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

Catalog Number	RMT261414
Medical Device Problem Code	Device Endoleak (4074)
Health Effect - Clinical Code	Clinical Endoleak (4843)
Date of Event	09/29/2014
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
The patient referenced in this event file is enrolled in a post market prospective observational cohort registry designed to obtain data on device performance and clinical outcomes of patients treated with gore endovascular aortic products through the global registry for endovascular aortic treatment (great).Medidata rave® is the clinical study database (csd), capturing the data through the grt 10-11 module.The above information was obtained from the csd.A review of the manufacturing records indicated the lot met pre-release specifications.The device remains implanted.Therefore, an evaluation on the device cannot be performed.The patient referenced in this event file is enrolled in a post market prospective observational cohort registry designed to obtain data on device performance and clinical outcomes of patients treated with gore endovascular aortic products through the global registry for endovascular aortic treatment (great).Medidata rave® is the clinical study database (csd), capturing the data through the grt 10-11 module.The above information was obtained from the csd.A review of the manufacturing records indicated the lot met pre-release specifications.The device remains implanted.Therefore, an evaluation on the device cannot be performed.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
The following was reported to gore from imedidata database: it was reported to gore that on (b)(6) 2014 this patient underwent an endovascular procedure and was implanted with gore® excluder® aaa endoprosthesis devices to treat an abdominal aortic aneurysm measuring 75 mm in diameter.On (b)(6) 2014 computed tomography angiography (cta) imaging found the aneurysm to measure 74 mm in diameter.On (b)(6) 2014 a type ii endoleak originating from the inferior mesenteric artery (ima) was diagnosed.On (b)(6) 2014 the ima was coil embolized.On (b)(6) 2015 ultrasound imaging identified the diameter of the aneurysm to measure 60 mm.It also was reported that on (b)(6) 2019 the study was discontinued as the patient had expired.
Additional Manufacturer Narrative
Update of h6: added code for health effect - impact code: f29 (death not related to reported adverse event).Code not listed in the section h6 due to system issue.
Additional Manufacturer Narrative
Updated g1 and g3.Updated h6: updated component code to g07001, code g07003 was inadvertently entered and should be removed.Added type of investigation code b20, and b11.Updated investigation findings code to c19, code c21 is no longer applicable.Updated investigation conclusions code to d12 and d1001, code d16 is no longer applicable.Per the gore® excluder® aaa endoprosthesis instructions for use (ifu), adverse events that may occur and / or require intervention or additional intraoperative procedure time include, but are not limited to: aneurysm enlargement, endoleak.The available information reported in the complaint does not reasonably suggest a potential malfunction or product packaging and/or labeling issue has occurred.

• 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 PHOENIX 2 B/P; 32470 n. north valley parkway; phoenix AZ 85085
• Manufacturer Contact: ena haskovic aran ; 1505 n. fourth street; flagstaff, AZ 86004 ; 9285263030
• MDR Report Key: 22529391
• Report Number: 3007284313-2025-04118
• Device Sequence Number: 18149853
• Product Code: MIH
• UDI-Device Identifier: 00733132610631
• UDI-Public: (01)00733132610631(17)161031
• Combination Product (Y/N): N
• Initial Reporter Country: FI
• PMA/510(K) Number: P020004
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2014
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Foreign,Study
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup,Followup
• Report Date (Section B): 09/23/2025

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: 10/31/2016
• Device Catalogue Number: RMT261414
• 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: 06/19/2025
• Supplement Date Received by Manufacturer: 09/05/2025; 09/10/2025
• Initial Report FDA Received Date: 07/17/2025
• Supplement Report FDA Received Date: 09/09/2025; 09/23/2025
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• Date Device Manufactured: 11/12/2013
• 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: Required Intervention
• Patient Age: 66 YR
• Patient Sex: Male
• Patient Weight: 92 KG