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The patient was undergoing a thrombectomy procedure in the distal m1 segment of the middle cerebral artery (mca) using a penumbra system red 72 silver reperfusion catheter (red72 silver) and a penumbra engine (engine).The physician advanced the red72 silver to the face of the clot and initiated aspiration.During the first pass, the physician noticed that there was no flow into the canister so the red72 silver was removed.Upon removal, the the red72 was found to be ovalized with clot in its distal tip and was removed from the procedure.Subsequently, a small clot was identified to have embolized in the m3 and was too distal to aspirate.A microcatheter was then used to deliver a thrombolytic agent (alteplase) and the procedure was completed.There was no additional adverse effect reported.
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Evaluation of the returned penumbra system red 72 silver reperfusion catheter (red72 silver) confirmed that the catheter was ovalized.This type of damage is consistent with the forcefully pinching, gripping, or manipulating the catheter near the hub of the parent device.Based on the reported complaint, the root cause of ovalization could not be determined.Penumbra devices are inspected during in-process inspection and during quality inspection after manufacturing.The manufacturing records for this lot were reviewed and did not reveal any outstanding discrepancies, design, or quality concerns.From the information provided, there is no indication that there was any device malfunction, nonconformance, or misuse that contributed to the reported event.
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