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It was reported to boston scientific corporation that an autotome rx 44 was used in the common bile duct during an endoscopic retrograde cholangiopancreatography (ercp) procedure to treat stones performed on (b)(6) 2025.During the procedure, the tome was advanced to the papillary opening through the duodenoscope.However, the tip became misaligned and could not achieve the correct angle for cannulation of the duodenal papilla.The procedure was completed with another of the same device.There were no patient complications reported as a result of this event and the patient's condition at the conclusion of the procedure was reported to be stable.This event has been deemed a reportable event based on the investigation results: the cutting wire kinked.Please refer to block h11 for full investigation details.
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Block h6: imdrf device code a040601 captures the reportable investigation results of wire kinked.Block h11: investigation results the returned autotome rx 44 was analyzed, and a visual inspection found that the working length was twisted at distal section.The catheter was incorrectly oriented due to the twisted section on the working length and due to this condition, the wire bowed out of plane.Additionally, the cutting wire was bent.No other problems with the device were noted.The product analysis of the returned device revealed that the working length was twisted at distal section.The catheter was incorrectly oriented due to the twisted section on the working length and due to this condition, the wire bowed out of plane.Additionally, the cutting wire was kinked.The problem of cutting wire kinked could be caused by operational factors, the used technique for the device manipulation or by the interaction between the device and a hard surface.Based on all gathered information, the most probable root cause is 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.A risk review was completed and confirmed that the event of wire kinked was defined in the risk documentation.This event type has been accounted for during product risk analysis to support acceptable risk benefit for the product.
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