inforMED
MalfunctionFDX

RX CYTOLOGY BRUSH

Received May 2, 2019 · Event occurred Mar 12, 2019

Report 3005099803-2019-02306 · MDR key 8573628

Device

Generic name

Endoscopic Cytology Brush

Model number

M00545000

Catalog number

4500

Lot number

0023268676

Product problems

  • Break
  • Mechanical Problem
  • Break
  • Mechanical Problem

Patient

Not reported

  • No Consequences Or Impact To Patient
  • No Consequences Or Impact To Patient

Narrative

Additional Manufacturer Narrative

(B)(4). INVESTIGATION RESULTS: AN RX CYTOLOGY BRUSH WAS RETURNED FOR ANALYSIS. A VISUAL ANALYSIS REVEALED THAT THE WORKING LENGTH (EXTRUSION AND PULL WIRE) WAS KINKED IN SEVERAL LOCATIONS. THE HANDLE WAS ACTUATED AND THE BRUSH WAS UNABLE TO EXTEND. THE DEVICE WAS DISASSEMBLED AND IT WAS OBSERVED THAT THE PULL WIRE WAS BROKEN AND KINKED ADJACENT TO THE HANDLE CANNULA JOINT. IT IS MOST LIKELY THAT PROCEDURAL OR ANATOMICAL FACTORS ENCOUNTERED DURING PROCEDURE COULD HAVE AFFECTED THE DEVICE PERFORMANCE AND ITS INTEGRITY. LIKELY, THE FAILURES FOUND (PULL WIRE/CATHETER KINKED, PULL WIRE BROKEN) WERE CAUSED DUE TO MANIPULATION AS THE CUSTOMER BRUSHED BACK AND FORTH DURING THE TESTING/USE OF THE DEVICE. HANDLING AND MANIPULATION OF THE DEVICE CAN LEAD TO KINKING OF THE CATHETER AND PULL WIRE. THIS CONDITION CAN CAUSE DIFFICULTIES TO EXTEND THE BRUSH. FORCE APPLIED TO THE HANDLE IN ORDER TO EXTEND THE BRUSH CAN RESULT IN KINKING THE PULL WIRE AT HANDLE CANNULA JOINT, ALSO CONTINUED MOVEMENTS OF THE HANDLE CAN RESULT IN PULL WIRE BREAKAGE. BASED ON THE INFORMATION AVAILABLE AND THE ANALYSIS PERFORMED, 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 AT THE TIME OF RELEASE FOR DISTRIBUTION.

Description of Event or Problem

IT WAS REPORTED TO BOSTON SCIENTIFIC CORPORATION THAT AN RX CYTOLOGY BRUSH WAS USED IN THE COMMON BILE DUCT DURING AN ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP) PROCEDURE PERFORMED ON (B)(6) 2019. ACCORDING TO THE COMPLAINANT, DURING THE PROCEDURE, THE BRUSH WAS UNABLE TO EXTEND OUT OF THE CATHETER. A SECOND BRUSH WAS USED, HOWEVER THE SAME ISSUE OCCURED. THE PROCEDURE WAS THEN COMPLETED WITH A THIRD RX CYTOLOGY BRUSH. THERE WERE NO PATIENT COMPLICATIONS REPORTED AS A RESULT OF THIS EVENT. THE PATIENT CONDITION FOLLOWING THE PROCEDURE WAS REPORTED TO BE STABLE. NOTE: THIS EVENT HAS BEEN DEEMED AN MDR-REPORTABLE EVENT BASED ON THE INVESTIGATION RESULTS WHICH REVEALED THAT THE PULL WIRE WAS BROKEN.