RESOLUTION II CLIP

K102764 · Boston Scientific Corporation · PKL · Dec 22, 2010 · Gastroenterology, Urology

Device Facts

• Record ID: K102764
• Device Name: RESOLUTION II CLIP
• Applicant: Boston Scientific Corporation
• Product Code: PKL · Gastroenterology, Urology
• Decision Date: Dec 22, 2010
• Decision: SESE
• Submission Type: Traditional
• Regulation: 21 CFR 876.4400
• Device Class: Class 2
• Attributes: Therapeutic

Intended Use

The Resolution II Clip is indicated for clip placement within the Gastrointestinal Tract for the purpose of: 1. Endoscopic Marking 2. Hemostasis for: Mucosal/sub-mucosal defects < 3 cm Bleeding ulcers Arteries < 2 mm Polyps < 1.5 cm in diameter Diverticula in the colon 3. Anchoring to affix jejunal feeding tubes to the wall of the small bowel 4. As a supplementary method for closure of GI tract luminal perforations <20mm that can be treated conservatively

Device Story

Resolution II Clip is a single-use, radiopaque endoscopic clipping device; used for hemostasis, marking, anchoring, and closure in the GI tract. Device consists of a pre-loaded clip on a flexible delivery system; compatible with gastroscopes (≥2.8mm channel) and duodenoscopes/colonoscopes (≥3.2mm channel). Jaws allow up to five open/close cycles for repositioning at lesion sites. Operated by physicians during endoscopic procedures. Deployed clip made of stainless steel; delivery system made of stainless steel, polyethylene, and polyester. Device provides mechanical closure or compression of tissue/vessels to achieve hemostasis or affix feeding tubes, aiding in patient management of GI defects and bleeding.

Clinical Evidence

Bench testing only. Evaluations conducted per EN ISO 10993-1:2009 (biocompatibility: cytotoxicity, sensitization, intracutaneous reactivity, subacute toxicity, genotoxicity, implantation, USP physicochemical) and ISO 14630:2008 (mechanical: forces, tensile strengths, corrosion resistance, dimensional, endoscope compatibility). All tests passed.

Technological Characteristics

Stainless steel clip; delivery system of stainless steel, polyethylene, and polyester. Flexible delivery system compatible with standard endoscopes. Mechanical actuation via delivery system. Biocompatibility per EN ISO 10993-1:2009; mechanical testing per ISO 14630:2008. Single-use.

Indications for Use

Indicated for patients requiring endoscopic marking, hemostasis (mucosal/sub-mucosal defects <3cm, bleeding ulcers, arteries <2mm, polyps <1.5cm, colonic diverticula), jejunal feeding tube anchoring, or closure of GI tract luminal perforations <20mm.

Regulatory Classification

Identification

A hemorrhoidal ligator is a device used to cut off the blood flow to hemorrhoidal tissue by means of a ligature or band placed around the hemorrhoid.

Special Controls

*Classification.* Class II (special controls). Except for a hemostatic metal clip intended for use in the gastrointestinal tract, the device is exempt from the premarket notification procedures in subpart E of part 807 of this chapter subject to the limitations in § 876.9.

Predicate Devices

• Resolution Hemostasis Clipping Device (K040148)

Submission Summary (Full Text)

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K102764
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SECTION 6 510(k) SUMMARY

#### 1. Submitter

Boston Scientific Corporation 100 Boston Scientific Way Marlborough, MA 01752 Telephone: [phone] Fax: [phone]

Contact: Elena Nieves Sr. Regulatory Affairs Specialist Date Prepared: August 30, 2010

### 2. Device

Trade Name: Resolution II Clip Common Name: Endoscopic Clipping Device Classification Name: Hemorrhoidal Ligator Regulation Number: 876.4400 Product Code: FIN and MND Classification: Class II

# 3. Predicate Devices

Boston Scientific Corporation, Resolution Hemostasis Clipping Device (K040148)

# 4. Device Description

The Resolution II Clip consists of a pre-loaded, radiopaque, single-use clip on u flexible delivery system.

