Bleeding complications following femoral angiographic access
Discussion
Unfortunately, the above examples represent the all too often complication of postprocedure bleeding following femoral access.
In case 1, early exploration would more likely than not, and within a reasonable degree of medical certainty, prevented the patient’s death. The presumption is that the patient died from the untreated complication of postcatheterization hemorrhage. The defendant’s claim that the patient’s hemoglobin was never lower than 8 mg did not serve as an adequate defense. Even if the patient was found at autopsy to have an occluded stent which caused an acute MI, the plaintiff’s attorney would likely argue successfully that if the bleeding had been appropriately treated, the stent would have remained patent. The cardiologist was found culpable for not consulting a vascular surgeon.
In the second example, the plaintiff’s expert explained to the jury that without surgery, the patient would continue to bleed and certainly die. He went on to opine that the only possible chance of the patient surviving was with surgical intervention, and this chance was denied to the patient by the vascular surgeon who refused to operate. In these types of cases, the surgeon incorrectly believes that he/she can avoid liability and involvement in the case by not operating on the patient. However, as this case demonstrated, the surgeon is still likely to be named as a defendant in the law suit.
The third case illustrates two common pitfalls for the vascular surgeon and perhaps represents the most dangerous situation for the vascular surgeon. The first pitfall occurs when the vascular surgeon relies on telephone information without examining the patient. Secondly, as in this case, a formal consult was never initiated by the cardiologist. The surgeon incorrectly assumed that because no formal consult was placed she had no liability. However, according to the plaintiff’s expert, since she had been informed about the patient she should have come in to see the patient.
Had she done so, he alleged she would have realized that the patient required an intervention either with a covered stent or a surgical repair of the bleeding external iliac artery. Clearly, the fact that no formal consult was placed in the chart did not prevent the vascular surgeon from being a named defendant in this case.
Several steps should be taken if a physician is to minimize the risk of being named as a defendant in a lawsuit involving postangiographic intervention bleeding. First, if the physician is a not a surgeon, surgical consultation should be obtained as soon as postprocedure bleeding is suspected. Second, surgeons should pursue an aggressive approach to the treatment of this complication. Whereas it may be reasonable to treat a single episode of hypotension with fluid or blood transfusion, unless there are mitigating circumstances, any patient who develops a second episode of hypotension in the face of ongoing bleeding should undergo intervention. Furthermore, there must be clear documentation as to why a particular approach (endovascular versus open repair) was chosen. A medical physician’s inability to perform an open approach or a surgeon’s inability to perform an endovascular approach are not sustainable defenses.
