Disposable Polypectomy Snare, Disposable Polypectomy Hybrid Snare

K220790 · Yangzhou Fartley Medical Instrument Technology Co., Ltd. · FDI · Jun 27, 2022 · Gastroenterology, Urology

Device Facts

• Record ID: K220790
• Device Name: Disposable Polypectomy Snare, Disposable Polypectomy Hybrid Snare
• Applicant: Yangzhou Fartley Medical Instrument Technology Co., Ltd.
• Product Code: FDI · Gastroenterology, Urology
• Decision Date: Jun 27, 2022
• Decision: SESE
• Submission Type: Traditional
• Regulation: 21 CFR 876.4300
• Device Class: Class 2
• Attributes: Therapeutic

Intended Use

Disposable Polypectomy Snare, Disposable Polypectomy Hybrid Snare is used endoscopically in the removal of diminutive polyps, sessile polyps, pedunculated polyps and tissue from within the GI tract. Disposable Polypectomy Snare shall be used with monopolar diathermic energy. Disposable Polypectomy Hybrid Snare shall be used with or without monopolar diathermic energy.

Device Story

Disposable polypectomy snares used for endoscopic removal of GI tract polyps/tissue; available in rotating and non-rotating configurations. Device consists of a catheter (1.8mm or 2.4mm diameter) and a wire loop (0.4mm diameter) in various shapes (Oval, Hexagon, Lune, Combination, Multiple, Composite, or Hybrid). Operated by clinicians during endoscopic procedures. Disposable Polypectomy Snare requires monopolar diathermic energy; Hybrid Snare functions with or without monopolar energy. Device facilitates mechanical capture and electrosurgical resection of tissue. Benefits include effective polyp removal during standard endoscopic interventions.

Clinical Evidence

No clinical data. Bench testing only, including appearance and physical properties testing, all of which passed.

Technological Characteristics

Materials comply with ISO 10993-1. Monopolar radio frequency energy source. Catheter diameters 1.8mm/2.4mm; wire diameter 0.4mm. Working lengths 1800mm/2300mm. Sterilization via Ethylene Oxide (ISO 11135-1, ISO 10993-7) to SAL 10^-6. Single-use, 3-year shelf life.

Indications for Use

Indicated for endoscopic removal of diminutive, sessile, and pedunculated polyps and tissue from the GI tract.

Regulatory Classification

Identification

An endoscopic electrosurgical unit and accessories is a device used to perform electrosurgical procedures through an endoscope. This generic type of device includes the electrosurgical generator, patient plate, electric biopsy forceps, electrode, flexible snare, electrosurgical alarm system, electrosurgical power supply unit, electrical clamp, self-opening rigid snare, flexible suction coagulator electrode, patient return wristlet, contact jelly, adaptor to the cord for transurethral surgical instruments, the electric cord for transurethral surgical instruments, and the transurethral desiccator.

Predicate Devices

• Polypectomy Snare (K172729)

Submission Summary (Full Text)

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June 27, 2022

Yangzhou Fartley Medical Instrument Technology Co., Ltd. % Ethan Liu, RA Specialist Shanghai Thinkwell Consulting Co., Ltd Room 211/6F, Xinling Road, Minhang District Shanghai, Shanghai 201100 CHINA

K220790 Re:

> Trade/Device Name: Disposable Polypectomy Snare, Disposable Polypectomy Hybrid Snare Regulation Number: 21 CFR 876.4300 Regulation Name: Endoscopic electrosurgical unit and accessories Regulatory Class: Class II Product Code: FDI Dated: May 17, 2022 Received: May 23, 2022

Dear Ethan Liu:

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. Although this letter refers to your product as a device, please be aware that some cleared products may instead be combination products. The 510(k) Premarket Notification Database located at https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm identifies combination product submissions. 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 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

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801); medical device reporting of medical device-related adverse events) (21 CFR 803) for devices or postmarketing safety reporting (21 CFR 4, Subpart B) for combination products (see https://www.fda.gov/combination-products/guidance-regulatory-information/postmarketing-safety-reportingcombination-products); good manufacturing practice requirements as set forth in the quality systems (QS) regulation (21 CFR Part 820) for devices or current good manufacturing practices (21 CFR 4. Subpart A) for combination products; and, if applicable, the electronic product radiation control provisions (Sections 531-542 of the Act); 21 CFR 1000-1050.

