MAUDE Adverse Event Report: ENDOLOGIX, INC. AFX; LIMB

Model Number	I16-16/C88 SA
Medical Device Problem Code	Failure To Adhere Or Bond (1031)
Health Effect - Clinical Code	Failure of Implant (1924)
Date of Event	01/22/2016
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
The device involved in the event will not be returned for evaluation as it remains implanted in the patient.If additional information pertinent to the incident is obtained, a follow-up report will be submitted.Devices remain implanted in the patient.
Event or Problem Description
Patient initially implanted with a bifurcated stent and three limb extensions on (b)(6) 2015.Upon follow-up, computed tomography (ct) revealed a type 1b endoleak on the right limb.The physician elected to implant a limb extension as well as an additional competitor device to resolve the endoleak.The patient is in stable condition.

• Brand Name: AFX
• Common Device Name: LIMB
• Manufacturer (Section D): ENDOLOGIX, INC.; 2 musick; irvine CA 92618
• MDR Report Key: 5448900
• Report Number: 2031527-2016-00066
• Device Sequence Number: 10862007
• Product Code: MIH
• UDI-Device Identifier: 00818009011404
• UDI-Public: (01)00818009011404(17)180909
• Combination Product (Y/N): N
• Initial Reporter State: FL
• Initial Reporter Country: US
• PMA/510(K) Number: P040002
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2015
• Reporter Type: Manufacturer
• Report Source: company representative,health
• Initial Reporter Occupation: Physician
• Type of Report: Initial
• Report Date (Section B): 01/22/2016

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: 09/09/2018
• Device Model Number: I16-16/C88 SA
• Device Lot Number: 1253156-021
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 01/22/2016
• Initial Report FDA Received Date: 02/19/2016
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 83 YR