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

Model Number	M00567330
Medical Device Problem Code	Material Puncture/Hole (1504)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Date of Event	02/01/2019
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Date of event: date of event was approximated to (b)(6) 2019 as no event date was reported.(b)(4).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
Note: this report pertains to one of two maxforce biliary dilatation balloons used during the same procedure.It was reported to boston scientific corporation that two maxforce biliary dilatation balloon were used during a biliary dilation procedure performed on an unknown date.According to the complainant, during the procedure, it was noted that the balloon had small holes.The same event occurred with the second device.The procedure was completed with another maxforce biliary dilatation balloon.There have been no patient complications reported as a result of this event.The patient condition at the conclusion of the procedure was reported to be stable.
Additional Manufacturer Narrative
Date of event: date of event was approximated to 02/01/2019 as no event date was reported.Investigation results a visual examination of the complaint device revealed that the balloon had a pinhole in the distal ro marker.The inner radio opaque (ro) markers inside the balloon were inspected for any sharp edge but none of them showed abnormalities.A functional examination was performed; however, it was not possible to inflate the balloon due to the lumen was occluded.It is possible that the procedural factors encountered during the procedure, the technique used by the physician, the amount of strength applied to the device during the movement, the interaction between the balloon and the scope, and/or the manner as the device was handled and manipulated by the customer when it was being used could have caused the damages found on the device.This failure is likely due to factors encountered during the procedure and/or the interaction with the scope that could have affected its performance and its intended purpose.Therefore, the most probable root cause is adverse event related to procedure.A review of the device history record (dhr) was performed and confirmed that this device met all material, assembly and performance specifications.A labeling review was performed and from the information available, this device was used per the directions for use (dfu)/product label.
Event or Problem Description
Note: this report pertains to one of two maxforce biliary dilatation balloons used during the same procedure.It was reported to boston scientific corporation that two maxforce biliary dilatation balloon were used during a biliary dilation procedure performed on an unknown date.According to the complainant, during the procedure, it was noted that the balloon had small holes.The same event occurred with the second device.The procedure was completed with another maxforce biliary dilatation balloon.There have been no patient complications reported as a result of this event.The patient condition at the conclusion of the procedure was reported to be stable.

• 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: 8440129
• Report Number: 3005099803-2019-01284
• Device Sequence Number: 13718867
• Product Code: FGE
• UDI-Device Identifier: 08714729097037
• UDI-Public: 08714729097037
• Combination Product (Y/N): N
• Initial Reporter Country: GM
• 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): 04/23/2019

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: 07/15/2021
• Device Model Number: M00567330
• Device Catalogue Number: 6733
• Device Lot Number: 22378509
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 03/12/2019
• Initial Date Received by Manufacturer: 02/25/2019
• Supplement Date Received by Manufacturer: 03/28/2019
• Initial Report FDA Received Date: 03/21/2019
• Supplement Report FDA Received Date: 04/23/2019
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1