MAUDE Adverse Event Report: BOSTON SCIENTIFIC CORPORATION PASSPORT KIT; DILATOR, CATHETER, URETERAL

Model Number	M0062181300
Medical Device Problem Code	Material Split, Cut or Torn (4008)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Date of Event	05/13/2019
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
(b)(4).Investigation result: a visual examination of the returned complaint device found that the balloon had a longitudinal tear which started at the distal transition end of the balloon and extended proximally along the balloon.There was no evidence to suggest that the device was used in a manner inconsistent with the labelled indications.This failure is likely due to factors or conditions related to procedure during the use of the device 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.
Event or Problem Description
It was reported to boston scientific corporation that a passport dilation balloon catheter was used in the ureter during a ureteroscopy (urs) procedure performed on (b)(6) 2019.According to the complainant, during the procedure, it was noticed that the balloon was perforated.The procedure was completed with another passport dilation balloon catheter.There were no patient complications reported as a result of this event.Investigation results revealed that the balloon was torn longitudinally; therefore, this is now an mdr reportable event.

• Brand Name: PASSPORT KIT
• Common Device Name: DILATOR, CATHETER, URETERAL
• Manufacturer (Section D): BOSTON SCIENTIFIC CORPORATION; 300 boston scientific way; marlborough MA 01752
• MDR Report Key: 8811035
• Report Number: 3005099803-2019-03625
• Device Sequence Number: 2513948
• Product Code: EZN
• UDI-Device Identifier: 08714729042594
• UDI-Public: 08714729042594
• Combination Product (Y/N): N
• Initial Reporter Country: BE
• PMA/510(K) Number: K941853
• 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
• Report Date (Section B): 07/22/2019

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: 04/15/2021
• Device Model Number: M0062181300
• Device Catalogue Number: 218-130
• Device Lot Number: 0022608903
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 05/28/2019
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 06/27/2019
• Initial Report FDA Received Date: 07/22/2019
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1