The product was not returned for evaluation.Without the return of the device, the reported issue cannot be confirmed and 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: 3005168196-2017-01670, 3005168196-2017-01671.The hospital retained the device for review.
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The patient was undergoing a coil embolization in the superior mesenteric vein using ruby coils and a lantern delivery microcatheter (lantern).During the procedure, the physician successfully deployed and detached the initial ruby coils in the target vessel using a lantern.While attempting to advance a new ruby coil into the lantern, the physician did not mention resistance; however, the ruby coil pusher assembly became bent upon advancement into the lantern.Therefore, it was removed.While attempting to advance another ruby coil into the target vessel, the physician immediately experienced resistance upon advancing the ruby coil out the lantern.Therefore, the physician decided to withdraw the ruby coil; however, the ruby coil would not withdraw.The physician then withdrew the lantern a couple of millimeters and attempted to advance the ruby coil; however, the ruby coil would not move.The physician then decided to retract the ruby coil; however, upon retraction, the ruby coil unintentionally detached in the patient¿s body.The physician attempted to use a snare device to remove the detached ruby coil; however, the physician was unable to remove the ruby coil and the ruby coil was left in the superior mesenteric vein.The procedure was completed by placing a non-penumbra stent device.There was no report of an adverse effect to the patient.
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