| Model Number |
M00545150 |
| Medical Device Problem Codes |
Break (1069); Deformation Due to Compressive Stress (2889); 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 |
09/17/2025
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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 an autotome rx 49 was attempted to be used in the common bile duct during an endoscopic retrograde cholangiopancreatography (ercp) procedure to treat common bile duct stone performed on (b)(6) 2025.During the procedure, an advancement of the endoscope was smooth, and cannulation was successful.Cholangiography was performed, but during the process of forming the bow, the cutting wire was fracture.A photo of the complaint device was provided by the complainant where it can be observed that the cutting wire was broken and kinked.It was reported that no part of the cutting wire detached and fell into the patient.The procedure was completed with another autotome rx 49.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 a2: patient's exact age is unknown; however, it was reported that the patient was over the age of 18.Block e1: initial reporter's facility name is (b)(6); reported here as the facility name exceeded the character limit for the designated field.Block h6: imdrf device code a0401 captures the reportable event of cutting wire break.Mdrf device code a0406 captures the reportable event of cutting wire kinked.
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Additional Manufacturer Narrative
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Block a2: patient's exact age is unknown; however, it was reported that the patient was over the age of 18.Block e1: initial reporter's facility name is (b)(6) hospital; reported here as the facility name exceeded the character limit for the designated field.Block h6: imdrf device code a0401 captures the reportable event of cutting wire break.Mdrf device code a0406 captures the reportable event of cutting wire kinked.Block h11: investigation results the returned autotome rx 49 was analyzed, and a visual inspection found that the cutting wire was blackened, kinked and broken from the proximal pierce hole.Media analysis was performed based on the photo provided by the complainant, where was possible to observe the device on top its pouch with the cutting wire broken and kinked.No other problems with the device were noted.With all the available information, boston scientific concludes the reported events of cutting wire break and cutting wire kinked were 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.The investigation findings and all information available concludes the most probable root cause is an 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 an autotome rx 49 was attempted to be used in the common bile duct during an endoscopic retrograde cholangiopancreatography (ercp) procedure to treat common bile duct stone performed on (b)(6) 2025.During the procedure, an advancement of the endoscope was smooth, and cannulation was successful.Cholangiography was performed, but during the process of forming the bow, the cutting wire was fracture.A photo of the complaint device was provided by the complainant where it can be observed that the cutting wire was broken and kinked.It was reported that no part of the cutting wire detached and fell into the patient.The procedure was completed with another autotome rx 49.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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Search Alerts/Recalls
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