Bypass graft complications (Case #331)

• Medical Probability: 9 / 10
• Medical Error Summary: Several issues with this case: a. The Mynx device like most arterial access closure devices is not indicated for use in the setting of a previous femoral to popliteal bypass (that is a prosthetic byp...
• Causation Probability: 9 / 10
• Causation Summary: Yes, please see points above. In particular there is no known indication to undertake an angioplasty in the providers outpatient center prior to the definitive re-operative approach to this patient, t...
• Expert Summary: I undertake and/or oversee several of these types of operative cases on the internal carotid artery as well as lower extremity bypass procedures. My experience included managing groin infections and/o...
• Similar Summary: As stated above, I have had experience with this type of complication. I do not use the Mynx closure device, that said I have operated on several patients in the past with complications from this devi...

Hypoglossal nerve injury requiring suture repair during carotid endarterectomy (Case #332)

• Medical Probability: 9 / 10
• Medical Error Summary: Injury to the hypoglossal nerve is a known complication in the setting of carotid endarterectomy and occurs in approximately 4.4 to 17.5% (Perler, 2023). Most of these injuries are based on traction a...
• Causation Probability: 9 / 10
• Causation Summary: Key aspects as it relates to causation and general liability in the case include: a. Who was actually undertaking the procedure? b. If a learner was undertaking the procedure (that is the vascular...
• Expert Summary: I undertake and/or oversee several of these types of operative cases during the year. I also follow several hundred patients with this disease state in pre-operative and post-operatively periods with ...
• Similar Summary: As stated above, traction injury does occur during this type of operation, and I have seen it in my own patients and that of my partners. Our rate of complication is less than the stated upwards limit...

bleeding from external iliac artery following endovascular procedure (Case #347)

• Medical Probability: 9 / 10
• Medical Error Summary: To briefly answer your question, these types of complications (access laceration and/or failure of the initial closure device that is the “AngioSeal” do occur and should have been managed in a mor...
• Causation Probability: 9 / 10
• Causation Summary: The close association of the procedure and subsequent finding on re-exploration indicates a strong causal link of the complication (bleeding) to the initial procedure and the delay in its diagnosis as...
• Expert Summary: I undertake and/or oversee several of these types of procedures in my practice. I am called as the senior partner to aid my partners in handling these types of complications. My experience over 14 ye...
• Similar Summary: Our practice undertakes around 75 cases in a given year similar to the one described. Our current rate of access complications is similar to the literature, 3% hematoma and 1% bleeding [1]. I have per...

Renal artery stenosis post infrarenal aortic aneurism repair with endograft and extension iliac grafts causing renal artery stenosis and resultant renal insufficiency (Case #360)

• Medical Probability: 6 / 10
• Medical Error Summary: - Based on large database studies, there is a known renal artery complication rate between 1% to 4% in the setting of endovascular aortic aneurysm repair (Zettervall, 2017). - The later higher end of...
• Causation Probability: 6 / 10
• Causation Summary: - Again, depending on the above points - The key aspect of this case was there an issue at the initial EVAR that led to the occurrence of renal artery stenosis
• Expert Summary: - I undertake and/or oversee several of these types of procedures in my practice. I am called as the senior partner to aid my partners in handling these types of complications. My experience over 14 ...
• Similar Summary: - Our group has also published on EVAR outcomes in our center and more broadly in the larger health system in a variety of aspects (Otoya, 2023; Tse, 2020; Newton, 2018). - Our practice undertakes ar...

Large AAA in 56yo male, possible delay in intervention, resulting in rupture and death in hospital. (Case #434)

• Medical Probability: 10 / 10
• Medical Error Summary: 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 car...
• Causation Probability: 10 / 10
• Causation Summary: 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 pat...
• Expert Summary: 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 ca...
• Similar Summary: A handle full of aortic aneurysms present this is manner is a given year.

63yo Right Lower Extremity Vascular Disease, Failed Bypass Procedures, and Eventual Amputation (Case #549)

• Medical Probability: 4 / 10
• Medical Error Summary: 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 ev...
• Causation Probability: 3 / 10
• Causation Summary: The case as described is a known clinical pathway for many of these patients who present in this way.
• Expert Summary: 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 chi...
• Similar Summary: I encounter patients like this one several times a week. I personally operate on patients like this one several times a year.