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

Model Number	M00567330
Medical Device Problem Codes	Material Puncture/Hole (1504); Use of Device Problem (1670)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Date of Event	11/01/2019
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
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 the two maxforce biliary dilatation balloon used during the same procedure.It was reported to boston scientific corporation that two maxforce biliary dilatation balloon devices were used in the bile duct during a biliary dilatation procedure performed on an unknown date.According to the complainant, during preparation, the balloon was pre-inflated and it was noticed 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 were no patient complications reported as a result of this event.The patient condition at the conclusion of the procedure was reported to be fine.
Event or Problem Description
This report pertains to one of the two maxforce biliary dilatation balloon used during the same procedure.It was reported to boston scientific corporation that two maxforce biliary dilatation balloon devices were used in the bile duct during a biliary dilatation procedure performed on an unknown date.According to the complainant, during preparation, the balloon was pre-inflated and it was noticed 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 were no patient complications reported as a result of this event.The patient condition at the conclusion of the procedure was reported to be fine.
Additional Manufacturer Narrative
Date of event: date of event was approximated to (b)(6) 2019 as no event date was reported.Problem code 1504 captures the reportable event result of balloon pinhole.Investigation result: a visual examination of the returned complaint device revealed that the balloon contained residues of dry contrast inside.The inner radio opaque (ro) markers inside the balloon were inspected for any sharp edge but none of them showed abnormalities.No kinks or damage was noted on the shaft of the device.Functional evaluation was performed; however, it was not possible to inflate the balloon due to the lumen was occluded and impossible to unclog.This failure is likely due to factors encountered during the procedure, such as handling of the device, the technique used by the physician and normal procedural difficulties encountered during the procedure, that could have affected device 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.

• 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: 9386418
• Report Number: 3005099803-2019-05517
• Device Sequence Number: 16260843
• 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): 12/30/2019

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: 0022378508
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 11/20/2019
• Initial Date Received by Manufacturer: 11/04/2019
• Supplement Date Received by Manufacturer: 12/03/2019
• Initial Report FDA Received Date: 11/27/2019
• Supplement Report FDA Received Date: 12/30/2019
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1