FDA Adverse Event Injury Summary report: N

TREO ABDOMINAL STENT-GRAFT SYSTEM

MDR report key: 20707762 · Received November 18, 2024

Report

Report Number
2247858-2024-00286
Event Type
Injury
Date Received
November 18, 2024
Date of Event
October 25, 2024
Report Date
January 13, 2025
Manufacturer
BOLTON MEDICAL, INC.
Product Code
MIH
PMA / PMN Number
P190015
Adverse Event
Yes
Report Source
Manufacturer report
Reporter Location
JA
Reporter Occupation
OTHER
Health Professional
N

Narratives

Additional Manufacturer Narrative · 0

BOLTON MEDICAL, INC. (D/B/A TERUMO AORTIC), HEREIN KNOWN AS THE "COMPANY", IS SUBMITTING THIS REPORT PURSUANT TO 21 CFR PART 803, HAS MADE REASONABLE EFFORTS TO OBTAIN COMPLETE INFORMATION, AND HAS PROVIDED AS MUCH AS IS AVAILABLE TO THE COMPANY AS OF THE SUBMISSION DATE OF THIS REPORT. THIS REPORT IS BASED ON INFORMATION OBTAINED BY THE COMPANY, WHICH MAY NOT HAVE BEEN ABLE TO FULLY INVESTIGATE OR VERIFY PRIOR TO THE DATE THE REPORT WAS REQUIRED BY THE REGULATIONS. ANY REQUIRED FIELDS THAT ARE UNPOPULATED ARE BLANK BECAUSE THE INFORMATION IS CURRENTLY UNKNOWN, UNAVAILABLE, OR NOT APPLICABLE. THIS REPORT DOES NOT CONSTITUTE AN ADMISSION OR A CONCLUSION BY ANYONE THAT THE DEVICE 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 CERTAIN REGULATIONS, 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.

Additional Manufacturer Narrative · 0

BOLTON MEDICAL, INC. (D/B/A TERUMO AORTIC), HEREIN KNOWN AS THE "COMPANY", IS SUBMITTING THIS REPORT PURSUANT TO 21 CFR PART 803, HAS MADE REASONABLE EFFORTS TO OBTAIN COMPLETE INFORMATION, AND HAS PROVIDED AS MUCH AS IS AVAILABLE TO THE COMPANY AS OF THE SUBMISSION DATE OF THIS REPORT. THIS REPORT IS BASED ON INFORMATION OBTAINED BY THE COMPANY, WHICH MAY NOT HAVE BEEN ABLE TO FULLY INVESTIGATE OR VERIFY PRIOR TO THE DATE THE REPORT WAS REQUIRED BY THE REGULATIONS. ANY REQUIRED FIELDS THAT ARE UNPOPULATED ARE BLANK BECAUSE THE INFORMATION IS CURRENTLY UNKNOWN, UNAVAILABLE, OR NOT APPLICABLE. THIS REPORT DOES NOT CONSTITUTE AN ADMISSION OR A CONCLUSION BY ANYONE THAT THE DEVICE 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 CERTAIN REGULATIONS, 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.

Description of Event or Problem · 0

"TYPE 1A ENDOLEAK DUE TO TIGHT CURVATURE OF THE NECK OF THE ANEURYSM: EVAR WAS PERFORMED AS PER NORMAL PROCEDURE. ALTHOUGH IT WAS UNCLEAR WHETHER THE DELIVERY SYSTEM WOULD BE ABLE TO REACH THE TARGET SITE, THE DELIVERY SYSTEM OF THE MAIN BIFURCATED STENT-GRAFT WAS SUCCESSFULLY DELIVERED FROM THE RIGHT LEG OVER A GUIDEWIRE (EGOIST ULTIMATE, MEDICO'S HIRATA). WHEN THE DELIVERY SYSTEM REACHED THE TARGET SITE, ANGIOGRAPHY REVEALED AN ACCORDION-SHAPED NECK OF THE ANEURYSM. THE STENT-GRAFT BEGAN TO BE DEPLOYED FROM JUST BELOW THE RENAL ARTERY AND WAS DEPLOYED TO THE CONTRALATERAL GATE. THE SUPRARENAL STENT WAS RELEASED AND BOTH CONTRALATERAL AND IPSILATERAL LEG EXTENSION STENT GRAFTS (EXCLUDER, GORE) WERE IMPLANTED, AND THE EVAR WAS COMPLETED. AFTER BALLOON MODELING WAS PERFORMED, FINAL ANGIOGRAPHY REVEALED TYPE 1A ENDOLEAK DUE TO INSUFFICIENT APPOSITION OF THE STENT-GRAFT TO THE CURVATURE OF THE NECK OF THE ANEURYSM. ADDITIONAL BALLOON MODELING WAS PERFORMED, BUT ANGIOGRAPHY STILL REVEALED A RESIDUAL ENDOLEAK. HOWEVER, THE INITIAL TREATMENT GOAL OF TREATING THE LUMBAR ANEURYSM WAS ACHIEVED, SO THE PHYSICIAN COMPLETED THE PROCEDURE. PHYSICIAN'S COMMENT: THE PROCEDURE WAS INITIALLY PLANNED TO USE AN EXCLUDER STENT-GRAFT. HOWEVER, THE PHYSICIAN BELIEVES THAT THE OUTCOME WOULD HAVE BEEN THE SAME EVEN WITH THE EXCLUDER STENT-GRAFT. AN ENDURANT STENT-GRAFT MAY HAVE BEEN OPTIMAL IN THIS CASE. OPERATION TYPE: EVAR BLOOD LOSS: THE AMOUNT WAS SMALL. NO IMAGE AVAILABLE DUE TO HOSPITAL POLICY NO PRE-CASE PLAN AVAILABLE: SCHEMA ATTACHED ADDITIONAL INFORMATION WILL BE OBTAINED UPON REQUEST DELIVERY SYSTEM WAS DISCARDED BY THE USER ANCILLARY DEVICES USED: EXCLUDER LEG 121400J, GORE EXCLUDER LEG 121400J, GORE. (TC# (B)(4). PATIENT OUTCOME: "NO HARM TO THE PATIENT'S HEALTH."

