BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    SPYSCOPE DS ACCESS & DELIVERY CATHETER

    MDR report key: 7356781 · Received March 21, 2018

    Report

    Report Number
    3005099803-2018-00833
    Event Type
    Malfunction
    Date Received
    March 21, 2018
    Date of Event
    February 23, 2018
    Report Date
    February 26, 2018
    Manufacturer
    BOSTON SCIENTIFIC - SPENCER
    Product Code
    FBN
    UDI-DI
    08714729863236
    PMA / PMN Number
    K142922
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Occupation
    PHYSICIAN

    Narratives

    Additional Manufacturer Narrative · 1

    PATIENT'S EXACT AGE IS UNKNOWN; HOWEVER IT WAS REPORTED THAT THE PATIENT WAS OVER THE AGE OF 18. 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 ASSESSMENT WAS PERFORMED. THE CATHETER WAS KINKED IN SEVERAL LOCATIONS, BEGINNING NEAR THE DISTAL TIP. AS RECEIVED, THE WORKING CHANNEL SLEEVE PROTRUDED. MAXIMUM WORKING CHANNEL SLEEVE PROTRUSION WAS NOTED WHEN THE SMALL KNOB WAS ARTICULATED COUNTERCLOCKWISE AND THE LARGE KNOB ARTICULATED IN BOTH DIRECTIONS. A FUNCTIONAL EVALUATION WAS PERFORMED. THE DEVICE WAS PLUGGED INTO THE CONTROLLER AND NO IMAGE WAS DISPLAYED, CONFIRMING A LOST IMAGE. THE DISTAL TIP WAS CUT. THE DISTAL CAP WAS REMOVED. THE CATHETER WAS CUT OPEN USING THE CUTTING FIXTURE. THE WORKING CHANNEL SLEEVE WAS REMOVED. WITNESS MARKS WERE NOTED ON THE PEBAX. THE WHITE AND CLEAR AREAS ALONG BOND A APPEAR TO SHOW EVIDENCE OF ADHESION. THE COMPLAINT WAS CONSISTENT WITH THE REPORTED COMPLAINT INCIDENT OF ¿WORKING CHANNEL SLEEVE PROTRUDING FROM SPYSCOPE DS.¿ FURTHER INVESTIGATION FOUND THAT THE UNDERLYING CAUSE OF WORKING CHANNEL SLEEVE PROTRUSION IS AN INSUFFICIENT BOND, PARTICULARLY THE SECOND HEAT CYCLE OF THE WORKING CHANNEL SLEEVE BONDING PROCESS [BOND B]. THEREFORE, THE COMPLAINT INVESTIGATION CONCLUSION CODE SELECTED FOR THE WORKING CHANNEL SLEEVE PROTRUSION ISSUE IS MANUFACTURING PROCESS DESIGN. AN INVESTIGATION IS UNDERWAY TO ADDRESS THIS ISSUE. A DHR (DEVICE HISTORY RECORD) REVIEW WAS PERFORMED AND NO DEVIATION WAS FOUND.

    Description of Event or Problem · 1

    IT WAS REPORTED TO BOSTON SCIENTIFIC CORPORATION THAT A SPYSCOPE DIGITAL ACCESS AND DELIVERY CATHETER WAS USED IN THE INTRAHEPATIC BILE DUCT DURING A BIOPSY PROCEDURE PERFORMED ON (B)(6) 2018. ACCORDING TO THE COMPLAINANT, DURING THE PROCEDURE, IT WAS NOTICED THAT THE WORKING CHANNEL SLEEVE OF THE SPYSCOPE DS PROTRUDED. IT WAS ALSO REPORTED THAT THE SPYSCOPE DS IMAGE WAS LOST INTERMITTENTLY. THE PROCEDURE WAS CONTINUED TO A CERTAIN EXTENT, BUT WHEN THE IMAGE BECAME SEVERELY DISTORTED, THE USAGE WAS STOPPED AT THAT TIME. REPORTEDLY, NO PART OF THE DEVICE WAS DETACHED. THE PROCEDURE WAS NOT COMPLETED DUE TO THIS EVENT. THERE WERE NO PATIENT COMPLICATIONS REPORTED AS A RESULT OF THIS EVENT.

    Description of Event or Problem · 1

    IT WAS REPORTED TO BOSTON SCIENTIFIC CORPORATION THAT A SPYSCOPE DIGITAL ACCESS AND DELIVERY CATHETER WAS USED IN THE INTRAHEPATIC BILE DUCT DURING A BIOPSY PROCEDURE PERFORMED ON (B)(6) 2018. ACCORDING TO THE COMPLAINANT, DURING THE PROCEDURE, IT WAS NOTICED THAT THE WORKING CHANNEL SLEEVE OF THE SPYSCOPE DS PROTRUDED. IT WAS ALSO REPORTED THAT THE SPYSCOPE DS IMAGE WAS LOST INTERMITTENTLY. THE PROCEDURE WAS CONTINUED TO A CERTAIN EXTENT, BUT WHEN THE IMAGE BECAME SEVERELY DISTORTED, THE USAGE WAS STOPPED AT THAT TIME. REPORTEDLY, NO PART OF THE DEVICE WAS DETACHED. THE PROCEDURE WAS NOT COMPLETED DUE TO THIS EVENT. THERE WERE NO PATIENT COMPLICATIONS REPORTED AS A RESULT OF THIS EVENT.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    200480 SPYSCOPE DS ACCESS & DELIVERY CATHETER CHOLEDOCHOSCOPE AND ACCESSORIES, FLEXIBLE/RIGID FBN BOSTON SCIENTIFIC - SPENCER M00546600 21664241 08714729863236

    Patients

    Seq Age Sex Outcome Treatment
    1