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Due to the automated manufacturing execution system (mes) there are controls in the manufacturing process to ensure the product met specifications upon release.During visual inspection, the coil delivery wire was seen to be kinked/bent.The coil delivery wire proximal end was seen to be broken/fractured and missing.The introducer sheath was intact.A functional inspection was not required.As the event was confirmed visually.The reported event of 'coil delivery wire kinked/bent' was confirmed during analysis.The device failed to meet specifications when received for complaint investigation based on the analyzed anomalies noted to the device.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 during surgery when physician advanced the subject coil through microcatheter.They observed the delivery wire was kinked.Additional details provided by customer indicated that the patient¿s anatomy was moderately tortuous the device was returned for analysis, during which the coil delivery wire was found to be kinked/bent, and the proximal end was observed to be broken and missing.Based on all available information and analysis of the device, it is probable that the patient¿s tortuous anatomy may have contributed to reported and analyzed defect therefore an assignable cause of 'procedural factors' will be assigned to the reported event of ¿coil delivery wire kinked/bent¿ and to the analyzed event of 'coil delivery wire kinked/bent' and 'coil delivery wire broken/fractured during use¿ as 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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The coil (subject device) was returned for analysis, and it was discovered that the coil delivery wire was kinked/bent and was broken/fractured during use.The subject device was reported to be replaced, and the procedure was reported to be completed successfully.No clinical consequences were reported to the patient.
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