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Evaluation of the returned penumbra system red 72 silver reperfusion catheter (red72 silver) confirmed that the catheter was fractured and revealed stretching at the fracture site.If the red72 silver is retracted against resistance, damage such as stretching and a subsequent fracture may occur.Based on the reported complaint, the patient¿s tortuous anatomy may have contributed to resistance during the procedure.Further evaluation of the device revealed kinks distal to the stretching, supporting that the device likely became pinned within the tortuous patient anatomy during the procedure and contributed to resistance during retraction.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.
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The patient was undergoing a thrombectomy procedure in the m1 segment of the middle cerebral artery (mca) using a penumbra system red 72 silver reperfusion catheter (red72 silver), a sendit delivery device (sendit), a neuron max 6f 088 long sheath (neuron max), and a guidewire.The patient¿s anatomy was noted to be tortuous.The red72 silver and sendit were advanced over a guidewire and through the neuron max to the target location, and aspiration was performed.The physician decided to retract the red72 silver.While retracting the red72 silver, the physician experienced resistance.The rhv was checked and confirmed not to be overly tightened.The physician continued to retract the red72 silver, and noticed that the distal tip was not moving.The red72 silver and neuron max were subsequently removed together from the patient.On the back table, the distal end of the red72 silver was observed to be unraveling within the neuron max.The red72 silver was not used for the remainder of the procedure.The procedure was completed using a new red72, the same sendit, and the same neuron max.There was no report of an adverse effect to the patient.
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