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The patient was undergoing a thrombectomy procedure in the m1 segment of the middle cerebral artery (mca) using a velocity delivery microcatheter (velocity), a penumbra system red 72 silver reperfusion catheter (red72 silver), and a stent retriever.The physician used the velocity to deliver the stent retriever to the target vessel and made one pass.While removing the velocity from the patient, the physician experienced resistance.The physician removed the red72 silver, velocity, and stent retriever together.After removal, the velocity was noted to be fractured.It was noted that while removing the velocity from the red72 silver on the back table, the red72 silver fractured.The procedure was completed with a new velocity and new red72 silver.There was no report of an adverse effect to the patient.
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Evaluation of the returned velocity delivery microcatheter (velocity) confirmed that the catheter was fractured.It was reported that the velocity fractured upon removal.If the velocity is retracted against resistance, damage such as this may occur.Based on the reported event, the root cause of resistance could not be determined.Further evaluation revealed that the distal fractured segment of the velocity was stuck inside the red72 silver.This damage likely occurred on the back table during removal of the velocity from the red72 silver.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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