MAUDE Adverse Event Report: INTERVASCULAR SAS HEMASHIELD PLATINUM WOVEN AORTIC ARCH 1B; GRAFT, VASCULAR, SYNTHETIC/BIOLOGIC COMPOSITE

Model Number	M00202175826P0
Medical Device Problem Code	Product Quality Problem (1506)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	09/14/2022
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
(b)(4).
Event or Problem Description
It was reporting to intervascular that while preparing for the aortic dissection surgery, a discolored area was discovered with melted collagen in the product.The operation was completed with another product of the same model stocked in the hospital.Complaint (b)(4).Please note that this complaint is one of a series of two complaints, the second complaint (b)(4) is also the subject of an initial emdr reporting.
Event or Problem Description
Complaint # (b)(4).
Additional Manufacturer Narrative
(10/213) the involved device was returned to intervascular on 27-sept-2022 for examination.A visual inspection by a qualified quality control technician was performed, the conclusion is as follow: "no identified default; no lack of collagen identification of white and yellow stains in relation with the collagen.".(67) the conducted investigation concludes that the product was conform to the specification.

• Brand Name: HEMASHIELD PLATINUM WOVEN AORTIC ARCH 1B
• Common Device Name: GRAFT, VASCULAR, SYNTHETIC/BIOLOGIC COMPOSITE
• Manufacturer (Section D): INTERVASCULAR SAS; zone industrielle athelia i; la ciotat 13705 ; FR 13705
• Manufacturer (Section G): INTERVASCULAR SAS; zone industrielle athelia i; la ciotat 13705 ; FR 13705
• Manufacturer Contact: laurence richard ; zone industrielle athelia i; la ciotat 13705 ; FR 13705 ; 442084646
• MDR Report Key: 15560044
• Report Number: 1640201-2022-00028
• Device Sequence Number: 5593566
• Product Code: MAL
• UDI-Device Identifier: 00384401018568
• UDI-Public: (01)00384401018568
• Combination Product (Y/N): N
• Initial Reporter Country: KS
• PMA/510(K) Number: K021213
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Health Professional
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 10/24/2022

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Operator of Device: Health Professional
• Device Expiration Date: 01/31/2026
• Device Model Number: M00202175826P0
• Device Catalogue Number: M00202175826P0
• Device Lot Number: 21B17
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 09/27/2022
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 09/14/2022
• Supplement Date Received by Manufacturer: 10/19/2022
• Initial Report FDA Received Date: 10/07/2022
• Supplement Report FDA Received Date: 10/24/2022
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 02/17/2021
• Is the Device Labeled for Single Use? (Y/N): Yes
• Usage of Device: Unknown
• Patient Sequence Number: 1
• Patient Sex: Prefer Not To Disclose