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The product was not returned for evaluation.Without the return of the device, the root cause of the problem cannot be determined.The manufacturing records for this lot were reviewed and did not reveal any outstanding discrepancies, design, or quality concerns.
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The patient was undergoing a coil embolization procedure in the left gonadal vein using ruby coils, ruby coil xls, a packing coil xl, and a non-penumbra catheter.The physician placed ruby coils and ruby coil xls in the target location.The catheter was then flushed.While advancing a packing coil xl into the target location, the physician noticed the embolization coil would not form and pack in the vessel.After making several attempts to advance and form the coil in the vessel, the physician decided to remove the packing coil xl.While retracting the packing coil xl, the embolization coil had unintentionally detached within the catheter with the distal end of the coil sticking out into the vessel.The catheter containing the detached packing coil xl was removed and the coil was flushed out from the catheter on the back table.The procedure was completed using additional ruby coil xls, a pod xl, and the same catheter.There was no report of an adverse effect to the patient.
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