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A territory manager reported an end user experienced an issue when using a 14cm solero applicator.The applicator was tested prior to the procedure with no issues.At the start of the percutaneous microwave ablation of the liver, a "high reflected power" message was immediately receive.No ablations had been performed.The applicator was repositioned several times, however the message was still received.The applicator was removed at which time it was observed the tip had detached and remained inside the patient.The procedure was aborted due to this event.The patient did not experience any harm as a result of this incident.
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The customer's reported complaint description of probe ceramic tip was fractured and detached was confirmed based on evaluation of the returned complaint sample.The applicator was received with the ceramic tip partially detached from the distal end of the shaft assembly.The ceramic ferrule and center conductor is completely detached.Approximately 3mm 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 serial number of the solero generator hardware unit used during this event was reported as (b)(6) case (b)(4) was opened to investigate the performance of the hardware unit in regards to this tip fractured complaint event.There was no reported complaint description regarding the performance of the solero generator, i.E.No unit malfunction.Unit passed functional testing, no issues observed.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 with this device 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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