MAUDE Adverse Event Report: ENDOLOGIX AFX; BIFURCATED STENT GRAFT

Model Number	BA28-90/I20-30
Medical Device Problem Code	Insufficient Device Problem Information (3190)
Health Effect - Clinical Code	Aneurysm (1708)
Date of Event	10/04/2020
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
The device involved in the 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 and a vela suprarenal stent graft to treat an abdominal aortic aneurysm (aaa).Approximately five and a half (5.5) years later during a routine follow up, aneurysm growth to 6.3cm was identified with no endoleak present.The physician elected to treat the patient by implanting an ovation ix abdominal aortic aneurysm stent on (b)(6) 2020.The patient is reportedly in stable condition post secondary endovascular repair.
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 sac growth event/incident was unconfirmed due to a lack of comparative imaging.This is not consistent with the reported adverse event/incident.The clinical evaluation also shows reasonable evidence to suggest multiple type ii endoleaks occurred.These findings were discovered during a review of the 62-month post-implant computed tomography (ct) scan.The most likely causation for the reported event is anatomy-related due to the multiple type ii endoleaks.The final patient status was reported as being alive and well.No additional investigation of this reported adverse event/incident 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/incidents.Device iteration is afx with duraply.Corrections: b5: describe event or problem updated g4: awareness date h6: device code: remove code 3190 h6: result code: remove code 3233 h6: conclusion code: remove code 11.
Event or Problem Description
The patient was initially implanted with an afx bifurcated stent graft and a vela suprarenal stent graft to treat an abdominal aortic aneurysm (aaa).Approximately five and a half (5.5) years later during a routine follow up, aneurysm growth to 6.3cm was identified with no endoleak present.The physician elected to treat the patient by implanting an ovation ix abdominal aortic aneurysm stent on (b)(6) 2020.The patient is reportedly in stable condition post secondary endovascular repair.Additional information: clinical assessment determined that there was evidence to reasonably suggest multiple type ii endoleaks occurred.The type ii endoleaks were discovered during a review of the 62 month post implant computed tomography (ct) scan.As a type ii endoleak is anatomy-related, this event is no longer reportable to the fda as there is no alleged deficiency related to the identity, quality, durability, reliability, safety, effectiveness, or performance of an endologix device.

• Brand Name: AFX
• Common Device Name: BIFURCATED STENT GRAFT
• Manufacturer (Section D): ENDOLOGIX; 2 musick; irvine CA 92618
• MDR Report Key: 10778488
• Report Number: 2031527-2020-00316
• Device Sequence Number: 16400067
• Product Code: MIH
• UDI-Device Identifier: 00818009012630
• UDI-Public: (01)00818009012630(17)170904
• Combination Product (Y/N): N
• Initial Reporter State: MA
• Initial Reporter Country: US
• PMA/510(K) Number: P040002
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2015
• Reporter Type: Manufacturer
• Report Source: company representative,health
• Initial Reporter Occupation: Physician
• Remedial Action: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 10/04/2020

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: 09/04/2017
• Device Model Number: BA28-90/I20-30
• Device Lot Number: 1251904008
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 10/04/2020
• Supplement Date Received by Manufacturer: 12/16/2020
• Initial Report FDA Received Date: 11/03/2020
• Supplement Report FDA Received Date: 12/31/2020
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Concomitant Medical Products and Therapy/Usage Dates: VELA SUPRARENAL, LOT # 1278767005; VELA SUPRARENAL, LOT # 1278767005
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 76 YR