51 year old male was undergoing a cardiac work-up for bariatiric surgery. This led to a cardiac catheterization. While no coronary intervention was warranted, the patient was found to have severe, distal aortic and iliac disease. Vascular surgery was consulted, and patient underwent an endograft placement along with a right femoral to popliteal and a right to left femoral to femoral bypass.
Post op day 1, patient is being transitioned OOB to chair for the first time and becomes hemodynamically unstable along with evidence of hemorrhage in the lower left abdomen and groin. Surgery occurred at a suburban, community hospital. Same day, patient was emergently life-flighted to Pittsburgh. Upon exploration, patient found to have hemorrhage of the left limb of the fem-fem bypass where "the heel of the graft over approximately 40% of the anastomosis had torn". and was "felt to be under tension" To repair, an inch of the graft was resected, and a 4-5 inch segment of Dacron graft was added. While revascularization was successful, the patient did not recover from the initial insult and multi-organ system failure and died roughly 3 weeks later.
A couple issues for consideration. What is the likelihood of graft failure as a general matter? Does the standard of care require that the surgeon ensure that the graft is not under undue tension? Are there non-negligent explanations for a graft failure such as this? Last, is it reasonable to perform such as complex, high risk procedure in a hospital, where, if such a complication occurs, it requires transfer to another facility?
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Do you believe there might have been medical error?
Disruption of a vascular anastomosis within 24 hours of surgery, generally speaking, is almost always a technical error (either too much tension on the anastomosis, bites too small on graft or artery, or a combination). Severe hypertension after surgery may contribute to bleeding, but a properly constructed anastomosis should not disrupt as described in this case. That said, the data available to me here are limited. The other important question is whether the patient needed the operation in the first place. The case description describes a patient that was being worked up for bariatric surgery and the vascular problem was incidentally found - the vascular operation described should only be performed for severely symptomatic patients, especially in patients with underlying comorbid conditions.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Had the operation not been performed, the patient would not have suffered these complications. However, I lack the complete data set to say this within a reasonable degree of medical certainty.
What makes you a good expert for this case?
This is an operation that I perform on a weekly, if not daily, basis. There may be more to this case than meets the eye. WRT the other questions above: 1. There is no “standard of care” regarding hospital capabilities and call coverage for these procedures. Doing these in community hospitals would be acceptable as long as disclosure is made to the patient ahead of time about what will happen if a complication occurs. 2. Immediate graft disruption as described in this case is something I have only seen in patients with vascular Ehlers-Danlos syndrome and Marfan syndrome. 3. Standard of care is indeed to ensure that a bypass graft is not under tension, in order to prevent the complication described in this case. 4. Patients with either a connective tissue disorder (Marfan syndrome, vEDS, Loeys-Dietz) or severe infection may be susceptible to this complication.
How often do you encounter cases similar to this one in your practice?
I perform the described operation quite routinely. I have never experienced this complication in elective surgery - I have seen it once in a patient with Marfan syndrome undergoing emergency surgery, which we immediately recognized and surgically corrected with a good outcome.
Do you believe there might have been medical error?
From the story given above, my best opinion is that the femoral-femoral graft did not take in consideration the obesity and anatomic changes that would occur with sitting up. Likely the anastomoses tore with change of positioning. It is surprising the patient would not have been taken immediately back to the OR for at least control of the hemorrhage before evacuation to a tertiary care center.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
As above - the surgery itself as well as the process of dealing with the hemorrhage.
What makes you a good expert for this case?
I’ve been practicing vascular surgery since 1997, and I’ve been involved with resident and fellow education through most of my career.
How often do you encounter cases similar to this one in your practice?
Usually two to three patients a month with similar pathology.
Do you believe there might have been medical error?
Based on the information supplied (a lot more information is required to render a real opinion, there may be a failure to uphold the standard of care. The standard of care during the 1st operation should be to examine the graft upon completion. The geometry of the graft tunneling should be carefully assessed; the graft should be in an inverted C (or gentle S) configuration to prevent undue tension and kinking at the anastomoses. If the operative note did not dictate that this was performed, and the graft truly was disrupted because of undue tension, then the standard of care may not have been upheld. Graft failure, in general, can occur in 5%-10% of major vascular cases. Most of the time, early graft failure is identified and corrected promptly by the same surgeon who performed the initial procedure. It is important to note that the cause of graft failure is not always a technical issue with how the procedure was performed and many times when re-operation is performed, a specific problem with the original operation is not identified. In this case, it will be particularly important to understand the opinion of the 2nd surgeon who re-operated on the patient and see what led him to believe the anastomosis was "under tension" and also examine the notes of the 1st surgeon to see if he documented care to ensure the graft was placed in a configuration that prevents undue tension.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Based on the case description, it appears at the 2nd operation that the surgeon identified the heel of the anastomosis to be "torn." Barring any other causes (infection, trauma are a few examples of non-negligent causes), if the graft was truly under "tension" and it can be shown that the surgeon did not allow enough slack in the graft (gentle C or S-curve) to prevent undue tension, then there may be negligence whereby causation could potentially be proven.
What makes you a good expert for this case?
I am a board certified vascular surgeon in private practice who performs the full breadth of vascular surgery cases. I perform femoral-femoral bypass procedures in my practice. I am also a Clinical Assistant Professor of Vascular Surgery.
How often do you encounter cases similar to this one in your practice?
Patients with aorto-iliac disease are routinely treated in my practice, using both open surgery and endovascular techniques.
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