MAUDE Adverse Event Report: PENUMBRA, INC. PENUMBRA SYSTEM RED72 REPERFUSION CATHETER; NRY

Catalog Number RED72KIT

Device Problem Fracture (1260)

Patient Problem No Clinical Signs, Symptoms or Conditions (4582)

Event Date 07/26/2023

Event Type  malfunction  

Event Description

The patient was undergoing a thrombectomy procedure in the right carotid artery and middle cerebral artery (mca) using a penumbra system red72 reperfusion catheter (red72), a benchmark bmx96 access system (bmx96), a neuron max 6f 088 long sheath (neuron max), and a non-penumbra microcatheter.During the procedure, the physician made one pass in the target vessel using the red72.After the pass, the physician noticed there was clot inside of the red72 and decided to remove the red72 for flushing.While removing the red72, the physician noticed majority of the red72 was being pulled out from the sheath.The physician performed a fluoroscopy and noticed the red72 appeared to be fractured in the vessel.The proximal red72 was removed with the bmx96.The physician then placed a neuron max and snared the distal red72.The procedure was completed using a new non-penumbra aspiration catheter and a non-penumbra guide catheter.There was no report of an adverse effect to the patient.

Manufacturer Narrative

The device has been returned and the investigation results are pending.A follow up mdr will be submitted upon completion of the device investigation.H3 other text : placeholder.

Manufacturer Narrative

Evaluation of the returned red72 confirmed that the catheter was fractured and revealed that the catheter was stretched at the fractured location.This damage typically occurs due to retraction against resistance.Further evaluation revealed multiple kinks on both proximal and distal fracture segments.This damage may have also occurred during manipulation.The kink on the distal fracture portion of the red72 near the fracture location likely occurred while snaring.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.H3 other text : placeholder.

• Brand Name: PENUMBRA SYSTEM RED72 REPERFUSION CATHETER
• Type of Device: NRY
• Manufacturer (Section D): PENUMBRA, INC.; one penumbra place; alameda CA 94502
• Manufacturer Contact: veronica farris ; one penumbra place; alameda, CA 94502 ; 5107483200
• MDR Report Key: 17577646
• MDR Text Key: 321866608
• Report Number: 3005168196-2023-00395
• Device Sequence Number: 1
• Product Code: NRY
• UDI-Device Identifier: 00815948023932
• UDI-Public: 815948023932
• Combination Product (y/n): N
• Reporter Country Code: US
• PMA/PMN Number: K211654
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: Health Professional,Company Representative
• Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date: 01/01/2005,09/12/2023

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Catalogue Number: RED72KIT
• Device Lot Number: H12725
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 08/11/2023
• Is the Reporter a Health Professional?: Yes
• Was the Report Sent to FDA?: Yes
• Date Report Sent to FDA: 01/01/2005
• Date Report to Manufacturer: 01/10/2005
• Initial Date Manufacturer Received: 07/26/2023
• Initial Date FDA Received: 08/18/2023
• Supplement Dates Manufacturer Received: 08/17/2023
• Supplement Dates FDA Received: 09/12/2023
• Was Device Evaluated by Manufacturer?: Yes
• Date Device Manufactured: 03/04/2022
• Is the Device Single Use?: Yes
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Initial
• Patient Sequence Number: 1
• Patient Age: 74 YR
• Patient Sex: Male