MAUDE Adverse Event Report: ENDOLOGIX SANTA ROSA OVATION IX; MAIN BODY

Model Number	TV-AB2980-J
Medical Device Problem Code	Insufficient Device Problem Information (3190)
Health Effect - Clinical Code	Failure of Implant (1924)
Date of Event	05/11/2021
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
The devices involved in this event will not be returned for evaluation and remain implanted in the patient.Patient medical records and imaging studies will be requested for further evaluation by a clinical specialist.If additional information pertinent to the incident is obtained, a follow-up report will be submitted.
Event or Problem Description
The patient was initially treated for an abdominal aortic aneurysm (aaa) with the ovation ix abdominal aortic aneurysm stent system.Approximately seven (7) months post initial procedure, the patient presented with an endoleak (at indeterminate origin).The physician elected to treat the patient by implanting two (2) ovation ix extenders and a palmaz stent on (b)(6) 2019.The seal was reportedly improved and patient was discharged in stable condition.Reference mfr.Report # 3008011247-2019-00047 for this previously reported event.Now another two (2) years later, patient presented at routine follow-up with a type ib endoleak (on right-side), type ii endoleak (non-device-related) and a persistent type ia endoleak (previously treated with a palmaz stent).The physician plans to re-intervene and the patient is reportedly in stable condition.
Event or Problem Description
The patient was initially treated for an abdominal aortic aneurysm (aaa) with the ovation ix abdominal aortic aneurysm stent system.Approximately seven (7) months post initial procedure, the patient presented with an endoleak (at indeterminate origin).The physician elected to treat the patient by implanting two (2) ovation ix extenders and a palmaz stent on (b)(6) 2019.The seal was reportedly improved and patient was discharged in stable condition.Reference mfr.Report # 3008011247-2019-00047 for this previously reported event.Now another two (2) years later, patient presented at routine follow-up with a type ib endoleak (on right-side), type ii endoleak (non-device-related) and a persistent type ia endoleak (previously treated with a palmaz stent).The physician plans to re-intervene and the patient is reportedly in stable condition.Additional information received indicating that the physician elected to treat the patient by implanting two (2) ovation ix iliac limbs on (b)(6) 2021.The endoleaks were successfully resolved and the patient is reportedly stable.
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 reported type ib endoleak (from right common iliac artery), persistent type ia endoleak, non-device-related type ii endoleak (from lumbar artery) and tertiary endovascular procedure are confirmed.This is 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.The final patient status was reported as discharged on postoperative day one following a tertiary endovascular procedure.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.Corrections: b2 outcomes attributed to ae.B5 describe event or problem.G2 contact office.G4 awareness date.H6 evaluation result codes; remove 3233.H6 evaluation conclusion codes; remove 11.

• Brand Name: OVATION IX
• Common Device Name: MAIN BODY
• Manufacturer (Section D): ENDOLOGIX SANTA ROSA; 3910 brickway blvd; santa rosa CA 95403
• MDR Report Key: 11846093
• Report Number: 3008011247-2021-00043
• Device Sequence Number: 19769976
• Product Code: MIH
• UDI-Device Identifier: M701TVAB2980J1
• UDI-Public: +M701TVAB2980J1/$$3210125FS010918121
• Combination Product (Y/N): N
• Initial Reporter State: PA
• Initial Reporter Country: US
• PMA/510(K) Number: P120006
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2018
• Reporter Type: Manufacturer
• Report Source: company representative,health
• Initial Reporter Occupation: Physician
• Remedial Action: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 05/11/2021

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: 01/25/2021
• Device Model Number: TV-AB2980-J
• Device Catalogue Number: TV-AB2980-J
• Device Lot Number: FS010918-12
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 05/11/2021
• Supplement Date Received by Manufacturer: 06/29/2021
• Initial Report FDA Received Date: 05/18/2021
• Supplement Report FDA Received Date: 07/26/2021
• 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: FILL POLYMER, SN (B)(6); OVATION IX EXTENDER, SN (B)(6); OVATION IX EXTENDER, SN (B)(6); OVATION IX ILIAC LIMB, SN (B)(6); OVATION IX ILIAC LIMB, SN (B)(6); OVATION IX ILIAC LIMB, SN (B)(6); PALMAZ STENT
• Outcome Attributed to Adverse Event: Other; Required Intervention
• Patient Age: 74 YR