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Model Number M00558680 |
Device Problems
Burst Container or Vessel (1074); Adverse Event Without Identified Device or Use Problem (2993)
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Patient Problem
No Clinical Signs, Symptoms or Conditions (4582)
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Event Date 03/06/2024 |
Event Type
malfunction
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Manufacturer Narrative
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Block h6: imdrf device code a0402 captures the reportable event of a balloon burst.
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Event Description
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It was reported to boston scientific corporation that a cre pro wireguided dilatation balloon was used in the bile duct during an endoscopic retrograde cholangiopancreatography (ercp) procedure performed on (b)(6) 2024.During the procedure, the bile duct papilla was initially inflated with a 10 mm balloon without any problem, and a quarry was performed with an extractor balloon.Subsequently, a 12 mm balloon was used for further inflation, but the balloon burst in the middle of the process, preventing further inflation.The physician reported that the remaining stones when quarrying was performed may have interfered and might have caused the balloon to burst.The procedure was completed with another cre pro wireguided dilatation balloon.There were no patient complications reported as a result of this event.
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Manufacturer Narrative
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Block h6: imdrf device code a0402 captures the reportable event of a balloon burst.Block h10: investigation results the returned cre pro wireguided dilatation balloon was analyzed, and a visual inspection found no damages to the device.Functional and microscopic inspection found that the balloon had a pinhole located approximately at 70 mm from the tip of the device.No other problems with the device were noted.With all the available information, boston scientific concludes the reported event of balloon burst was not confirmed.The pinhole problem found could have been interpreted by the customer as the reported event of a balloon burst.The pinhole found is likely to have occurred due to procedural factors such as excess of pressure, interaction with other devices, or anatomical conditions.Also, it is possible that interaction with a sharp surface during or previous to the procedure could have caused the problem found on the distal section of the balloon.Therefore, the most probable root cause is an adverse event related to procedure.Block h11: additional information: block b5 (describe event or problem).
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Event Description
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It was reported to boston scientific corporation that a cre pro wireguided dilatation balloon was used in the bile duct during an endoscopic retrograde cholangiopancreatography (ercp) procedure performed on (b)(6) 2024.During the procedure, the bile duct papilla was initially inflated with a 10 mm balloon without any problem, and a quarry was performed with an extractor balloon.Subsequently, a 12 mm balloon was used for further inflation, but the balloon burst in the middle of the process, preventing further inflation.The physician reported that the remaining stones when quarrying was performed may have interfered and might have caused the balloon to burst.The procedure was completed with another cre pro wireguided dilatation balloon.There were no patient complications reported as a result of this event.Additional information received on april 2, 2024.The balloon burst at 11 mm.The customer stated that no pieces of the balloon detached inside the patient.
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Search Alerts/Recalls
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