MAUDE Adverse Event Report: BOSTON SCIENTIFIC CORPORATION MAXFORCE; CATHETER, BILIARY, DIAGNOSTIC

Model Number	M00567420
Medical Device Problem Code	Deflation Problem (1149)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Date of Event	11/07/2018
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
(b)(6).Problem code for the reportable issue of balloon failed to deflate.Although the suspect device has been received, 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 mdr will be filed.
Event or Problem Description
It was reported to boston scientific corporation that a maxforce biliary dilatation balloon was used in the papilla during an endoscopically performed biliary drainage (epbd) procedure performed on (b)(6) 2018.According to the complainant, during the procedure, it was noted that there was difficulty in inflating the balloon, after adding pressure the balloon successfully inflated; however, it cannot be deflated.Reportedly, the catheter was forcibly removed from the patient and papillotomy was additionally performed.The procedure was completed with a non-bsc device.There were no patient complications reported as a result of this event.
Additional Manufacturer Narrative
Initial reporter city: (b)(6).(b)(4).Investigation result: a visual examination of the returned complaint device did not show visual defects.A functional examination was performed and the balloon was inflated successfully and no resistance encountered.The balloon was able to be successfully deflated.Based on the analysis performed and the information provided, the most probable root cause for the complaint event is no problem detected since the device complaint or problem cannot be confirmed.  a review of the device history record (dhr) was performed and confirmed that this device met all material, assembly and performance specifications.
Event or Problem Description
It was reported to boston scientific corporation that a maxforce biliary dilatation balloon was used in the papilla during an endoscopically performed biliary drainage (epbd) procedure performed on (b)(6) 2018.According to the complainant, during the procedure, it was noted that there was difficulty in inflating the balloon, after adding pressure the balloon successfully inflated; however, it cannot be deflated.Reportedly, the catheter was forcibly removed from the patient and papillotomy was additionally performed.The procedure was completed with a non-bsc device.There were no patient complications reported as a result of this event.

• Brand Name: MAXFORCE
• Common Device Name: CATHETER, BILIARY, DIAGNOSTIC
• Manufacturer (Section D): BOSTON SCIENTIFIC CORPORATION; 300 boston scientific way; marlborough MA 01752
• MDR Report Key: 8126327
• Report Number: 3005099803-2018-61657
• Device Sequence Number: 2166022
• Product Code: FGE
• UDI-Device Identifier: 08714729097099
• UDI-Public: 08714729097099
• Combination Product (Y/N): N
• Initial Reporter Country: JA
• PMA/510(K) Number: K910931
• 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): 12/31/2018

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: 05/19/2019
• Device Model Number: M00567420
• Device Catalogue Number: 6742
• Device Lot Number: 0019277317
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 11/21/2018
• Initial Date Received by Manufacturer: 11/07/2018
• Supplement Date Received by Manufacturer: 12/04/2018
• Initial Report FDA Received Date: 12/03/2018
• Supplement Report FDA Received Date: 12/31/2018
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1