MAUDE Adverse Event Report: BOSTON SCIENTIFIC CORPORATION RESOLUTION CLIP; CLIP, HEMOSTATIC

Model Number M00522610

Device Problem Activation, Positioning or Separation Problem (2906)

Patient Problem No Clinical Signs, Symptoms or Conditions (4582)

Event Date 09/06/2022

Event Type  malfunction  

Manufacturer Narrative

Medical device code a15 captures the reportable event of clip unable to release from catheter.

Event Description

It was reported to boston scientific corporation that a resolution clip device was used in the stomach during an endoscopic gastric polypectomy procedure performed on (b)(6) 2022.During the procedure, the clip was able to grasp and lock onto tissue; however, the clip was unable to release from the catheter to deploy.Ultimately, the clip fell off into the stomach of the patient.The procedure was completed with another resolution clip device.There were no patient complications reported as a result of this event.The patient's condition at the conclusion of the procedure was reported to be stable.

Manufacturer Narrative

Block h2: additional information: block b5 (describe event or problem) has been updated based on the additional information received on october 8, 2022.Block h6: medical device code a15 captures the reportable event of clip unable to release from catheter.

Event Description

It was reported to boston scientific corporation that a resolution clip device was used in the stomach during an endoscopic gastric polypectomy procedure performed on (b)(6)2022.During the procedure, the clip was able to grasp and lock onto tissue; however, the clip was unable to release from the catheter to deploy.Ultimately, the clip fell off into the stomach of the patient.The procedure was completed with another resolution clip device.There were no patient complications reported as a result of this event.The patient's condition at the conclusion of the procedure was reported to be stable.Additional information received on october 8, 2022: it was clarified that the procedure performed was endoscopic mucosal resection (emr).

Manufacturer Narrative

Block h6: medical device code a15 captures the reportable event of clip unable to release from catheter.Block h10: investigation results: the returned resolution clip device was analyzed, and a visual evaluation noted that the device was returned without the clip assembly and with evidence of premature deployment.Microscopic examination was performed, and it was confirmed that the device had evidence of premature deployment.Additionally, the bushing had hit marks.Dimensional examination was performed on the bushing outer diameter, and it was found to be within specification.A dimensional analysis was also performed between the hooks of the bushing and both sides were noted to be within specification.No other problems with the device were noted.The reported event of clip unable to release from catheter was not confirmed.Investigation found that the yoke was returned attached to the control wire, this is likely due to operational factors during the procedure such as trying to open the clip once it was already activated.Additionally, the hit marks found on the bushing is likely due to the interaction between the yoke and the capsule, in order to deploy the clip.However, the device was returned without the clip assembly, and it is important to mention that the presence of this component is very important to the investigation in order to analyze any failure that could contribute with the problem faced by the physician.Additionally, it is important to take in consideration that during the product analysis, the dimensions between the hooks of the bushing were measured, and they were within specification, excluding the possibility that the device components dimensions interfered with the device performance.The investigation findings and all information available do not lead to a clear conclusion about the cause of the reported adverse event.Therefore, the most probable root cause is cause not established.

Event Description

It was reported to boston scientific corporation that a resolution clip device was used in the stomach during an endoscopic gastric polypectomy procedure performed on (b)(6) 2022.During the procedure, the clip was able to grasp and lock onto tissue; however, the clip was unable to release from the catheter to deploy.Ultimately, the clip fell off into the stomach of the patient.The procedure was completed with another resolution clip device.There were no patient complications reported as a result of this event.The patient's condition at the conclusion of the procedure was reported to be stable.It was clarified that the procedure performed was endoscopic mucosal resection (emr).

• Brand Name: RESOLUTION CLIP
• Type of Device: CLIP, HEMOSTATIC
• Manufacturer (Section D): BOSTON SCIENTIFIC CORPORATION; 300 boston scientific way; marlborough MA 01752
• Manufacturer (Section G): BOSTON SCIENTIFIC DE COSTA RICA S.R.L.; 2546 calle primera; propark, coyol; alajuela ; CS
• Manufacturer Contact: carole morley ; 300 boston scientific way; marlborough, MA 01752 ; 5086834015
• MDR Report Key: 15528343
• MDR Text Key: 306508352
• Report Number: 3005099803-2022-05602
• Device Sequence Number: 1
• Product Code: MCH
• UDI-Device Identifier: 08714729504795
• UDI-Public: 08714729504795
• Combination Product (y/n): N
• Reporter Country Code: CH
• PMA/PMN Number: K040148
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: Other,Foreign,Health Professional,Company Representative,Distributor
• Reporter Occupation: Physician
• Type of Report: Initial,Followup,Followup
• Report Date: 12/01/2022

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
• Device Operator: Health Professional
• Device Model Number: M00522610
• Device Catalogue Number: 2261
• Device Lot Number: 0028579517
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Is the Reporter a Health Professional?: Yes
• Initial Date Manufacturer Received: 09/06/2022
• Initial Date FDA Received: 10/03/2022
• Supplement Dates Manufacturer Received: 10/08/2022; 11/07/2022
• Supplement Dates FDA Received: 11/02/2022; 12/01/2022
• Was Device Evaluated by Manufacturer?: Yes
• Date Device Manufactured: 12/17/2021
• Is the Device Single Use?: Yes
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Initial
• Patient Sequence Number: 1
• Patient Age: 49 YR
• Patient Sex: Female
• Patient Weight: 63 KG