FDA Adverse Event Malfunction Summary report: N

AXIOS

MDR report key: 21103444 · Received January 8, 2025

Report

Report Number
3005099803-2024-06845
Event Type
Malfunction
Date Received
January 8, 2025
Date of Event
December 10, 2024
Report Date
April 22, 2025
Manufacturer
BOSTON SCIENTIFIC CORPORATION
Product Code
KNS
UDI-DI
08714729904595
PMA / PMN Number
K233318
Product Problem
Yes
Report Source
Manufacturer report
Reporter Location
TX, US
Reporter Occupation
PHYSICIAN
Health Professional
Yes

Narratives

Additional Manufacturer Narrative · 0

BLOCK H6: IMDRF DEVICE CODE F1001 CAPTURES THE REPORTABLE EVENT OF PROCEDURE ABORTED OR CANCELLED. BLOCK H11: AN AXIOS STENT AND ELECTROCAUTERY ENHANCED DELIVERY SYSTEM WAS RECEIVED FOR ANALYSIS. VISUAL EXAMINATION OF THE RETURNED DEVICE FOUND THAT THE TIP OF THE NOSECONE HAD EVIDENCE OF CAUTERY. THE ELECTRICAL INSPECTION RELATED TO THE CONTINUITY BETWEEN THE RF CONNECTOR AND DISTAL RF ELECTRODE WAS PERFORMED AND NO ISSUES WERE NOTED. ALSO, THE DEVICE WAS CONNECTED TO THE ERBE, AND BUBBLES WAS SEEN IN THE SALINE SOLUTION THAT IS EVIDENCE THAT THE TIP IS WORKING PROPERLY. AN IMAGE RECEIVED FROM THE CUSTOMER WHICH WAS ANALYZED AND SHOWED THE DEVICE INSIDE THE PATIENT. THERE WERE NO DAMAGES NOTED ON THE RETURNED DEVICE. PRODUCT ANALYSIS DID NOT CONFIRM THE REPORTED EVENT OF CAUTERY FAILURE TO DELIVER ENERGY AS THE RETURNED DEVICE PASSED ALL THE ELECTRICAL AND FUNCTIONAL INSPECTIONS. THERE WAS NO EVIDENCE FOUND THAT THE CAUTERY DID NOT DELIVER ENERGY. THEREFORE, A REVIEW AND ANALYSIS OF ALL AVAILABLE INFORMATION INDICATED THE MOST PROBABLE CAUSE IS NO PROBLEM DETECTED.

Additional Manufacturer Narrative · 0

BLOCK D2B: PRODUCT CODE : KNS, PCU, QXH; REPORTED HERE AS THE PRODUCT CODE EXCEEDED CHARACTER LIMIT FOR THE DESIGNATED FIELD. BLOCK H6: IMDRF DEVICE CODE F1001 CAPTURES THE REPORTABLE EVENT OF PROCEDURE ABORTED OR CANCELLED.

Description of Event or Problem · 0

IT WAS REPORTED TO BOSTON SCIENTIFIC CORPORATION THAT AN AXIOS STENT AND ELECTROCAUTERY ENHANCED DELIVERY SYSTEM WAS TO BE IMPLANTED TRANSDUODENAL TO THE GALLBLADDER TO TREAT A CHOLITHIASIS DURING AN ENDOSCOPIC ULTRASOUND (EUS) PROCEDURE PERFORMED ON (B)(6) 2024. DURING THE PROCEDURE, THE PHYSICIAN ATTEMPTED TO ACTIVATE THE CAUTERY TO PUNCTURE THE DUODENUM TO PLACE ACCESS INTO THE GALLBLADDER VIA ES IMAGE. WHEN THE ENDOSCOPIC VIEW WAS REGAINED, IT WAS SEEN THAT THE AXIOS CATHETER WOULD NOT PUNCTURE THE DUODENAL WALL. THE PROCEDURE WAS ABORTED AS A RESULT OF THIS EVENT. TO COMPLETE THE PROCEDURE, THE PATIENT WAS SENT FOR A GALLBLADDER REMOVAL THAT WAS PERFORMED ON (B)(6) 2024. THERE WAS NO PATIENT COMPLICATIONS REPORTED AS A RESULT OF THIS EVENT.

Description of Event or Problem · 0

IT WAS REPORTED TO BOSTON SCIENTIFIC CORPORATION THAT AN AXIOS STENT AND ELECTROCAUTERY ENHANCED DELIVERY SYSTEM WAS TO BE IMPLANTED TRANSDUODENAL TO THE GALLBLADDER TO TREAT A CHOLITHIASIS DURING AN ENDOSCOPIC ULTRASOUND (EUS) PROCEDURE PERFORMED ON (B)(6) 2024. DURING THE PROCEDURE, THE PHYSICIAN ATTEMPTED TO ACTIVATE THE CAUTERY TO PUNCTURE THE DUODENUM TO PLACE ACCESS INTO THE GALLBLADDER VIA ES IMAGE. WHEN THE ENDOSCOPIC VIEW WAS REGAINED, IT WAS SEEN THAT THE AXIOS CATHETER WOULD NOT PUNCTURE THE DUODENAL WALL. THE PROCEDURE WAS ABORTED AS A RESULT OF THIS EVENT. TO COMPLETE THE PROCEDURE, THE PATIENT WAS SENT FOR A GALLBLADDER REMOVAL THAT WAS PERFORMED ON (B)(6) 2024. THERE WAS NO PATIENT COMPLICATIONS REPORTED AS A RESULT OF THIS EVENT.

Devices

Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
1235099 AXIOS UNIT, ELECTROSURGICAL, ENDOSCOPIC (WITH OR WITHOUT ACCESSORIES) KNS BOSTON SCIENTIFIC CORPORATION M00553650 0034101934 08714729904595

Patients

Seq Age Sex Outcome Treatment
1 NA Unknown