MAUDE Adverse Event Report: MEDOS INTERNATIONAL SARL CEREPAK FREEFORM; CEREPAK FREEFORM MINI DETACHABLE COIL SYSTEM

Catalog Number	MCR092060
Medical Device Problem Code	Separation Failure (2547)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	04/08/2025
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Manufacturer ref#: (b)(4).Information regarding patient weight, height, medical history, race, and ethnicity was not reported.Section d2b: procode: krd/hcg.Section h3: the device is available to be returned for evaluation and testing.However, it has not been received to date.If the device returns, a device investigation will be performed.Missing information from this report is identified as blank; this information was not provided in the reported event or available at the time of report submission.This report is being submitted pursuant to the provisions of 21 cfr, part 803 (and/or part 4, as applicable).This report may be based on information which has not been investigated or verified prior to the required reporting date.This report does not reflect a conclusion by cerenovus, or its employees that the report constitutes an admission that the product, cerenovus, or its employees caused or contributed to the potential event described in this report.If information is obtained that was not available for the initial report, a follow-up report will be filed as appropriate.
Event or Problem Description
As reported by a health care professional, during a coil embolization to the middle meningeal artery (mma), the physician used a cerepak freeform mini (mcr091540) with no issue with detachment.Then a second freeform mini 2mm x 6cm coil (mcr092060, 31111682) was used.The operating room (or) technician used the mechanical detachment handle (mdh1, 102109430) and the coil didn't detach.A 3rd freeform mini 2mm x 6cm coil (mcr092060, 31111682) was used, and this time the physician first used a mechanical detacher, it failed.Then tried a manual method and it again failed to detach the coil.Additional event information received on 15-apr-2025 indicated that a headway duo 156cm microcatheter was used.Neither the tech nor physician expressed any particular or difficulty in advancement or positioning the coils.The packaging of the coils was intact and in proper sealing.The coils itself were handed over to the tech and as far as we could see there was no issue in that regard.The vessel was excessively tortuous or with acute bends.The physician does not know exactly why the event happened, ¿maybe it was his first time using our coils on patients¿.
Additional Manufacturer Narrative
Manufacturer ref#: (b)(4).Updated sections on this medwatch: b4, d9, g3, g6, h2, h3 and h11.The product has been returned for evaluation and testing; however, the engineering evaluation has not been completed.A supplemental report will be submitted if new facts arise which materially alter information submitted in a previous mdr report.
Additional Manufacturer Narrative
Manufacturer ref#: (b)(4) updated sections on this medwatch: b4, g3, g6, h2, h3, h6 and h11.Complaint conclusion: as reported by a health care professional, during a coil embolization to the middle meningeal artery (mma), the physician used a cerepak freeform mini (mcr091540) with no issue with detachment.Then a second freeform mini 2mm x 6cm coil (mcr092060, 31111682) was used.The operating room (or) technician used the mechanical detachment handle (mdh1, 102109430) and the coil didn¿t detach.A 3rd freeform mini 2mm x 6cm coil (mcr092060, 31111682) was used, and this time the physician first used a mechanical detacher, it failed.Then tried a manual method and it again failed to detach the coil.Additional event information received on 15-apr-2025 indicated that a headway duo 156cm microcatheter was used.Neither the tech nor physician expressed any particular or difficulty in advancement or positioning the coils.The packaging of the coils was intact and in proper sealing.The coil itself was handed over to the tech and as far as we could see there was no issue in that regard.The vessel was excessively tortuous or with acute bends.The physician does not know exactly why the event happened, ¿maybe it was his first time using our coils on patients¿.The device was returned to j&j medtech for further evaluation.A non-sterile freeform mini 2mm x 6cm coil was received contained in the decontamination pouch.Upon receiving the device, visual inspection was performed, and as described in the event, the manual break was attempted at the proper location without embolic coil detachment.No damages were noted on the delivery system.The embolic coil was inspected under magnification, and the coil was found slightly kinked and stretched.Dried biological matter was found in the proximal key engagement with the detachment tube.No unintentional weld was noted at the loophole.A manufacturing record evaluation was performed for the finished device 31111682 number, and no non-conformances related to the malfunction were identified.With the information available, the root cause of the failure encountered cannot be determined.It is possible that clinical and procedural factors, including device manipulation, may have contributed to the reported failure.The occluded condition of the proximal key engagement suggests that the saline flush could had been insufficient, however, with the information available, this remains speculative.There is no indication that the issues reported in the complaint result from a defect inherently related to the cerepak device.The slight kinked and stretched conditions of the embolic coil were not originally reported; it is suspected that these damages could be related to the manipulation of the device post-procedure; therefore, these are not considered related to the issue reported.As part of j&j medtech quality process all devices are manufactured, inspected, and released to approved specifications.Since there was no evidence to suggest the event was related to a manufacturing or design issue, no capa activity is required.The instructions for use (ifu) contain the following recommendations: 1.Remove the detacher from the protective packaging and place it within the sterile field.The detacher is packaged separately for single patient use only.2.Confirm again under fluoroscopy that the coil alignment marker of the delivery tube creates a ¿t¿ with the proximal marker of the microcatheter.3.Verify that the rhv is firmly locked around the delivery tube to ensure that the coil does not move during connection process.Ensure the delivery tube is straight between the rhv and the detacher.4.Hold the delivery tube approximately 3 inches from proximal end and bring the detacher over the delivery tube until a firm stop is felt.5.Maintain the delivery tube position within the detacher and use a thumb to pull back the slider on the detacher.6.Continue to pull on the slider until end of travel or a click is heard.Gently release the slider until it returns to starting position or a second click is heard.Remove detacher by slowly withdrawing it from the delivery tube.Note: detacher must remain in sterile field until the procedure is completed.7.Fluoroscopically verify that the coil is detached by gently pulling back the delivery tube approximately 1cm.If the coil has detached, remove the delivery tube from the microcatheter.8.If the coil has not detached, repeat steps 3-7.If 2 unsuccessful detachments occur, discard the detacher and proceed to the manual break section.9.Repeat steps 1-8 until the procedure is completed.Discard the detacher.Caution: always perform fluoroscopic verification of detachment prior to withdrawing the delivery system fully.Failure to do so may lead to an embolic complication.10.After detaching the coil, remove the delivery tube from the microcatheter and discard.11.Repeat the above sequence for all additional coils until the procedure is complete.As part of the post market surveillance program, information from this complaint is trended to identify statistical signals for consideration of further correction action.Since there was no evidence to suggest the event was related to a manufacturing or design issue, no corrective actions will be taken at this time.A supplemental report will be submitted if new facts arise which materially alter information submitted in a previous mdr report.

