Skip to content

Varian Multileaf Collimator [MLC] recallZ-1899-2020 · Varian Medical Systems, Inc. · initiated Aug 12, 2019

Terminated

Is my device affected?

  1. Compare the model, catalog and lot or serial numbers on your device or its packaging with the code information below. A recall usually covers only specific models or lots.
  2. If yours is listed, follow the instructions from Varian Medical Systems, Inc. or your healthcare provider. The company's action is summarized under what the company is doing.
  3. Do not stop using a prescribed or implanted device on your own — talk to your healthcare provider first.

Where to find your model and lot numbers · What recall classes and statuses mean

Why it was recalled

After a recent upgrade to the collimator software version 8.5, the firm became aware that the multi-leaf collimator leaves did not move during an arc treatment. The issue is related to a transient carriage primary- secondary interlock due to carriage fault on the MLC that immediately preceded the initiation of the arc treatment. The issue will occur only with MLC software version 8.5 and only affects conformal arc treatments, including VMAT and RapidArc. There have been no reports of adverse health consequences due to this issue.

FDA root cause category: Software Design Change

What the company is doing

Urgent Medical Device Correction Field Safety Notice letters were sent to customer beginning August 12, 2019. Letters were sent to U.S. and Canadian customers via Fed-Ex, and via local third-party courier or email for the rest of the world. Users were instructed to: 1. monitor MLC leaf movement on the 4DITC console screen, 2. observe the start of every arc treatment and verify that the leaves are moving as intended, and 3. stop treatment immediately if MLC leaves are not moving and contact Varian to assess the MLC status. Users may contact Varian Support for help to verify whether carriage faults have been recorded for the MLC. If carriage fault is confirmed in the TerminalLog file, users were instructed to contact Varian Service Representative to assess the MLC status. Customers were requested to complete and return the response form provided to [email protected], and to contact their local Varian Medical Systems service manager with any questions. The notification letter includes Varian Support Information with the following contact information: phone number for North America Customers: 1 888.827.4265; Global email address [email protected]; and website contact address for customers outside of North America: https://www.myvarian.com/s/contactus?lang=en.

Recall details

Recall number
Z-1899-2020
Status
Terminated
Initiated by the company
Aug 12, 2019
Recalling firm
Varian Medical Systems, Inc.
Quantity
151 units
Product code
IYE
FDA submissions
K181404
Distribution
Worldwide distribution - US Nationwide distribution including in the states of TN, FL, IN, PA, NV, WA, DC, CA, AL, IL, MD, VA, TX, MN, AR, GA, OR, MS, MO, NY, SC, DE, AZ, NH, MI, NC, OH, PA and OK. The country of Canada.

Product description

Varian Multileaf Collimator [MLC]; Millenium Multileaf Collimator [52, 80, 120 leaf]; High Definition 120 Multileaf Collimator Model Number(s): product code: H54 and H56; MLC software version 8.5 - Product Usage: is intended to assist the clinician in the delivery of external beam radiation to defined target volumes during radiosurgery and radiotherapy while sparing surrounding normal tissue and critical organs from excess radiation.

Code information (models, lots, serial numbers)

Model Number(s): product code: H54 and H56; MLC software version 8.5.  UDIs:  HD 120 MLC Head Assembly. UDI: 00899475002318 80 Leaf Assy, MLC Head, UDI: 00899475002325 120 Leaf Assy, MLC Head, UDI: 00899475002332

Devices named in this recall

3 devices in the FDA device registry whose identifier appears in the recall's code information.

Sources and updates

How recalls are matched to devices · Editorial policy · Report an error on this page