MAUDE Adverse Event Report: BOSTON SCIENTIFIC CORPORATION SPYGLASS RETRIEVAL SNARE; ENDOSCOPIC GRASPING/CUTTING INSTRUMENT, NON-POWERED

Model Number	M00546560
Medical Device Problem Code	Detachment of Device or Device Component (2907)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Date of Event	10/25/2018
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
(b)(4).The device has not been received for analysis.Upon receipt and 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 that a spyglass retrieval snare was used during an endoscopic retrograde cholangiopancreatography (ercp) procedure performed in the common bile duct on (b)(6) 2018.According to the complainant, during the procedure, two spysnares broke while trying to retrieve a plastic stent.One of the spysnares had the loop wire break inside the patient.The loop wire was retrieved with a forcep.The procedure was completed with a different device.There were no patient complications reported as a result of this event.
Additional Manufacturer Narrative
(b)(4).Block h10: a visual assessment was performed and found that the peek extrusion was detached from the handle.The handle was actuated.The loop could not be extended due to the section of the device that was found to be damaged (peek extrusion detached), confirming the complaint.The loop was detached from the metal cannula from the distal section of the device.The metal cannula was inspected.Glue residues and crimp marks were observed, indicating that the device was properly assembled during the manufacturing process.The failure of loop detached is an issue that could have been generated by excessive manipulation of the device by the user and/or excess of force applied to the distal section of the device.Therefore, the appropriate conclusion code is cause traced to component failure, since the failure was an expected or random component failure without any design or manufacturing issue.A review of the device history record (dhr) was performed and no anomalies were observed.The review confirmed that the accepted device met all manufacturing specifications.
Event or Problem Description
It was reported to boston scientific corporation that a spyglass retrieval snare was used during an endoscopic retrograde cholangiopancreatography (ercp) procedure performed in the common bile duct on (b)(6) 2018.According to the complainant, during the procedure, two spysnares broke while trying to retrieve a plastic stent.One of the spysnares had the loop wire break inside the patient.The loop wire was retrieved with a forcep.The procedure was completed with a different device.There were no patient complications reported as a result of this event.

• Brand Name: SPYGLASS RETRIEVAL SNARE
• Common Device Name: ENDOSCOPIC GRASPING/CUTTING INSTRUMENT, NON-POWERED
• Manufacturer (Section D): BOSTON SCIENTIFIC CORPORATION; 100 boston scientific way; marlborough MA 01752 1242
• MDR Report Key: 8094167
• Report Number: 3005099803-2018-61545
• Device Sequence Number: 2178992
• Product Code: PTS
• UDI-Device Identifier: 08714729965893
• UDI-Public: 08714729965893
• Combination Product (Y/N): N
• Initial Reporter State: AL
• Initial Reporter Country: US
• PMA/510(K) Number: EXEMPT
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: company representative,health
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 01/03/2019

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: 06/10/2020
• Device Model Number: M00546560
• Device Catalogue Number: 4656
• Device Lot Number: 0022236120
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 11/16/2018
• Initial Date Received by Manufacturer: 10/25/2018
• Supplement Date Received by Manufacturer: 12/11/2018
• Initial Report FDA Received Date: 11/21/2018
• Supplement Report FDA Received Date: 01/03/2019
• 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
• Patient Age: 70 YR