MAUDE Adverse Event Report: TYRX, INC. AIGIS-R MEDIUM; MESH, SURGICAL, POLYMERIC

Model Number	NMRM6122
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Code	Wound Dehiscence (1154)
Date of Event	01/05/2018
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
The initial reported event was received on (b)(6) 2018.Of note, the serious injury would have been submitted via a bimonthly submission pursuant to a1996009, and it would have been due april 10, 2018.As of march 08, 2018, these reports for this product are being transitioned to a 30-day reporting timeframe.Concomitant medical product: 3058 interstim urinary mgu lead implanted (b)(6) /2017.If information is provided in the future, a supplemental report will be issued.
Event or Problem Description
It was reported that the patient's incision has opened up, wound dehiscence present.The absorbable antibacterial envelope remains in use.No further patient complications have been reported as a result of this event.
Additional Manufacturer Narrative
If information is provided in the future, a supplemental report will be issued.

• Brand Name: AIGIS-R MEDIUM
• Common Device Name: MESH, SURGICAL, POLYMERIC
• Manufacturer (Section D): TYRX, INC.; 1 deer park dr.; suites g, e; monmouth jct NJ 08852
• MDR Report Key: 7342312
• Report Number: 3005619263-2018-00031
• Device Sequence Number: 19221432
• Product Code: FTL
• UDI-Device Identifier: 00643169624788
• UDI-Public: 00643169624788
• Combination Product (Y/N): N
• Initial Reporter State: FL
• Initial Reporter Country: US
• PMA/510(K) Number: K150291
• 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): 10/29/2018

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: Lay User/Patient
• Device Expiration Date: 01/31/2018
• Device Model Number: NMRM6122
• Device Catalogue Number: NMRM6122
• Device Lot Number: 17L10210
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 01/05/2018
• Supplement Date Received by Manufacturer: 01/05/2018
• Initial Report FDA Received Date: 03/15/2018
• Supplement Report FDA Received Date: 10/29/2018
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Concomitant Medical Products and Therapy/Usage Dates: 3889-28 INTERSTIM URINARY MGU LEAD; 3889-28 INTERSTIM URINARY MGU LEAD
• Outcome Attributed to Adverse Event: Other
• Patient Age: 61 YR