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A distributor reported an end user experienced an issue when using a 14cm solero applicator.The treating physician planned to percutaneously treat four liver lesions during the ablation procedure.The applicator was successfully tested for 10 seconds at 100 watts.The unit was set for 140 watts for 4 minutes to treat the first lesion, the second lesion ablation was set for 140 watts for 2 minutes, and the third lesion ablation was set for 100 watts for 2 minutes.One minute into the ablation for the third lesion, the unit displayed an error 209 "coolant temperature >52".The unit was turned off and restarted after 2 minutes and the procedure was proceeded to treat the fourth lesion.The applicator had been removed and inspected between each ablation cycle.The fourth lesion treatment was performed at 140 watts for 1 minute.When the radiologist removed the applicator, it was noted the ceramic tip of the applicator had broken off inside the patient.The radiologist was confident the tip would not move or migrate, so it was determined to not attempt to remove the tip.The patient did not experience any harm as a result of this incident.
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