| 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 |
02/10/2025
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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 of vater during an endoscopic retrograde cholangiopancreatography (ercp) procedure performed on (b)(6) 2025.During the procedure, the device was inserted, and the wire was tightened as ordered by the physician.The device was then connected to the diathermy machine and at first application of current the cutting wire of the truetome hydra 44 on the proximal side broke.It was reported that no part of the cutting wire detached and fell into the patient.The procedure was completed with another truetome utilizing the hydra guidewire from the first sphincterotome.There were no patient complications reported as a result of this event.Note: photos of the complaint device outside the patient were provided by the customer and showed the cutting wire was broken and kinked.
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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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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 of vater during an endoscopic retrograde cholangiopancreatography (ercp) procedure performed on (b)(6) 2025.During the procedure, the device was inserted, and the wire was tightened as ordered by the physician.The device was then connected to the diathermy machine and at first application of current the cutting wire of the truetome hydra 44 on the proximal side broke.It was reported that no part of the cutting wire detached and fell into the patient.The procedure was completed with another truetome utilizing the hydra guidewire from the first sphincterotome.There were no patient complications reported as a result of this event.Note: photos of the complaint device outside the patient were provided by the customer and showed the cutting wire was broken and kinked.
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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 evaluation noted that the cutting wire was blackened, kinked, and broken from the proximal pierce hole.Media evaluation also shows broken and kinked cutting wire of the device.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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Search Alerts/Recalls
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