| Model Number |
M00584190 |
| 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 |
04/14/2025
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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 broken.
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Event or Problem Description
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It was reported to boston scientific corporation that a truetome 39 was used in the ampulla of vater (aov) during an endoscopic sphincterotomy (est) procedure performed on (b)(6) 2025 during the procedure, when the physician tries to cut the aov, the cutting wire of the truetome 39 broke.It was reported that no part of the cutting wire detached and fell into the patient.The procedure was completed with another of the same device.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.Block h11: (investigation result) the returned truetome 39 was analyzed, and a visual evaluation noted that the cutting wire was blackened, kinked, and broken at 5 mm from the proximal pierce hole.Additionally, the working length was twisted.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 at 5 mm 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.The twisted working length could be caused after multiple attempts to rotate handle of the device or during the introduction of the device into the scope.Based on all gathered information, the most probable root cause is adverse event related to procedure.
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Event or Problem Description
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It was reported to boston scientific corporation that a truetome 39 was used in the ampulla of vater (aov) during an endoscopic sphincterotomy (est) procedure performed on (b)(6) 2025.During the procedure, when the physician tries to cut the aov, the cutting wire of the truetome 39 broke.It was reported that no part of the cutting wire detached and fell into the patient.The procedure was completed with another of the same device.There were no patient complications reported as a result of this event.
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Search Alerts/Recalls
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