Description of Event or Problem · 1
DURING TREATMENT OF A PT WITH AN ANEURYSM, THE TIP OF A MICRO THERAPEUTICS X-PEDION GUIDEWIRE FRACTURED LEAVING AN 8 CM FRAGMENT IN THE DISTAL VERTABRAL ARTERY. THE PHYSICIAN ATTEMPTED TO RETRIEVE THE GUIDEWIRE FRAGMENT USING A BSC IN-TIME AND A MICROVENA SNARE BEFORE USING THE MERCI RETRIEVER X6. HE ENSNARED THE GUIDEWIRE FRAGMENT WITH THE RETRIEVER, BUT THE GUIDEWIRE FRAGMENT DEFORMED, OCCLUDING BLOOD FLOW IN THE VESSEL AND DAMAGING THE RETRIEVER X6. HE USED THE SAME DEVICE IN A SECOND ATTEMPT TO RETRIEVE THE GUIDEWIRE FRAGMENT AND FRACTURED THE MERCI RETRIEVER X6 HELICAL TIP, LEAVING THE RETRIEVER X6 TIP IN THE SAME AREA AS THE GUIDEWIRE FRAGMENT. THE PHYSICIAN ATTEMPTED TO RETRIEVE THE DEVICES USING A 2ND IN-TIME DEVICE; A SMALL DISSECTION RESULTED, THE PHYSICIAN THEN DISCONTINUED THE PROCEDURE. THE RETRIEVER X6 IFU WARNS AGAINST USING DAMAGED DEVICES. NO CLINICAL SEQUELAE WERE ASSOCIATED WITH THE FRACTURE.