MAUDE Adverse Event Report: BOSTON SCIENTIFIC CORPORATION ULTRATOME; SNARE, FLEXIBLE

Model Number	M00530820
Medical Device Problem Code	Break (1069)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	11/18/2022
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Imdrf device code a0401 captures the reportable event of cutting wire broken.
Event or Problem Description
Note: this report pertains to two ultratome xl and one ultratome used in the same procedure.It was reported to boston scientific corporation that two ultratome xl and one ultratome were used during an endoscopic retrograde cholangiopancreatography (ercp) procedure performed in the bile duct on (b)(6) 2022.During the procedure, the cutting wire broke upon tightening and cutting.A second ultratome xl was used and the same problem happened.A new ultratome device was used; however, the same problem occurred.It was reported that no part of the cutting wire detached and fell into the patient.The procedure was completed with a new ultratome xl device.There were no patient complications reported as a result of this event.
Event or Problem Description
Note: this report pertains to two ultratome xl and one ultratome used in the same procedure.It was reported to boston scientific corporation that two ultratome xl and one ultratome were used during an endoscopic retrograde cholangiopancreatography (ercp) procedure performed in the bile duct on november 18, 2022.During the procedure, the cutting wire broke upon tightening and cutting.A second ultratome xl was used and the same problem happened.A new ultratome device was used; however, the same problem occurred.It was reported that no part of the cutting wire detached and fell into the patient.The procedure was completed with a new ultratome xl device.There were no patient complications reported as a result of this event.
Additional Manufacturer Narrative
Block h6: imdrf device code a0401 captures the reportable event of cutting wire broken.Block h10: the returned ultratome was analyzed, and a visual evaluation noted that the cutting wire was broken, blackened, and kinked.The device was observed under magnification and the cutting wire was blackened and broken from the proximal pierced hole of the working length.No other problems with the device were noted.The reported event of cutting wire break was confirmed.Upon analysis, it was found that the cutting wire was broken, kinked and blackened.The cutting wire being blackened indicates that the device was energized.Based on the condition of the device, the problem found could have been generated if there was contact between the device and the scope during energization or if the generator exceeded the maximum of voltage during the procedure.Also, energizing the device prior to performing sphincterotomy can compromise the cutting wire's integrity and cause a premature cutting wire fatigue.Additionally kinking/bending the cutting wire can lead to break it.It is most likely that procedural or anatomical factors encountered during the use of the device could have affected the device performance and its integrity.Based on all gathered information, the most probable root cause of this complaint is adverse event related to procedure.A labeling review was performed and, from the information available, this device was used per the instructions for use (ifu) / product label.

• Brand Name: ULTRATOME
• Common Device Name: SNARE, FLEXIBLE
• Manufacturer (Section D): BOSTON SCIENTIFIC CORPORATION; 300 boston scientific way; marlborough MA 01752
• Manufacturer (Section G): BOSTON SCIENTIFIC CORPORATION; 2546 calle primera; alajuela ; CS
• Manufacturer Contact: carole morley ; 300 boston scientific way; marlborough, MA 01752 ; 5086834015
• MDR Report Key: 15971409
• Report Number: 3005099803-2022-07347
• Device Sequence Number: 5668652
• Product Code: FDI
• UDI-Device Identifier: 08714729193418
• UDI-Public: 08714729193418
• Combination Product (Y/N): N
• Initial Reporter Country: GM
• PMA/510(K) Number: K930022
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Other,Foreign,Health Professional,Company Representative
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 01/11/2023

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: 12/08/2022
• Device Model Number: M00530820
• Device Catalogue Number: 3082
• Device Lot Number: 0026483295
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Follow-Up
• Initial Date Received by Manufacturer: 11/21/2022
• Supplement Date Received by Manufacturer: 12/20/2022
• Initial Report FDA Received Date: 12/13/2022
• Supplement Report FDA Received Date: 01/11/2023
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 12/08/2020
• 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