MAUDE Adverse Event Report: COOK INC MREYE EMBOLIZATION COIL; KRD DEVICE, EMBOLIZATION, VASCULAR

Model Number	N/A
Medical Device Problem Codes	Entrapment of Device (1212); Improper or Incorrect Procedure or Method (2017); Difficult to Advance (2920)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	09/20/2023
Type of Reportable Event	Malfunction
Event or Problem Description
It was reported that a mreye embolization coil became lodged in a spinal needle.The device was required for an ultrasound guided coiling of a fundus.During the procedure, the coil could not be advanced with the wire guide and became stuck within the spinal needle.A portion of the coil exited the distal tip of the spinal needle.The procedure was completed with another coil of the same size.It was noted the device was flushed prior to attempted advancement.As reported, the patient did not experience any adverse effects or require any additional procedures due to this occurrence.
Additional Manufacturer Narrative
Blank fields on this form indicate the information is unknown or unavailable.E1 - customer (person): mobile: (b)(6).This report includes information known at this time.A follow-up report will be submitted should additional, relevant information become available.This report is required by the fda under 21 cfr part 803 and is based on unconfirmed information submitted by others.Neither the submission of this report nor any statement contained herein is intended to be an admission that any cook device is defective or malfunctioned or that a death or serious injury occurred; nor is it admission that any cook device caused, contributed to, or is likely to cause or contribute to a death or serious injury if a malfunction occurred.
Additional Manufacturer Narrative
Blank fields on this form indicate the information is unknown, unavailable, or unchanged.Correction: annex a.Investigation ¿ evaluation: it was reported that a mreye embolization coil became lodged in a spinal needle.The device was required for an ultrasound guided coiling of a fundus.During the procedure, the coil could not be advanced with the wire guide and became stuck within the spinal needle.A portion of the coil exited the distal tip of the spinal needle.The procedure was completed with another coil of the same size.It was noted the device was flushed prior to advancement.As reported, the patient did not experience any adverse effects or require any additional procedures due to this occurrence.Reviews of the complaint history, device history record (dhr), quality control, and instructions for use (ifu), as well as a visual inspection and functional test of the returned device, were conducted during the investigation.One device was received (loading cartridge with coil inside, and shipping bracket) in an opened condition.During table top testing, the shipping bracket was removed and an 0.035" wire guide was advanced through the loading cannula, and the coil came out without any resistance.Cook has concluded that the device was manufactured to specification.Additionally, a document-based investigation evaluation was performed.A review of the device master record (dmr) concluded that sufficient inspection activities are in place to identify this failure mode prior to distribution.A review of the dhr for the reported complaint device lot revealed no recorded non-conformances relevant to the failure mode.A complaint history search did not identify any other events associated with the reported device lot.Based on the available information, cook has concluded that there is no evidence suggesting nonconforming product exists either in house or in the field.Cook also reviewed product labeling.The ifu [t_ce_imwce_rev6] packaged with the device contains the following in relation to the reported failure mode: "device description: mreye embolization coils are made of inconel, an mr conditional super alloy with spaced synthetic fibers and are supplied preloaded in a loading cartridge.They are designed to be delivered to the target vessel using a soft, straight wire guide through a standard angiographic catheter.Precautions: this product is intended for use by physicians trained and experienced in embolization techniques.Standard techniques for placement of vascular access sheaths, angiographic catheters and wire guides should be employed.Prior to introduction of the embolization coil, flush the angiographic catheter with saline." based on the information provided, inspection of the returned device, and the results of the investigation, a potential root cause has been traced to unintended use error due to this device being deployed through a needle, and not through a standard angiographic catheter, as stated in the instructions for use.The appropriate personnel have been notified.Cook will continue to monitor for similar complaints.Per the risk assessment no further action is required.This report is required by the fda under 21 cfr part 803 and is based on unconfirmed information submitted by others.Neither the submission of this report nor any statement contained herein is intended to be an admission that any cook device is defective or malfunctioned, that a death or serious injury occurred, nor that any cook device caused, contributed to, or is likely to cause or contribute to a death or serious injury if a malfunction occurred.
Event or Problem Description
No additional information regarding the patient and/or event has been received since the previous medwatch report was sent.

• Brand Name: MREYE EMBOLIZATION COIL
• Common Device Name: KRD DEVICE, EMBOLIZATION, VASCULAR
• Manufacturer (Section D): COOK INC; 750 daniels way; bloomington IN 47404
• Manufacturer (Section G): COOK INC.; 750 daniels way; bloomington IN 47404
• Manufacturer Contact: jason crouch ; 750 daniels way; bloomington, IN 47404 ; 8123392235
• MDR Report Key: 18067906
• Report Number: 1820334-2023-01498
• Device Sequence Number: 7593676
• Product Code: KRD
• UDI-Device Identifier: 00827002200982
• UDI-Public: (01)00827002200982(17)250304(10)13006483
• Combination Product (Y/N): N
• Initial Reporter Country: IN
• PMA/510(K) Number: K150931
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Other,Foreign,Company Representative,Distributor
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 02/22/2024

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: 03/04/2025
• Device Model Number: N/A
• Device Catalogue Number: IMWCE-35-4-4
• Device Lot Number: 13006483
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 10/25/2023
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Follow-Up
• Initial Date Received by Manufacturer: 11/02/2023
• Supplement Date Received by Manufacturer: 02/13/2024
• Initial Report FDA Received Date: 11/03/2023
• Supplement Report FDA Received Date: 02/22/2024
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 03/04/2020
• Is the Device Labeled for Single Use? (Y/N): Yes
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Usage of Device: Initial
• Patient Sequence Number: 1
• Patient Age: 47 YR
• Patient Sex: Female
• Patient Weight: 55 KG