—#69073

Product

Siemens Medical Solutions, PRIMUS Plus Digital Linear Accelerator, part number 4504200 equipped with a Digital Electron Variable Applicator (DEVA, Part Number 8485971) with available energy of 6 MeV.

FDA product code: IYE — Accelerator, Linear, Medical
Device class: Class 2
Medical specialty: Radiology
510(k) numbers: K993425
Affected lot / code info: Serial Numbers:3174 3241 3254 2938 3193 3359 3488 3529 3536 3717 3813 3844 3876 3985 3991 4033 4047 2782 2783 2785 2797 2815 2832 2862 2878 2904 2916 2918 2922 2942 2964 2973 2979 2989 2992 2993 2994 3007 3031 3043 3044 3046 3106 3117 3144 3183 3234 3242 3249 3262 3278 3284 3299 3308 3326 3334 3373 3389 3396 3408 3421 3431 3438 3455 3475 3481 3531 3561 3594 3632 3642 3689 3724 3728 3762 3767 3782 3814 3833 3867 3915 4004 4045 4051 4131 4232 5007 3431 3158 3216 3356, and 3619

Why it was recalled

Radiation leak: When used with field sizes of 5cm x 5cm or smaller, product may leak radiation at a distance of 2 cm from the side of the applicator body up to 13%, in excess of IEC standards.

Root cause (FDA determination)

Device Design

Action the firm took

Siemens sent a Customer Safety Advisory Notice dated 12/12/2007 to DEVA customers. The letter stated that Siemens would temporarily disable energies 5MeV and below for all customers that decide to continue using the DEVA, resulting in the temporary unavailability of energies 5MeV and below for all available. Customers wishing not to have these energies blocked must return their DEVA and they would be contacted by a local Siemens rep to schedule a service appointment. The letter stated that as a preventative measure that those customers should refrain from using the DEVA with any combination of energies 5MeV and below with field sizes smaller than 6cm x 6cm. The firm suggested using the fixed field electron applicators and cutouts with these energies and field sizes. Siemens will release a new control console software in 2008 for free-of-charge, that will limit the use of the DEVA to energies 6MeV and above, while allowing the use of lower energies using the fixed field electron applicatiors.

Recalling firm

Firm: Siemens Medical Solutions USA, Inc
Address: 4040 Nelson Ave, Concord, California 94520-1200

Distribution

Distribution pattern: Worldwide Distribution: USA, Canada, Belgium, Bulgaria, France, Germany, Hungary, India, Italy, Japan, Malaysia, P.R. China, Pakistan, Poland, Portugal, Qatar, Republic Korea, South Africa, Spain, Sweden, and United Kingdom.

Timeline

Recall initiated: 2007-12-10
Posted by FDA: 2008-09-29
Terminated: 2011-05-13
Status: —

Source: openFDA Device Recall endpoint. Recall record ID #69073. The FDA issues recall classifications as health-hazard assessments, not legal findings; for legal claims consult a licensed attorney.