Allegation:
The patient alleged that the failure of the defendant vascular surgeon to properly perform a repair of an abdominal aortic aneurysm resulted in his right buttock pain.
The Case:
The patient, a 75 YOM (5’10”, 251 lbs.), with a history of painful knee joints when walking, tilted disc in lumbar area, coughing, exertional chest discomfort, diabetes, and sleep apnea presented to a cardiologist with complaints of atrial flutter. The patient underwent a CT angiogram of the abdomen and pelvis. Imaging showed an infrarenal abdominal aortic aneurysm (AAA), which appeared eccentric right, measuring 4.6 x 4.3 x 6.3 cm in transverse, AP, and craniocaudal dimensions, respectively. The patient wanted the aneurysm treated before the atrial flutter and was referred to a vascular surgeon.
Upon reviewing the angiogram, the defendant vascular surgeon advised the patient and the referring cardiologist that the patient had a 5 cm saccular aortic aneurysm. The patient had no claudication and good radial and carotid pulses without carotid bruits. He also had good femoral and pedal pulses. The plan was to proceed with aortic endograting. The patient signed a consent form for the procedure that indicated: “complications may occur which include but are not limited to: infection, pain, allergic reactions, disfiguring scar, severe loss of blood or loss of function of any limb or organ, paralysis and/or nerve injury, brain damage, cardiac or respiratory arrest, or death.”
The patient presented to the hospital the following week for endograft AAA repair; the procedure was successful. In his operative report, the defendant vascular surgeon noted, in part: “I was fooled as were others at the table, by the location of the internal iliac takeoff, which appeared to come down lower, but it actually was higher. The right internal iliac was covered. I did not think it was worth the effort to try and reopen it given the situation. The left internal was satisfactory fortunately, as were all of the renals. Final films showed no endoleak. Sheaths, wires and catheters were pulled. There were good Dopplers in both feet and he was taken to recovery room in satisfactory condition.” The patient was discharged one week after surgery and instructed to follow up with the defendant vascular surgeon in three to four weeks.
One month after the aneurysm repair, the patient was admitted to the hospital for treatment of hematuria and difficulty emptying his bladder. His history noted complaints of right buttock pain with walking. He was discharged 10 days later.
Three months after the aneurysm repair, the defendant vascular surgeon performed a cardiac ablation to treat atrial flutter. During a follow-up exam, a certified physician assistant (PA-C) from the surgeon’s office noted patient complaints of numbness in the right lower extremity with prolonged walking. Pedal pulses were 2+ on the left, and 1+ on the right. A duplex scan of the lower extremity arteries/bypass grafts with ankle brachial indexes was ordered, and the patient was instructed to follow up in six months. The duplex scan showed normal resting perfusion in both lower extremities; patient aortic endograft with aneurysm sac of 4.7 cm in max diameter; and no significant findings on aortoiliac duplex, right leg duplex, or ankle brachial index.
The patient presented to his PCP 11 weeks after the cardiac ablation with complaints of claudication-like symptoms at 30 feet of ambulation. The PCP told the patient to have another evaluation performed by the defendant vascular surgeon. Three weeks later, a PA-C at the surgeon’s office evaluated the patient.
During the evaluation, the PA-C told the patient that the defendant vascular surgeon endografted the AAA during the aneurysm repair; in doing so, the surgeon had performed a right limb extension 10 cm x 18mm, which covered the right internal iliac. The PA-C explained that this was the cause of his right buttock claudication symptoms, and offered management with medication; the patient declined. The patient also complained of right buttock pain with sitting which the PA-C noted would not be vasculogenic in nature. The PA-C ordered a lumbar spine x-ray that revealed the patient’s right lower extremity duplex was patent with adequate perfusion.
Two weeks after the appointment, the patient returned to his PCP with complaints of claudication-like symptoms in his right buttock. He received a referral for a second opinion. The second vascular surgeon advised the patient that CT scans showed the right limb of the endograft covered the origin of the right internal iliac artery. The artery remained patent but had no antegrade flow. The surgeon explained that this may be the cause of his problems and offered revascularization; the patient ultimately chose not to undergo the procedure.
Verdict:
At trial, the patient was unable to prove that the AAA repair was the cause of his right buttock pain. A no-cause verdict was entered in favor of the insured vascular surgeon.
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