The product was not returned for evaluation.Without the return of the device, the root cause of the problem cannot be determined.The manufacturing records for this lot were reviewed and did not reveal any outstanding discrepancies, design, or quality concerns.This report is associated with mfr report numbers: 3005168196-2020-00969, 3005168196-2020-00970, 3005168196-2020-00971.
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The patient was undergoing a coil embolization in the aorta using ruby coils, pod packing coils (podjs) and a lantern delivery microcatheter (lantern).During the procedure, the physician placed three ruby coils into the target vessel using the lantern.While attempting to insert the next coil, a ruby coil into the lantern, the pusher assembly of the ruby coil kinked.Subsequently, the ruby coil detached within its introducer sheath; therefore, the ruby coil was removed.The physician then placed two ruby coils into the target vessel using the lantern.While attempting to insert a podj into the lantern, the same issue occurred.The pusher assembly of the podj kinked and subsequently, the podj detached within its introducer sheath; therefore, the podj was removed.The physician then placed one podj into the target vessel using the lantern.While attempting to insert a ruby coil into the lantern, the pusher assembly of the ruby coil kinked.Subsequently, the ruby coil detached within its introducer sheath; therefore, the ruby coil was removed.Then, the physician attempted to insert a podj into the lantern; however, the same issue occurred; therefore, the podj was removed.The procedure was completed using a ruby coil and the same lantern.There was no report of an adverse effect to the patient.
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