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      Litigation in Nontraumatic Aortic Diseases – A Tempest in the Malpractice Maelstrom

      , ,
      S. Karger AG
      Litigation, Legal, Dissection, Malpractice

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          Objectives: Physicians are vulnerable to highly litigated thoracic aortic diseases. On the basis of a review of litigated cases, we aim to determine legally protective strategies for physicians and methods to improve treatment. Methods: Thirty-three nontraumatic, thoracic aorta-related legal cases were analyzed. Results: Twenty-three patients (69.7%) had dissections (21 ascending, 2 descending), 8 (24.2%) had aneurysms and 2 had miscellaneous other phenomena (1 coarctation and 1 iatrogenic descending aortic rupture). The adverse event was death in 30 (90.9%) patients and paraplegia or stroke in 3 (9.1%). Allegations included: failure/delay in diagnosis (19), delay in surgery (4), error in surgical technique (5), failure to prevent paraplegia (2) and miscellaneous (3). Medical treatment was retrospectively judged suboptimal in 22 cases (66.6%) for reasons consonant with allegations. Conclusions: Aortic disease can be diagnostically elusive, as ‘the great masquerader’. Emergency physicians must maintain a high index of suspicion for aneurysm and dissection. The D-dimer test can effectively rule out aortic dissection. ‘Triple rule-out’ CT scans should be performed liberally. CT scan readers must remember to evaluate the aorta. Operating room administrators must be aware that postponing a scheduled thoracic aortic case may result in interim rupture and consequent litigation. With virulent thoracic aortic diseases, adverse outcome itself does not imply substandard care.

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          Most cited references19

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          The International Registry of Acute Aortic Dissection (IRAD)

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            Diagnosis and management of aortic dissection.

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              What is the appropriate size criterion for resection of thoracic aortic aneurysms?

              Although many articles have described techniques for resection of thoracic aortic aneurysms, limited information on the natural history of this disorder is available to aid in defining criteria for surgical intervention. Data on 230 patients with thoracic aortic aneurysms treated at Yale University School of Medicine from 1985 to 1996 were analyzed. This computerized database included 714 imaging studies (magnetic resonance imaging, computed tomography, echocardiography). Mean size of the thoracic aorta in these patients at initial presentation was 5.2 cm (range 3.5 to 10 cm). The mean growth rate was 0.12 cm/yr. Overall survivals at 1 and 5 years were 85% and 64%, respectively. Patients having aortic dissection had lower survival (83% 1 year; 46% 5 year) than the cohort without dissection (89% 1 year; 71% 5 year). One hundred thirty-six patients underwent surgery for their thoracic aortic aneurysms. For elective operations, the mortality was 9.0%; for emergency operations, 21.7%. Median size at time of rupture or dissection was 6.0 cm for ascending aneurysms and 7.2 cm for descending aneurysms. The incidence of dissection or rupture increased with aneurysm size. Multivariable regression analysis to isolate risk factors for acute dissection or rupture revealed that size larger than 6.0 cm increased the probability by 32.1 percentage points for ascending aneurysms (p = 0.005). For descending aneurysms, this probability increased by 43.0 percentage points at a size greater than 7.0 cm (p = 0.006). If the median size at the time of dissection or rupture were used as the intervention criterion, half of the patients would suffer a devastating complication before the operation. Accordingly, a criterion lower than the median is appropriate. We recommend 5.5 cm as an acceptable size for elective resection of ascending aortic aneurysms, because resection can be performed with relatively low mortality. For aneurysms of the descending aorta, in which perioperative complications are greater and the median size at the time of complications is larger, we recommend intervention at 6.5 cm.

                Author and article information

                S. Karger AG
                March 2008
                17 September 2007
                : 109
                : 4
                : 263-272
                Section of Cardiothoracic Surgery, Yale University School of Medicine, New Haven, Conn., USA
                107790 Cardiology 2008;109:263–272
                © 2007 S. Karger AG, Basel

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                : 28 December 2006
                : 06 January 2007
                Page count
                Figures: 4, Tables: 1, References: 32, Pages: 10
                Original Research

                General medicine,Neurology,Cardiovascular Medicine,Internal medicine,Nephrology


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