The Resolution II Clip is designed to be compatible with Gastroscopes with working channels ≥2.8, and/or Duodenoscopes and Colonoscopes with working channels ≥3.2mm.

The Resolution II Clip jaws are engineered to open and close no more than five times, aiding in repositioning of the clip at the lesion site. Opening and closing capability may be linited by clinical circumstances and patient anatomy, among other factors.

The Resolution II Clip will be offered in 155cm and 235cm lengths. The deployed clip is constructed of stainless steel while the delivery system is constructed of stainless steel, polyethylene, and polyester materials.

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DEC 2 2 2010

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K102764
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#### 5. Indication for Use:

The Resolution II Clip is indicated for clip placement within the Gastrointestinal Tract for the purpose ol:

- 1. Endoscopic Marking
- 2. Hemostasis for:
- Mucosal/sub-mucosal defects < 3 cm
- Blecding ulcers
- . Arteries < 2 mm
- Polyps < 1.5 cm in diameter .
- Diverticula in the colon �
- 3. Anchoring to affix jejunal feeding tubes to the wall of the small bowel
- 4. As a supplementary method for closure of GI tract luminal perforations <20mm that can be treated conservatively

# 6. Technological Characteristics:

The proposed Resolution™ II Clip has the same technological characteristics as the predicate Resolution" M Hemostasis Clipping Device (K040148).

The proposed device has the same intended use and is placed using the same methodology as the predicate device via a flexible delivery system. However, the proposed device functions in a different manner by allowing for clip placement within the gastrointestinal tract with fewer deployment steps.

The materials of the proposed Resolution II Clip can be found above in part 4 of this 510(k) summary.

#### 7. Performance Data:

The proposed Resolution II Clip deployed clip was evaluated in accordinge with EN ISO 10993-1:2009. The following tests were performed on the deployed clip: Cytotoxicity. Sensitization. Intracutaneous Reactivity, Subacute (Subchronic) Toxicity -Intraperitoncal and Intravenous. Genotoxicity - Ames Assay and Mouse Lymphoma, Implantation, and USP Physicochemical.

The delivery system was evaluated in accordance with EN ISO 10993-1:2009. The following tests were performed on the delivery system: Cytotoxicity, Sensitization, and Intracutaneous Reactivity.

The proposed Resolution II Clip was evaluated in accordance with ISO 14630:2008. The following tests were conducted on the Resolution II Clip: Forces, Tensile Strengths, Corrosion Resistance, Dimensional, and Endoscope Compatibility.

#### 8. Conclusion:

All biocompatibility tests conducted on the Resolution II Clip passed. Therefore, the Resolution II Clip is considered biocompatible for its intended use.

All device bench test results were acceptable. The data demonstrate that the Resolution II Clip sufficiently mects the design specifications and is suitable for the intended use.

Boston Scientific has demonstrated that the proposed Resolution II Clip is substantially equivalent to Boston Scientific Corporations currently marketed Resolution Clip (K040148).

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Image /page/2/Picture/1 description: The image is a black and white logo for the U.S. Department of Health & Human Services. The logo consists of a stylized eagle with three lines forming its body and wings. The words "DEPARTMENT OF HEALTH & HUMAN SERVICES USA" are arranged in a circular pattern around the eagle.

Food and Drug Administration 10903 New Hampshire Avenue Document Control Center - WO66-G609 Silver Spring, MD 20993-0002

March 25, 2015

Boston Scientific Corporation Elena Nieves Sr. Regulatory Affairs Specialist 100 Boston Scientific Way Marlborough, MA 01752

Re: K102764 Trade/Device Name: Resolution II Clip Regulation Number: 21 CFR§ 876.4400 Regulation Name: Hemorrhoidal ligator Regulatory Class: II Product Code: PKL Dated (Date on orig SE ltr): September 23, 2010 Received (Date on orig SE ltr): September 24, 2010

Dear Elena Nieves,

This letter corrects our substantially equivalent letter of December 22, 2010.

