The patient was undergoing a thrombectomy procedure in the right m1 segment of the middle cerebral artery (mca) using a velocity delivery microcatheter (velocity), a neuron max 6f 088 long sheath (neuron max), a non-penumbra short sheath, a non-penumbra catheter, a non-penumbra revascularization device, and a guidewire.During the procedure, the physician placed the neuron max in the high cervical.Then advanced the catheter over the guidewire through the neuron max to the proximal location of the thrombus.Afterwards, the scrub nurse prepared the velocity by flushing it and subsequently, while the physician inserted approximately ten centimeters of the distal tip of the velocity into the rotating hemostasis valve (rhv) of the catheter, the physician noticed that the mid-shaft of the velocity was fractured.Therefore, the velocity was removed.The procedure was completed using a new velocity, the same neuron max, the same catheter, the same revascularization device, and the same guidewire.It was reported that a thrombolysis in cerebral infarction (tici) grade 3 was achieved.There was no report of an adverse effect to this patient.
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Results: the velocity was fractured approximately 48.5 cm from the hub.Conclusions: evaluation of the returned velocity confirmed that the catheter was fractured.If the velocity is forcefully advanced against resistance, damage such as a kink and subsequent fracture may occur.Penumbra catheters 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.
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