The patient was undergoing a thrombectomy procedure in the m1 bifurcation segment of the middle cerebral artery (mca) using a penumbra system red 72 reperfusion catheter (red72), a velocity delivery microcatheter (velocity), a neuron max 6f 088 long sheath (neuron max), and a guidewire.It was reported that the patient¿s anatomy was tortuous.During the procedure, the physician completed one pass using the red72.While retracting the red72 to flush, the physician experienced resistance and the red72 fractured at the midshaft within the neuron max.Therefore, the neuron max containing the fractured red72 was removed from the patient.It was reported that the red72 was still connected by the coil winds of the catheter.The procedure was completed using a new red72, a new neuron max, and the same velocity.There was no report of an adverse effect to the patient.
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Evaluation of the returned red72 confirmed that the catheter was fractured.If the red72 is retracted against resistance, damage such as a fracture may occur.It was reported that the patient¿s anatomy was tortuous.This likely contributed to the resistance during the procedure.Further evaluation revealed a kink on the catheter shaft.This damage was incidental to the reported complaint and may have occurred during packaging of the device for return to penumbra.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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