Catalog Number 5MAXACE068KIT |
Device Problems
Kinked (1339); Device Damaged Prior to Use (2284); Out-Of-Box Failure (2311)
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Patient Problem
No Patient Involvement (2645)
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Event Date 10/03/2017 |
Event Type
malfunction
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Manufacturer Narrative
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The penumbra system ace 68 reperfusion catheter (ace68) was fractured approximately 3.0 cm from the hub at the end of the strain relief.Evaluation of the returned ace68 revealed a fracture in the proximal shaft.This damage was likely a result of attempting to remove the device from its packaging before first removing the top packaging tray.This would require the device to be positioned at extreme angles and may have contributed to the fracture.Penumbra catheters are inspected during in-process inspection and during quality inspection after manufacturing.The manufacturing records for this lot were reviewed and did not reveal any outstanding discrepancies, design, or quality concerns.
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Event Description
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During preparation for a thrombectomy procedure, the hospital staff noticed that the penumbra system ace 68 reperfusion catheter (ace68) was kinked upon inspection before removal from the packaging of the penumbra system ace 68 hi-flow kit (kit).It was reported that the device packaging box was not bent.The damaged ace68 was found prior to use and therefore, was not used in the procedure.The procedure was completed using a new kit.
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Search Alerts/Recalls
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