FDA Adverse Event Malfunction Summary report: N

CRE WIREGUIDED

MDR report key: 21355259 · Received February 11, 2025

Report

Report Number
3005099803-2025-00419
Event Type
Malfunction
Date Received
February 11, 2025
Date of Event
January 20, 2025
Report Date
April 9, 2025
Manufacturer
BOSTON SCIENTIFIC CORPORATION
Product Code
FDF
PMA / PMN Number
K110833
Product Problem
Yes
Report Source
Manufacturer report
Reporter Location
CO, US
Reporter Occupation
PHYSICIAN
Health Professional
Yes

Narratives

Additional Manufacturer Narrative · 0

BLOCK D2B: THE REMAINING PRO CODES (PRODUCT CODES) ARE FDT AND KNQ; REPORTED HERE AS PRO CODES (PRODUCT CODES) EXCEEDED THE CHARACTER LIMIT FOR THE DESIGNATED FIELD. BLOCK H6: IMDRF DEVICE CODE A0402 CAPTURES THE REPORTABLE EVENT OF A BALLOON BURST. BLOCK H11: INVESTIGATION RESULTS THE RETURNED CRE WIREGUIDED DILATATION BALLOON WAS ANALYZED, AND A VISUAL AND MICROSCOPIC EVALUATION FOUND THE BALLOON HAD A LONGITUDINAL TEAR. NO OTHER PROBLEMS WITH THE DEVICE WERE NOTED. WITH ALL THE AVAILABLE INFORMATION, BOSTON SCIENTIFIC (BSC) CONCLUDES THAT THE REPORTED EVENT OF BALLOON BURST COULD NOT BE CONFIRMED. THE RETURNED DEVICE HAD A LONGITUDINAL TEAR AND COULD HAVE BEEN INTERPRETED BY THE CUSTOMER AS THE REPORTED EVENT OF BALLOON BURST. IT IS LIKELY THE LONGITUDINAL TEAR OCCURRED DUE TO FACTORS ENCOUNTERED DURING THE PROCEDURE, SUCH AS EXCESS PRESSURE, INTERACTION WITH OTHER DEVICES, OR ANATOMICAL FACTORS. ALSO, IT IS POSSIBLE THAT INTERACTION WITH ANY KIND OF SHARP SURFACE DURING OR PREVIOUS TO THE PROCEDURE COULD CREATE FRICTION ON THE BALLOON, CAUSING THE LONGITUDINAL TEAR DURING THE PROCEDURE. THEREFORE, THE MOST PROBABLE ROOT CAUSE IS ADVERSE EVENT RELATED TO PROCEDURE.

Additional Manufacturer Narrative · 0

BLOCK D2B: THE REMAINING PRO CODES (PRODUCT CODES) ARE FDT AND KNQ; REPORTED HERE AS PRO CODES (PRODUCT CODES) EXCEEDED THE CHARACTER LIMIT FOR THE DESIGNATED FIELD. BLOCK H6: IMDRF DEVICE CODE A0402 CAPTURES THE REPORTABLE EVENT OF A BALLOON BURST.

Description of Event or Problem · 0

IT WAS REPORTED TO BOSTON SCIENTIFIC CORPORATION THAT A CRE WIREGUIDED DILATATION BALLOON WAS ATTEMPTED TO BE USED IN THE ESOPHAGUS DURING AN ESOPHAGEAL DILATION PROCEDURE PERFORMED ON (B)(6) 2025. DURING THE PROCEDURE, THE BALLOON WAS INFLATED FIRST TO 16.5 MM AT 4.5 ATM THEN DEFLATED AND WENT UP TO 18 MM AT 7 ATM. THE BALLOON POPPED AT 6.5 ATM. IT WAS REPORTED THAT NO PIECE OF THE BALLOON DETACHED INSIDE THE PATIENT. THE PROCEDURE WAS COMPLETED WITH ANOTHER CRE WIREGUIDED DILATATION BALLOON. THERE WERE NO PATIENT COMPLICATIONS REPORTED AS A RESULT OF THIS EVENT.

Description of Event or Problem · 0

IT WAS REPORTED TO BOSTON SCIENTIFIC CORPORATION THAT A CRE WIREGUIDED DILATATION BALLOON WAS ATTEMPTED TO BE USED IN THE ESOPHAGUS DURING AN ESOPHAGEAL DILATION PROCEDURE PERFORMED ON (B)(6) 2025. DURING THE PROCEDURE, THE BALLOON WAS INFLATED FIRST TO 16.5 MM AT 4.5 ATM THEN DEFLATED AND WENT UP TO 18 MM AT 7 ATM. THE BALLOON POPPED AT 6.5 ATM. IT WAS REPORTED THAT NO PIECE OF THE BALLOON DETACHED INSIDE THE PATIENT. THE PROCEDURE WAS COMPLETED WITH ANOTHER CRE WIREGUIDED DILATATION BALLOON. THERE WERE NO PATIENT COMPLICATIONS REPORTED AS A RESULT OF THIS EVENT.

Devices

Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
1625266 CRE WIREGUIDED COLONOSCOPE AND ACCESSORIES, FLEXIBLE/RIGID FDF BOSTON SCIENTIFIC CORPORATION M00558490 0032269665

Patients

Seq Age Sex Outcome Treatment
1 NA Unknown