Catalog Number RBY2C0725 |
Device Problems
Kinked (1339); Physical Resistance (2578)
|
Patient Problem
No Consequences Or Impact To Patient (2199)
|
Event Date 11/27/2017 |
Event Type
malfunction
|
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.
|
|
Event Description
|
The patient was undergoing a coil embolization procedure to treat a dialysis fistula in the ulnar vein using ruby coils.During the procedure, a ruby coil pusher assembly became kinked and subsequently, resistance was met upon advancing the ruby coil into the non-penumbra microcatheter.Therefore, the ruby coil was removed and the procedure was completed using additional ruby coils and the same microcatheter.There was no report of an adverse effect to the patient.
|
|
Manufacturer Narrative
|
Results: the ruby coil pusher assembly was kinked in multiple locations along its length, including approximately 77.0 cm from the proximal end.The embolization coil was intact with the pusher assembly.Conclusions: evaluation of the returned device confirmed that the pusher assembly was kinked.This damage may have occurred due to forceful handling of the ruby coil during advancement into a microcatheter.The kinks prevented the ruby coil from being re-sheathed into a demonstration introducer sheath during functional analysis, and likely contributed to the resistance experienced while advancing into the microcatheter.The ruby coil introducer sheath and the non-penumbra microcatheter mentioned in the complaint were not returned for evaluation.Penumbra coils 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.
|
|
Manufacturer Narrative
|
Please note that the following sections were incorrectly reported on the initial mfr report and are being updated on this follow-up #2 mfr report: box 1.Title; box 3.Occupation; box 3.Other occupation (description).
|
|
Search Alerts/Recalls
|