FLEXIVA SF SIDE-FIRING SINGLE-USE LASER FIBER

K140503 · Boston Scientific · GEX · Apr 15, 2014 · General, Plastic Surgery

Device Facts

• Record ID: K140503
• Device Name: FLEXIVA SF SIDE-FIRING SINGLE-USE LASER FIBER
• Applicant: Boston Scientific
• Product Code: GEX · General, Plastic Surgery
• Decision Date: Apr 15, 2014
• Decision: SESE
• Submission Type: Traditional
• Regulation: 21 CFR 878.4810
• Device Class: Class 2
• Attributes: Therapeutic, 3rd-Party Reviewed

Intended Use

The Flexiva SF Side-Firing Single-Use Laser Fiber is designed for use with Ho:YAG lasers for indications that are cleared for these laser systems, including, but not limited to endoscopic, and open surgical procedures involving vaporization, ablation, coagulation, hemostasis, excision of soft and cartitaginous tissue, and fragmentation of urinary and biliary calculi (Ho:YAG wavelength only). The fiber is designed for use with a standard SMA-905 connector that has been cleared for surgical use.

Device Story

Flexiva SF is a single-use fiber optic laser energy delivery device; consists of coated silica core fiber with ETFE jacket, SMA-905 connector, metal cap, adjustable hand piece, and rigid tubing. Device connects to external Ho:YAG or Nd:YAG laser systems; delivers laser energy at approximately 70° angle to tissue. Used in endoscopic, laparoscopic, or open surgical procedures; operated by physicians. Metal cap features circumferential black line guides for endoscopic positioning; adjustable hand piece and rigid tubing facilitate tip manipulation and control at treatment site. Output is directed laser energy for tissue vaporization, ablation, coagulation, hemostasis, excision, or calculus fragmentation. Benefits include precise energy delivery to target tissue during minimally invasive or open surgery.

Clinical Evidence

Bench testing only. Testing included operating life, hand-piece retention strength, fiber power transmission, fiber control, protective cap retention, fiber length, distal fiber max OD, aiming beam, connector temperature/durability, connector tensile, and seal integrity. Samples tested at T=0 and T=6 months accelerated aging.

Technological Characteristics

Fiber optic delivery system; coated silica core fiber with ETFE jacket; SMA-905 connector; metal cap with 70° laser aperture; adjustable hand piece; rigid tubing. Single-use. Passive device; no internal energy source or software.

Indications for Use

Indicated for patients requiring endoscopic, laparoscopic, or open surgical procedures involving vaporization, ablation, coagulation, hemostasis, excision, or incision of soft and cartilaginous tissue, and fragmentation of urinary and biliary calculi using Ho:YAG or Nd:YAG laser systems.

Regulatory Classification

Identification

(1) A carbon dioxide laser for use in general surgery and in dermatology is a laser device intended to cut, destroy, or remove tissue by light energy emitted by carbon dioxide.(2) An argon laser for use in dermatology is a laser device intended to destroy or coagulate tissue by light energy emitted by argon.

Predicate Devices

• DuoTome™ SideLite™ Fiber (K011703)
• Flexiva™ High Power Single-Use Laser Fiber (K100078)

Submission Summary (Full Text)

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APR 1 5 2014

Side-Firing Laser Fiber Traditional 510(k)

K140503 Boston Scientific

#### 510K SUMMARY SECTION 5 . .

## 510(k) Summary for Flexiva™ SF Side-Firing Single-Use Laser Fiber

## A. Sponsor

Boston Scientific Corporation Urology and Women's Health Division 100 Boston Scientific Way Marlborough, MA 01756

## B. Contact

Jeanne O'Toole Senior Specialist, Regulatory Affairs' ·508-683-4271 [e-mail]

or

Nichole Riek Manager, Regulatory Affairs 508-683-4175 [e-mail]

## C. Device Name

Flexiva™ SF Side-Firing Single-Use Laser Fiber Trade name: Common usual/name: Laser Instrument, Surgical, Powered GEX - Laser surgical instrument for use in general and Classification: plastic surgery and in dermatology 21 CFR 878.4810. Class II

## D. Predicate Device(s)

| Trade name: | DuoTome™ SideLite™ Fiber (cleared under K011703 as<br>Lumenis delivery devices) |
|--------------------|---------------------------------------------------------------------------------------------------------------------------|
| Common usual/name: | Laser Instrument, Surgical, Powered |
| Classification: | GEX - Laser surgical instrument for use in general and<br>plastic surgery and in dermatology<br>21 CFR 878.4810, Class II |

Premarket Notification: Lumenis, K011703

and

| Trade name: | Flexiva™ High Power Single-Use Laser Fiber (cleared under K100078 as Modified Straight Fire Laser Fiber) |
|-------------------------|------------------------------------------------------------------------------------------------------------------------|
| Common usual/name: | Laser Instrument, Surgical, Powered |
| Classification: | GEX - Laser surgical instrument for use in general and plastic surgery and in dermatology<br>21 CFR 878.4810, Class II |
| Premarket Notification: | Boston Scientific K100078 |

Premarket Notification: Boston Scientific, K 100078

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#### 510K SUMMARY SECTION 5

## E. Device Description

The Flexiva SF Side-Firing Single-Use Laser Fibers (Flexiva SF) are fiber optic laser energy delivery devices consisting of an SMA-905 connector and a coated silica core fiber jacketed with ethylene tetrafluoroethylene (ETFE). The Flexiva SF fibers are equipped with a metal cap with circumferential solid black line guides, an adjustable hand piece and rigid tubing. The laser aperture is located near the tip of the metal cap. Laser energy is delivered at an approximately 70° angle to tissue from the tip of the fiber. The line guides assist with correct positioning of the fiber tip within the endoscope. The adjustable hand piece enables manipulation of the laser fiber tip at the treatment site. The rigid tubing aids in control of the fiber tip. These fibers may be used in a variety of laserbased surgical cases as an integral part of laser systems.

