FDA Adverse Event Injury Summary report: N

EXTRACTOR? PRO RX

MDR report key: 3943245 · Received July 18, 2014

Report

Report Number
3005099803-2014-02555
Event Type
Injury
Date Received
July 18, 2014
Report Date
June 27, 2014
Manufacturer
BOSTON SCIENTIFIC - CORK
Product Code
FGE
PMA / PMN Number
K102082
Adverse Event
Yes
Product Problem
Yes
Report Source
Manufacturer report
Reporter Location
GA, US
Reporter Occupation
PHYSICIAN

Narratives

Additional Manufacturer Narrative · 1

(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.

Additional Manufacturer Narrative · 1

A VISUAL EXAMINATION OF THE COMPLAINT DEVICE REVEALED THAT THE BALLOON WAS DETACHED FROM THE CATHETER. THE REST OF THE CATHETER WAS EXAMINED AND NO ISSUES WERE NOTED. THE DETACHED BALLOON WAS RETURNED AND THE DISTAL TIP WAS INTACT. THE BALLOON BONDS WERE FOUND TO BE CONTINUOUS AND INTACT. IT IS LIKELY THAT THE BALLOON COULD HAVE BEEN BURST AND THEN DETACHED FROM THE CATHETER UPON CATHETER WITHDRAWAL. THE MOST PROBABLE ROOT CAUSE OF OPERATIONAL CONTEXT WILL BE ASSIGNED TO THIS COMPLAINT AS IT IS MOST LIKELY THAT THE COMPLAINT WAS DUE TO SOME PROCEDURAL/ANATOMICAL FACTORS ENCOUNTERED DURING THE PROCEDURE WHICH LIMITED PERFORMANCE OF THE DEVICE. A REVIEW OF THE DEVICE HISTORY RECORD (DHR) WAS PERFORMED AND CONFIRMED THAT THIS DEVICE MET ALL MATERIAL, ASSEMBLY AND PERFORMANCE SPECIFICATIONS. A SEARCH OF THE COMPLAINT DATABASE REVEALED THAT NO OTHER COMPLAINTS EXIST FOR THE SPECIFIED LOT. A LABELING REVIEW WAS PERFORMED AND FROM THE INFORMATION AVAILABLE, THIS DEVICE WAS USED PER THE DIRECTIONS FOR USE (DFU) / PRODUCT LABEL.

Description of Event or Problem · 1

IT WAS REPORTED TO BOSTON SCIENTIFIC CORPORATION THAT AN EXTRACTOR PRO RETRIEVAL BALLOON WAS USED IN AN ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY PROCEDURE IN THE COMMON BILE DUCT. ACCORDING TO THE COMPLAINANT, DURING THE PROCEDURE, INSIDE THE PATIENT, THE BALLOON POPPED OFF AT FULL INFLATION. IT IS UNCLEAR FROM THE INFORMATION AVAILABLE WHETHER THE BALLOON MATERIAL DETACHED OR IF THE DISTAL TIP DETACHED. REPORTEDLY, THEY WERE ABLE TO RETRIEVE THE DETACHED FRAGMENT SUCCESSFULLY WITH A RAT TOOTH RETRIEVAL DEVICE. THE PROCEDURE WAS FINISHED WITH ANOTHER EXTRACTOR BALLOON. THERE WERE NO COMPLICATIONS REPORTED AS A RESULT OF THIS EVENT. THE PATIENT'S CONDITION AT THE CONCLUSION OF THE PROCEDURE WAS REPORTED TO BE FINE. ATTEMPTS TO OBTAIN ADDITIONAL PATIENT AND PROCEDURE INFORMATION HAVE BEEN UNSUCCESSFUL. IF FURTHER INFORMATION IS OBTAINED, A SUPPLEMENTAL MDR WILL BE FILED.

Description of Event or Problem · 1

IT WAS REPORTED TO BOSTON SCIENTIFIC CORPORATION THAT AN EXTRACTOR PRO RETRIEVAL BALLOON WAS USED IN AN ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY PROCEDURE IN THE COMMON BILE DUCT. ACCORDING TO THE COMPLAINANT, DURING THE PROCEDURE, INSIDE THE PATIENT, THE BALLOON POPPED OFF AT FULL INFLATION. IT IS UNCLEAR FROM THE INFORMATION AVAILABLE WHETHER THE BALLOON MATERIAL DETACHED OR IF THE DISTAL TIP DETACHED. REPORTEDLY, THEY WERE ABLE TO RETRIEVE THE DETACHED FRAGMENT SUCCESSFULLY WITH A RAT TOOTH RETRIEVAL DEVICE. THE PROCEDURE WAS FINISHED WITH ANOTHER EXTRACTOR BALLOON. THERE WERE NO COMPLICATIONS REPORTED AS A RESULT OF THIS EVENT. THE PATIENT'S CONDITION AT THE CONCLUSION OF THE PROCEDURE WAS REPORTED TO BE FINE. ATTEMPTS TO OBTAIN ADDITIONAL PATIENT AND PROCEDURE INFORMATION HAVE BEEN UNSUCCESSFUL. IF FURTHER INFORMATION IS OBTAINED, A SUPPLEMENTAL MDR WILL BE FILED.

Devices

Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
421448 EXTRACTOR? PRO RX CATHETER, BILIARY, DIAGNOSTIC FGE BOSTON SCIENTIFIC - CORK M00547020 0016494762

Patients

Seq Age Sex Outcome Treatment
1 Required Intervention