| Catalog Number |
M0035424060 |
| Medical Device Problem Code |
Device Dislodged or Dislocated (2923)
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| Health Effect - Clinical Code |
No Clinical Signs, Symptoms or Conditions (4582)
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| Date of Event |
02/27/2025
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Type of Reportable Event
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Malfunction
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Event or Problem Description
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It was reported that when inserting the subject coil into the rhv (rotating hemostasis valve) of the microcatheter during an aneurysm coil embolization procedure, the fluoro-saver markers were visible on the coil delivery wire.However, the subject coil had already reached the aneurysm when the fluoroscopy was turned to visualize the coil position.The subject coil was implanted without any issues, the procedure was completed successfully and there were no clinical consequences to the patient due to the reported event.
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Event or Problem Description
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It was reported that when inserting the subject coil into the rhv (rotating hemostasis valve) of the microcatheter during an aneurysm coil embolization procedure, the fluoro-saver markers were visible on the coil delivery wire.However, the subject coil had already reached the aneurysm when the fluoroscopy was turned to visualize the coil position.The subject coil was implanted without any issues, the procedure was completed successfully and there were no clinical consequences to the patient due to the reported event.
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Additional Manufacturer Narrative
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Due to the automated mes (manufacturing execution system) system there are controls in the manufacturing process to ensure the product met specifications upon release.The subject device was not returned; therefore, physical as well as functional evaluation could not be performed.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.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.It was reported that the physician observed that the fluoro-saver markers on the subject delivery wire were till outside the microcatheter when the subject coil had already exited the microcatheter distal tip.Additional information provided indicated that an rhv was used and there was no reported subject coil stretching.The subject coil was implanted successfully.A review of the device manufacturing records did not identify any potential cause for the reported event.While there are a number of potential causes for the reported issue, because review and analysis of available information failed to identify a definitive cause, a cause of undeterminable was assigned.
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Search Alerts/Recalls
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