MAUDE Adverse Event Report: PENUMBRA, INC. PENUMBRA SMART COIL; HCG, KRD

Model Number	400SMTSFT0408
Medical Device Problem Code	Difficult or Delayed Separation (4044)
Health Effect - Clinical Codes	No Consequences Or Impact To Patient (2199); No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	12/01/2020
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
The product was not returned for evaluation.Without the return of the device, the root cause of the problem cannot be determined.The manufacturing records for this lot were reviewed and did not reveal any outstanding discrepancies, design, or quality concerns.This report is associated with mfr report numbers: 3005168196-2020-02342, 3005168196-2020-02343, 3005168196-2020-02344.
Event or Problem Description
The patient was undergoing a coil embolization procedure in the left posterior communicating artery (pcom) using penumbra smart coils (smart coil), penumbra smart coil detachment handle (handle), and non-penumbra microcatheter.During the procedure, the physician advanced a smart coil into the target vessel and attempted to detach it using a handle; however, the smart coil failed to detach.The handle was removed and saved for later use.The physician made another attempt to detach the smart coil using a new handle, but the smart coil still failed to detach.Therefore, the physician used a hemostat on the back of the pusher assembly to manually detach the smart coil.Next, another smart coil was advanced into the vessel and the physician attempted to detach it using both handles; however, the smart coil failed to detach.The physician attempted to manually detach the smart coil, but the coil still failed to detach.Therefore, both handles and the smart coil were removed.The procedure was completed using a new handle and smart coil.There was no report of an adverse effect to the patient.

• Brand Name: PENUMBRA SMART COIL
• Common Device Name: HCG, KRD
• Manufacturer (Section D): PENUMBRA, INC.; one penumbra place; alameda CA 94502
• MDR Report Key: 11066894
• Report Number: 3005168196-2020-02341
• Device Sequence Number: 14552027
• Product Code: HCG
• UDI-Device Identifier: 00814548015088
• UDI-Public: 00814548015088
• Combination Product (Y/N): Y
• Initial Reporter State: TX
• Initial Reporter Country: US
• PMA/510(K) Number: K160832
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2020
• Reporter Type: Manufacturer
• Report Source: company representative,health
• Initial Reporter Occupation: Physician
• Type of Report: Initial
• Report Date (Section B): 12/01/2020
• Report Date (Section F): 01/01/2005

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
• Operator of Device: Health Professional
• Device Expiration Date: 12/31/2024
• Device Model Number: 400SMTSFT0408
• Device Catalogue Number: 400SMTSFT0408
• Device Lot Number: F95240
• Was Device Available for Evaluation?: No
• Was the Report Sent to FDA?: Yes
• Date Report to Manufacturer: 01/10/2005
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 12/01/2020
• Initial Report FDA Received Date: 12/23/2020
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Patient Age: 78 YR
• Date Report Sent to FDA: 01/01/2005