MAUDE Adverse Event Report: PENUMBRA, INC. RUBY COIL; HCG,KRD

Catalog Number	RBY2C1857
Medical Device Problem Codes	Kinked (1339); Device Damaged Prior to Use (2284); Failure to Advance (2524)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Date of Event	07/17/2017
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
(b)(4).The product was disposed of by the hospital and is no longer available for return.Without the return of the device, the root cause of the problem cannot be determined.The manufacturing records for this lot were reviewed and did not reveal any outstanding discrepancies, design, or quality concerns.Hospital disposed of the device.
Event or Problem Description
The patient was undergoing a coil embolization procedure in the splenic artery using ruby coils.During the procedure, the physician noticed that the ruby coil pusher assembly was bent upon removal from the dispenser hoop.However, the physician continued to use the ruby coil.While attempting to advance the ruby coil through the rotating hemostasis valve (rhv) of the lantern delivery microcatheter (lantern), the physician experienced resistance and was unable to advance the ruby coil through the lantern; therefore, the ruby coil was removed.The procedure was completed using a new ruby coil and the same lantern without resistance.There was no report of an adverse effect to the patient.

• Brand Name: RUBY COIL
• Common Device Name: HCG,KRD
• Manufacturer (Section D): PENUMBRA, INC.; one penumbra place; alameda CA 94502
• MDR Report Key: 6778607
• Report Number: 3005168196-2017-01366
• Device Sequence Number: 13893206
• Product Code: HCG
• UDI-Device Identifier: 00814548013060
• UDI-Public: 00814548013060
• Combination Product (Y/N): N
• Initial Reporter State: CA
• Initial Reporter Country: US
• PMA/510(K) Number: K120330
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: company representative,health
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial
• Report Date (Section B): 07/17/2017

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Operator of Device: Physician
• Device Expiration Date: 03/30/2024
• Device Catalogue Number: RBY2C1857
• Device Lot Number: F68766
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 07/17/2017
• Initial Report FDA Received Date: 08/09/2017
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Patient Age: 64 YR