The patient had significant preexisting vascular and medical risk factors, including peripheral artery disease, diabetes, hypertension, hyperlipidemia, chronic kidney disease, and a history of smoking. In January 2025, he underwent a right lower-extremity bypass procedure for severe arterial disease. Although initially successful, the bypass gradually failed over the following months, and by late July 2025 there was substantial loss of function in the graft with ongoing poor blood flow to the right leg and foot. A second bypass was performed in October 2025 in an attempt to restore circulation, and the seriousness of the limb ischemia, including the possibility of future amputation, was reportedly discussed afterward.
After the second bypass, the patient was transferred to a rehabilitation facility with an anticipated need for wound vacuum management and ongoing medications. On arrival, there were reported problems with wound vacuum compatibility and medication availability, resulting in a period during which he was without the wound vacuum, had interruptions in medication administration, and required transport back to an emergency department for wound evaluation and dressing management before returning to the rehab facility.
The record provided describes continued delays in obtaining compatible wound-vac equipment and resuming medications. He was later discharged home and, at follow-up in mid-November 2025, reported that the right foot was again becoming cold. Given the failure of two bypass attempts in the setting of severe arterial disease, the decision was made to proceed with a below-knee amputation.
The below-knee amputation with skin graft was performed in early December 2025. In the days that followed, there were reports of poor wound healing, foul odor, and concern for infection. Readmission for intravenous antibiotics and conversion to an above-knee amputation was recommended. After an unsuccessful attempt to seek care elsewhere, the patient ultimately underwent an above-knee amputation in mid-December 2025. Following that procedure, he received intravenous antibiotics and pain management, and additional issues addressed during the hospitalization included markedly elevated blood pressure, glucose control, and MRSA colonization precautions. He was discharged to an inpatient rehabilitation facility later in December 2025.
**Please see attached progress notes and photos for reference**
1: was the patient’s outcome was due to negligent wound care and transfer coordination versus progression of severe peripheral arterial disease despite repeated revascularization attempts.
2: whether the amputation outcome was avoidable or instead a foreseeable consequence of poor limb perfusion and failed bypass procedures.
Files:
Q: Do you have a preoperative cardiac echo report?
A: —
Do you believe there might have been medical error?
This is a difficult case to tell. It really depends at rehab what is the reason the VAC was not applied and which medications was he not recieving. What was the documented reason for this? 1st. I would ask typically on discharge, the VAC paperwork is documented and arranged and confirmed. Was he sent to rehab without a VAC in place? 2. Was he not recieving antiplatelet or anticoagulation as part of the medications he was not recieving? This could lead to graft failure. Given his past medical hx this bypass was likely a last ditch effort to salvage the limb.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Likely in the sense that if his VAC and medication delay did not have a valid reason that would potentially lead to graft failure.
What makes you a good expert for this case?
I have reviewed peripheral arterial cases for quite some time now. I am happy to send CV. I think in general this is a difficult case for the plantiff given comorbidities. Likely would hinge on if there was negligent care in not getting the VAC in timely fashion and why some medications were not administered to him.
How often do you encounter cases similar to this one in your practice?
I just did a distal redo bypass last week. We also had a separate patient this week we debrided a wound after bypass and sent home with wound vac therapy. This is often a common scenario in our practice.
Do you believe there might have been medical error?
There is an evolving medical literature that patients with the list co-morbid conditions, in particular diabetes with end stage renal disease have worst outcomes with revascularization is attempted even for limb salvage. The delay with the wound vacuum system more likely than not did not contribute to the progression of the wounds. There is a large randomized trial published in the last year from England calling into question the value of wound vacuum systems. That said, a limited interruption from the description did not contribute to the eventual outcome.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The case as described is a known clinical pathway for many of these patients who present in this way.
What makes you a good expert for this case?
I have practiced vascular surgery including handling patients like the one since 2009. I have maintained my board status as a general and vascular surgeon. I actively take call and am the division chief of vascular surgery.
How often do you encounter cases similar to this one in your practice?
I encounter patients like this one several times a week. I personally operate on patients like this one several times a year.
Do you believe there might have been medical error?
First, how to defend against a “failing bypass” in Summer 2025 after the first operation? Was anything done to try to salvage the graft and if no, why not? Second, is the lack of documentation in November 2025 with the departure from the hospital after the 2nd bypass and take back that the graft was open on the day of discharge to rehab. If not, then you would be sending the patient to rehab with a wound VAC that likely would fail in the absence of a vascularized lower extremity.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Despite some of the lack of documenation with this case, there were multiple attempts to save the leg-3 bypasses, all of which failed. While there may be a differnce in management, it seems that the surgeon made valiant attempts to save the leg. It also states the patient consented to proceed with amputation. It is unclear if the patient only allowed the surgeon to proceed with BKA first, or if that was the surgeons choice? There is no documentation to acknowledge this part of the decision making. In my professional opinion, at face value there does not appear to be what some might call negligent management of the patient. He appeared to be treated in a timely and valiant manner in the absence of other extenuating medical issues with progression of disease alone quite potentially the cause for the amputation. However, there is an issue with factual causation regarding follow up of the first postoperative bypass around the time the bypass was failing in Summer of 2025. If you have ultrasonographic evidence that the bypass graft was failing, yet nothing was done or attempted then ultimately the bypass graft would have expectedly failed. If you have documentation of a discussion with the patient refusing to proceed with bypass graft salvage or noncompliance (no shows, loss to follow up, stopping medications etc.) then you are reasonably covered. The vignette does not state that though. Ultimately the failure of the first bypass graft would have led to (the need for) the second bypass graft and revision during the second hospitalization in November 2025. That ultimately failed, necessitating the need for an amputation. Second, with regards to the 2nd operation in November 2025, there does not appear to be documentation to prove that the bypass graft was open when the patient left the hospital for rehab. If the patient went to rehab with an ischemic extremity, the wounds most certainly would have broken down, and this might be interpreted as negligent as well. Inevitably, if the first bypass graph occluded and nothing was done about it, it certainly might be a interpreted as negligent, which ultimately created a chain of events, causing the second bypass graft, which ultimately failed and the patient progressed to an amputation. Also, failure to adequately survey the graft (without an ultrasound prior to going to rehab) which was problematic after the 2nd bypass in November alone could also be separately interpreted as negligent with factual causation as well. I believe this case could be considered as separate factual causations as two separate cases (the 2 bypasses considered separately) or one long factual causation with the one bypass failure leading to the next bypass failure followed by the loss of limb. Thank you for the opportunity to review this case.
