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The event did not involve death or serious injury and it was stated the case was completed with a different device.This mdr has been filed out of an abundance of caution due to the potential for serious injury if non-target embolism occurred due to the loss of visualization of the lava and the procedural delay in transitioning to a different device.The ifu states adequate fluoroscopic visualization must be maintained during lava delivery and to stop lava delivery if visualization is lost until adequate visualization is reestablished.The batch record review found the device to be manufactured in accordance with the approved specifications.The radiopacity of the device is dependent on the the tantalum added to the product during manufacturing and tantalum amounts were found to be within specification.The investigation is on-going as the customer has stated they will return the device.Based on the information currently available, sirtex medical affairs has stated reduced visualization may theoretically impact embolic control and increase the risk of non-target embolization; however, this is a known procedural consideration mitigated through standard practice, including fluoroscopic monitoring and cessation of delivery if visualization is inadequate.Manufacturing review confirmed the device met all specifications, and no device deficiency has been identified.Overall, this represents a device performance concern without patient harm, with low to remote risk of injury.
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