MAUDE Adverse Event Report: BOSTON SCIENTIFIC - GALWAY WALLFLEX¿ COLONIC; STENT, COLONIC, METALIC, EXPANDABLE

Model Number	M00565080
Medical Device Problem Code	Activation Failure (3270)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Date of Event	05/18/2018
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Patient's exact age is unknown; however, it was reported that the patient was over the age of 18.(b)(4).The device has been received for analysis; however the evaluation has not been completed.Therefore, the cause of the reported malfunction has not been determined.Upon completion of the failure analysis of the complaint device, if there is any further relevant information from that review, a supplemental medwatch will be filed.
Event or Problem Description
It was reported to boston scientific corporation on may 23, 2018 that a wallflex colonic stent was to be used to treat a colonic stenosis during a stenting procedure performed on (b)(6) 2018.According to the complainant, during the procedure, the stent was able to be deployed.However, the stent failed to fully expand on one end.The stent was removed with forceps and the procedure was completed with another wallflex colonic stent.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.X-ray image of the wallflex colonic deployed within the patient was received and seems to show an unexpanded portion of the stent within the anatomy.Video of the physician manipulating the stent after it was removed from patient was also received and appears to show that the flared end of the stent was slightly unexpanded.
Additional Manufacturer Narrative
A deployed wallflex colonic stent was received for analysis; the delivery system was not returned.Visual examination of the returned device found the stent was fully expanded.The stent was measured to be within specifications.The reported event that the stent failed to expand was unable to be confirmed based on the condition of the returned device; the stent was received fully expanded.However, a photo of the stent provided by the complainant showed the stent did not expand sufficiently.Taking all available information into consideration, the investigation concluded that the reported failure was likely due to anatomical or procedural factors encountered during the procedure which limited the performance of the device.Therefore, the most probable root cause is operational context.A labeling review was performed, and from the information available, this device was used per the directions for use (dfu) / product label.A review of the device history record (dhr) confirmed that the device met all material, assembly and product specifications at the time of release to distribution.A search of the complaint database revealed that no other similar complaints exist for the specified batch.
Event or Problem Description
It was reported to boston scientific corporation on may 23, 2018 that a wallflex colonic stent was to be used to treat a colonic stenosis during a stenting procedure performed on (b)(6) 2018.According to the complainant, during the procedure, the stent was able to be deployed.However, the stent failed to fully expand on one end.The stent was removed with forceps and the procedure was completed with another wallflex colonic stent.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.X-ray image of the wallflex colonic deployed within the patient was received and seems to show an unexpanded portion of the stent within the anatomy.Video of the physician manipulating the stent after it was removed from patient was also received and appears to show that the flared end of the stent was slightly unexpanded.

• Brand Name: WALLFLEX¿ COLONIC
• Common Device Name: STENT, COLONIC, METALIC, EXPANDABLE
• Manufacturer (Section D): BOSTON SCIENTIFIC - GALWAY
• MDR Report Key: 7601963
• Report Number: 3005099803-2018-01830
• Device Sequence Number: 18890386
• Product Code: MQR
• UDI-Device Identifier: 08714729456551
• UDI-Public: 08714729456551
• Combination Product (Y/N): N
• Initial Reporter Country: CN
• PMA/510(K) Number: K061877
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: company representative,foreig
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 05/23/2018

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: Yes
• Operator of Device: Health Professional
• Device Expiration Date: 09/21/2019
• Device Model Number: M00565080
• Device Catalogue Number: 6508
• Device Lot Number: 0021162046
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 05/28/2018
• Initial Date Received by Manufacturer: 05/23/2018
• Supplement Date Received by Manufacturer: 07/06/2018
• Initial Report FDA Received Date: 06/14/2018
• Supplement Report FDA Received Date: 08/01/2018
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention