MAUDE Adverse Event Report: MEDTRONIC IRELAND VALIANT CAPTIVIA - FF; SYSTEM, ENDOVASCULAR GRAFT, AORTIC ANEURYSM TREATMENT

Model Number	VAMF3838C150TU
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Code	Vascular Dissection (3160)
Date of Event	09/28/2017
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
If information is provided in the future, a supplemental report will be issued.
Event or Problem Description
A valiant stent graft system was implanted in a patient for the endovascular treatment of an ulcer.However, it was reported that approximately 3 months post implant, a ct revealed proximal remodeling with a small tear/dissection approximately 2 cm in length with communication to the proximal bare spring, starting 4 cm distal to the left subclavian artery extending to the top of the stent graft material.The physician does not consider the event to be symptomatic at this time; therefore, no intervention was perfumed.As per the physician, the cause of the event was related to the patient¿s anatomy.No additional clinical sequelae were reported and the patient will continue to be monitored by the physician.
Additional Manufacturer Narrative
Films review summary: the exact cause of the dissection flap seen just above the proximal bare spring could not be determined from the post-implant films provided.The pre-implant anatomy is unknown and films during implant were not available.Ct¿s returned from 3 months post-implant revealed that a single valiant captivia stent graft had been implanted in the patient¿s descending thoracic.The proximal bare spring was positioned just past the aortic arch ~12 cm caudal to the lsa, in an essentially straight segment of the descending thoracic.A thoracic dissection flap was seen extending ~15 mm above the bare spring.It is possible that this dissection flap may have been related to a pre-existing anatomical condition, caused by the reported uncontrolled hypertension, or was possibly related to the implant of the stent graft.If information is provided in the future, a supplemental report will be issued.

• Brand Name: VALIANT CAPTIVIA - FF
• Common Device Name: SYSTEM, ENDOVASCULAR GRAFT, AORTIC ANEURYSM TREATMENT
• Manufacturer (Section D): MEDTRONIC IRELAND; parkmore business park west; galway
• MDR Report Key: 6998642
• Report Number: 2953200-2017-01689
• Device Sequence Number: 1292470
• Product Code: MIH
• UDI-Device Identifier: 00643169346956
• UDI-Public: 00643169346956
• Combination Product (Y/N): N
• Initial Reporter State: TN
• Initial Reporter Country: US
• PMA/510(K) Number: P100040
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2017
• Reporter Type: Manufacturer
• Report Source: company representative,health
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 11/28/2017

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: 12/06/2018
• Device Model Number: VAMF3838C150TU
• Device Catalogue Number: VAMF3838C150TU
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 10/11/2017
• Supplement Date Received by Manufacturer: 11/08/2017
• Initial Report FDA Received Date: 11/03/2017
• Supplement Report FDA Received Date: 11/28/2017
• 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: Other
• Patient Age: 83 YR