Commentary:
Despite a poor outcome for the plaintiff, the jury quickly returned from their deliberations, rendering a defense verdict in favor of the general surgeon.
The Case:
A 75 YOWM (6’1”, 219 lbs.) presented to the defendant general/vascular surgeon for evaluation of his abdominal aortic aneurysm (AAA). The patient had a history of stable coronary artery disease (CAD) and hyperlipidemia. Past surgical history included two coronary artery bypass grafts (CABG) and three inguinal hernia repairs. He had a urological history of urinary retention and he self-catheterized.
On examination, the patient reported no abdominal or back pain. No family history of AAA was noted by the defendant general surgeon. The AAA measured 4.4 cm and the patient was asymptomatic. The defendant general surgeon ordered a duplex scan and instructed the patient to return in six months or sooner if he developed symptoms. The patient returned in seven months and again seven months later. The AAA had increased in size to 4.8 cm.
Almost two years from the initial visit, the patient underwent a CT angiography of the abdomen and pelvis. A fusiform infrarenal AAA measured 7.3 x 5.7 cm in greatest AP and transverse diameter, and extended for approximately 8 cm. Atherosclerotic calcification of the aorta was noted with the distal aorta being tortuous.
The CT revealed a large exophytic cyst of the left kidney measuring 10.7 cm in diameter. No renal hydronephrosis or hydroureter were present. Diffuse intramural gas involving the bladder was highly suspicious for emphysematous cystitis. Pulmonary fibrosis and cholelithiasis were also noted. The radiologist discussed the findings with the defendant surgeon.
Three days later, urology evaluated the patient due to dark-colored urine. The urologist’s impression was urinary retention secondary to neurogenic bladder and a large left renal cyst. The urologist recommended the patient obtain a urine culture 10 days prior to any surgery; he also recommended the patient start antibiotics two to three days before surgery to treat asymptomatic bacteriuria.
The defendant surgeon reviewed the results of the CT with the patient the next day. The patient had no abdominal or back pain. The planned procedure was explained and the patient was informed he would require cardiac clearance. The procedure would be a coil embolization of the left internal iliac artery and would take place in six days. An endograft would be performed approximately one month later.
Placement of the endograph and coil embolization would be difficult, however, since the patient had a tortuous iliac bifurcation. The defendant surgeon planned to address the problems endovascularly since an open procedure was precluded because of the patient’s heart and lung issues. Because of the plaintiff’s kidney function, a two-step process was recommended to keep the dye load to a minimum. The patient and his wife agreed to the plan.
The day after meeting with the defendant surgeon, cardiology evaluated the patient to obtain clearance for the anticipated AAA repair. A recent echocardiogram showed an ejection fraction of 40% with an increase in pulmonary pressure compared to a prior echo. The patient was taking Lasix® 40mg once a day, but had stopped taking his digoxin a few days prior, as it made him short of breath. The cardiologist noted the patient was very non-compliant with his medication due to the side effects. The cardiologist noted the patient was a moderate cardiovascular risk for complications from the anticipated AAA endograft repair. He cleared the patient for surgery, which was scheduled to be performed in five days.
Two days after the cardiology visit, the patient complained of abdominal discomfort after dinner. His wife was finally able to convince him to go the ED. She drove him to the hospital and the pain increased significantly on the way to the ED. When he arrived at the hospital, the patient had severe back pain and was diaphoretic. The patient’s wife indicated he may have had a seizure in the car; she said he had been more alert but on the way to the ED that he was slow to respond. Intravenous access was obtained and a bedside ultrasound was completed. A CTA revealed abdominal aortic rupture. The patient was taken to the operating room where an on-call vascular surgeon performed an endovascular repair.
Following surgery, the patient was noted to have elevated troponins with evidence of a non-ST myocardial infarction. He also suffered from renal insufficiency, distal embolic disease of the lower extremities, neurological impairment, and pulmonary impairment. Six days later, care was withdrawn and the patient expired. The cause of death was listed as cardiac/respiratory arrest and ruptured AAA.
Plaintiff experts testified the standard of care required the general surgeon to immediately admit the patient to repair the AAA that had increased in size.
Defense experts testified there were no signs of impending rupture and that there is no predictability as to when an AAA will rupture. Arguments were made over the exact measurements of the AAA, and the superiority of measurements obtained from ultrasound versus CT. Experts asserted the defendant met the standard of care, since the patient was asymptomatic and awaiting clearance due to his co-morbidities.
In less than 45 minutes, the jury returned a defense verdict.
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