Recall of EXACTRAC Version 6.0.0 through to 6.0.5 (Image Guided Radiation Therapy Patient Positioning System)

According to Department of Health, Therapeutic Goods Administration, this recall involved a device in Australia that was produced by Brainlab Australia Pty Ltd.

What is this?

A correction or removal action taken by a manufacturer to address a problem with a medical device. Recalls occur when a medical device is defective, when it could be a risk to health, or when it is both defective and a risk to health.

Learn more about the data here
  • Type of Event
    Recall
  • Event ID
    RC-2015-RN-00731-1
  • Event Risk Class
    Class I
  • Event Initiated Date
    2015-08-12
  • Event Country
  • Event Source
    DHTGA
  • Event Source URL
  • Notes / Alerts
    Australian data is current through July 2018. All of the data comes from the Australian Therapeutic Goods Administration, except for the categories Manufacturer Parent Company and Product Classification.
    The Parent Company and the Product Classification were added by ICIJ.
    The parent company information is based on 2017 public records. The device classification information comes from FDA’s Product Classification by Review Panel, based on matches of recall data from the U.S. and Australia.
  • Extra notes in the data
  • Reason
    Loading and processing of large treatment plans, e.G. with a large image scan range and with a high number of outlined contours, may lead to an error in the exactrac internal graphic memory. after such a memory error has occurred, this might, under specific conditions, cause exactrac to display the digitally reconstructed radiograph (drr) of the previously loaded patient data set instead of the correct drr during the positioning workflow of any subsequently opened patient treatment plan until the exactrac application is restarted.This issue affects x-ray correction and verification based on bony fusion to the drr. the xray images acquired for current patient positions are not affected and still correct even if this issue occurs. only if the mismatch of displayed patient image data in exactrac is not discovered by the operator, the incorrect drr might be used for image fusion to the acquired x-ray images, potentially resulting in the calculation of an incorrect shift.
  • Action
    Brainlab will provide a software revision (ExacTrac v. 6.0.6) with this issue solved to affected customers.Brainlab will contact affected customers starting December 2015 to schedule the update. In the interim, to minimise the probability of this issue to occur for the affected ExacTrac versions: - Reduce the amount of contours exported to ExacTrac as far as possible (export only contours needed for positioning to ExacTrac). - Avoid exporting large contours, such as couch top models, to ExacTrac. - After every (re-)start of the ExacTrac application on any workstation, always first load a phantom plan not containing contours. Generate DRRs of that phantom plan once by selecting the Define DRR Settings tab, before loading any other patient treatment plans. This action has been closed-out on 17/08/2016.

Device

  • Model / Serial
    EXACTRAC Version 6.0.0 through to 6.0.5 (Image Guided Radiation Therapy Patient Positioning System)Versions: 6.0.0; 6.0.1; 6.0.2; 6.0.3; 6.0.4; 6.0.5ARTG Number 121226
  • Product Classification
  • Manufacturer

Manufacturer