Brainlab AG: ExacTrac 6.0.x Patient Positioning System, Radiation therapy. Intended to be used to place patients at an accurately defined point within the treatment beam of a medical accelerator for stereotactic radiosurgery or radiotherapy procedures.

Recall number

Z-2440-2015

Recalling firm

Brainlab AG

Product

ExacTrac 6.0.x Patient Positioning System, Radiation therapy. Intended to be used to place patients at an accurately defined point within the treatment beam of a medical accelerator for stereotactic radiosurgery or radiotherapy procedures.

Status

Terminated

Initiated

2015-08-05

Posted

2015-08-21

Terminated

2017-01-05

Reason

ExacTrac 6.0 Patient Positioning System: Display of potentially incorrect Digitally Reconstructed Radiograph (DRR) for x-ray correction and verification.

Root cause

Software in the Use Environment

Action

Brainlab intends to distribute the Field Safety Notice / Product Notification letter CAPA-20150713-001446, dated July 20, 2015, to the customers. The letter provides instructions for the user on how to address this issue, and to avoid a patient and treatment target position potentially different than intended due to this issue. The Field Safety Notice / Product Notification letter states that as generally required, always verify that the correct DRRs for the current patient are displayed in ExacTrac and an accurate fusion to the X-Ray images is possible for patient positioning. In case incorrect DRRs are displayed, exit and re-start the ExacTrac software. To minimize the probability of this issue occurring for the affected ExacTrac versions: -Reduce the amount of contours exported to ExacTrac as far as possible. -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. The Field Safety Notice / Product Notification letter states that as a general reminder the user should always follow the instructions and warnings as described in the user guide. In the context of this notification please specifically consider the safety notes relevant for X-ray correction and verification: -The image overlay functions must be used to verify fusion accuracy in both image views, especially if the images contain a series of similar structures such as vertebrae. -Do not perform patient treatment unless accurate image fusion is possible. -Large correction shifts (e.g. greater than 10 mm) may indicate incorrect automatic fusion. In such cases, verify the correction shift a second time. Brainlab Corrective Action: 1. Existing potentially affected ExacTrac 6.0.x customers receive the product notification information. 2. Brainlab will provide a software revision (ExacTrac v. 6.0.6) with this issue solved to affe

Quantity

361 systems

Distribution

Worldwide Distribution - USA including the states of AL, AZ, AK, CA CO, CT, FL, GA, ID, IL IN, KY, LA, MD, MA, MI, MN, NE, NY, NC, ND, OH, OK, OR, PA, RI, SC, TN, TX, VA, WA, and WI; and, the countries of Australia, Austria, Belgium, Brazil, Canada, China, Denmark, Finland, France, Germany, Hong Kong, India, Israel, Italy, Japan, Netherlands, Panama, Qatar, Russia, Slovenia, South Africa, South Korea, Spain, Switzerland, Taiwan, Thailand, Turkey, and United Kingdom.

Lot, serial or model codes

Affected are ExacTrac versions 6.0.0 through 6.0.5 (v. 6.0.0, 6.0.1, 6.0.2, 6.0.3, 6.0.4, 6.0.5).   Serial numbers/lot numbers are not applicable for a software version. Software revisions of the ExacTrac software have a specific software version number.   Model/catalogue numbers: 70359-01 EXACTRAC 6.0 IR POSITIONING SOFTWARE FOC 20833 EXACTRAC 6.0 IR POSITIONING SOFTWARE 20833A EXACTRAC 6.0 IR POSITIONING SOFTWARE 20833B EXACTRAC 6.0 IR POSITIONING SOFTWARE 20833C EXACTRAC 6.0 IR POSITIONING SOFTWARE 20833D EXACTRAC 6.0 IR POSITIONING SOFTWARE 49926 ET UPGRADE SOFTWARE 3.X TO 6.0 (IR+XR) 49926A ET UPGRADE SOFTWARE 3.X TO 6.0 (IR+XR) 49926B ET UPGRADE SOFTWARE 3.X TO 6.0 (IR+XR) 49927 ET UPGRADE SOFTWARE 4.X TO 6.0 (IR+XR) 49927A ET UPGRADE SOFTWARE 4.X TO 6.0 (IR+XR) 49927B ET UPGRADE SOFTWARE 4.X TO 6.0 (IR+XR) 49933 ET UPGRADE TRUEBEAM 5.5 TO 6.0 LIMITED 49933A ET UPGRADE TRUEBEAM 5.5 TO 6.0 LIMITED 49933B ET UPGRADE TRUEBEAM 5.5 TO 6.0 LIMITED 49934 EXACTRAC UPGRADE 5.5 TO 6.0 BASIC 49934A EXACTRAC UPGRADE 5.5 TO 6.0 BASIC 49996 ET UPGRADE SOFTWARE X.X TO 6.0 SW ONLY 49996A ET UPGRADE SOFTWARE X.X TO 6.0 SW ONLY 49996B ET UPGRADE SOFTWARE X.X TO 6.0 SW ONLY 49997 ET UPGRADE SOFTWARE 5.5 TO 6.0 LIMITED 49997A ET UPGRADE SOFTWARE 5.5 TO 6.0 LIMITED 49997B ET UPGRADE SOFTWARE 5.5 TO 6.0 LIMITED 49928 ET UPGRADE SOFTWARE 5.X TO 6.0 (IR+XR) 49928A ET UPGRADE SOFTWARE 5.X TO 6.0 (IR+XR) 49928B ET UPGRADE SOFTWARE 5.X TO 6.0 (IR+XR) 49939 ET SOFTWARE UPDATE 6.0.X to 6.0.4 P&R 49939A ET SOFTWARE UPDATE 6.0.X to 6.0.5 P&R 49936 ET SOFTWARE UPDATE 6.0.X TO 6.0.3 49936A ET SOFTWARE UPDATE 6.0.X TO 6.0.4 49936B ET SOFTWARE UPDATE 6.0.X TO 6.0.5 49938 ET SOFTWARE UPDATE 6.0.3TO 6.0.4 49938A ET SOFTWARE UPDATE 6.0.3TO 6.0.5 49973 ET DATA PREP / REVIEW SYSTEM 49973A ET DATA PREP / REVIEW SYSTEM 49973B ET DATA PREP / REVIEW SYSTEM 49998 ET 6.0 DATA PREP/REVIEW SYSTEM UPG. KIT 49998A ET 6.0 DATA PREP/REVIEW SYSTEM UPG. KIT 49998B ET 6.0 DATA PREP/REVIEW SYSTEM UPG. KIT

510(k) numbers

["K120789"]

PMA numbers

not on file

Product code

IYE

Firm FEI

3002619595

Firm city

Feldkirchen

Firm state

not on file

Firm country

Germany

Cite as

FDA Medical Device Recalls (openFDA) (U.S. Food and Drug Administration (openFDA)), device-recall-0001-of-0001.json.zip, sha256 b87518bfe2e8, published 2026-09-28

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