MAUDE Adverse Event Report: TRIVASCULAR, INC. OVATION IX ILIAC LIMB STENT GRAFT SYSTEM; ENDOVASCULAR GRAFT, ABDOMINAL AORTIC ANEURYSM

Model Number TV-IL1410100-J

Device Problem Adverse Event Without Identified Device or Use Problem (2993)

Patient Problems Occlusion (1984); Stenosis (2263)

Event Date 11/27/2016

Event Type  Injury  

Event Description

An ovation ix abdominal stent graft system was implanted to treat an abdominal aortic aneurysm.The 10 month post-operative ct showed the presence of an occlusion of the right iliac limb stent graft and thrombus in the left iliac limb stent graft in the presence of anatomical narrowing.The patient underwent a re-intervention to place two balloon expandable stents bilaterally to maintain lumenal patency.As of the date of this report, there have been no additional patient sequelae reported.

• Brand Name: OVATION IX ILIAC LIMB STENT GRAFT SYSTEM
• Type of Device: ENDOVASCULAR GRAFT, ABDOMINAL AORTIC ANEURYSM
• Manufacturer (Section D): TRIVASCULAR, INC.; 3910 brickway blvd.; santa rosa CA 95403
• Manufacturer (Section G): TRIVASCULAR, INC.; 3910 brickway blvd.; santa rosa CA 95403
• Manufacturer Contact: alexis weil ; 3910 brickway blvd.; santa rosa, CA 95403 ; 7075438835
• MDR Report Key: 6216746
• MDR Text Key: 63687715
• Report Number: 3008011247-2016-00139
• Device Sequence Number: 1
• Product Code: MIH
• UDI-Device Identifier: M701TVIL1410100J1
• UDI-Public: +M701TVIL1410100J1/$$3160831FS02261511B
• Combination Product (y/n): N
• Reporter Country Code: US
• PMA/PMN Number: P120006
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: company representative,health
• Reporter Occupation: Physician
• Type of Report: Initial
• Report Date: 12/30/2016

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: No
• Device Operator: Physician
• Device Expiration Date: 08/31/2016
• Device Model Number: TV-IL1410100-J
• Device Catalogue Number: TV-IL1410100-J
• Device Lot Number: FS022615-11
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Initial Date Manufacturer Received: 11/30/2016
• Initial Date FDA Received: 12/31/2016
• Was Device Evaluated by Manufacturer?: Yes
• Date Device Manufactured: 08/31/2016
• Is the Device Single Use?: Yes
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Initial
• Patient Sequence Number: 1
• Treatment: BES STENTS (X2)
• Patient Outcome(s): Required Intervention