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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.During visual inspection, the subject coil delivery wire and introducer sheath were not returned.The subject main coil was seen to be detached with no anomalies.For functional inspection, main coil failed/unable to detach functional test ¿ unable to perform as main coil returned detached.The reported event is covered in the device direction 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 " main coil failed/unable to detach " it could not be replicated during device analysis; however, the analysis results are consistent with the reported event.The device failed to meet specifications when received for complaint investigation based on the analyzed anomalies noted to the device.It was reported that during the surgical procedure, the physician made more than eight attempts using two different power supply detachment systems to detach the subject coil but was still unable to achieve detachment within the aneurysm sac.In order to successfully complete the procedure, the subject coil was retrieved and replaced with a new subject coil.Additional information from the customer indicated that the patient¿s anatomy was moderately tortuous, and the proximal end of the delivery wire had not been wiped with alcohol prior to insertion into the power supply system.The device was returned for analysis.The subject main coil was noted to be prematurely detached/separated from the delivery wire.Since the subject coil delivery wire and introducer sheath were not returned, no functional testing could be performed.An assignable cause of procedural factors will be assigned to the reported code " main coil failed/unable to detach " as it could not be replicated during analysis however, the analysis results are consistent with the reported event.It is probable that the proximal end of the delivery wire was not wiped with alcohol prior to inserting into the power supply, resulting in reported defects in the device.An assignable cause of procedural factors will be assigned to ¿main coil prematurely detached/separated during use.' although there is no conclusive evidence identifying the exact cause of the event, it likely occurred during retrieval of the subject coil through moderately tortuous anatomy.This complaint appears to be associated with a product that met stryker design and manufacturing specifications and was used in accordance with the dfu, but performance was limited due to procedural factors during use.
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