MAUDE Adverse Event Report: W. L. GORE & ASSOCIATES, INC. GORE® INTERING® VASCULAR GRAFT; PROSTHESIS, VASCULAR GRAFT

Model Number	IRS47045L
Medical Device Problem Code	Patient Device Interaction Problem (4001)
Health Effect - Clinical Code	Hematoma (1884)
Date of Event	03/16/2021
Type of Reportable Event	Serious Injury
Event or Problem Description
The following information was reported to gore: on (b)(6) 2021, a gore® intering® vascular graft was intended for hemodialysis treatment.On (b)(6) 2022, the patient presented with seroma.A gore® intering® vascular graft was sewn in as a interposition graft.On (b)(6) 2022, the patient presented with seroma.A gore® viabahn® endoprosthesis (vsx device) was endovascularly placed to reline the second gore® intering® vascular graft, for treatment of ultrafiltration.Ultrafiltration was identified during the procedure after the vsx device was successfully implanted.On (b)(6) 2022, the gore® intering® vascular graft, and vsx device were explanted.(b)(4).
Additional Manufacturer Narrative
Manufacturing records were reviewed, and the device met all pre-release specifications.An evaluation of the device could not be conducted because no specimen returned.Consequently, a direct product analysis was not possible.Cause of the reported event cannot be established based on evaluation of the information reported to gore.Further information regarding this event was requested by gore, but no further information has been reported, therefore this investigation is considered complete.

• Brand Name: GORE® INTERING® VASCULAR GRAFT
• Common Device Name: PROSTHESIS, VASCULAR GRAFT
• Manufacturer (Section D): W. L. GORE & ASSOCIATES, INC.; 1505 n. fourth street; flagstaff AZ 86004
• Manufacturer (Section G): MEDICAL WEST B/P; 1505 n. fourth street; flagstaff AZ 86004
• Manufacturer Contact: nick lafave ; 1505 n. fourth street; flagstaff, AZ 86004 ; 9285263030
• MDR Report Key: 14603491
• Report Number: 2017233-2022-02987
• Device Sequence Number: 6147261
• Product Code: DSY
• UDI-Device Identifier: 00733132607204
• UDI-Public: 00733132607204
• Combination Product (Y/N): N
• Initial Reporter State: LA
• Initial Reporter Country: US
• PMA/510(K) Number: K991602
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2021
• Device Explanted Year: 2022
• Reporter Type: Manufacturer
• Report Source: Company Representative
• Initial Reporter Occupation: Physician
• Type of Report: Initial
• Report Date (Section B): 06/06/2022

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: 10/31/2025
• Device Model Number: IRS47045L
• Device Catalogue Number: IRS47045L
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 05/12/2022
• Initial Report FDA Received Date: 06/06/2022
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• Date Device Manufactured: 11/05/2020
• Is the Device Labeled for Single Use? (Y/N): Yes
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Usage of Device: Initial
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Hospitalization; Other; Required Intervention
• Patient Sex: Unknown