MAUDE Adverse Event Report: W. L. Gore & Associates, Inc. GORE® Molding & Occlusion Balloon Catheter; Catheter, Intravascular Occluding, Temporary

Catalog Number	MOB37
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Codes	Unspecified Infection (1930); Pseudoaneurysm (2605)
Date of Event	04/10/2026
Type of Reportable Event	Serious Injury
Event or Problem Description
The following was reported to gore from the imedidata database: on (b)(6), 2026, the patient underwent endovascular treatment for an aortoiliac aneurysm.The patient was treated with gore®¿excluder®¿conformable aaa endoprosthesis, gore® excluder® aaa endoprosthesis devices and gore®¿excluder®¿iliac branch endoprosthesis devices.The gore® devices were successfully navigated to the intended location and successfully deployed.On (b)(6), 2026, the patient developed an infected inguinal pseudoaneurysm.A percutaneous transluminal angioplasty was performed to treat it.On (b)(6), 2026, the infected inguinal pseudoaneurysm was recovered / resolved with sequelae.
Additional Manufacturer Narrative
A1: no patient specific details have been provided.Therefore, the patient initials reflect the w.L.Gore internal case number.H6: a review of the manufacturing records for the device verified that the lot met all pre-release specifications.Please note that the same patient was captured in medwatch report number 3007284313-2026-05079, 3013164176-2026-03218 and 3013164176-2026-03219.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.

• Brand Name: GORE® Molding & Occlusion Balloon Catheter
• Common Device Name: Catheter, Intravascular Occluding, Temporary
• Manufacturer (Section D): W. L. Gore & Associates, Inc.; 1505 n. fourth street; flagstaff AZ 86004
• Manufacturer (Section G): Medical Phoenix 1 B/P; 32360 n. north valley parkway; phoenix AZ 85085
• Manufacturer Contact: asami aizawa ; 1505 n. fourth street; flagstaff, AZ 86004 ; +1(928)526-3030
• MDR Report Key: 50768468
• Report Number: 3007284313-2026-05080
• Device Sequence Number: 21200289
• Product Code: MJN
• UDI-Device Identifier: 00733132639489
• Combination Product (Y/N): N
• Initial Reporter Country: JA
• PMA/510(K) Number: K172567
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Foreign,Study
• Initial Reporter Occupation: Physician
• Type of Report: Initial
• Report Date (Section B): 09/15/2026

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 Catalogue Number: MOB37
• 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: 08/31/2026
• Initial Report FDA Received Date: 09/15/2026
• Was Device Evaluated by Manufacturer? (Y/N): No
• Date Device Manufactured: 10/02/2025
• 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: 74 YR
• Patient Sex: Male
• Patient Weight: 162 LB