Block d4, h4: the complainant was unable to provide the suspect device lot number; therefore, the lot expiration and device manufacture dates are unknown.Block h6: device code a040506 captures the reportable event of coil was cracked.Block h10: the returned trapezoid rx basket was analyzed, and a visual evaluation noted that the blue outer sheath was extended past the distal stop of the device.Furthermore, the cone was found to be inside the blue sheath as well.The sheath was not able to be moved and the coil could not be unsheathed as the distal stop created significant resistance.The reported complaint of "coil peeled" was not confirmed because visual inspection of the tip could not be performed during the product analysis because it was pushed into the blue sheath.Based on all available information, the risk documentation contains specifics about the reported event."prior to use, ensure that the coil is working properly by advancing the sheath over the coil to the positive stop and then retracting the sheath to open the coil," according to the ifu.During testing, the device sheath should be straight." product investigation revealed that the sheath had been extended past the distal stop and that the coil was completely contained within the blue sheath.Excessive force on the outer sheath during testing and use is likely to have caused it to extend past the positive stop, contradicting the instruction to advance the sheath to the positive stop, and the coil to be unable to open or close.Therefore, the most probable root cause is unintended use error.A review of the manufacturing documentation for this device revealed that no anomalies or deviations related to the event occurred during manufacturing.
|