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Manufacturer ref#: (b)(4).The purpose of this mdr submission is to report the findings of the device investigation.The embolic coil was stretched, meeting regulatory reporting criteria.Information regarding patient weight, height, medical history, race, and ethnicity was not reported.Section d2b: procode: krd/hcg.Section d4: udi: as the lot number for the device involved in the event was not provided, the full udi is currently not available.Section h4: the device manufacture date is not known as the device lot number is not available / not reported.The device was returned to j&j medtech for further evaluation.A non-sterile og tdl cmplx fill coil 5x10 was received contained in the decontamination pouch.Upon receiving the device, a visual inspection was performed, and the coil was noted to be inside from the introducer.The device was inspected under microscopic magnification, and the coil was found severely stretched leaving the internal blue fiber exposed, however, it was still attached to the gripper.The issue documented regarding a coil being unable to be advanced nor retrieved could not be evaluated through proper functional test since the stretched condition found on the coil prevented the ability to move the coil through the introducer.The coil stretching was not originally reported in the complaint.Such damage suggest that excessive force was inadvertently applied during the attempts to withdraw and re-insert the device.It is possible that clinical and procedural factors, including device manipulation and operator's technique, may have contributed to the reported failure.According to the risk documentation, coil damage is a potential issue that can occur during microcoil placement due to excessive system manipulation, which can result in coil stretching.Based on this, the customer complaint was confirmed.Also, risk documentation states that a delivery tube / embolic coil that cannot be pushed through the microcatheter is a potential issue that can occur during coil placement due to: 1) excessively tortuous anatomy; or 2) clot formation in the microcatheter.With the limited information available, the root cause remains speculative, however, there is no indication that the issues encountered during the procedure are a result of a defect inherently related to the device.The manufacturing record evaluation (mre) cannot be performed due to the lot number was not provided.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 proposed at this time.It should be noted that product failure is multifactorial.The instructions for use contain the following precautions and warnings: if unusual friction is still noticed during advancement or retraction of the microcoil system, verify flush lines are open and properly pressurized.Then, slowly withdraw the entire microcoil system and examine for damage.Replace it with a new microcoil system.If friction still exists, withdraw and examine the delivery catheter system.During coil retraction, verify under fluoroscopy that a one-to-one relationship exists between the delivery tube and the coil.If not, the coil has been stretched, which could lead to premature detachment or coil fracture.If the one-to-one relationship does not exist, remove the infusion catheter and the detachable coil as an assembly and replace.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.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.
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