| Catalog Number |
M0036182450 |
| Medical Device Problem Code |
Fracture (1260)
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| Health Effect - Clinical Code |
No Clinical Signs, Symptoms or Conditions (4582)
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| Date of Event |
04/03/2025
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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 during the coil embolization of a hepatic artery aneurysm procedure, the operator guided a microcatheter into the aneurysm.When the operator was advancing the subject coil as the second coil, resistance was encountered in the shaft as well as during coil withdrawal.When the subject coil was retrieved, it was confirmed that it had been fractured from the delivery wire.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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Additional Manufacturer Narrative
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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 friction was encountered during advancement and retrieval of the coil through a microcatheter and when it was retrieved, the coil was fractured.No anomalies were noted to the device prior to use.Compatibility of the coil with the microcatheter could not be determined as the information was not readily available.The device was not returned for analysis.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 to the reported events: ¿coil in catheter friction', 'coil difficult to remove/withdraw from catheter', 'main coil broken/fractured during use'.
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Event or Problem Description
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It was reported that during the coil embolization of a hepatic artery aneurysm procedure, the operator guided a microcatheter into the aneurysm.When the operator was advancing the subject coil as the second coil, resistance was encountered in the shaft as well as during coil withdrawal.When the subject coil was retrieved, it was confirmed that it had been fractured from the delivery wire.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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Search Alerts/Recalls
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