We have reviewed your Section 510(k) premarket notification of intent to market the device referenced above and have determined the device is substantially equivalent (for the indications for use stated in the enclosure) to legally marketed predicate devices marketed in interstate commerce prior to May 28, 1976, the enactment date of the Medical Device Amendments or to devices that have been reclassified in accordance with the provisions of the Federal Food, Drug, and Cosmetic Act (Act) that do not require approval of a premarket approval application (PMA). You may, therefore, market the device, subject to the general controls provisions of the Act. The general controls provisions of the Act include requirements for annual registration, listing of devices, good manufacturing practice, labeling, and prohibitions against misbranding and adulteration. Please note: CDRH does not evaluate information related to contract liability warranties. We remind you, however, that device labeling must be truthful and not misleading.

If your device is classified (see above) into either class II (Special Controls) or class III (PMA), it may be subject to additional controls. Existing major regulations affecting your device can be

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found in the Code of Federal Regulations, Title 21, Parts 800 to 898. In addition, FDA may publish further announcements concerning your device in the Federal Register.

Please be advised that FDA's issuance of a substantial equivalence determination does not mean that FDA has made a determination that your device complies with other requirements of the Act or any Federal statutes and regulations administered by other Federal agencies. You must comply with all the Act's requirements, including, but not limited to: registration and listing (21 CFR Part 807); labeling (21 CFR Part 801); medical device reporting (reporting of medical device-related adverse events) (21 CFR 803); good manufacturing practice requirements as set forth in the quality systems (QS) regulation (21 CFR Part 820); and if applicable, the electronic product radiation control provisions (Sections 531-542 of the Act); 21 CFR 1000-1050.

If you desire specific advice for your device on our labeling regulation (21 CFR Part 801), please contact the Division of Small Manufacturers. International and Consumer Assistance at its toll-free number [phone] or [phone] or at its Internet address http://www.fda.gov/MedicalDevices/ResourcesforYou/Industry/default.htm. Also, please note the regulation entitled, "Misbranding by reference to premarket notification" (21CFR Part 807.97). For questions regarding the reporting of adverse events under the MDR regulation (21 CFR Part 803), please go to http://www.fda.gov/MedicalDevices/Safety/ReportaProblem/default.htm for the CDRH's Office

of Surveillance and Biometrics/Division of Postmarket Surveillance.

You may obtain other general information on your responsibilities under the Act from the Division of Small Manufacturers, International and Consumer Assistance at its toll-free number [phone] or [phone] or at its Internet address http://www.fda.gov/MedicalDevices/ResourcesforYou/Industry/default.htm.

Sincerely yours,

# Joyce M. Whang -S

for Beniamin R. Fisher, Ph.D. Director Division of Reproductive, Gastro-Renal, and Urological Devices Office of Device Evaluation Center for Devices and Radiological Health

Enclosure

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Indications for Use:

K102764

510(k) Number (if known):4

Device Name: Resolution II Clip

Indications for Use:

The Resolution II Clip is indicated for clip placement within the Gastrointestinal Tract for the purpose of:

- Endoscopic Marking ﻨﺴﺘ
- ni Hemostasis for:
- . Mucosal/sub-mucosal defects < 3 cm
- Bleeding ulcers
- . Arteries < 2 mm
- Polyps < 1.5 cm in diameter
- Diverticula in the colon .
- Anchoring to affix jejunal feeding tubes to the wall of the small bowel నే...
సా
- 4. As a supplementary method for closure of GI tract huminal perforations <20mm that can be tranted conservatively

Prescription Use X (Part 21 CFR 801 Part D) AND/OR

Over-The-Counter Usc (21 CFR 807 Subpart C)

(PLEASE DO NOT WRITE BELOW THIS LINE-CONTINUE ON ANOTHER PAGE IF NEEDED)

Concurrence of CDRH, Office of Device Evaluation (ODE)

Haleen

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Premarket Notification, Resolution II Clip

DEC 2 2 2 2010