MAUDE Adverse Event Report: BOSTON SCIENTIFIC CORPORATION CRE FIXED WIRE; DILATOR, ESOPHAGEAL

Model Number	M00558360
Medical Device Problem Code	Material Puncture/Hole (1504)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	08/14/2024
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Block h6: imdrf device code a041001 captures the reportable event of a balloon pinhole in the esophagus.
Event or Problem Description
Note: this report pertains to one of two cre fixed wire dilatation balloons used in the same patient and procedure.It was reported to boston scientific corporation that a cre fixed wire dilatation balloon was attempted to be used in the esophagus during an esophagogastroduodenoscopy (egd) with dilation procedure performed on (b)(6) 2024.During the procedure, when the balloon was inflated, water was leaking out.It was reported that the balloon had a hole.The same problem occurred with the second cre fixed wire dilatation balloon.The procedure was completed with a third cre fixed wire dilatation balloon.There were no patient complications reported as a result of this event.
Event or Problem Description
Note: this report pertains to one of two cre fixed wire dilatation balloons used in the same patient and procedure.It was reported to boston scientific corporation that a cre fixed wire dilatation balloon was attempted to be used in the esophagus during an esophagogastroduodenoscopy (egd) with dilation procedure performed on august 14, 2024.During the procedure, when the balloon was inflated, water was leaking out.It was reported that the balloon had a hole.The same problem occurred with the second cre fixed wire dilatation balloon.The procedure was completed with a third cre fixed wire dilatation balloon.There were no patient complications reported as a result of this event.
Additional Manufacturer Narrative
Imdrf device code a041001 captures the reportable event of a balloon pinhole in the esophagus.Investigation results: the returned cre fixed wire dilatation balloon was inspected and a pinhole was discovered located approximately 109 mm from the device tip after a functional test.With all the available information, boston scientific (bsc) concludes the reported event of balloon pinhole was confirmed.The returned device was inspected, and functional testing revealed a pinhole located approximately 109 mm from the device tip.The most probable cause for this event is adverse event related to procedure.It is possible that the pinhole found in the balloon occurred due to procedural factors such as excess pressure, interaction with other devices, or anatomical conditions.Also, it is possible that interaction with a sharp surface during/previous the procedure could have caused the failure found on the distal section of the balloon.

• Brand Name: CRE FIXED WIRE
• Common Device Name: DILATOR, ESOPHAGEAL
• 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 T12 Y K88; EI T12 YK88
• Manufacturer Contact: carole morley ; 300 boston scientific way; marlborough, MA 01752 ; 5086834015
• MDR Report Key: 20140751
• Report Number: 3005099803-2024-04308
• Device Sequence Number: 18007823
• Product Code: KNQ
• UDI-Device Identifier: 08714729195986
• UDI-Public: 08714729195986
• Combination Product (Y/N): N
• Initial Reporter State: NY
• Initial Reporter Country: US
• PMA/510(K) Number: K971320
• 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: Nurse
• Type of Report: Initial,Followup
• Report Date (Section B): 10/21/2024

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: 08/27/2025
• Device Model Number: M00558360
• Device Catalogue Number: 5836
• Device Lot Number: 0032304956
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 08/14/2024
• Supplement Date Received by Manufacturer: 09/25/2024
• Initial Report FDA Received Date: 09/04/2024
• Supplement Report FDA Received Date: 10/21/2024
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 08/28/2023
• 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