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The patient was undergoing a thrombectomy procedure in the left m1 segment of the middle cerebral artery (mca) using a penumbra system red 68 reperfusion catheter (red68) and a neuron max 6f 088 long sheath (neuron max).The physician performed one pass in the target location using the red68.After removing the red68 from the patient, the physician found that it was fractured on the distal length.Therefore, the red68 was no longer used in the procedure.The procedure was completed using a new red68 and the same neuron max.There was no report of an adverse effect to the patient.
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Evaluation of the returned penumbra system red 68 reperfusion catheter (red68) confirmed a fracture on the distal shaft.Based on the reported complaint, the red68 likely fractured due to a kink upon retraction after completion of one pass.If the red68 is retracted at an angle during removal from the patient, damage such as a kink and fracture may occur.The root cause could not be determined.Further evaluation of the red68 revealed an additional damage consisting of fractures, ovalizations and kinks on its distal length.This damage likely occurred during packaging for return and was incidental to the reported complaint.Penumbra catheters 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.
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