The patient had a history of gastroesophageal cancer, for which he had previously undergone esophagectomy and jejunostomy tube placement several years earlier. His cancer was considered to be in remission. He was admitted to the hospital with extensive acute portal vein thrombosis and ascites. A paracentesis ruled out malignant ascites, and the patient was started on anticoagulation. Several days later, an interventional radiologist attempted percutaneous transhepatic portal venography, cholangiography, and portal vein thrombectomy. During the procedure the radiologist advanced a 21-gauge Chiba needle AND a 6 French Accustick catheter into the right hepatic artery. Gel foam embolization was done during withdrawal. The thrombectomy was unsuccessful. The interventional radiologist apparently told the patient's other providers that the hepatic artery injury would most likely resolve on its own, and that it was OK to restart the Heparin drip after two hours.
After the procedure, the patient became more tachycardic and hypotensive, and was started on pressors.
The patient underwent a successful transsplenic portal vein thrombectomy the following day, but developed acute liver failure, DIC, supected bowel necrosis, and encephalopathy. He received multiple blood products and continued to decline. Ultimately, he was placed on palliative measures only and died 9 days after the hepatic artery puncture.
The death certificate lists as causes of death: (a) acute liver failure, portal vein thrombosis; (b) acute renal failure; (c) acute hypoxic respiratory failure; and (d) portal venous thrombectomy, hepatic artery injury.
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Do you believe there might have been medical error?
It is somewhat difficult to glean from the information given the extent of the injury caused by the 21-gauge Chiba needle. As an aside, a Chiba is typically 22 gauge in this context, whereas an Accustick needle, the one that comes with the Accustick kit, is 21 gauge. Inadvertent puncture of a branch of the hepatic artery may occur during trans hepatic access. The critical question is where along the course of the common or proper hepatic artery did the puncture occur. Once the puncture was made with the Chiba needle, was it immediately recognized? Presumably the needle was being used to access the occluded portal venous system, although the synopsis mentions cholangiography, so it is uncertain what was being attempted. Was the guidewire passed through the Chiba, and the Accustick advanced over the wire which was itself traversing a branch of the hepatic artery? The upshot is that the nature and extent of the injury needs to be better defined, whether it was recognized in real time by the operator, and how gel foam was deployed in an attempt to treat the injury. This is not easily discerned from the description. The patient's eventual decompensation may very well have been a result of inadequately treated arterial injury. This, in fairness, may be very difficult to establish, and absolutely requires perusal of the imaging.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Again, as noted above, there are many factors that go to causation, not least being the precarious starting point, in which a patient presents with extensive portal vein thrombosis. We would need to know the presenting symptoms, as this bears greatly on both the treatment and the prognosis. Furthermore, it would be necessary to explore other options for access to the portal venous system: more typically, portal thrombectomy would be performed through a TIPS type trans jugular access, although the transsplenic approach has found favor in recent years. All of this makes difficult to determine definitively the source of bleeding during the procedure.
What makes you a good expert for this case?
This case very much encompasses my areas of expertise.
How often do you encounter cases similar to this one in your practice?
These are encountered a few times a year.
Do you believe there might have been medical error?
It depends where the laceration of the HA occurred. Was the entrance into the liver parenchyma sealed? Pt still under went splenic access and thrombectomy. No problems with the procedure. He died several days afterwards. Arterial bleeding using kills fairly quickly.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The patient would have likely died with or without any procedures.
What makes you a good expert for this case?
I do these cases. I made mistakes and have helped patient. These are last ditch effort, usually intended to give the patient a few more days of life. They are Hail Marys cases.
How often do you encounter cases similar to this one in your practice?
Hail Marys cases, please save my father type of cases, four to five a month. Portal thrombectomies, 4-5 per year.
Do you believe there might have been medical error?
I believe there was a medical error since the hepatic artery was catheterized during attempt at portal vein access. Nonetheless, this is a possible expected complication and it appears that is was managed appropriately.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The hepatic artery was inadvertent access was identified and treated appropriately with tract embolization. Moreover, even if there was a hepatic artery branch injury it is unlikely that this would lead to liver failure and that the patient's death was due to the hepatic artery access. Moreover, the next day the portal vein thrombosis which was ultimately likely to lead to the fulminant hepatic failure was treated successfully. It is likely that the patient already had a very poor prognosis at initial presentation since ascites was already present, which is a sign of more advanced liver failure from the portal thrombosis. The portal thrombosis also led to the bowel injury, which likely also contributed to the mortality. In summary, it appears the physician responded appropriately and despite an expected complication, it was identified and managed and the thrombectomy procedure was ultimately successful.
