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Due to the automated mes (manufacturing execution system) system there are controls in the manufacturing process to ensure the product met specifications upon release.During visual inspection, the coil delivery wire was noted to be kinked/bent.The distal end of delivery wire was noted to be broken/fractured.The main coil was noted to be kinked and stretched.The introducer sheath was not returned.A functional inspection was not carried out due to the damage 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.The as 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 the subject coil was placed at the aneurysm, and the physician attempted to detach it using a detacher device however, the detachment failed despite multiple attempts.The detacher was then replaced, but the issue persisted.To successfully complete the surgery, both the subject coil and the detacher were replaced.The returned device was analyzed, and it was found that the coil delivery wire was kinked and bent at several points.It was also observed that the distal end of the coil was broken/fractured.Additionally, the main coil appeared to be kinked and stretched.The introducer sheath was not returned with the device.Additional information provided by the customer indicated that the delivery wire was broken at the proximal contact.It was also reported that the device was not wiped with alcohol prior to insertion into the power supply.Multiple attempts were made to detach the subject coil, during which the device may have been pushed and pulled against resistance.These factors may be the probable cause of the reported event 'main coil failed/unable to detach', and the analyzed events, including 'coil delivery wire broken/fractured during use', 'main coil kinked/bent' and 'main coil stretched.' an assignable cause of 'use error' will be assigned to 'main coil failed/unable to detach' since there was a deviation from the supplied dfu that resulted in a different medical product response than intended by the manufacturer or expected by the user.An assignable cause of 'procedural factors' will be assigned to this analyzed code including 'coil delivery wire broken/fractured during use', 'main coil kinked/bent' and 'main coil stretched' 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.An assignable cause of 'handling damage' will be assigned to the as analyzed 'coil delivery wire kinked/bent' since this issue is most likely due to handling of the product or portion of the product during the clinical procedure, upon removal of the product from the packaging, or preparation of the product prior to use.
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