• Brand Name: CEREPAK FREEFORM
• Common Device Name: CEREPAK FREEFORM MINI DETACHABLE COIL SYSTEM
• Manufacturer (Section D): MEDOS INTERNATIONAL SARL; chemin-blanc 38; le locle neuchatel CH-24 00; SZ CH-2400
• Manufacturer (Section G): CERENOVUS, INC.; calle circuito int norte 1820; parque industrial salvacar; juarez 32574 ; MX 32574
• Manufacturer Contact: henry boden ; 31 technology dr; irvine, CA 92618 ; 9497882078
• MDR Report Key: 21918101
• Report Number: 3008114965-2025-00360
• Device Sequence Number: 8720139
• Product Code: KRD
• UDI-Device Identifier: 10886704083016
• UDI-Public: (01)10886704083016(17)260731(10)31111682
• Combination Product (Y/N): N
• Initial Reporter State: CA
• Initial Reporter Country: US
• PMA/510(K) Number: K220040
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Health Professional
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial,Followup,Followup
• Report Date (Section B): 06/09/2025

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: 07/31/2026
• Device Catalogue Number: MCR092060
• Device Lot Number: 31111682
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 04/08/2025
• Supplement Date Received by Manufacturer: 04/28/2025; 06/02/2025
• Initial Report FDA Received Date: 04/28/2025
• Supplement Report FDA Received Date: 05/14/2025; 06/09/2025
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 08/30/2023
• 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
• Concomitant Medical Products and Therapy/Usage Dates: HEADWAY DUO 156CM MICROCATHETER; MECHANICAL DETACHMENT HANDLE
• Patient Sex: Female