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| Model Number |
700106002-US |
| Medical Device Problem Code |
Detachment of Device or Device Component (2907)
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| Health Effect - Clinical Code |
Device Embedded In Tissue or Plaque (3165)
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| Date of Event |
04/16/2025
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Type of Reportable Event
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Malfunction
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Event or Problem Description
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A distributor reported an end user experienced an issue when using a 19cm solero applicator.After unboxing a new ablation probe, a functional testing was performed at 100w for 30 seconds.At that time, the probe functioned normally and was considered as suitable for use.The first ablation was then initiated with a setting of 100w for 6 minutes, the probe was percutaneously placed, and the ablation was started.However, when the remaining ablation time was approximately 4 minutes and 30 seconds, the system displayed an error message: "high reflected power.Reposition applicator and retry." in response, the cable and pump were reconnected, and the system was restarted, but the same error message continued to appear.It was recommended the physician to remove the probe and check for any issues.After the removal, it was discovered that the ceramic part of the tip had broken at the midpoint (not at the junction between the ceramic and stainless steel).The broken ceramic tip remained inside the patient.Although it was suggested that the physician use a new probe to complete the procedure, the physician declined and determined that the procedure could not be continued, thus it was terminated.Regarding the broken ceramic tip retained in the patient's body, the physician stated that follow-up observation and monitoring would be conducted.The physician has been using solero for greater than 1 year.The total time of ablation was 1 minute, 30 seconds, ablation size was 2cm.
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Additional Manufacturer Narrative
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The reported device has been returned to the manufacturer for a device evaluation.An investigation into the root cause for product problem is currently in progress.The results of the investigation will be sent via a follow up medwatch.Reference (b)(4).
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Additional Manufacturer Narrative
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Received one (1) 19cm solero probe for evaluation.The applicator was received with the ceramic tip detached from the distal end of the shaft assembly.The device was received without cable attached or cartridge.The ceramic ferrule and center conductor is completely detached.Approximately 4mm of the tip remained attached there are signs of a thermal event occurring.Center conductor detached internal to semi rigid.There are no known manufacturing defects.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.Hardware unit review: solero generator s/n (b)(6) was used during this procedure with the probe in question.Unit was manufactured in jun-2017 and the most recent service was: case (b)(4) on (b)(6) 2024 for routine service/testing.Unit passed functional testing.A complaint search review of the s/n shows no previous repairs, servicing and/or upgrades for this unit associated with probe tip detached failure mode since the unit was distributed.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.(b)(4).
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Search Alerts/Recalls
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