Model Number M00521230 |
Device Problem
Activation, Positioning or Separation Problem (2906)
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Patient Problem
No Clinical Signs, Symptoms or Conditions (4582)
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Event Date 12/02/2021 |
Event Type
malfunction
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Event Description
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It was reported to boston scientific corporation that two resolution 360 clip devices were used during a colonoscopy procedure performed on (b)(6) 2021.During the procedure, both clips grasped and locked onto tissue, but did not release from the catheter to deploy.In the stages of deployment, snap and crackle were felt but there was no pop.The same issue happened with the second resolution 360 clip device.The procedure was completed with another resolution 360 clip device.There were no patient complications reported as a result of this event.
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Manufacturer Narrative
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The complainant was unable to provide the suspect device lot number; therefore, the lot expiration and device manufacture dates are unknown.(b)(4) captures the reportable event of clip was unable to release from catheter.The device has not been received for analysis.Upon receipt and completion of the problem analysis of the complaint device, if there is any further relevant information from that review, a supplemental medwatch will be filed.
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Manufacturer Narrative
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Block d4, h4: the complainant was unable to provide the suspect device lot number; therefore, the lot expiration and device manufacture dates are unknown.Block h6: medical device problem code a15 captures the reportable event of clip was unable to release from catheter.Block h10: investigation results the returned resolution 360 clip device was analyzed, and a visual evaluation noted that the clip assembly was not returned and the device had evidence of a full deployment.Microscope examination was performed, and it was observed that the bushing had hit marks on the bushing surface, indicating the interaction between the yoke and the capsule in order to make the deployment of the clip.Dimensional analysis was performed on the bushing outer diameter, and it was observed to be within specification.A dimensional analysis was performed between the hooks of the bushing, and both sides a and b were within specification.The bushing tabs measurement were symmetric and the flattening wire was confirmed to be within specification.Further dimensional analysis was performed on the braided shaft, and the lengths of various parts were within specification.No other problems with the device were noted.The reported event was not confirmed.The device 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.The returned device review showed no evidence of either the alleged(s) or any defect which could have contributed to the event.Therefore, the most probable root cause for this complaint is no problem detected.A review of the manufacturing documentation for this device was unable to be performed as the lot number is unknown.However, a ship history review was performed to identify the most probable lots, and a device history review (dhr) on the most probable lots did not identify any anomalies or deviations within manufacturing/service processes that could have contributed to the event.
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Event Description
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It was reported to boston scientific corporation that two resolution 360 clip devices were used during a colonoscopy procedure performed on (b)(6) 2021.During the procedure, both clips grasped and locked onto tissue, but did not release from the catheter to deploy.In the stages of deployment, snap and crackle were felt but there was no pop.The same issue happened with the second resolution 360 clip device.The procedure was completed with another resolution 360 clip device.There were no patient complications reported as a result of this event.
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Search Alerts/Recalls
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