MAUDE Adverse Event Report: BOSTON SCIENTIFIC CORPORATION CRE PULMONARY; BRONCHOSCOPE ACCESSORY

Model Number	M00550320
Medical Device Problem Codes	Burst Container or Vessel (1074); Use of Device Problem (1670)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	12/07/2021
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
(b)(4).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 mdr will be filed.
Event or Problem Description
It was reported to boston scientific corporation that a cre pulmonary dilatation balloon was used on a balloon dilation of the gastrointestinal tract procedure performed on (b)(6) 2021.During the procedure, the balloon stopped inflating and contrast leaked out.The balloon was noted to have ruptured at 4 atm.There were no patient complications reported as a result of this event.
Additional Manufacturer Narrative
Block h2: additional information: block a2 ( age at time of event ) and block a2 ( sex ).Block h6: device code a0402 captures the reportable event of balloon burst.Block h10: investigation results a visual examination of the returned complaint device found that the device had no visual damages.Microscopic inspection was done and found the balloon had a pinhole, which does not confirm the reported event of balloon burst.The pinhole problem found could have been interpreted by the customer as the reported event of balloon burst.Functional evaluation was performed, the balloon was inflated with water and a pinhole was noticed.Based on the available information, it is possible that factors encountered during the procedure, such as excess pressure, interaction with other devices, or anatomical affairs caused the balloon to have a pinhole.Therefore, the most probable root cause is adverse event related to procedure.A review of the device history record (dhr) was performed and confirmed that this device met all material, assembly and performance specifications.A labeling review was performed and from the information available, this device was not used per the directions for use (dfu)/product label as the balloon was used in the gastrointestinal tract.
Event or Problem Description
It was reported to boston scientific corporation that a cre pulmonary dilatation balloon was used on a balloon dilation of the gastrointestinal tract procedure performed on (b)(6) 2021.During the procedure, the balloon stopped inflating and contrast leaked out.The balloon was noted to have ruptured at 4 atm.There were no patient complications reported as a result of this event.

• Brand Name: CRE PULMONARY
• Common Device Name: BRONCHOSCOPE ACCESSORY
• Manufacturer (Section D): BOSTON SCIENTIFIC CORPORATION; 300 boston scientific way; marlborough MA 01752
• Manufacturer (Section G): BOSTON SCIENTIFIC CORK LIMITED; cork business technology park; model farm road; cork ; EI
• Manufacturer Contact: carole morley ; 300 boston scientific way; marlborough, MA 01752 ; 5086834015
• MDR Report Key: 13366882
• Report Number: 3005099803-2022-00248
• Device Sequence Number: 12100842
• Product Code: KTI
• UDI-Device Identifier: 08714729456209
• UDI-Public: 08714729456209
• Combination Product (Y/N): N
• Initial Reporter State: VA
• Initial Reporter Country: US
• PMA/510(K) Number: K023337
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Health Professional,Company Representative
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 02/22/2022

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
• Operator of Device: Health Professional
• Device Expiration Date: 09/06/2024
• Device Model Number: M00550320
• Device Catalogue Number: 5032
• Device Lot Number: 0027977130
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 02/03/2022
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Follow-Up
• Initial Date Received by Manufacturer: 12/13/2021
• Supplement Date Received by Manufacturer: 02/07/2022
• Initial Report FDA Received Date: 01/27/2022
• Supplement Report FDA Received Date: 02/22/2022
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 09/07/2021
• Is the Device Labeled for Single Use? (Y/N): Yes
• Usage of Device: Unknown
• Patient Sequence Number: 1
• Patient Age: 51 YR
• Patient Sex: Male