| Model Number |
M00584150 |
| Medical Device Problem Codes |
Break (1069); Adverse Event Without Identified Device or Use Problem (2993)
|
| Health Effect - Clinical Code |
No Clinical Signs, Symptoms or Conditions (4582)
|
| Date of Event |
11/06/2025
|
|
Type of Reportable Event
|
Malfunction
|
|
Additional Manufacturer Narrative
|
|
Block e1: initial reporter facility name: (b)(6).Block h6: imdrf device code a0401 captures the reportable event of cutting wire break.
|
| |
|
Event or Problem Description
|
|
It was reported to boston scientific corporation that a truetome 49 was used in the common bile duct during an endoscopic retrograde cholangiopancreatography (ercp) procedure to treat bile duct stones performed on (b)(6) 2025.It was reported that while on the process of duodenal papilla incision, the wire was fractured when the tome was electrified.The procedure was completed with another truetome 49.There were no patient complications as a result of this event and the patient's condition at the conclusion of the procedure was reported to be stable.
|
| |
|
Additional Manufacturer Narrative
|
|
Block e1: initial reporter 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.Block h11: investigation results.The returned truetome 49 was analyzed, and a visual inspection found that the cutting wire was blackened, kinked and broken from the proximal pierce hole.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.The investigation findings and all information available concludes the most probable root cause is an adverse event related to procedure.A review of the manufacturing documentation for this device revealed that no anomalies or deviations related to the event occurred during manufacturing.
|
| |
|
Event or Problem Description
|
|
It was reported to boston scientific corporation that a truetome 49 was used in the common bile duct during an endoscopic retrograde cholangiopancreatography (ercp) procedure to treat bile duct stones performed on (b)(6) 2025.It was reported that while on the process of duodenal papilla incision, the wire was fractured when the tome was electrified.The procedure was completed with another truetome 49.There were no patient complications as a result of this event and the patient's condition at the conclusion of the procedure was reported to be stable.
|
| |
|
Search Alerts/Recalls
|