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

Catalog Number	RBY2C0530
Medical Device Problem Codes	Bent (1059); Physical Resistance (2578)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Date of Event	02/26/2018
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
The product was not returned for evaluation.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.This report is associated with mfr report number: 3005168196-2018-00616.The hospital disposed of the device.
Event or Problem Description
The patient was undergoing a coil embolization procedure in the right internal iliac artery using ruby coils.It was noted that the patient¿s anatomy was tortuous.During the procedure, while attempting to insert the first ruby coil into a lantern delivery microcatheter (lantern), the physician experienced resistance and subsequently, the ruby coil pusher assembly became bent; therefore, it was removed.Next, the physician advanced a new ruby coil through the lantern and into the target vessel; however, the coil was undersized and was not forming.Therefore, the physician decided to re-sheath it; however, while trying to re-sheath the ruby coil, its pusher assembly became bent.The ruby coil was then removed and the procedure was completed using a pod6, another ruby coil and the same lantern.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: 7358243
• Report Number: 3005168196-2018-00615
• Device Sequence Number: 13758191
• Product Code: HCG
• UDI-Device Identifier: 00814548012919
• UDI-Public: 00814548012919
• Combination Product (Y/N): N
• Initial Reporter State: UT
• 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: Physician
• Type of Report: Initial
• Report Date (Section B): 02/26/2018

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: 05/30/2024
• Device Catalogue Number: RBY2C0530
• Device Lot Number: F69583
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 02/26/2018
• Initial Report FDA Received Date: 03/21/2018
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Patient Age: 67 YR