What makes you a good expert for this case?
board certified and practicing vascular and endovascular surgeon x 20+ years, treating thousands of cases yearly and PVD daily.
How often do you encounter cases similar to this one in your practice?
I would like to thank the organizers for the opportunity and inviting me to review this case. I have several comments and questions. First, what was the indication for the original bypass in January of 2025. Was it for rest pain, limb salvage or claudication? Was the conduit PTFE or autologous vein? The first bypass was performed on 2/3/2025 which was the right fem pop bypass graft. It's documented that it occluded according to the note on 9/29/2025. That's a fairly short amount of time (7 mos) for longevity of the bypass. The vignette states “Although initially successful, the bypass gradually failed over the following months, and by late July 2025 there was substantial loss of function in the graft with ongoing poor blood flow to the right leg and foot”. In the setting of a potentially “failing” bypass graft, was there any attempt made to go back to salvage the original graft? If not, why not? What were the patient’s symptoms during this period? Are there graft surveillances of the bypass graft during the interim on post operative clinic visits? Is there any thought process as to why the original bypass may have failed in such a short amount of time? Does the patient have any preoperative medical conditions (i.e. poorly controlled DM, hypercholesteremia etc.) that portends a poor prognosis for success of lower extremity bypass? According to the 11/10/2025 note, it sounds like the patient underwent a right femoral to peroneal bypass graft and had an immediate postoperative occlusion and was taken back for a revision during the same admission. Most likely an immediate occlusion in a perioperative setting is from a technical consideration at the time of the original operation. May I see the operative notes of both procedures including the second procedure and the revision? Are there any other extenuating perioperative circumstances/complications in the hospital that may have caused the bypass graft to fail ( ie. perioperative MI, bleeding, unexplained anemia, acute or chronic renal failure, prolonged ventilation, use of perioperative pressors, hemodynamic instability, and/or arrythmias). What was the patient’s nutritional status? Is there a perioperative prealbumin/transferrin which might have predicted poor wound healing and possible infection perioperatively? Also, during the same admission is there any documentation with either a bedside note documenting normal pulses on discharge or a hospital acquired graft surveillance after surgery showing that the graft was open and functioning prior to the patient going to rehab? If not, the last sentence in the note dated 11/10/2025 states that they would only obtain an arterial duplex in three months? Please explain. If the bypass graft was problematic and originally went down and then had to be taken back and revised, why wouldn't the surgeon have obtained immediate postoperative graft surveillances as opposed to waiting three months? What was the operative surgeon's perioperative use of DOACs and antiplatelet therapy? It is unclear that the problems with the wound vac management in the rehab facility led to the wound complications and breakdown. It appears the wound complications existed prior to going to rehab? If the bypass graft was occluded on discharge to rehab, the patient’s leg would have been ischemic therefore any attempt at wound healing either without or with a wound VAC most likely would have failed. Also, another question is why would you proceed with a below knee amputation with an occluded SFA and popliteal artery as opposed to just proceeding with an above knee amputation? The chance of healing an above knee amputation would be far greater with the 2-segment occlusion (SFA & Popliteal) in a critical limb ischemia patient versus a BKA which would be somewhat problematic to heal. The vignette also states that a BKA was performed in addition to a skin graft. In the setting of a failed bypass graft with an ischemic stump, a skin graft would most likely fail as well. Why not VAC the stump, and if it was healing and doing well at a later clinic visit, then schedule for PTSG at a later time? Answers to questions 1. It is my opinion based off the documentation provided, the patients outcome albeit complicated with negligent and hard to control wound care in the rehab facility, the limb loss was most likely secondary to the patient’s severe peripheral arterial disease secondary to repeated and failed revascularization attempts. 2. While amputations are potentially avoidable, however, it is most likely a foreseeable consequence of poor limb perfusion and failed bypass procedures secondary to the patient’s untreated peripheral vascular disease. There are 2 points of serious consideration that I see with this case based on the documentation that I have access to. First, how to defend against a “failing bypass” in Summer 2025 after the first operation? Was anything done to try to salvage the graft and if no, why not? Second, is the lack of documentation in November 2025 with the departure from the hospital after the 2nd bypass and take back that the graft was open on the day of discharge to rehab. If not, then you would be sending the patient to rehab with a wound VAC that likely would fail in the absence of a vascularized lower extremity. If I am wrong about my facts or conclusions about this case, please let me know. Again, I would like to thank Kalivar for the opportunity to review this case and am open to discuss further. Many thanks.
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