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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 kinked.The main coil was seen to be detached and not returned.The main coil was not returned so the functional inspection could not be carried out.The reported event ¿main coil failed/unable to detach could not be replicated¿; 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 on 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.During the procedure, the coil was advanced through the microcatheter into the middle meningeal artery (mma) as usual; however, it failed to deploy.A different power supply was tried, but the coil still did not deploy.The device was returned for analysis.The coil delivery wire was found to be kinked/bent.The main coil was observed detached and not returned.Main coil failed/unable to detach could not be replicated; however, the analysis results are consistent with the reported event.Based on the available information and device analysis, it is probable that kinking of the coil delivery wire near the proximal contact contributed to the detachment failure.Additionally, it is probable that manipulation of the subject coil against resistance during advancement and withdrawal led to coil detachment.Therefore an assignable cause of 'procedural factors' will be assigned to the reported event ¿main coil failed/unable to detach¿ and to the analysed event ¿coil delivery wire kinked/bent¿ and ¿main coil prematurely detached/separated 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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