| Model Number |
M00583100 |
| Medical Device Problem Codes |
Break (1069); Adverse Event Without Identified Device or Use Problem (2993)
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| Health Effect - Clinical Code |
No Clinical Signs, Symptoms or Conditions (4582)
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| Date of Event |
02/17/2025
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Type of Reportable Event
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Malfunction
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Additional Manufacturer Narrative
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Block h6: imdrf device code a0401 captures the reportable event of cutting wire break.
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Event or Problem Description
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T was reported to boston scientific corporation that a truetome jag 44 was attempted to be used in the common bile duct (cbd) during an endoscopic retrograde cholangiopancreatography (ercp) procedure performed on (b)(6) 2025.During the procedure, after successfully completing the intubation, when the tome was used to cut the papilla, the cutting wire was fractured.It was reported that no part of the cutting wire detached and fell into the patient.The procedure was completed with another truetome jag 44.There were no patient complications reported as a result of this event.The patient's condition at the conclusion of the procedure was reported to be stable.
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Event or Problem Description
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T was reported to boston scientific corporation that a truetome jag 44 was attempted to be used in the common bile duct (cbd) during an endoscopic retrograde cholangiopancreatography (ercp) procedure performed on (b)(6) 2025.During the procedure, after successfully completing the intubation, when the tome was used to cut the papilla, the cutting wire was fractured.It was reported that no part of the cutting wire detached and fell into the patient.The procedure was completed with another truetome jag 44.There were no patient complications reported as a result of this event.The patient's condition at the conclusion of the procedure was reported to be stable.
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Additional Manufacturer Narrative
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Block h6: imdrf device code a0401 captures the reportable event of cutting wire break.Block h11: investigation results the returned truetome jag 44 was analyzed, and a visual inspection found that the cutting wire was blackened, kinked and broken from the proximal pierce hole.Also, the working length was twisted.No other problems with the device were noted.With all the available information, boston scientific concludes the reported event of cutting wire break was confirmed.The results of the analysis performed on the returned device found that the cutting wire was kinked and broken from the proximal pierce hole.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.The break in the cutting wire could have been generated if there was contact between the device and the scope during energization or if the device exceeded the maximum of voltage during procedure.Also, energizing the device prior to performing sphincterotomy can compromise the cutting wires integrity, causing premature cutting wire fatigue.Once the cutting wire breaks, any attempt to remove the device from the scope can bend the cutting wire as observed in the product analysis.Also, it was found the working length was twisted, this problem could be caused after multiple attempts to rotate handle of the device or during the introduction of the device into the scope.The investigation findings and all information available concludes the most probable root cause is an adverse event related to procedure.
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Search Alerts/Recalls
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