Relieva SpinPlus Balloon Sinuplasty System

K143541 · Acclarent, Inc. · LRC · Apr 22, 2015 · Ear, Nose, Throat

Device Facts

• Record ID: K143541
• Device Name: Relieva SpinPlus Balloon Sinuplasty System
• Applicant: Acclarent, Inc.
• Product Code: LRC · Ear, Nose, Throat
• Decision Date: Apr 22, 2015
• Decision: SESE
• Submission Type: Traditional
• Regulation: 21 CFR 874.4420
• Device Class: Class 1
• Attributes: Therapeutic, Pediatric

Intended Use

The Relieva SpinPlus Balloon Sinuplasty System is intended to: provide a means to access the sinus space and illuminate within and transilluminate across nasal and sinus structures; dilate the sinus ostia and spaces associated with the paranasal sinus cavities for diagnostic and therapeutic procedures; and irrigate from within a target simus for therapeutic procedures and to facilitate diagnostic procedures. For children aged 17 and under, the Relieva SpinPlus Balloon Sinuplasty System is intended to: provide a means to access the sinus space and illuminate within and transilluminate across nasal and sinus structures; dilate sinus ostia and spaces associated with the maxillary sinus for diagnostic procedures; and irrigate from within the maxillary sinus for therapeutic procedures and to facilitate diagnostic procedures.

Device Story

Integrated sinus dilation system; combines handle, guide catheter, sinus balloon catheter, and illuminated guidewire into single device. Used by physicians in clinical settings to access, illuminate, and transilluminate nasal/sinus structures; dilates sinus ostia and spaces; enables irrigation from within target sinus without instrument exchanges. Device provides visual confirmation via transillumination; assists physician in navigating sinus anatomy. Benefits include reduced procedural complexity and ability to perform access, dilation, and irrigation with one device.

Clinical Evidence

Bench testing only. Evaluated simulated use, dimensional attributes, cycle fatigue, balloon burst, bond separation, irrigation flow rate, and wire light output. Biocompatibility and sterilization (AAMI/ANSI/ISO 11135-1:2007) validated. Packaging shelf life established per ASTM F1980-07. No clinical data required.

Technological Characteristics

Integrated handle assembly with sinus guide catheter, balloon catheter, and illuminated guidewire. Sterilization via ethylene oxide (ISO 10993-7:2008). Packaging shelf life 3 months (ASTM F1980-07). Mechanical operation for sinus access and dilation.

Indications for Use

Indicated for patients (including children aged 17 and under) requiring access, illumination, and transillumination of nasal/sinus structures; dilation of sinus ostia and associated spaces (maxillary sinus for children) for diagnostic/therapeutic procedures; and irrigation of target sinuses.

Regulatory Classification

Identification

An ear, nose, and throat manual surgical instrument is one of a variety of devices intended for use in surgical procedures to examine or treat the bronchus, esophagus, trachea, larynx, pharynx, nasal and paranasal sinus, or ear. This generic type of device includes the esophageal dilator; tracheal bistour (a long, narrow surgical knife); tracheal dilator; tracheal hook; laryngeal injection set; laryngeal knife; laryngeal saw; laryngeal trocar; laryngectomy tube; adenoid curette; adenotome; metal tongue depressor; mouth gag; oral screw; salpingeal curette; tonsillectome; tonsil guillotine; tonsil screw; tonsil snare; tonsil suction tube; tonsil suturing hook; antom reforator; ethmoid curette; frontal sinus-rasp; nasal curette; nasal rasp; nasal rongeur; nasal saw; nasal scissors; nasal snare; sinus irrigator; sinus trephine; ear curette; ear excavator; ear rasp; ear scissor, ear snare; ear spoon; ear suction tube; malleous ripper; mastoid gauge; microsurgical ear chisel; myringotomy tube inserter; ossici holding clamp; sacculotomy tack inserter; vein press; wire ear loop; microrule; mirror; mobilizer; ear, nose, and throat punch; ear, nose and throat knife; and ear, nose, and throat trocar.

Predicate Devices

• Relieva Spin Sinus Dilation System (K111875)
• Relieva Solo Elite Sinus Balloon Catheter (K111254)
• Relieva Luma Sinus Illumination System (K071845)

Submission Summary (Full Text)

{0}------------------------------------------------

Image /page/0/Picture/1 description: The image shows the logo for the U.S. Department of Health and Human Services. The logo features the department's name in a circular arrangement around a stylized symbol. The symbol consists of three human profiles facing right, layered on top of each other, with flowing lines beneath them.

