MAUDE Adverse Event Report: WILSON-COOK MEDICAL INC FUSION QUATTRO EXTRACTION BALLOON; No Match

Model Number	G31922
Medical Device Problem Code	Material Rupture (1546)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	09/11/2025
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Continued: d2a common device name: biliary catheter for stone removal that may also allow for irrigation and contrast injection.E1 - phone: (b)(6).Investigation evaluation: the product said to be involved was returned in an open pouch from the lot number provided in the report.The label matches the returned product.Our laboratory evaluation of the product said to be involved confirmed the report.The device was returned with the syringe loose in the pouch, and the balloon ruptured.Under magnification, it was identified there was a portion where the balloon material did not match up and a portion appears to be missing.The missing portion of the balloon was not returned with the device.No other anomalies were detected with the device.The device history record for the lot number said to be involved was reviewed.A discrepancy or anomaly was not observed with the product that was released for distribution.Investigation conclusion: our evaluation of the returned device confirmed the report.A corrective action has been initiated to reduce occurrences of balloon ruptures.The product said to be involved is included in the scope of the corrective actions.Based on the information provided in the report, it is unknown if the balloon was tested prior to advancement down the endoscope accessory channel.The instruction for use states: "verify balloon integrity prior to use by attaching the enclosed syringe to the stopcock and inflating the balloon with air only." a pinhole, split, or rupture in the balloon can occur if the balloon material has come into contact with a sharp object, such as a sharp stone or possibly a burr in the endoscope channel.Prior to distribution, all fusion quattro extraction balloon are subjected to a visual inspection and functional testing to ensure device integrity.A review of the device history record confirmed that the lot said to be involved met all manufacturing requirements prior to shipment.Corrective action: a corrective action has been initiated in an effort to reduce occurrences of this nature.This product was manufactured prior to implementation of this corrective action.A review of the complaint history was conducted.Quality assurance will continue to monitor for complaint trends.
Event or Problem Description
During an unknown procedure, the physician used a cook fusion quattro extraction balloon through the papilla.It was initially reported that the balloon ruptured upon the initial inflation.There was no reportable information at that time.The device was received on 06oct2025 and during the evaluation, the device was determined to have missing pieces [subject of report].A section of the device did not remain inside the patient¿s body.The patient did not require any additional procedures due to this occurrence.According to the initial reporter, the patient did not experience any adverse effects due to this occurrence.

• Brand Name: FUSION QUATTRO EXTRACTION BALLOON
• Common Device Name: No Match
• Manufacturer (Section D): WILSON-COOK MEDICAL INC; winston-salem NC 27105
• Manufacturer (Section G): WILSON-COOK MEDICAL INC; 4900 bethania station rd; winston-salem NC 27105
• Manufacturer Contact: sabrina o¿brien ; 4900 bethania station rd; winston-salem, NC 27105 ; 3367440157
• MDR Report Key: 23442263
• Report Number: 1037905-2025-00742
• Device Sequence Number: 8672821
• Product Code: GCA
• UDI-Device Identifier: 00827002319226
• UDI-Public: (01)00827002319226(17)260203(10)W4910591
• Combination Product (Y/N): N
• Initial Reporter Country: JP
• PMA/510(K) Number: K063677
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Foreign,Company Representative
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial
• Report Date (Section B): 10/31/2025

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Operator of Device: Health Professional
• Device Expiration Date: 02/03/2026
• Device Model Number: G31922
• Device Catalogue Number: FS-QEB-XL-B
• Device Lot Number: W4910591
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 10/06/2025
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 10/06/2025
• Initial Report FDA Received Date: 10/31/2025
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 02/03/2025
• Is the Device Labeled for Single Use? (Y/N): Yes
• Usage of Device: Initial
• Patient Sequence Number: 1
• Patient Sex: Unknown