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Catalog Number 400SMTSTD0410 |
Device Problems
Material Protrusion/Extrusion (2979); Unintended Movement (3026)
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Patient Problem
No Consequences Or Impact To Patient (2199)
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Event Date 01/31/2017 |
Event Type
Injury
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Manufacturer Narrative
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The product was not returned for evaluation.Without the return of the device, the root cause of the problem cannot be determined.The product lot number was not provided, therefore, the manufacturing records could not be reviewed.This report is associated with mfr report numbers: 3005168196-2017-00351, 3005168196-2017-00353.The device was implanted into the patient.
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Event Description
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The patient was undergoing a coil embolization procedure to treat a basilar tip aneurysm using penumbra smart coils (smart coil).During the procedure, after the third smart coil was deployed and detached, the angiography showed a protrusion of a previously placed coil.The physician continued the procedure by placing six additional smart coils.Towards the end of the procedure, clot formation was identified on the displaced loop of coil and an integrilin drip was started.The physician then decided to place a stent in order to tack the protruding coil against the wall of the vessel.The patient was discharged home on (b)(6) 2017.The reported clot formation was adjudicated to have no relationship to the penumbra devices.However, the reported coil protrusion was possibly related to the aneurysm, procedure and penumbra smart coils.It is unknown which of the three previously placed smart coils protruded out.
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Search Alerts/Recalls
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