MAUDE Adverse Event Report: W.L. GORE & ASSOCIATES AORTIC EXCLUDER AAA ENDOPROSTHESIS (LOW PERM); SYSTEM, ENDOVASCULAR GRAFT, AORTIC ANEURYSM TREATMENT

Model Number	PXT261414
Medical Device Problem Code	Insufficient Device Problem Information (3190)
Health Effect - Clinical Code	No Code Available (3191)
Date of Event	03/31/2020
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Please note: medwatch report #2017233-2020-00275 references the same patient and captures the reported type ii endoleak.As it is unknown which gore® excluder® device may have contributed to the reported aneurysm enlargement, two additional components will be included in this report: pxc161200/10014754; udi: (b)(4).Pxl161007/10386447; udi: (b)(4).(b)(4).Per the gore® excluder® aaa endoprosthesis instructions for use (ifu), adverse events that may occur and/or require intervention include, but are not limited to endoleak, aneurysm enlargement, and surgical conversion.
Event or Problem Description
On (b)(6) 2012, the patient underwent endovascular treatment of an abdominal aortic aneurysm using a system of gore® excluder® aaa endoprostheses.According to the report, a type ii endoleak was observed post-operatively.The physician continued to monitor the patient.On an unknown date, follow-up computed tomographic angiography reportedly identified a proximal type i endoleak with aneurysm enlargement (amount unknown, aneurysm measurement not available).The cause of the proximal type i endoleak was not reported.A persistent type ii endoleak was also reportedly seen.The type ii was thought to originate from the inferior mesenteric artery.It was reported an open surgical conversion would be performed on (b)(6) 2020.However, further information regarding the procedure could not be accessed due to the covid-19 pandemic.

• Brand Name: AORTIC EXCLUDER AAA ENDOPROSTHESIS (LOW PERM)
• Common Device Name: SYSTEM, ENDOVASCULAR GRAFT, AORTIC ANEURYSM TREATMENT
• Manufacturer (Section D): W.L. GORE & ASSOCIATES; flagstaff AZ
• MDR Report Key: 10005194
• Report Number: 2017233-2020-00276
• Device Sequence Number: 16995804
• Product Code: MIH
• UDI-Device Identifier: 00733132610228
• UDI-Public: 00733132610228
• Combination Product (Y/N): N
• Initial Reporter Country: JA
• PMA/510(K) Number: P020004
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2012
• Reporter Type: Manufacturer
• Report Source: company representative
• Initial Reporter Occupation: Physician
• Type of Report: Initial
• Report Date (Section B): 03/31/2020

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
• Operator of Device: Health Professional
• Device Expiration Date: 01/31/2015
• Device Model Number: PXT261414
• Device Catalogue Number: PXT261414
• Device Lot Number: 10030247
• Was Device Available for Evaluation?: No
• Was the Report Sent to FDA?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: Not provided
• Initial Report FDA Received Date: 04/28/2020
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Hospitalization; Required Intervention