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Stealthstation s7 treatment guidance system

Official notice

22 Dec 2021

Last checked

22 Dec 2021

Medium riskHealth Canada

An official Health Canada notice concerns Stealthstation s7 treatment guidance system. Medtronic has identified an anomaly with the Stealth Station™ System Cranial Software biopsy depth gauge graphical display which presents during navigation in a cranial biopsy procedure. On June 9, 2021, a complaint was reported to Medtronic that during navigation in a cranial biopsy procedure, the user may encounter an anomaly with the biopsy depth gauge graphical display in the software. Between 01-Jan-2019 through 10-Sep-2021, Medtronic has received four (4) complaints, with one confirmed to be directly related to this software anomaly. The software can enter a state where the biopsy depth gauge is no longer synchronized with the rest of the navigational information on the screen and displays an inaccurate position of the biopsy needle. In order for this software anomaly to occur, all of the following must happen: • The biopsy trajectory is locked, and • Guidance view is turned off or turned to a different view, and • The crosshairs are repositioned by clicking the 2D or 3D image, and • Guidance view is returned as an active view or • The biopsy trajectory is locked, and • The crosshairs are repositioned by clicking the 2D or 3D image, and • Guidance view is turned off or turned to a different view, and • Guidance view is returned as an active view if performed, these actions may cause the biopsy depth gauge graphical display to incorrectly depict the tip of the biopsy needle. The graphical depiction of the biopsy needle may appear in a position relative to the plan target that does not represent the actual physical position of the biopsy needle, which may result in potential biopsy of healthy tissue or damage to critical structures. Recall start date: Nov 29, 2021 Published 2021-12-22.

What to do now

Contact the manufacturer if you require additional information.

Recall number

63757

Official notice

2021-12-22

The hazard

Medtronic has identified an anomaly with the Stealth Station™ System Cranial Software biopsy depth gauge graphical display which presents during navigation in a cranial biopsy procedure. On June 9, 2021, a complaint was reported to Medtronic that during navigation in a cranial biopsy procedure, the user may encounter an anomaly with the biopsy depth gauge graphical display in the software. Between 01-Jan-2019 through 10-Sep-2021, Medtronic has received four (4) complaints, with one confirmed to be directly related to this software anomaly. The software can enter a state where the biopsy depth gauge is no longer synchronized with the rest of the navigational information on the screen and displays an inaccurate position of the biopsy needle. In order for this software anomaly to occur, all of the following must happen: • The biopsy trajectory is locked, and • Guidance view is turned off or turned to a different view, and • The crosshairs are repositioned by clicking the 2D or 3D image, and • Guidance view is returned as an active view or • The biopsy trajectory is locked, and • The crosshairs are repositioned by clicking the 2D or 3D image, and • Guidance view is turned off or turned to a different view, and • Guidance view is returned as an active view if performed, these actions may cause the biopsy depth gauge graphical display to incorrectly depict the tip of the biopsy needle. The graphical depiction of the biopsy needle may appear in a position relative to the plan target that does not represent the actual physical position of the biopsy needle, which may result in potential biopsy of healthy tissue or damage to critical structures. Recall start date: Nov 29, 2021

How to check if you're affected

Compare the product name and identifiers below with the item you own. Follow the official notice if they match.

Recall Numbers

63757

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Affected products

Product 1

Affected Products - Stealthstation S7 Treatment Guidance System, Lot or serial number - More than 10 numbers, contact manufacturer., Model or catalog number - 9733763

Risk / hazard

Medtronic has identified an anomaly with the Stealth Station™ System Cranial Software biopsy depth gauge graphical display which presents during navigation in a cranial biopsy procedure. On June 9, 2021, a complaint was reported to Medtronic that during navigation in a cranial biopsy procedure, the user may encounter an anomaly with the biopsy depth gauge graphical display in the software. Between 01-Jan-2019 through 10-Sep-2021, Medtronic has received four (4) complaints, with one confirmed to be directly related to this software anomaly. The software can enter a state where the biopsy depth gauge is no longer synchronized with the rest of the navigational information on the screen and displays an inaccurate position of the biopsy needle. In order for this software anomaly to occur, all of the following must happen: • The biopsy trajectory is locked, and • Guidance view is turned off or turned to a different view, and • The crosshairs are repositioned by clicking the 2D or 3D image, and • Guidance view is returned as an active view or • The biopsy trajectory is locked, and • The crosshairs are repositioned by clicking the 2D or 3D image, and • Guidance view is turned off or turned to a different view, and • Guidance view is returned as an active view if performed, these actions may cause the biopsy depth gauge graphical display to incorrectly depict the tip of the biopsy needle. The graphical depiction of the biopsy needle may appear in a position relative to the plan target that does not represent the actual physical position of the biopsy needle, which may result in potential biopsy of healthy tissue or damage to critical structures. Recall start date: Nov 29, 2021

Where it was sold

The source does not list specific retailers. See the official notice for where affected products were sold.

Location 1

CA · Canada

Affected area 1

CA · Canada

Company & contacts

Manufacturer

Not provided

Phone

Not provided

Brand: Medtronic Navigation, Stealthstation S7 Treatment Guidance System.

Source & status

Source

Health Canada

Tier

official

Category

HEALTH

Classification

Type II

App estimate

medium

Recall details

Recall number

63757

Classification

Type II

Source tier

official

Documents, notices & source

See the official notice and source documents for full details.

View full official notice
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