Also, please note the regulation entitled, "Misbranding by reference to premarket notification" (21 CFR Part 807.97). For questions regarding the reporting of adverse events under the MDR regulation (21 CFR Part 803), please go to https://www.fda.gov/medical-device-safety/medical-device-reportingmdr-how-report-medical-device-problems.

For comprehensive regulatory information about medical devices and radiation-emitting products, including information about labeling regulations, please see Device Advice (https://www.fda.gov/medicaldevices/device-advice-comprehensive-regulatory-assistance) and CDRH Learn (https://www.fda.gov/training-and-continuing-education/cdrh-learn). Additionally, you may contact the Division of Industry and Consumer Education (DICE) to ask a question about a specific regulatory topic. See the DICE website (https://www.fda.gov/medical-device-advice-comprehensive-regulatoryassistance/contact-us-division-industry-and-consumer-education-dice) for more information or contact DICE by email ([e-mail]) or phone [phone] or 301-796-7100).

Sincerely,

Shanil P. Haugen, Ph.D. Assistant Director DHT3A: Division of Renal, Gastrointestinal, Obesity and Transplant Devices OHT3: Office of GastroRenal, ObGyn, General Hospital and Urology Devices Office of Product Evaluation and Quality Center for Devices and Radiological Health

Enclosure

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DEPARTMENT OF HEALTH AND HUMAN SERVICES Food and Drug Administration

# Indications for Use

510(k) Number (if known) K220790

Device Name

Disposable Polypectomy Snare, Disposable Polypectomy Hybrid Snare

Indications for Use (Describe)

Disposable Polynectomy Snare, Disposable Polypectomy Hybrid Snare is used endoscopically in the removal of diminutive polyps, sessile polyps, pedunculated polyps and tissue from within the GI tract. Disposable Polypectomy Snare shall be used with monopolar diathermic energy. Disposable Polypectomy Hybrid Snare shall be used with or without monopolar diathermic energy.

| Type of Use (Select one or both, as applicable) | | |
|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|------------------------------------------------------------------------------------------------------------------|--------------------------------------------------------------------------------------------------|
| <table style="border:none;"><tr><td><div> <label><input checked="true" type="checkbox"/> Prescription Use (Part 21 CFR 801 Subpart D)</label> </div></td><td><div> <label><input type="checkbox"/> Over-The-Counter Use (21 CFR 801 Subpart C)</label> </div></td></tr></table> | <div> <label><input checked="true" type="checkbox"/> Prescription Use (Part 21 CFR 801 Subpart D)</label> </div> | <div> <label><input type="checkbox"/> Over-The-Counter Use (21 CFR 801 Subpart C)</label> </div> |
| <div> <label><input checked="true" type="checkbox"/> Prescription Use (Part 21 CFR 801 Subpart D)</label> </div> | <div> <label><input type="checkbox"/> Over-The-Counter Use (21 CFR 801 Subpart C)</label> </div> | |

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Image /page/3/Picture/0 description: The image contains a logo for "ARTLEY UNIQUE ENDOSCOPY". The word "ARTLEY" is in a stylized, bold, blue font with a yellow accent on the "Y". Below "ARTLEY" is the phrase "UNIQUE ENDOSCOPY" in a smaller, sans-serif font, also in blue. The logo appears to be for a company specializing in endoscopy equipment.

# 510(k) Summary

This summary of 510(k) safety and effectiveness information is being submitted in accordance with requirements of 21 CFR Part 807.92.

## 5.1 Submitter

| Submitted by: | Yangzhou Fartley Medical Instrument Technology Co., Ltd. |
|--------------------|----------------------------------------------------------|
| | Address:Beizhou Road, Lidian Town, Guangling District, |
| | Yangzhou 225106 Jiangsu, China |
| Contact<br>Person: | Ethan Liu<br>RA Specialist |
| | Shanghai Thinkwell Consulting Co., Ltd |
| | Address: Room 211/6F, Xinling Road, Minhang Districtt, |
| | Shanghai, China. |
| | Phone: [phone] |
| | Email: [e-mail] |
| Date<br>Prepared: | May 17, 2022 |

