MAUDE Adverse Event Report: MEDOS INTERNATIONAL SARL PULSERIDER T, 4MM, 8MM ARCH; INTRACRANIAL NEUROVASCULAR STENT

Model Number 203-D

Device Problem Adverse Event Without Identified Device or Use Problem (2993)

Patient Problem Thrombosis/Thrombus (4440)

Event Type  Injury  

Manufacturer Narrative

Manufacturer¿s ref.No: (b)(4).Information regarding patient identifier, date of birth, age, gender, weight, race, and ethnicity were not provided.Date of event: the date of the event is not known.The expiration date of the device is not known as the device lot number is not available / not reported.Implantation day, implantation month, and implantation year are not known.The name, phone and email address of the initial reporter are not available / reported.Initial reporter facility name, address information are not available.The device manufacture date is not known as the device lot number is not available / not reported.Based on complaint information, the device remains implanted and is thus not available for evaluation.The device lot number was not available.The manufacturing documentation review could not be performed without the lot number.Product analysis cannot be conducted as the product was not returned for analysis.No determination of causes and possible contributing factors could be made.As such, the investigation will be closed.Thrombosis is a known potential adverse event associated with coil embolization procedures.This is a known potential complication associated with the use of the pulserider anrd and is listed in the instructions for use (ifu) as such.Per the information provided, the device performed as intended.This complaint was discussed with the medical safety officer (mso) on (b)(6) 2023 and even though the device performed as intended with no reported malfunction, the event will be conservatively reported to the fda under 21 cfr 803 with a classification of ¿serious injury.¿ the file will be re-reviewed if additional information is received at a later date.As part of the post market surveillance program, information from this complaint is trended for statistical signals and corrective / preventive action may be triggered at a later time.Since there was no evidence to suggest the event was related to a manufacturing or design issue, no corrective actions will be taken at this time.This report is being submitted pursuant to the provisions of 21 cfr, part 803.This report may be based on information which has not been investigated or verified prior to the required reporting date.This report does not reflect a conclusion by cerenovus, or its employees that the report constitutes an admission that the product, cerenovus, or its employees caused or contributed to the potential event described in this report.If information is obtained that was not available for the initial report, a follow-up report will be filed as appropriate.Missing information from this report is identified as blank; this information was not provided in the reported event or available at the time of report submission.The manufacturer will submit a supplemental report if new facts arise which materially alter information submitted in a previous mdr report.Additional information will be submitted within 30 days of receipt.

Event Description

The cerenovus sales representative reported that a patient underwent an endovascular embolization procedure that employed the use of a pulserider t shape, 8mm , 3.5mm ¿ 4.5mm aneurysm neck reconstruction device (anrd) (203d / lot# unknown); the pulserider anrd was implanted ¿but there was issue.¿ at the complaint initiation, the sales representative reported that ¿details are unknown.¿ on (b)(6) 2023, additional information was received.It was reported that the physician said, ¿i have been told that there has been a case of thrombosis following the use of pulserider.I have not been able to identify the facility or the patient.¿ on (b)(6) 2023, additional information was received indicating that no further information can be obtained.The physician who reported this event does not know at which facility the event occurred at and there is no means to investigate further.Based on the additional information received on 30-mar-2023 and 17-apr-2023, the event will be conservatively reported to the fda under 21 cfr 803 with a classification of ¿serious injury.¿.

• Brand Name: PULSERIDER T, 4MM, 8MM ARCH
• Type of Device: INTRACRANIAL NEUROVASCULAR STENT
• Manufacturer (Section D): MEDOS INTERNATIONAL SARL; chemin-blanc 38; le locle neuchatel CH-24 00; SZ CH-2400
• Manufacturer (Section G): CODMAN & SHURTLEFF, INC. (FREMONT); 47709 fremont blvd; fremont CA 94538
• Manufacturer Contact: kate karberg ; 31 technology dr; irvine, CA 92618 ; 303552-689
• MDR Report Key: 16764083
• MDR Text Key: 313535052
• Report Number: 3008114965-2023-00250
• Device Sequence Number: 1
• Product Code: NJE
• UDI-Device Identifier: 00859030005147
• UDI-Public: 00859030005147
• Combination Product (y/n): N
• Reporter Country Code: JA
• PMA/PMN Number: H160002
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: Foreign,Health Professional,Company Representative
• Reporter Occupation: Physician
• Type of Report: Initial
• Report Date: 04/18/2023

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: No
• Device Operator: Health Professional
• Device Model Number: 203-D
• Device Catalogue Number: 203D
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Initial Date Manufacturer Received: 03/30/2023
• Initial Date FDA Received: 04/18/2023
• Was Device Evaluated by Manufacturer?: Device Not Returned to Manufacturer
• Is the Device Single Use?: Yes
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Initial
• Patient Sequence Number: 1
• Patient Outcome(s): Life Threatening