Description of Event or Problem · 0

"TYPE 1A ENDOLEAK DUE TO TIGHT CURVATURE OF THE NECK OF THE ANEURYSM: EVAR WAS PERFORMED AS PER NORMAL PROCEDURE. ALTHOUGH IT WAS UNCLEAR WHETHER THE DELIVERY SYSTEM WOULD BE ABLE TO REACH THE TARGET SITE, THE DELIVERY SYSTEM OF THE MAIN BIFURCATED STENT-GRAFT WAS SUCCESSFULLY DELIVERED FROM THE RIGHT LEG OVER A GUIDEWIRE (EGOIST ULTIMATE, MEDICO'S HIRATA). WHEN THE DELIVERY SYSTEM REACHED THE TARGET SITE, ANGIOGRAPHY REVEALED AN ACCORDION-SHAPED NECK OF THE ANEURYSM. THE STENT-GRAFT BEGAN TO BE DEPLOYED FROM JUST BELOW THE RENAL ARTERY AND WAS DEPLOYED TO THE CONTRALATERAL GATE. THE SUPRARENAL STENT WAS RELEASED AND BOTH CONTRALATERAL AND IPSILATERAL LEG EXTENSION STENT GRAFTS (EXCLUDER, GORE) WERE IMPLANTED, AND THE EVAR WAS COMPLETED. AFTER BALLOON MODELING WAS PERFORMED, FINAL ANGIOGRAPHY REVEALED TYPE 1A ENDOLEAK DUE TO INSUFFICIENT APPOSITION OF THE STENT-GRAFT TO THE CURVATURE OF THE NECK OF THE ANEURYSM. ADDITIONAL BALLOON MODELING WAS PERFORMED, BUT ANGIOGRAPHY STILL REVEALED A RESIDUAL ENDOLEAK. HOWEVER, THE INITIAL TREATMENT GOAL OF TREATING THE LUMBAR ANEURYSM WAS ACHIEVED, SO THE PHYSICIAN COMPLETED THE PROCEDURE. PHYSICIAN'S COMMENT: THE PROCEDURE WAS INITIALLY PLANNED TO USE AN EXCLUDER STENT-GRAFT. HOWEVER, THE PHYSICIAN BELIEVES THAT THE OUTCOME WOULD HAVE BEEN THE SAME EVEN WITH THE EXCLUDER STENT-GRAFT. AN ENDURANT STENT-GRAFT MAY HAVE BEEN OPTIMAL IN THIS CASE. OPERATION TYPE: EVAR BLOOD LOSS: THE AMOUNT WAS SMALL. NO IMAGE AVAILABLE DUE TO HOSPITAL POLICY NO PRE-CASE PLAN AVAILABLE: SCHEMA ATTACHED ADDITIONAL INFORMATION WILL BE OBTAINED UPON REQUEST DELIVERY SYSTEM WAS DISCARDED BY THE USER ANCILLARY DEVICES USED: EXCLUDER LEG 121400J, GORE EXCLUDER LEG 121400J, GORE (TC#BM 241002564)" PATIENT OUTCOME: "NO HARM TO THE PATIENT'S HEALTH."

Devices

Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
2608675 TREO ABDOMINAL STENT-GRAFT SYSTEM STENT, ENDOVASCULAR GRAFT, AORTIC MIH BOLTON MEDICAL, INC. 2306150045

Patients

Seq Age Sex Outcome Treatment
1 NA Unknown Other