## 5.2 Device

| Device Name: | Disposable Polypectomy Snare,<br>Disposable Polypectomy Hybrid Snare |
|----------------------|----------------------------------------------------------------------|
| Classification Name: | Endoscopic electrosurgical unit and accessories |
| Regulatory Class: | II |
| Regulation Number: | 21 CFR 876.4300 |
| Product Code: | FDI |

## 5.3 Predicate Device

| Device Name: | Polypectomy Snare<br>K172729 | |
|----------------------|-------------------------------------------------|--|
| Manufacturer: | Hangzhou AGS MedTech CO., Ltd. | |
| Classification Name: | Endoscopic electrosurgical unit and accessories | |
| Regulatory Class: | II | |
| Regulation Number: | 21 CFR 876.4300 | |
| Product Code: | FDI | |

## 5.4 Device Description

## Disposable Polypectomy Snare

The Disposable Polypectomy Snare is available in two different types with rotating snare and non-rotating snare.

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Image /page/4/Picture/0 description: The image shows the logo for ARTLEY. The logo is in blue and yellow. The text "UNIQUE ENDOSCOPY" is below the main logo.

The cutting wire diameter of the snares is 0.4mm. The catheter diameters are 1.8mm and 2.4mm the depending on the version. The snares are available in different forms, lengths and openings depending on the type.

### - Non-rotating snares

The non-rotating snare is available in six different loop shape: Oval, Hexagon, Lune, Combination, Multiple and Composite. The snares are available in the opening widths 10mm, 15mm, 20mm, 25mm,30mm, 35mm.The snares are available in the working lengths 1800mm and 2300mm.

#### - Rotatable snares

The rotary snare is available in six different loop shape: Oval, Hexagon, Lune, Combination, Multiple and Composite. The opening widths are 10mm, 15mm, 20mm.25mm. 30mm. 35mm. depending on the version. The snares are available in the working lengths 1800mm and 2300mm.

### Disposable Polypectomy Hybrid Snare

The Disposable Polypectomy Hybrid Snare is available in two different types with rotating snare and non-rotating snare. Only one available loop shape is Hybrid.

The cutting wire diameter of the snares is 0.4mm. The catheter diameters is 2.4mm. The snares are available in different forms, lengths and openings depending on the type.

- Non-rotating snares
The non-rotating snare is available in the opening widths 10mm, 15mm,depending on the version.The snares are available in the working lengths 1800mm and 2300mm.

- Rotatable snares
The rotary snares are available 10mm, 15mm, depending on the version. The snares are available in the working lengths 1800mm and 2300mm.

### 5.5 Indication for Use:

Disposable Polypectomy Snare, Disposable Polypectomy Hybrid Snare is used endoscopically in the removal of diminutive polyps, sessile polyps, pedunculated polyps and tissue from within the GI tract. Disposable Polypectomy Snare shall be used with monopolar diathermic energy. Disposable Polypectomy Hybrid Snare shall be used with or without monopolar diathermic energy.

### 5.6 Comparison of Technological Characteristics

The Disposable Polypectomy Snare, Disposable Polypectomy Hybrid Snare has substantially equivalent device design, configuration, packaging fundamental technology, sterilization process and intended use as those featured in the predicate device Hangzhou AGS MedTech CO., Ltd's Polypectomy Snare, K172729. The

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Image /page/5/Picture/0 description: The image shows the logo for ARTLEY UNIQUE ENDOSCOPY. The logo is in blue, except for the "Y" in ARTLEY, which is in yellow. The word "UNIQUE" is stacked on top of the word "ENDOSCOPY".

differences between the proposed device and the predicate devices do not raise any questions regarding its safety and effectiveness. The differences are listed in the table below.

