MAUDE Adverse Event Report: ENDOLOGIX AFX; BIFURCATED STENT GRAFT

Model Number	BA25-120/I20-40
Medical Device Problem Code	Insufficient Device Problem Information (3190)
Health Effect - Clinical Code	Failure of Implant (1924)
Date of Event	08/20/2020
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
The device involved in this event will not be returned for evaluation as it remains implanted in the patient.Patient medical records and imaging studies will be requested for further evaluation by the clinical specialist.If additional information pertinent to the incident is obtained, a follow-up report will be submitted.Device iteration is afx with duraply.
Event or Problem Description
The patient was initially implanted with an afx bifurcated stent graft, an afx infrarenal aortic extension, vela suprarenal and vela infrarenal devices and an iliac limb stent graft to treat an abdominal aortic aneurysm (aaa).There was a type 2 endoleak (anatomy-related) reported post initial procedure.Due to sac growth two years post implant the sac, lumbar arteries and ima were coiled.It seemed to have some benefit but the endoleak continued.Approximately 4.5 years post initial procedure a computed tomography angiogram (cta) shows a type 3a endoleak between the main body and first proximal extension.The physician elected to reline the bifurcated stent graft, vela suprarenal and limb stent graft.The endoleak was confirmed resolved, and the patient is stable and at home.
Additional Manufacturer Narrative
The reported adverse event/incident was investigated in alignment with endologix operating procedures and work instructions.Where possible, it is endologix practice to make at least three good faith efforts to retrieve a reported adverse event/incident related device as well as medical records and medical imaging.An evaluation of the manufacturing record was completed.A review of the part number/lot number combination needed for device identification shows the device to have been properly manufactured and released in accordance with the device master record.The review confirms there were no manufacturing or processing non-conformities identified that would contribute to the reported adverse event/incident.An evaluation of the device could not be completed.The device was not returned to endologix for evaluation because it remains implanted.A clinical evaluation of the adverse event/incident was completed.An examination of medical records and/or medical imaging received by endologix shows the type iiia endoleak event is unconfirmed.This is not consistent with the reported adverse event/incident.Procedure related harms, device, user, procedure, or anatomy relatedness of this event could not be determined with the medical records available for review.During the investigation and with the information available, endologix found no evidence to suggest the device was used off-label.The final patient status was reported as stable post the secondary endovascular procedure.No additional investigation of this reported adverse event is planned however, should additional information relevant to the investigation outcome become available, a follow-up report will be submitted.Endologix will continue to monitor this and similar adverse events.Device iteration is afx with duraply.

• Brand Name: AFX
• Common Device Name: BIFURCATED STENT GRAFT
• Manufacturer (Section D): ENDOLOGIX; 2 musick; irvine CA 92618
• MDR Report Key: 10587471
• Report Number: 2031527-2020-00274
• Device Sequence Number: 19137323
• Product Code: MIH
• UDI-Device Identifier: 00818009011985
• UDI-Public: (01)00818009011985(17)171212
• Combination Product (Y/N): N
• Initial Reporter State: KY
• Initial Reporter Country: US
• PMA/510(K) Number: P040002
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2016
• Reporter Type: Manufacturer
• Report Source: company representative,health
• Initial Reporter Occupation: Physician
• Remedial Action: Other,Recall
• Type of Report: Initial,Followup
• Report Date (Section B): 08/28/2020

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: 12/12/2017
• Device Model Number: BA25-120/I20-40
• Device Lot Number: 1283306005
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 08/28/2020
• Supplement Date Received by Manufacturer: 11/06/2020
• Initial Report FDA Received Date: 09/25/2020
• Supplement Report FDA Received Date: 11/24/2020
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• If action reported to FDA under 21 USC 360i(g), list FDA-assigned Recall Number or include a statement: Z-0006-2019
• Patient Sequence Number: 1
• Concomitant Medical Products and Therapy/Usage Dates: AFX INFRARENAL AORTIC EXTENSION - 1298666056; AFX LIMB STENT GRAFT - 1047368-008; AFX VELA INFRARENAL - 1252166044; AFX VELA SUPRARENAL - 1252432018; AFX INFRARENAL AORTIC EXTENSION - 1298666056; AFX LIMB STENT GRAFT - 1047368-008; AFX VELA INFRARENAL - 1252166044; AFX VELA SUPRARENAL - 1252432018
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 77 YR