MAUDE Adverse Event Report: PENUMBRA, INC. POD 3; HCG, KRD

Catalog Number	RBYPOD3
Medical Device Problem Code	Failure to Fold (1255)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Date of Event	06/27/2019
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: 3005168196-2019-01456.
Event or Problem Description
The patient was undergoing a coil embolization procedure in the renal artery using a pod3, ruby coils and a lantern delivery microcatheter (lantern).During the procedure, the hospital technician opened the packaging and the lantern was inadvertently dropped on the floor.Therefore, the lantern was not used in the procedure.Next, the physician placed a new lantern in the target vessel and attempted to advance a pod3; however, the coil would not take its intended shape.Therefore, the pod3 was removed.The physician then attempted to advance a ruby coil; however, the same issue occurred, and the coil would not take its intended shape, therefore, the ruby coil was removed.The procedure was then completed using a non-penumbra embolic agent.There was no report of an adverse effect to the patient.

• Brand Name: POD 3
• Common Device Name: HCG, KRD
• Manufacturer (Section D): PENUMBRA, INC.; one penumbra place; alameda CA 94502
• MDR Report Key: 8832865
• Report Number: 3005168196-2019-01455
• Device Sequence Number: 3294852
• Product Code: HCG
• UDI-Device Identifier: 00814548019581
• UDI-Public: 00814548019581
• Combination Product (Y/N): Y
• Initial Reporter State: NC
• Initial Reporter Country: US
• PMA/510(K) Number: K173614
• 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): 06/27/2019
• Report Date (Section F): 01/01/2005

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: Health Professional
• Device Expiration Date: 09/02/2026
• Device Catalogue Number: RBYPOD3
• Device Lot Number: F85647
• Was Device Available for Evaluation?: No
• Was the Report Sent to FDA?: Yes
• Date Report to Manufacturer: 01/10/2005
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 06/27/2019
• Initial Report FDA Received Date: 07/26/2019
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Patient Age: 82 YR
• Date Report Sent to FDA: 01/01/2005