| Model Number |
M00583170 |
| Medical Device Problem Codes |
Break (1069); Material Deformation (2976)
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| Health Effect - Clinical Code |
No Clinical Signs, Symptoms or Conditions (4582)
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| Date of Event |
01/16/2025
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Type of Reportable Event
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Malfunction
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Event or Problem Description
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It was reported to boston scientific corporation that a truetome hydra 44 was used in the papilla during an endoscopic retrograde cholangiopancreatography (ercp) procedure performed on (b)(6) 2025.During the procedure, the truetome hydra 44 was inserted through the papilla and into the biliary tract by the physician and contrast was administered.The device was connected to the generator and the cutting wire was tensioned.When the first current was applied, the proximal part of the cutting wire broke.It was then removed and replaced with another of the same device that completed the procedure successfully.It was reported that no part of the cutting wire detached and fell into the patient.A photo of the complaint device outside the patient were provided by the customer and showed the cutting wire was broken and kinked.There were no patient complications reported as a result of this event.
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Additional Manufacturer Narrative
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Block h6: imdrf device code a0401 captures the reportable event of cutting wire broken.
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Additional Manufacturer Narrative
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Block h6: imdrf device code a0401 captures the reportable event of cutting wire broken.Block h11: (investigation result) the returned truetome hydra 44 was analyzed, and a visual and microscopic evaluation noted that the cutting wire was blackened, kinked, and broken from the proximal pierce hole.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 blackened, kinked, and broken from the proximal pierce hole.Based on the condition of the device, the wire break 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 integrity and cause a premature cutting wire fatigue.Once the cutting wire breaks, any attempt to remove the device from the scope can lead to the broken section hitting the working channel of the scope.This can kink the cutting wire.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 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.
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Event or Problem Description
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It was reported to boston scientific corporation that a truetome hydra 44 was used in the papilla during an endoscopic retrograde cholangiopancreatography (ercp) procedure performed on (b)(6) 2025.During the procedure, the truetome hydra 44 was inserted through the papilla and into the biliary tract by the physician and contrast was administered.The device was connected to the generator and the cutting wire was tensioned.When the first current was applied, the proximal part of the cutting wire broke.It was then removed and replaced with another of the same device that completed the procedure successfully.It was reported that no part of the cutting wire detached and fell into the patient.A photo of the complaint device outside the patient were provided by the customer and showed the cutting wire was broken and kinked.There were no patient complications reported as a result of this event.
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Search Alerts/Recalls
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