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An end user reported an issue with a 19cm solero applicator.The 1st applicator was successfully tested at 100w for 30 seconds.It was laparoscopically placed with no difficulty in the liver and the unit was set for 4 minutes at 100watts.Two ablation cycles were performed without removing the applicator.Subsequently, a new needle (same batch number) was opened, and another ablation was performed at 100w-4min to complete the operation.The situation occurred when the second needle was set to 100w.The wattage dropped to 75w 50 seconds after the start.Then the machine displayed a high-energy feedback message.The needle was immediately removed, and it was found that the ceramic needle had broken into the tumor.The tip remains inside the patient as the doctor was unable to remove it.The doctor has been using solero product for 3 years.The total time of the ablation was 8 minutes and the ablation size was 3.2cm.
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Received one (1) 19cm probe.The applicator was received with the ceramic tip detached from the distal end of the shaft assembly.The tip, ceramic ferrule and center conductor are completely detached.The cartridge was connected to the lab solero generator along with the pump connected to the pump tubing.The pump was started and primed using water to test coolant flow, flow was observed to function normally.There were no signs of saline under the outer jacket of the cable.The pump functions normally as expected.The mcx and n type connections were visually inspected, the n type connector cavity and mcx did not indicate any issues visually and had a dry appearance and adequate solder joints.There are no known manufacturing defects found.This failure is the result of a thermal event, root cause of which could not be definitively determined.The customer's reported complaint description of the ceramic tip was fractured and detached is confirmed.Root cause for the thermal event/tip detachment could not be definitively determined.A review of the device history records was performed for the indicated lots for any deviations related to the reported failure mode of the complaint.The review confirms that the lots met all material, assembly and performance specifications; i.E.No ncr associated with reported failure mode.Labeling review: the directions for use (dfu) which is supplied to the user with the solero applicators contains the following statements: intended use/indications for use the solero microwave tissue ablation (mta) system and accessories are indicated for the ablation of soft tissue* during open, laparoscopic, or percutaneous procedures.Testing the device - prior to placing the device in the target tissue for ablation, place the tip of the device (including the black shaded zone of the shaft) in a container of sterile water or saline and activate the device at 100 watts for 10 seconds to ensure that the system is functional.Warning: do not initiate the procedure/anesthesia until the applicator has been connected, primed, and the generator status bar indicates "ready".Precautions - avoid placing lateral forces on the applicator tip during placement or removal.- always use the lowest power and shortest time necessary to achieve the targeted ablation.- each applicator may be used to ablate up to three separate areas of target tissue for each patient at the maximum power and time setting.- inspect the applicator after each ablation.If the applicator appears damaged, utilize another applicator for subsequent ablations.Warning: do not bend the applicator as this may impair the function of the cooling system and may damage the microwave feed line inside the applicator.Warning: when using percutaneously the tip of the antenna may be used to puncture the skin at the point of insertion.Use the minimum force necessary to achieve this and take care not to over advance the applicator.Refer to the shaft depth markings to monitor placement depth.Take care to not bend the tip as it may cause damage to the device.Operational instructions - inspect all devices and packaging for damage prior to use.Do not use any devices that are damaged or if the sterile barrier is breached.Do not use the solero generator if it has been dropped or damaged.Warning: after each ablation inspect the applicator for any damage.If any damage is observed the applicator should be discarded and replaced with a new applicator.A review of the angiodynamics complaint system noted no adverse trends for this complaint type and product family.This type of complaint will continue to be monitored for trends.Reference (b)(4).
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