEALTH & HUMAN SERVICES - USA" is arranged in a semi-circle around the symbol.

Food and Drug Administration 9200 Corporate Boulevard Rockville MD 20850

SEP 2 8 2007

Mr. Mike Burnside Sr. Regulatory Affairs Associate Possis Medical, Inc. 9055 Evergreen Boulevard NW Minneapolis, MN 55433-8003

Re: K072269

Trade/Device Name: AngioJet Ultra DVX Thrombectomy Set, Model 106552 Regulation Number: 21 CFR 870.5150 Regulation Name: Embolectomy Catheter Regulatory Class: Class II Product Code: DXE, KRA Dated: August 10, 2007 Received: August 15, 2007

Dear Mr. Burnside:

We have reviewed your Section 510(k) premarket notification of intent to market the device referenced above and have determined the device is substantially equivalent (for the indications for use stated in the enclosure) to legally marketed predicate devices marketed in interstate commerce prior to May 28, 1976, the enactment date of the Medical Device Amendments, or to devices that have been reclassified in accordance with the provisions of the Federal Food, Drug, and Cosmetic Act (Act) that do not require approval of a premarket approval application (PMA), You may, therefore, market the device, subject to the general controls provisions of the Act. The general controls provisions of the Act include requirements for annual registration, listing of devices, good manufacturing practice, labeling, and prohibitions against misbranding and adulteration.

If your device is classified (see above) into either class II (Special Controls) or class III (PMA), it may be subject to such additional controls. Existing major regulations affecting your device can be found in the Code of Federal Regulations, Title 21, Parts 800 to 898. In addition, FDA may publish further announcements concerning your device in the Federal Register.

Please be advised that FDA's issuance of a substantial equivalence determination does not mean that FDA has made a determination that your device complies with other requirements of the Act or any Federal statutes and regulations administered by other Federal agencies. Yourse va comply with all the Act's requirements, including, but not limited to: registration and listing (21

2

Page 2 - Mr. Michael Burnside

CFR Part 807); labeling (21 CFR Part 801); good manufacturing practice requirements as set forth in the quality systems (QS) regulation (21 CFR Part 820); and if applicable, the electronic product radiation control provisions (Sections 531-542 of the Act); 21 CFR 1000-1050. This letter will allow you to begin marketing your device as described in your Section 510(k) premarket notification. The FDA finding of substantial equivalence of your device to a legally marketed predicate device results in a classification for your device and thus, permits your device to proceed to the market.

If you desire specific advice for your device on our labeling regulation (21 CFR Part 801), please contact the Center for Devices and Radiological Health's (CDRH's) Office of Compliance at (240) 276-0120. Also, please note the regulation entitled, "Misbranding by reference to premarket notification" (21CFR Part 807.97). For questions regarding postmarket surveillance, please contact CDRH's Office of Surveillance and Biometric's (OSB's) Division of Postmarket Surveillance at 240-276-3474. For questions regarding the reporting of device adverse events (Medical Device Reporting (MDR)), please contact the Division of Surveillance Systems at 240-276-3464. You may obtain other general information on your responsibilities under the Act from the Division of Small Manufacturers, International and Consumer Assistance at its toll-free number (800) 638-2041 or (240) 276-3150 or at its Internet address http://www.fda.gov/cdrh/industry/support/index.html.

Sincerely vours.

una R. Vo Ames

$\xi$

Bram D. Zuckerman, M.D. Director Division of Cardiovaslar Office of Device Evaluation Center for Devices and Radiological Health

Enclosure

3

Indications for Use

510(k) Number (if known): K072269

Device Name: AngioJet® Ultra DVX® Thrombectomy Set

Indications for Use:

The AngioJet Ultra DVX Thrombectomy Set is intended for use with the AngioJet Ultra Console to break apart and remove thrombus from upper and lower extremity peripheral arteries ≥3 mm in diameter; break apart and remove thrombus from upper extremity and infra-inguise lower extremity peripheral veins ≥3 mm in diameter, and for use with the AngioJet Uura Power Puble, Kit for the control and selective infusion of physician specified fluids, including throm business agents, into the peripheral vascular system.

Prescription Use X (Part 21 CFR 801 Subpart D)

AND/OR

Over-The-Counter Use (21 CFR 801 Subpart C)

3

(PLEASE DO NOT WRITE BELOW THIS LINE-CONTINUE ON ANOTHER PAGE IF NEEDED)

Concurrence of CDRH, Office of Device Evaluation (ODE)

sung R. Jo a

(Division Sign-Off) Division of Cardiovascular Devices

510(k) Number Ko722G

4

K072269

2007

Section 5 – 510(k) Summary

20

| Submitter: | Possis Medical, Inc.
9055 Evergreen Boulevard NW
Minneapolis, MN 55433-8003 USA | SEP 28 |
|-----------------------------------|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|--------|
| Contact Person: | Mike Burnside
Sr. Regulatory Affairs Associate
Phone: (763) 780-4555
Fax: (763) 780-2227
Email: mike.burnside@possis.com | |
| Date Prepared: | August 10, 2007 | |
| Trade Name: | AngioJet® Ultra DVX® Thrombectomy Set | |
| Classification: | 870.5150 and 870.1210 | |
| Product Code: | DXE and KRA | |
| Predicate Device(s): | The subject devices are equivalent to the following devices:
K071342 AngioJet Ultra XPEEDIOR Thrombectomy Set K071514 AngioJet XPEEDIOR® 120 Catheter K052256 and K061951- AngioJet XPEEDIOR® 120 Catheter K050794 - AngioJet DVX Rheolytic Thrombectomy Catheter | |
| Device Description: | Each AngioJet Ultra DVX Thrombectomy Set is a sterile, single use,
disposable set that includes the Thrombectomy Catheter and Pump in
one combined unit. The AngioJet Ultra DVX Thrombectomy Set is
used with the AngioJet Ultra Console. | |
| Intended Use: | The AngioJet Ultra DVX Thrombectomy Set is intended for use with
the AngioJet Ultra Console to break apart and remove thrombus from
upper and lower extremity peripheral arteries ≥3 mm in diameter;
break apart and remove thrombus from upper extremity and infra-
inguinal lower extremity peripheral veins ≥3 mm in diameter; and for
use with the AngioJet Ultra Power Pulse Kit for the control and
selective infusion of physician specified fluids, including thrombolytic
agents, into the peripheral vascular system. | |
| Functional and
Safety Testing: | Representative samples of the devices underwent bench testing,
including but not limited to mechanical testing, biocompatibility,
sterility, comparative testing to demonstrate appropriate functional
and performance characteristics. | |
| Conclusion: | Possis Medical, Inc. considers the AngioJet Ultra DVX
Thrombectomy Set to be substantially equivalent to the predicate
devices listed above. This conclusion is based upon the devices'
similarities in functional design, materials, indications for use, and
principles of operation. | |