BEUDAMED
    FDA Adverse Event Injury Summary report: N

    GORE EXCLUDER AAA ENDOPROSTHESIS

    MDR report key: 2801470 · Received October 11, 2012

    Report

    Report Number
    2017233-2012-00708
    Event Type
    Injury
    Date Received
    October 11, 2012
    Date of Event
    August 27, 2012
    Report Date
    September 17, 2012
    Manufacturer
    W.L. GORE & ASSOCIATES
    Product Code
    MIH
    PMA / PMN Number
    P020004
    Adverse Event
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    LA, US
    Reporter Occupation
    PHYSICIAN

    Narratives

    Additional Manufacturer Narrative · 1

    THE MFG RECORDS REVIEW VERIFIED THAT THE LOT MET ALL PRE-RELEASE SPECIFICATIONS.

    Description of Event or Problem · 1

    ON (B)(6) 2007, THE PT UNDERWENT TREATMENT FOR AN ABDOMINAL AORTIC ANEURYSM WITH GORE EXCLUDER AAA ENDOPROSTHESIS. THE PT HAS SINCE EXPERIENCED APPROX 1 CM OF ANEURYSM ENLARGEMENT, AND THERE IS A POSSIBLE PROXIMAL TYPE I ENDOLEAK ON THE TRUNK.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 GORE EXCLUDER AAA ENDOPROSTHESIS MIH / SYSTEM, ENDOVASCULAR GRAFT, AORTIC ANEURYSM TREATMENT MIH W.L. GORE & ASSOCIATES 04783695

    Patients

    Seq Age Sex Outcome Treatment
    1 87 YR Other AORTIC VALVE REPLACEMENT| HYDROCHLOROTHIAZIDE| ECOTRIN| TRICOR| NIFEDIPINE