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

Model Number	M00566490
Medical Device Problem Code	Detachment of Device or Device Component (2907)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	01/01/2022
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Date of event was approximated to (b)(6) 2022 as no event date was reported.(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 medwatch will be filed.
Event or Problem Description
It was reported to boston scientific corporation that an endovive safety peg kit push method was used during a percutaneous endoscopic gastrostomy placement procedure.The procedure date is unknown.During the procedure, the peg tube detached at transition zone while physician pulled it through the stoma site.It was reported that the detached portion was pulled out by the physician.The procedure was completed with a new endovive safety peg kit push method.There were no patient complications reported as a result of this event.
Additional Manufacturer Narrative
Block b3 (date of event): date of event was approximated to (b)(6) 2022 as no event date was reported.Block h6 (device codes): device code a0501captures the reportable event of peg tube detached.Block h10: an endovive safety peg tube was returned.Visual assessment was performed on the joint where the peg tube meets the rigid tubing.No damage or defect was noted.Gentle pressure was applied to the joint by grasping the peg tube and rigid tubing in each hand and pulling them apart, but the peg tube would not detach from the joint.Additionally, the peg tube was noted to have been cut, and the remainder of the tube was not returned.Therefore, the reported event of peg detached was not confirmed.Based on the condition of the returned device, engineers determined that the peg tube was cut, which is part of the process for completing the procedure with the device.This indicates that the device may have been used to complete the procedure.Boston scientific has determined the most probable cause of this complaint is no problem detected.The correct complaint device was returned.A review of the manufacturing documentation for this device revealed that no anomalies or deviations related to the event occurred during manufacturing.A labeling review was performed and, from the information available, this device was used per the instructions for use (ifu) / product label.
Event or Problem Description
It was reported to boston scientific corporation that an endovive safety peg kit push method was used during a percutaneous endoscopic gastrostomy placement procedure.The procedure date is unknown.During the procedure, the peg tube detached at transition zone while physician pulled it through the stoma site.It was reported that the detached portion was pulled out by the physician.The procedure was completed with a new endovive safety peg kit push method.There were no patient complications reported as a result of this event.

• Brand Name: ENDOVIVE SAFETY PEG KIT
• Common Device Name: TUBES, GASTROINTESTINAL (AND ACCESSORIES)
• Manufacturer (Section D): BOSTON SCIENTIFIC CORPORATION; 300 boston scientific way; marlborough MA 01752
• Manufacturer (Section G): BOSTON SCIENTIFIC CORPORATION; 780 brookside drive; spencer IN 47460
• Manufacturer Contact: carole morley ; 300 boston scientific way; marlborough, MA 01752 ; 5086834015
• MDR Report Key: 13497108
• Report Number: 3005099803-2022-00594
• Device Sequence Number: 19951123
• Product Code: KNT
• UDI-Device Identifier: 08714729748410
• UDI-Public: 08714729748410
• Combination Product (Y/N): Y
• Initial Reporter State: CT
• 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: Health Professional,Company Representative
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 03/21/2022

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: 04/30/2022
• Device Model Number: M00566490
• Device Catalogue Number: 6649
• Device Lot Number: 0028441930
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 01/20/2022
• Supplement Date Received by Manufacturer: 03/01/2022
• Initial Report FDA Received Date: 02/09/2022
• Supplement Report FDA Received Date: 03/21/2022
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 04/01/2020
• Is the Device Labeled for Single Use? (Y/N): Yes
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Usage of Device: Initial
• Patient Sequence Number: 1
• Patient Sex: Unknown