| Catalog Number |
M0036121040 |
| Medical Device Problem Code |
Adverse Event Without Identified Device or Use Problem (2993)
|
| Health Effect - Clinical Code |
No Clinical Signs, Symptoms or Conditions (4582)
|
| Date of Event |
09/03/2025
|
|
Type of Reportable Event
|
Serious Injury
|
|
Event or Problem Description
|
|
It was reported that during a coiling procedure, resistance was encountered while advancing the subject coil through the introducer sheath, and the subject coil was not moved as intended while repositioning for framing the aneurysm.To retrieve the subject coil, the hub of the catheters was cut, and a snare device was inserted from a stryker catheter since pulling back the delivery wire was not considered effective.While guiding the snare, the coil was intentionally moved.A coil stretch was confirmed outside the patient during inspection after retrieval.The coil was located in the aneurysm at the time the snare was used.The subject device was replaced, and the procedure was completed successfully.No clinical consequences were reported to the patient due to this event.
|
| |
|
Additional Manufacturer Narrative
|
|
Due to the automated manufacturing execution system (mes) system there are controls in the manufacturing process to ensure the product met specifications upon release.The subject device was not available; therefore, a visual inspection as well as a 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 subject coil did not move as intended while repositioning for framing the aneurysm.Additional information provided by the customer indicated that there was a feeling of premature detachment and a snare was used to remove the coil.After removal it was noticed that the coil had stretched but not detached.Friction was noted during advancement of the coil in the sheath which may have contributed to the coil damage.The anatomy was also noted to be severely tortuous which may also have been a factor in the reported events.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.
|
| |
|
Event or Problem Description
|
|
It was reported that during a coiling procedure, resistance was encountered while advancing the subject coil through the introducer sheath, and the subject coil was not moved as intended while repositioning for framing the aneurysm.To retrieve the subject coil, the hub of the catheters was cut, and a snare device was inserted from a stryker catheter since pulling back the delivery wire was not considered effective.While guiding the snare, the coil was intentionally moved.A coil stretch was confirmed outside the patient during inspection after retrieval.The coil was located in the aneurysm at the time the snare was used.The subject device was replaced, and the procedure was completed successfully.No clinical consequences were reported to the patient due to this event.
|
| |
|
Search Alerts/Recalls
|