Results: the pet lock was intact on the proximal end of the pusher assembly.The pusher assembly was kinked approximately 32.0, 36.0, and 90.0 cm from the proximal end.The stretch resistance wire (sr wire) was fractured, the proximal constraint sphere was inside the distal detachment tip (ddt) and the embolization coil was detached from its pusher assembly.The second ruby coil embolization coil was detached from its pusher assembly and, therefore, the ruby coil could not be functionally tested.Conclusions: evaluation of the first evaluated ruby coil revealed that the pusher assembly was fractured and the embolization coil was detached from its pusher assembly.If the device forcefully advance against resistance, damage such as a kink may occur.Subsequently, if the kinked device is further manipulated, it may result in a fracture.Further evaluation of the returned ruby coil revealed that the pull wire was completely retracted out of its pusher assembly and the embolization coil was detached.The pull wire being retracted out of the pusher assembly will likely cause the embolization coil to detach from its pusher assembly.Evaluation of the second evaluated ruby coil revealed that the sr wire was fractured and the embolization coil was detached from its pusher assembly.If the device is forcefully retracted against resistance, damage such as a fractured sr wire may occur, and result in the embolization coil detaching from its pusher assembly.The root cause of the initial resistance could not be determined.Further evaluation of the returned ruby coil revealed that the pusher assembly was kinked.These kinks likely occurred due to forceful manipulation during the procedure.The non-penumbra microcatheter identified in the complaint and the first ruby coil embolization coil were not returned to penumbra for evaluation.Penumbra coils are visually 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.This report is associated with mfr report number: 3005168196-2018-01585.
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The patient was undergoing a coil embolization procedure in the left hepatic artery using ruby coils.During the procedure, while attempting to advance a ruby coil through a non-penumbra microcatheter, the physician experienced resistance; consequently, the ruby coil became kinked, therefore it was removed.The physician then attempted to advance another ruby coil, again resistance was felt; subsequently the coil unintentionally detached within the microcatheter; therefore, the microcatheter was removed with the detached coil inside and the coil was flushed out of the microcatheter.The procedure was completed using additional ruby coils and the same microcatheter.There was no report of an adverse effect to the patient.
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