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Due to the automated manufacturing execution system (mes) system there are controls in the manufacturing process to ensure the product met specifications upon release.Visual and functional inspections were not performed due to the device was not returned.The reported event is covered in the device directions for use (dfu).As well, the risk of the reported event is documented in the risk documentation and there are current controls to mitigate the risk of the as reported event.The reported complaint could not be confirmed, and it could not be definitively determined if the device failed to meet specifications because the product was not returned.It was reported that premature detachment occurred after repositioning the subject coil twice.Part of the coil remained in the microcatheter, so negative pressure was applied to retrieve it.A new coil of the same type was then taken out and used without any problem and the procedure was completed successfully using the same microcatheter.Additional information provided by the customer indicated that the device was confirmed to be in good condition during preparation/prior to use on the patient and was prepared for use as per the dfu, continuous flush was set up and maintained throughout the clinical procedure, and the coil was advanced slowly and gently without applying excessive force.While there are a number of potential causes for the reported issue, because review of available information failed to identify a definitive cause and the device was not returned for analysis, an assignable cause of undeterminable was assigned to the reported event ¿main coil prematurely detached/separated during use'.
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It was reported that during hepatic artery coil embolization procedure the subject coil was repositioned twice, after which it prematurely detached inside the microcatheter.Negative pressure was applied to retrieve the subject coil from the microcatheter.The subject device was replaced, and the procedure was completed successfully.No clinical consequences were reported to the patient due to this event.
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