| Item | Disposable<br>Polypectomy Snare,<br>Disposable<br>Polypectomy Hybrid<br>Snare(Proposed Device) | Polypectomy Snare,<br>K172729 | Discussion |
|-----------------------|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-----------------------------|
| Indication for<br>Use | Disposable Polypectomy<br>Snare, Disposable<br>Polypectomy Hybrid<br>Snare is used<br>endoscopically in the<br>removal of diminutive<br>polyps, sessile polyps,<br>pedunculated polyps and<br>tissue from within the GI<br>tract. Disposable<br>Polypectomy Snare shall<br>be used with monopolar<br>diathermic energy.<br>Disposable Polypectomy<br>Hybrid Snare shall be<br>used with or without<br>monopolar diathermic<br>energy. | Polypectomy Snare is<br>used endoscopically<br>in the removal<br>and/or cauterization<br>of diminutive polyps,<br>sessile polyps,<br>pedunculated polyps<br>and tissue from within<br>the GI tract. | Substantially<br>equivalent |
| Product Code | FDI | FDI | Same |
| Energy Use | Monopolar Radio<br>Frequency Current | Monopolar Radio<br>Frequency Current | Same |
| Loop Shape | Disposable<br>Polypectomy<br>Snare:Oval, Hexagon,<br>Lune, Combination,<br>Multiple and Composite<br><br>Disposable<br>Polypectomy Hybrid<br>Snare:Hybrid | Hexagonal, Polygon ,<br>Oval, Round, Duck<br>Bill | Substantially<br>equivalent |
| Loop Width | Disposable<br>Polypectomy<br>Snare:10mm, 15mm,<br>20mm,25mm, 30mm,<br>35mm | Hexagonal: 10mm,<br>15mm, 25mm, 32mm<br>Polygon:10mm,<br>15mm, 25mm, 32mm<br>Oval:10mm, 15mm, | Similar |
| Item | Disposable<br>Polypectomy Snare,<br>Disposable<br>Polypectomy Hybrid<br>Snare(Proposed Device) | Polypectomy Snare,<br>K172729 | Discussion |
| | Disposable<br>Polypectomy Hybrid<br>Snare:10mm, 15mm | 25mm, 32mm<br>Round: 10mm,<br>15mm, 25mm, 32mm<br>Duck Bill: 10mm,<br>15mm, 25mm, 32mm | |
| Out tube<br>diameter | Disposable<br>Polypectomy<br>Snare:1.8mm, 2.4mm<br><br>Disposable<br>Polypectomy Hybrid<br>Snare:2.4mm | 1.8mm, 2.4mm | Same |
| Working<br>Length | 1800mm, 2300mm | 1800mm, 2300mm | Same |
| Sterilization | EO Sterilization;<br>SAL:10-6 | EO Sterilization;<br>SAL:10-6 | Same |
| Single Use | Yes | Yes | Same |
| Shelf Life | 3 years | 3 years | Same |
| Biocompatibility | Comply with ISO<br>10993-1 | Comply with ISO<br>10993-1 | Same |

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Image /page/6/Picture/0 description: The image shows the logo for "ARTLEY UNIQUE ENDOSCOPY". The word "ARTLEY" is in large, bold, blue font, with a yellow streak on the right side of the "Y". Below "ARTLEY" is the phrase "UNIQUE ENDOSCOPY" in a smaller, blue font. The logo appears to be for a medical device company.

### 5.7 Non-clinical Performance Data

The proposed device meets the requirements of ISO 10993 "Biological Evaluation of Medical Devices - Part 1: Evaluation and Testing", ISO 11135-1 "Sterilization of Health Care products Ethylene Oxide - Part 1: Requirements for Development, Validation, and Routine Control of Sterilization processes for Medical Devices", and ISO 10993-7 "Biological evaluation of medical devices - Part 7: ethylene oxide sterilization residuals" .

The following bench tests were performed on Disposable Polypectomy Snare, Disposable Polypectomy Hybrid Snare: Appearance, Physical properties. The results of all testing were passing.

#### 5.8 Clinical Test Data

No Clinical Study is included in this submission.

#### 5.9 Conclusion

In accordance with the Federal Food, Drug and Cosmetic Act, 21 CFR Part 807, Based on the information provided in this premarket notification, Yangzhou Fartley

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Image /page/7/Picture/0 description: The image shows the "ARTLEY UNIQUE ENDOSCOPY" logo. The word "ARTLEY" is in large, bold, blue font. Below that, the words "UNIQUE ENDOSCOPY" are in a smaller, blue font. There is a yellow line above the "EY" in "ARTLEY".

Medical Instrument Technology Co., Ltd. has demonstrated that proposed device Disposable Polypectomy Snare, Disposable Polypectomy Hybrid Snare is substantially equivalent to Hangzhou AGS MedTech CO., Ltd's currently marketed Polypectomy Snare, K172729.