MAUDE Adverse Event Report: W. L. GORE & ASSOCIATES, INC. GORE® EXCLUDER® AAA ENDOPROSTHESIS; SYSTEM, ENDOVASCULAR GRAFT, AORTIC ANEURYSM TREATMENT

Model Number	RLT231416
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Code	Aneurysm (1708)
Date of Event	06/22/2022
Type of Reportable Event	Death
Additional Manufacturer Narrative
The instructions for use (ifu) for the gore® excluder® aaa endoprosthesis states, adverse events that may occur and / or require intervention include but are not limited to: death.Patient medical history includes but is not limited to: medical history positive for chronic kidney disease, diabetes mellitus (type 2) , hypertension, hyperlipidemia, chronic subdural hematoma, spinal stenosis.Patient medications include but are not limited to: alprazolam (xanax) 0.25 mg tablet, amitiza 24 mcg capsule, cyanocobalamin (vitamin b-12) 100 mcg tablet take 100 mcg by mouth daily, empagliflozin (jardiance) 10 mg tab take by mouth, lantus solostar u-100 insulin 100 unit/ml (3 ml) injection, lisinopril (prinivil; zestril) 10 mg tablet.As gore was unable to determine which device was involved in the event if any; additional device(s) implanted include: pll161407/24753448.W.L.Gore & associates, inc.(gore) is submitting this report to comply with 21 c.F.R.Part 803, the medical device reporting regulation.This report is based upon information obtained by gore, which the company may not have been able to fully investigate or verify prior to the date the report was required by the fda.Blank fields present on this report include required fields and fields determined to be not applicable.Blank required fields indicate that the information was not provided, was deemed unavailable or was not applicable.This report does not constitute an admission or a conclusion by fda, gore, or its associates that the device, gore or its associates caused or contributed to the event described in the report.In particular, this report does not constitute a legal admission by anyone that the product described in this report has any defects or has malfunctioned, as defined from a legal standpoint.These words are included in the report and are fixed items for selection created by the fda, to categorize the type of event solely for the purpose of reporting pursuant to part 803.This statement should be included with any information or report disclosed to the public under the freedom of information act.
Event or Problem Description
On (b)(6) 2022, this patient underwent endovascular treatment for an abdominal aortic aneurysm and left common iliac artery aneurysm >4 cm in diameter and was implanted with gore® excluder® aaa endoprostheses featuring c3® delivery system.Additionally, the kidney, spleen, small and large bowel; as well as the left lower extremity were embolized.The patient tolerated the procedure.On (b)(6) 2022, the physician reported the patient expired and that a diagnostic laparoscopy and exploratory laparotomy were performed this date.The physician reports the cause of death (cod) was dead gut and that the death was not device related.The physician stated there was no deficiency of the gore devices and believes wire manipulation in the aorta during placement of the gore devices may have contributed to the patient¿s death.No further details were provided by the physician.

• Brand Name: GORE® EXCLUDER® AAA ENDOPROSTHESIS
• Common Device Name: SYSTEM, ENDOVASCULAR GRAFT, AORTIC ANEURYSM TREATMENT
• Manufacturer (Section D): W. L. GORE & ASSOCIATES, INC.; 1505 n. fourth street; flagstaff AZ 86004
• Manufacturer (Section G): MEDICAL SILICON VALLEY B/P; 2890 de la cruz blvd.; santa clara CA 95050
• Manufacturer Contact: laura crawford ; 1505 n. fourth street; flagstaff, AZ 86004 ; 9285263030
• MDR Report Key: 15032657
• Report Number: 3013164176-2022-01435
• Device Sequence Number: 5139378
• Product Code: MIH
• UDI-Device Identifier: 00733132622382
• UDI-Public: 00733132622382
• Combination Product (Y/N): N
• Initial Reporter State: NY
• Initial Reporter Country: US
• PMA/510(K) Number: P020004
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2022
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Health Professional,Company Representative
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup,Followup
• Report Date (Section B): 10/20/2022

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: 08/17/2024
• Device Model Number: RLT231416
• Device Catalogue Number: RLT231416
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 06/29/2022
• Supplement Date Received by Manufacturer: 06/29/2022; 06/29/2022
• Initial Report FDA Received Date: 07/15/2022
• Supplement Report FDA Received Date: 07/27/2022; 10/20/2022
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• Date Device Manufactured: 08/19/2021
• 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: Other; Death; Hospitalization
• Patient Age: 85 YR
• Patient Sex: Male
• Patient Weight: 74 KG