## F. Intended Use

The Flexiva SF fiber is designed for use with Ho:YAG and Nd:YAG lasers for indications that are cleared for these laser systems, including, but not limited to endoscopic, laparoscopic, and open surgical procedures involving vaporization, ablation, coagulation, hemostasis, excision, resection, incision of soft and cartilaginous tissue, and fragmentation of urinary and biliary calculi (Ho:YAG wavelength only). The fiber is designed for use with a standard SMA-905 connector that has been cleared for surgical use.

## G. Technological Characteristics

The Flexiva SF fiber has the same technological characteristics and fundamental design as the predicate devices. The proposed Flexiva SF fiber is available in a single configuration.

## H. Substantial Equivalence

A direct comparison of key characteristics demonstrates that the Flexiva SF fiber is substantially equivalent to the predicate devices in terms of intended use, technological characteristics, and performance characteristics. The Flexiva SF fiber is as safe and effective as the predicate devices.

## I. Performance Testing (Bench Evaluation)

Boston Scientific has conducted performance testing with samples aged at T=0 and T=6 months accelerated aging in support of the proposed laser device. The following testing was completed to evaluate the effects of the design change:

- Operating Life .
- Hand-Piece Retention Strength ●
- Initial Fiber Power Transmission .
- Fiber Power Transmission .
- Fiber Control .

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Side-Firing Laser Fiber Traditional 510(k)

#### SECTION 5 -510K SUMMARY 11

- Protective Cap Retention Strength .
- Fiber Length .
- Distal Fiber Max OD .
- . Aiming Beam
- . Connector Temperature/Durability
- Connector Tensile . .
- Seal Integrity .
- Seal Strength .

The results of the performance testing demonstrate that the Flexiva SF fiber is considered safe and effective for its intended use.

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Image /page/3/Picture/0 description: The image shows the logo for the U.S. Department of Health & Human Services. The logo features a stylized depiction of an eagle or bird-like figure with three curved lines representing its body and wings. The text "DEPARTMENT OF HEALTH & HUMAN SERVICES - USA" is arranged in a circular fashion around the bird symbol.

## DEPARTMENT OF HEALTH & HUMAN SERVICES

Public Health Service

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

April 15, 2014

Boston Scientific Corporation Ms. Jeanne O'Toole Senior Specialist, Regulatory Affairs 100 Boston Scientific Way Marlborough, Massachusetts 01756

Re: K140503

Trade/Device Name: Flexiva" SF Side-Firing Single-Use Laser Fiber Regulation Number: 21 CFR 878.4810 Regulation Name: Laser surgical instrument for use in general and plastic surgery and in dermatology Regulatory Class: Class II Product Code: GEX Dated: March 31, 2014 Received: April 1, 2014

Dear Ms. O'Toole:

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 10 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 docs 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 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 that I Dri has made a and regulations administered by other Federal agencies. You must or any Federal 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

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Page 2 - Ms. Jeanne O'Toole

device-related adverse events) (21 CFR 803); good manufacturing practice requirements as set forth in the quality systems (OS) 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 tollfree number [phone] or [phone] or at its Internet address

http://www.fda.gov/MedicalDevices/Resourcesfor You/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 Industry and Consumer Education at its toll-free number [phone] or [phone] or at its Internet address

http://www.fda.gov/MedicalDevices/ResourcesforYou/Industry/default.htm.

Sincerely yours.

# David Krause -S

for

Binita S. Ashar, M.D., M.B.A., F.A.C.S. Acting Director Division of Surgical Devices Office of Device Evaluation Center for Devices and Radiological Health

Enclosure

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## DEPARTMENT OF HEALTH AND HUMAN SERVICES Food and Drug Administration

## Indications for Use

Form Approved: OMB No. 0910-0120 Expiration Date: January 31, 2017 See PRA Statement on last page.

510(k) Number (if known) K140503

## Device Name

Flexiva™ SF Side-Firing Single-Use Laser Fiber

## Indications for Use (Describe)

The Flexiva SF Side-Firing Single-Use Laser Fiber is designed for use with Ho:Y AG lasers for indications that are cleared for these laser systems, including, but not limited to endoscopic, and open surgical procedures involving vaporization, ablation, coagulation, hemostasis, excision of soft and cartitaginous tissue, and fragmentation of urinary and biliary calculi (Ho:Y AG wavelength only). The fiber is designed for use with a standard SMA-905 connector that has been cleared for surgical use.

Type of Use (Select one or both, as applicable)

[x] Prescription Use (Part 21 CFR 801 Subpart D)

Over-The-Counter Use (21 CFR 801 Subpart C)

## PLEASE DO NOT WRITE BELOW THIS LINE – CONTINUE ON A SEPARATE PAGE IF NEEDED.

FOR FDA USE ONLY Concurrence of Center for Devices and Radiological Health (CDRH) (Signature)

Consistence of Center for Devices and Radiological Health (CDRH) (original)

# Neil R Oga 2014.04.14 1

FORM FDA 3881 (1/14) For BSA