It was reported that a markerband malposition occurred.The target lesion was located in the kidney.An accustick ii was selected for use.During the procedure, while inserting the introducer sheath, the radiopaque marker band moved away from the tip preventing the physician from seeing where the tip of the sheath was under fluoroscopy.During an attempt to advance the sheath, the kidney was perforated with the tip of the introducer sheath.Another accustick package was opened, and the same thing happened with the next 3 sheaths.The marker band had moved; the patient already had contrast in the kidney, so visibility was an issue to begin with.One of the marker bands from a different kit actually came completely off and had to be snared out of the kidney on its own.The procedure was successfully completed with another of the same device.The patient was expected to fully recover.
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