Lady in for a lymph node biopsy also gets a left subclavian vein port-a-cath placed. Surgeon causes a through and through injury of the cath through the subclavian vein and into the aortic arch with the tip of the catheter winding up all the way down in the thoracic aorta. The patient requires major open heart surgery.
Looking for general surgeon who, on occasion places port-a-caths as in Florida we require same specialty experts.
Regards to all.
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Do you believe there might have been medical error?
Definitely a known error placing the catheter into the subclavian artery instead of the subclavian vein. However, I would be curious to know if the hole was in the aortic arch (extremely uncommon and would represent severe error which is not a known complication) or just the subclavian artery (more common and could be considered a known error). Also, the fact that the catheter was placed in the artery (any artery) before checking to see if there was pulsatile flow (indicating arterial flow) from the needle stick should have been confirmed. Additionally, most hospitals require ultrasound guidance which would indicate the needle in the wrong vessel. Also, most port-a-caths are placed under fluoroscopy so this should have shown been some assistance to the surgeon.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
I think it comes down to if the catheter was actually placed in the aortic arch or if it was placed in the subclavian artery. If it was placed in the subclavian artery there is probably no need to have open-heart surgery for the repair and either the cardiac surgeon should not have operated OR the dilator was placed into the artery which should have been confirmed before dilating the vessel and placing the catheter.
What makes you a good expert for this case?
I've done thousands of subclavian catheter placements. I have actually put the needle in the subclavian artery a few times but not dilated the artery because I checked to see if there was a pulsatile flow or not.
How often do you encounter cases similar to this one in your practice?
I do not do these much anymore but as I said have done probably thousands. Probably less than 10 per year now, but I'm very familiar with the technique, known and unknown complications of the procedure, and how to fix them.
Do you believe there might have been medical error?
Placement of a central venous catheter should result in the catheter tip at the junction of the right atrium and the superior vena cava. This catheter was not even placed in the venous system, rather arterial. This should have been recognized early on in the procedure by the following signs: 1. return of arterial blood in the syringe at time of initial percutaneous access of the vessel 2. high pressure back bleeding with removal of the syringe 3. atypical course of the guidewire on fluoroscopy which should have been used prior to dilation and catheter placement At this point the wire could have been removed and the patient most likely would not have required major surgery
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
This medical error led to the patient having major (unanticipated, additional) surgery and being exposed to all concomitant risks (heart attack, stroke, death, infection, major bleeding, hospital stay, significantly added cost of care).
What makes you a good expert for this case?
I have experience as an expert consultant for medical malpractice cases. I am board certified in general surgery I am fellowship trained in surgical oncology, caring for cancer patients, placing central venous ports on a regular basis.
How often do you encounter cases similar to this one in your practice?
Port placements usually go smoothly but can on occasion present complications. I have encountered a rare patient who had arterial cannulation but never required major open chest surgery.
Do you believe there might have been medical error?
If anatomy is normal, there is not a situation where a line should go through-and-through the subclavian vein into the aortic arch. The question to be answered is whether an anatomic variant exists that would predispose to this complication, which would be very unusual; but right sided aortic arch, for example, could predispose a patient to this complication. I would only know this by review of the patient films (angiography, ultrasound, CT), not from a review of radiology reports.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
It is hard to envision a situation where the line placement was incidental to/unrelated to the complication described; but again, I would need to perform a detailed review of the patient's radiology studies.
What makes you a good expert for this case?
I have personally treated this complication, which is extremely rare; and repair of vascular access complications is a very common part of my practice.
How often do you encounter cases similar to this one in your practice?
I have only seen this case once before, which I successfully treated with endovascular techniques and not open surgery. This complication is very rare and in normal human anatomy should be a never event. The biggest question to answer in this case, from this very brief review, is whether the patient had any significant anatomic variants, which are actually surprisingly (relatively) common.
Do you believe there might have been medical error?
I am a general surgeon who places approximately 50 ports a year. My preferred route is the left subclavian approach as in this case. It is extremely likely that a medical error was performed because there are several steps that need to be taken while placing the catheter that safeguard against placing the catheter in the aorta. It is not clear from the summary if the incorrect placement was discovered at the time of placement or whether it was discovered at a later date. If it was discovered at a later date, then it would be even more likely that a medical error occurred.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
If the patient required open heart surgery then the only reason why that would have been necessary would have been to remedy the incorrect catheter placement
What makes you a good expert for this case?
Intimately familiar with the procedure and it's alternative routes for placement. I am also intimately familiar with the legal aspects of incorrect placement. Over my practice I've probably placed over 2,000 ports via this approach and currently place them on a weekly basis.
How often do you encounter cases similar to this one in your practice?
In my practice it has never happened to me personally. However, I'm aware of other instances when this has happened.
Do you believe there might have been medical error?
would be important to review in detail the operative note. Was fluoro used? How many times did it take to access the vein? When was the injury recognized? These types of errors are usually not subtle. The artery bleeds a LOT and should be recognized immedicately. My other thought is was ultrasound used? This has now become SOC for any intervention.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Thi sound like more "actual cause" If the SOC was met, more likely than not, the injury does not occur, prevention major heart surgery
What makes you a good expert for this case?
Been teaching, training and education for over 20 year. Lots of case reviews Active practice familiar with this procedure ability to explain complex cases in simple terms
How often do you encounter cases similar to this one in your practice?
often Board certified in general and colorectal place my own ports in my colon cancer patients.
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