Food and Drug Administration 10903 New Hampshire Avenue Document Control Center - WO66-G609 Silver Spring, MD 20993-0002

April 22, 2015

Acclarent, Inc. Pavan Sethi, Ph.D. Manager, Regulatory Affairs 1525-B O'Brien Drive Menlo Park, CA 94025

Re: K143541

> Trade/Device Name: Relieva SpinPlus Balloon Sinuplasty System Regulation Number: 21 CFR 874.4420 Regulation Name: Ear, Nose, And Throat Manual Surgical Instrument Regulatory Class: Class I Product Code: LRC Dated: March 20, 2015 Received: March 23, 2015

Dear Dr. Sethi:

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. Please note: CDRH does not evaluate information related to contract liability warranties. We remind you, however, that device labeling must be truthful and not misleading.

If your device is classified (see above) into either class II (Special Controls) or class III (PMA), it may be subject to 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.

{1}------------------------------------------------

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. You must comply with all the Act's requirements, including, but not limited to: registration and listing (21 CFR Part 807); labeling (21 CFR Part 801); medical device reporting of medical device-related adverse events) (21 CFR 803); 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.

If you desire specific advice for your device on our labeling regulation (21 CFR Part 801), please contact the Division of Industry and Consumer Education at its toll-free number [phone] or [phone] or at its Internet address

http://www.fda.gov/MedicalDevices/ResourcesforYou/Industry/default.htm. Also, please note the regulation entitled, "Misbranding by reference to premarket notification" (21 CFR Part 807.97). For questions regarding the reporting of adverse events under the MDR regulation (21 CFR Part 803), please go to

http://www.fda.gov/MedicalDevices/Safety/ReportaProblem/default.htm for the CDRH's Office of Surveillance and Biometrics/Division of Postmarket Surveillance.

You may obtain other general information on your responsibilities under the Act from the Division of Industry and Consumer Education at its toll-free number [phone] or [phone] or at its Internet address

http://www.fda.gov/MedicalDevices/ResourcesforYou/Industry/default.htm.

Sincerely yours.

# Eric A. Mann -S

for Malvina B. Eydelman, M.D. Director Division of Ophthalmic and Ear, Nose and Throat Devices Office of Device Evaluation Center for Devices and Radiological Health

Enclosure

{2}------------------------------------------------

### Indications for Use

510(k) Number (if known) K143541

Device Name Relieva SpinPlus Balloon Sinuplasty System

#### Indications for Use (Describe)

The Relieva SpinPlus Balloon Sinuplasty System is intended to: provide a means to access the sinus space and illuminate within and transilluminate across nasal and sinus structures; dilate the sinus ostia and spaces associated with the paranasal sinus cavities for diagnostic and therapeutic procedures; and irrigate from within a target simus for therapeutic procedures and to facilitate diagnostic procedures.

For children aged 17 and under, the Relieva SpinPlus Balloon Sinuplasty System is intended to: provide a means to access the sinus space and illuminate within and transilluminate across nasal and sinus structures; dilate sinus ostia and spaces associated with the maxillary sinus for diagnostic procedures; and irrigate from within the maxillary sinus for therapeutic procedures and to facilitate diagnostic procedures.

#### Type of Use (Select one or both, as applicable)

2 Prescription Use (Part 21 CFR 801 Subpart D)

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

#### PLEASE DO NOT WRITE BELOW THIS LINE - CONTINUE ON A SEPARATE PAGE IF NEEDED.

#### FOR FDA USE ONLY

Concurrence of Center for Devices and Radiological Health (CDRH) (Signature)

This section applies only to requirements of the Paperwork Reduction Act of 1995.

#### *DO NOT SEND YOUR COMPLETED FORM TO THE PRA STAFF EMAIL ADDRESS BELOW.*

The burden time for this collection of information is estimated to average 79 hours per response, including the time to review instructions, search existing data sources, gather and maintain the data needed and complete and review the collection of information. Send comments regarding this burden estimate or any other aspect of this information collection, including suggestions for reducing this burden, to:

> Department of Health and Human Services Food and Drug Administration Office of Chief Information Officer Paperwork Reduction Act (PRA) Staff PRAStaff(@fda.hhs.gov

"An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB number."