What makes you a good expert for this case?
I have been Chief of Interventional Radiology at major Los Angeles hospitals for several years. I am also a Research Associate in Radiology at UC San Francisco. I have an BSE in Bioengineering from University of Pennsylvania, an MD from Harvard Medical School, and completed residency and fellowship training in Diagnostic and Interventional Radiology at the University of California, San Francisco. I have performed countless complex IR cases such as the one in this case. I have also served as an expert for dozens of legal cases ranging from medical malpractice to representing major insurance companies and corporations such as Disney and Honda. I have published numerous peer-reviewed publications in interventional radiology and presented my work internationally. Lastly, I have invented new interventional radiology devices and work with multiple medical device companies on novel IR devices and techniques.
How often do you encounter cases similar to this one in your practice?
These cases are rare, but I do encounter them a handful of times each year. I also have reviewed cases similar to these in past in a research setting.
Do you believe there might have been medical error?
It is hard to give a definite opinion on whether a medical error has been made here without more complete information such as the imaging from the procedure and more complete medical records. However, I do believe that there is the possibility of error. Accessing the hepatic artery with a Chiba needle is not uncommon with these types of procedures. As a result, this would be a known risk. However, advancing the accustick device into the hepatic artery is not within the standard of care.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
This is a more difficult question than whether a medical error occurred. It seems that the cause of death was from acute liver failure which from the short description of the case may have been caused by the acute portal vein thrombus. I would need to review the rest of the medical records to determine whether the hepatic artery puncture actually caused an injury. The case description states that there was hypotension after the procedure which can in some cases worsen organ perfusion and can worsen liver failure.
What makes you a good expert for this case?
An expert who routinely performs transhepatic procedures. These include transhepatic portal interventions such as in this case. However, there are other more common procedures such as percutaneous transhepatic cholangiography, biliary drain placement, transhepatic vascular access, etc.
How often do you encounter cases similar to this one in your practice?
Transhepatic portal interventions for thrombectomy of acute portal vein thrombus are rare. I do approximately 1 per year. The other transhepatic procedures that I describe above are more common. I perform those procedures several times a week.
Do you believe there might have been medical error?
Arterial injury is a known risk while accessing the portal vein via percutaneous transhepatic route, though it is usually recognized prior to insertion of large access. It is unfortunate that the physician in this case failed to recognize that s/he had accessed an artery rather than a branch of the portal vein before s/he placed the 6 French Accustick. This is certainly not ideal. However, it seems that s/he recognized her/his error and took steps to minimize complications by embolizing the artery prior to withdrawal of the sheath. It is not clear based on this description how aggressively the artery was embolized-- conservatively so that just a small branch was occluded? Just the tract? Too aggressively so that a large portion of the hepatic artery was occluded? This is important since overly aggressive embolization may lead to decreased arterial flow to a large portion of the liver. In the setting of portal vein thrombosis, there would then be no flow to the embolized portion of liver. Based on the provided timeline, I assume that the patient did not suffer significant hemorrhage from the injured artery after the initial procedure, since a repeat embolization would have been performed rather than proceeding to portal vein thrombolysis. It is unclear to me why the description states that the thrombolysis was successful, since the patient developed bowel necrosis after the second procedure. My guess is that the thrombosis was severe and diffuse and that thrombolysis opened parts but not all of the portal venous system. This is common in the setting of very extensive thrombus-- thrombolysis often fails in this setting and this would not have been the fault of the operator. So given the description of events, it is possible but unlikely that the arterial injury contributed to this unfortunate patient's death. It seems that there was no major hemorrhage after the first procedure. It is possible that embolization of the artery was overly aggressive and contributed to liver failure, but this is not clear and would be difficult to prove without imaging performed after the first procedure. Overall, it seems the extensive thrombosis of the portal venous system was the cause of this patient's death. The thrombolysis procedure likely cleared some but not all of the extensive clot. This is a limitation of the procedure and may have not been due to factors related to the operator.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
See above. Based on the description of events, my feeling is that the extensive portal vein thrombosis was the primary cause of this patient's death.
What makes you a good expert for this case?
I am an interventional radiologist at a major transplant referral center for patients with liver disease.
How often do you encounter cases similar to this one in your practice?
Members of my group encounter this type of problem at least 5 times per year
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