MAUDE Adverse Event Report: ATRIUM MEDICAL CORPORATION C-QUR TACSHIELD; MESH, SURGICAL, POLYMERIC

Model Number	31633
Medical Device Problem Code	Appropriate Device Problem Term/Code Not Available (3191)
Health Effect - Clinical Codes	Adhesion(s) (1695); Unspecified Infection (1930); Hernia (2240)
Type of Reportable Event	Serious Injury
Event or Problem Description
This event is deemed reportable based on the allegations in a potential lawsuit which, while unsubstantiated, suggest that a reportable event may have occurred during use of an atrium medical mesh product.Plaintiff allegedly experienced recurrence, incarcerated bowel, pain, swelling, adhesions, lysis of adhesions, loop of bowel, inflammation, infection, fistula, abscess, draining wound, recurrence, debridement, cellulitis, fibrosis and multiple revision surgeries on (b)(6) 2023.Since this is a potential legal matter, the case has been turned over to legal counsel and further information obtained through investigation or discovery may fall under the attorney/client and/or work product privilege.However, atrium will supplement this report as appropriate if additional information comes to its attention.
Additional Manufacturer Narrative
B7 continued: bowel repair, colon resection from diverticulitis, covidien symbotex and unknown mesh implanted subsequently, cardiac disease, obesity, hypertension, bladder cancer, hyperlipidemia, type 2 diabetes, incarceration, sigmoid colectomy, colovesical fistula, adhesions, multiple enterotomies, arteriosclerosis of coronary artery, gerd.Investigation: based on the review of the device history and sterilization records and product complaint details atrium can find no fault with the product.This lot of mesh passed all quality and performance requirement.This report is based upon allegations made in a potential lawsuit in which atrium medical would be named as a defendant.This report shall not be considered as an admission by atrium medical that the product described in the pre-suit claim and described herein is or was defective, or that it had any causal relationship to any injuries allegedly suffered by the claimant.Note: lot number and device manufacturer date are provided as this information is available; however, this data is not on the label as pi.

• Brand Name: C-QUR TACSHIELD
• Common Device Name: MESH, SURGICAL, POLYMERIC
• Manufacturer (Section D): ATRIUM MEDICAL CORPORATION; 40 continental blvd; merrimack NH
• Manufacturer (Section G): ATRIUM MEDICAL CORPORATION; 40 continental blvd; merrimack NH
• Manufacturer Contact: lori gosselin ; 40 continental blvd; merrimack, NH
• MDR Report Key: 20235953
• Report Number: 3011175548-2024-000021
• Device Sequence Number: 8089563
• Product Code: FTL
• UDI-Device Identifier: 00650862316339
• UDI-Public: (01)00650862316339(17)141230
• Combination Product (Y/N): N
• Initial Reporter Country: US
• PMA/510(K) Number: K100076
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2014
• Device Explanted Year: 2023
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Other
• Initial Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial
• Report Date (Section B): 09/17/2024

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: 12/30/2014
• Device Model Number: 31633
• Device Catalogue Number: 31633
• Device Lot Number: 10813748
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 09/04/2024
• Initial Report FDA Received Date: 09/17/2024
• Was Device Evaluated by Manufacturer? (Y/N): No
• Date Device Manufactured: 12/30/2011
• Is the Device Labeled for Single Use? (Y/N): Yes
• Usage of Device: Initial
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 58 YR
• Patient Sex: Male