56-year-old male with a history of hypertension, CAD.
July 5 (Friday) Goes to ER with 10/10 abdominal and back pain. CT shows large, calcified, partially thrombosed infrarenal aortic aneurysm measuring 8.6 cm in diameter and 11 cm in length. Collaterals had already began to form. IP also has history of aortic dissection in the family. Vascular surgeon is consulted who recommends surgical repair (obviously), elects to do an EVAR, but it is not scheduled until July 8 (Monday). He wanted cardiac clearance.
Cardiology sees him on Friday the 5th, orders an echo to finish off the clearance. TTE echo was done on Saturday the 6th in the morning and he was “cleared”.
After the echo was completed, multiple nursing notations show that he was complaining of extreme abdominal and back pain for the remainder of Saturday night into Sunday morning. They also noted multiple times that no further testing was pending or ordered. He was getting Dilaudid IV multiple times with little/no relief. The surgeon and hospitalists were notified multiple times, no additional radiology or testing was ordered, but they added Simethicone.
At 7a.m. on Sunday the 7th, IP is tachycardic and unresponsive. Rapid response is called and he is now in full cardiac arrest. They work him for about an hour. He is pronounced dead at 7:57 a.m.
Attached you will find a screenshot of the CT scan and treatment plan, etc.
We seek an expert with current and past experience in AAA management, has performed EVAR and/or open repairs of similar AAA's in this case.
Thank you in advance.
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Do you believe there might have been medical error?
This is a classic presentation of a symptomatic infrarenal aortic aneurysm. Per the CT read it is not ruptured setting up a clinical picture of an urgent repair (that is admission to the intensive care unit, clearance of possible and expedited repair).
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Symptomatic aneurysms need to be addressed at the time of admission. As in this case, work up with cardiac clearance and other test is reasonable as long as the patient symptoms are stable and the patient remains hemodynamically stable. However, in the setting, the patient needs to be taken to the operating room on Sunday or Saturday after Clarence was obtained. This is a clear violation of the standard of care.
What makes you a good expert for this case?
My practice and I handle roughly 20 to 30 aortic aneurysm cases a year. Commonly a handful of these present in a symptomatic fashion. We have managed these in the correct way within the standard of care as outlined above.
How often do you encounter cases similar to this one in your practice?
A handle full of aortic aneurysms present this is manner is a given year.
Do you believe there might have been medical error?
I completed my fellowship at Stanford where we specialized in treatment of complex aortic aneurysms. I furthermore completed an additional aortic fellowship in China. One of the tenants of aortic aneurysm treatment is symptomatic aortic aneurysms ( especially of this size) need to be fixed emergently. Even though the CTA did not read rupture, this should have been done in a more expeditous fashion. Cardiac "clearance" is a misnomer as in this case, would not change decision making and patient should goto OR. Patient has to accept cardiac risk.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Please see above however the patient ruptured the aneurysm in the time that was a delay to the operating room. If this was fixed expeditiously, he would not have ruptured.
What makes you a good expert for this case?
I have done countless number of endovascular aortic repairs for aneurysm and dissection. I have testified previously in these cases as well. I have a second non acgme fellowhsip for advanced endovascular aortic work internationally. In my current practice, I do aortic aneurysm repairs regularly and frequently (symptomatic/asymptomatic/ruptured).
How often do you encounter cases similar to this one in your practice?
As mentioned above, I routinely perform operations on these types of cases. We do anywhere from 30-50 a year and a mix of symptomatic/asymptomatic/ruptured. I have done hundreds in my career and would be happy to review this case for you.
Do you believe there might have been medical error?
Although the CT did not show frank signs of rupture, this is a very large (> 8 cm) aortic aneurysm that was symptomatic. Symptomatic aneurysms portend to imminent rupture and ought to be repaired urgently. The optimal timing for repair of symptomatic nonruptured abdominal aortic aneurysms has not been well established. The timing for surgery ought to be individualized to a particular patient's clinical details. In this case, it is likely that the patient's complaints of severe back pain were misattributed to his history of L4-5 lumbar fusion. However, chronic back issues and history of lumbar fusion would not account for his severe abdominal pain. In fact, urgent surgical repair is indicated for patients with symptoms that cannot be unequivocally attributed to another etiology, regardless of size. Initial evaluation by cardiology to medically optimize the patient may have been justified. Nevertheless, once the patient was subsequently "cleared" or optimized by cardiology Saturday morning, there was no good reason to delay the surgery further until Monday, given the patient's continued complaints of severe abdominal and back pain. At the very least, when the surgeon and hospitalist were notified multiple times of unremitting abdominal and back pain, they should have considered the possibility that the symptoms were due to the aneurysm and that the patient was progressing to rupture. This consideration should have prompted either bringing the patient to the OR more urgently or, at minimum, obtaining subsequent imaging with CT to confirm frank rupture or to look for interval radiographic changes suggesting impending rupture, such as periaortic fat stranding, periaortic fluid, broken calcification, asymmetry, etc. Any of these CT findings or the patient's continued unremitting pain should have prompted emergency surgical repair.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The patient presented with a symptomatic nonruptured aortic aneurysm and died of a frank rupture 2 days after hospital admission. The delay in diagnosis of the rupture and delay in surgical treatment are a breach of the standard of care and, more likely than not, the proximate cause of death.
What makes you a good expert for this case?
I am a board-certified vascular surgeon who has performed open and endovascular surgical repair of abdominal aortic aneurysms in both the elective setting and the emergency ruptured setting. I am experienced in reviewing medical malpractices cases for both plaintiff and defense. I am experienced in giving deposition and trial testimony as an expert witness. I have an active Florida Medical Doctor Expert Witness Certificate.
How often do you encounter cases similar to this one in your practice?
Symptomatic nonruptured aortic aneurysms are less common than ruptured aortic aneurysms and much less common than asymptomatic nonruptured aneurysms. In my 12 years of practice, I have encountered a similar scenario in a patient admitted with a large asymptomatic nonruptured aneurysm. The patient subsequently progressed to becoming symptomatic. Upon being notified, this prompted me to obtain immediate repeat imaging, confirming a rupture. While the imaging was being obtained, I simultaneously called in the OR team for suspected rupture in order to bring the patient to the OR for emergency surgical repair in the middle of the night. The standard of care is to minimize delays when aneurysm rupture is suspected.
Do you believe there might have been medical error?
This patient has a large, essentially symptomatic aneurysm. That is considered a surgical emergency and needs repair immediately. The request for cardiac "clearance" is a stalling tactic. The surgical management shouldn't change, as the risk of a cardiac event perioperatively that would lead to his demise is certainly much smaller than his near-certain risk of death from rupture of his aneurysm.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Delay in repair = randomized to chance. Rupturing a symptomatic aneurysm IN THE HOSPITAL is inexcusable.
What makes you a good expert for this case?
I am a managing partner in a CT and Vascular practice with 24 years experience. I repair 50 to 60 aneurysms a year, both open and Endovascular. I am happy to discuss this case in more detail at your convenience.
How often do you encounter cases similar to this one in your practice?
We treat 4 or 5 symptomatic aneurysms each year. In each case, the patient is treated on the day of diagnosis. We consider this standard practice for our hospital systems.
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