MAUDE Adverse Event Report: BOSTON SCIENTIFIC CORPORATION ENDOVIVE STANDARD PEG KIT; TUBES, GASTROINTESTINAL (AND ACCESSORIES)

Model Number	M00568201
Medical Device Problem Code	Appropriate Device Problem Term/Code Not Available (3191)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	05/25/2021
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
(b)(4).If there is any further relevant information from that review, a supplemental medwatch will be filed.
Event or Problem Description
This report pertains to two endovive standard peg kits pull method.Refer to manufacturer report# (b)(4) and 3005099803-2021-03308 for the other associated device information.It was reported to boston scientific corporation that an endovive standard peg kit pull method used during a percutaneous endoscopic gastrostomy (peg) placement procedure on (b)(6) 2021.During procedure, the physician made an incision, placed a trocar and the needle of the trocar was removed to feed the blue insertion wire.Once the needle was removed, the trocar catheter retracted in the abdominal wall, however, the physician was no longer able to visualize the trocar catheter.A second endovive standard peg kit pull method was obtained and the same event occured.The trocar retracted again after the needle was removed.The procedure was stopped.The patient was taken to recovery and there were no untoward patient effects reported.

• Brand Name: ENDOVIVE STANDARD PEG KIT
• Common Device Name: TUBES, GASTROINTESTINAL (AND ACCESSORIES)
• Manufacturer (Section D): BOSTON SCIENTIFIC CORPORATION; 300 boston scientific way; marlborough MA 01752
• MDR Report Key: 12131541
• Report Number: 3005099803-2021-03306
• Device Sequence Number: 11869412
• Product Code: KNT
• UDI-Device Identifier: 08714729285199
• UDI-Public: 08714729285199
• Combination Product (Y/N): Y
• Initial Reporter State: TN
• Initial Reporter Country: US
• PMA/510(K) Number: K031538
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: company representative,health
• Initial Reporter Occupation: Physician
• Type of Report: Initial
• Report Date (Section B): 07/07/2021

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
• Operator of Device: Health Professional
• Device Expiration Date: 10/22/2022
• Device Model Number: M00568201
• Device Catalogue Number: 6820
• Device Lot Number: 0027198829
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 06/15/2021
• Initial Report FDA Received Date: 07/07/2021
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Patient Age: 59 YR