{3}------------------------------------------------

Image /page/3/Picture/0 description: The image shows the logo for Acclarent. The word "Acclarent" is written in a sans-serif font, with the "A" in black and the rest of the letters in a dark purple color. There is a curved line above the "ent" in purple.

## 510(K) SUMMARY

| Sponsor/Submitter: | Acclarent, Inc.<br>1525-B O'Brien Drive<br>Menlo Park, California 94025 |
|-----------------------------------|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Contact Person: | Pavan Sethi, Ph.D.<br>Manager, Regulatory Affairs<br>Phone: [phone]<br>Fax: [phone] |
| Date of Submission: | December 12, 2014 |
| Device Trade Name: | Relieva SpinPlus Balloon Sinuplasty System |
| Common Name: | Sinus Dilation System |
| Device Classification: | Class I |
| Regulation Number: | 21 CFR 874.4420 |
| Classification Name: | Ear, Nose, and Throat Manual Surgical Instrument |
| Product Code: | LRC |
| Predicate Devices: | Relieva Spin Sinus Dilation System (Primary Predicate, K111875)<br>Relieva Solo Elite Sinus Balloon Catheter (K111254)<br>Relieva Luma Sinus Illumination System (K071845) |
| Device Description: | The Relieva SpinPlus Balloon Sinuplasty System is an integrated<br>device that incorporates an ergonomically designed Handle, an<br>illuminated Guidewire, a Sinus Balloon Catheter, and a Guide Catheter.<br>The Sinus Balloon Catheter enables sinus irrigation without instrument<br>exchanges. The principles of operation of SpinPlus are similar to the<br>predicate devices in allowing for access and enlargement of sinus ostia,<br>and irrigation from within the target sinus. |
| Indications for Use: | The Relieva SpinPlus Balloon Sinuplasty System is intended to: provide<br>a means to access the sinus space and illuminate within and<br>transilluminate across nasal and sinus structures; dilate the sinus ostia<br>and spaces associated with the paranasal sinus cavities for diagnostic<br>and therapeutic procedures; and irrigate from within a target sinus for<br>therapeutic procedures and to facilitate diagnostic procedures. |
| | For children aged 17 and under, the Relieva SpinPlus Balloon<br>Sinuplasty System is intended to: provide a means to access the sinus |
| | space and illuminate within and transilluminate across nasal and sinus<br>structures; dilate sinus ostia and spaces associated with the maxillary<br>sinus for diagnostic and therapeutic procedures; and irrigate from within<br>the maxillary sinus for therapeutic procedures and to facilitate<br>diagnostic procedures. |
| Technological<br>Characteristics: | The Relieva SpinPlus Balloon Sinuplasty System combines a Sinus<br>Guide Catheter and Handle Assembly (integrated with Sinus Balloon<br>Catheter, Sinus Irrigation and Illuminated Sinus Guidewire) into a<br>single device. |
| Performance Data: | Bench testing met all acceptance criteria for attributes such as simulated<br>use testing, dimensional attributes, cycle fatigue, balloon burst, bond<br>separation, irrigation flow rate and wire light output. Testing also<br>showed that the SpinPlus Balloon Sinuplasty System is biocompatible. |
| | The sterilization process has been validated per AAMI/ANSI/ISO<br>11135-1: 2007 and demonstrated a sterility assurance level of 10-6. The<br>method used for sterilization validation is the overkill (half-cycle<br>approach) in a fixed chamber. Ethylene oxide residuals have been<br>tested and meet ISO 10993-7:2008 requirements. The subject device is<br>not tested nor labeled as “non-pyrogenic”. |
| | Packaging shelf life has been established to be 3 months per ASTM<br>F1980-07. |
| | Clinical data were not necessary for the SpinPlus Balloon Sinuplasty<br>System. The performance data demonstrate that the device performs as<br>intended. |

{4}------------------------------------------------

Image /page/4/Picture/0 description: The image shows the logo for Acclarent. The word "Acclarent" is written in a sans-serif font, with the "A" and "ccla" in black and the "rent" in purple. There is a purple curved line above the "rent" portion of the logo.