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

Catalog Number	RBY2C1035
Medical Device Problem Codes	Physical Resistance/Sticking (4012); Premature Separation (4045)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Date of Event	11/28/2019
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: 3005168196-2019-02314.
Event or Problem Description
The patient was undergoing a coil embolization procedure in the testicular vein using ruby coils and a non-penumbra microcatheter (progreat).During the procedure, while advancing the ruby coil through the microcatheter, the ruby coils got stuck inside the microcatheter and subsequently unintentionally detached inside of the microcatheter.Therefore, the microcatheter containing the detached ruby coil was removed and the ruby coil was flushed out.The physician then reinserted the same microcatheter and attempted to advance a new ruby coil; however, the same issue occurred and, the ruby coil unintentionally detached inside of the microcatheter.Therefore, the microcatheter containing the detached ruby coil was removed and the ruby coil was flushed out.It was reported that the unintentional detachments may have occurred during retraction of the ruby coils after they became stuck.The procedure was then completed using additional ruby coils and a new microcatheter.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: 9470258
• Report Number: 3005168196-2019-02315
• Device Sequence Number: 2146048
• Product Code: HCG
• UDI-Device Identifier: 00814548013008
• UDI-Public: 00814548013008
• Combination Product (Y/N): Y
• Initial Reporter Country: AS
• PMA/510(K) Number: K120330
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: company representative,foreig
• Initial Reporter Occupation: Physician
• Type of Report: Initial
• Report Date (Section B): 11/28/2019
• 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 Catalogue Number: RBY2C1035
• Device Lot Number: F87834
• 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: 11/28/2019
• Initial Report FDA Received Date: 12/13/2019
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Patient Age: 29 YR
• Date Report Sent to FDA: 01/01/2005