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332 Elefteriades
Diseases of the thoracic aorta are highly morbid conditions. Chronic
aneurysms frequently produce death within several years of diagnosis. Acutely
presenting aortic aneurysms and aortic dissections are often lethal within hours
or days of onset. These conditions leave little room for error in diagnosis. Once
diagnosed, thoracic aortic aneurysms require major surgery for correction.
Although thoracic aortic operations are becoming progressively safer, reflecting
improvements in hemostasis, graft materials, and surgical techniques, risks
remain substantial and complications, when they do occur, can be devastating.
Death, stroke, and paraplegia are the cardinal complications feared by thoracic
surgeons. These are complications that can either take patients’ lives or destroy
their quality of life.
It is not surprising, with these high stakes, that diseases of the thoracic
aorta are highly charged medico-legally and are frequently fodder for litigation.
Extensive attention has been placed in the past on litigation issues involving
traumatic aortic transection—among the most highly litigated situations in cardiot-
horacic surgery and medicine in general. Mattox has addressed legal issues in trau-
matic aortic transection dissection insightfully and eloquently (9,10). Nontraumatic
aneurysms and dissections, despite being much more common than traumatic
aortic transections, have not received the same kind of direct attention to litigation-
related issues. In fact, diseases of the thoracic aorta are responsible for more deaths
in the United States than AIDS. This chapter study focuses specifically on nontrau-
matic aortic diseases and litigation surrounding their care.
In this chapter, we examine patterns of litigation in a relatively large number
of legal cases revolving around diseases of the thoracic aorta. The author has pub-
lished extensively on the scientific basis, natural history, and optimal treatment
patterns of thoracic aortic aneurysm and dissection (11). For this reason, he is
often asked to review patient files where suspicion exists that clinical evaluation
and/or management fell below the standard of care. This chapter examines these
cases for patterns of adverse events and resulting litigation.
It is hoped that focusing on litigation in nontraumatic aortic diseases may
provide benefit in two forms. First, such examination may disclose pertinent, bona
fide medical shortcomings, whose correction may enhance patient care and safety.
Second, from concerted examination of legal case materials, suggestions for
means to prevent litigation may be feasible—based on corollaries that can be
drawn from the clinical patterns of the litigated cases. Thus, we hope that clinical
and legal benefit may ensue from this examination of litigated cases.
CASE MATERIALS
In the last several years, the author has reviewed 30 legal cases involving thoracic
aortic disease (Table 1). Among the 30 involved patients, there were 22 males and
eight females. Ages range from 19 to 74 (mean 48.7).
Eight cases involved nondissecting aneurysms (three ascending, two
descending, and three thoracoabdominal), 20 involved dissections [18 Type A
(Text continues on pg. 337)
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Legal Considerations in Acute Aortic Diseases 333
(Continued )
Table 1 Individual Nontraumatic Thoracic Aortic Cases Reviewed
Patient
no.
Age
(decile)/sex
Aneurysm or dissection
(plus location) Onset of symptoms Malpractice claim
Alive (A)
or dead (D)
Meritorious
(Yes/No)
1 50s/M Type A dissection Lifting heavy device on
job
Failure to exclude from hazardous
duty
DN
2 71/F Thoracoabdominal
aneurysm
Ruptured in OR holding
area, after case
cancellation
Delay in surgery D N
3 50s/M Type A dissection Doing arm push-ups Failure to diagnose (not until
postmortem)
DY
4 40s/F Type A dissection Developed abdominal
symptoms (nausea,
vomiting, pain,
anorexia)
Failure to diagnose on 2 ER visits
(not until post-mortem) (CXR
misread)
DY
5 50s/M Type A dissection Stress at work. Chest and
abdominal symptoms
Delay in diagnosis
(CT scan eventually demonstrated
dissection, but patient died upon
transfer to tertiary facility)
DN
6 60s/M Descending aneurysm
(9 cm)
Surgery performed Failure to prevent paraplegia A N
7 40s/M Type B dissection Subacute presentation
(thoracic back pain)
Delay in diagnosis D Y
8 50s/M Aortic rupture
(descending)
Iatrogenic perforation
during IABP placement
Surgical error. IABP placed during
cardiac arrest resuscitative
efforts
DN
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334 Elefteriades
Table 1 Individual Nontraumatic Thoracic Aortic Cases Reviewed (Continued )
Patient
no.
Age
(decile)/sex
Aneurysm or dissection
(plus location) Onset of symptoms Malpractice claim
Alive (A)
or dead (D)
Meritorious
(Yes/No)
9 60s/M Aortic rupture
(descending)
Weeks of chest and
back pain
Delay in diagnosis (missed on
CT scan)
DY
10 20s/M Type A dissection One week back pain,
abdominal pain, bloody
diarrhea
Failure to diagnose (not until
postmortem)
DY
11 Teens/M Type A dissection Chest pain after training Delay in diagnosis (died before
transfer to tertiary facility)
DY
12 30s/F Coarctation Presented with CHF Failure to prevent paraplegia A N
13 50s/M Type B dissection
(prior Type A repair)
Sudden onset chest pain Delay in surgery. Ruptured
awaiting catheterization
DN
14 50s/F Type A dissection Pain on watching TV Failure to diagnose
(CXR misread)
DY
15 50s/M Type A dissection Pain on job Failure to diagnose (arrested
during cardiac catheterization)
D Y
16 70s/M Type A Dissection Atypical chest pain Delay in surgery for symptomatic
aneurysm. 6.8 cm aorta
ruptured
DY
17 70s/M Thoracoabdominal
aneurysm
Abdominal pain Delay in surgery. Aneurysm
diagnosed. Repeated CT scans
looking for “signs of rupture.”
Patient’s 7 cm aneurysm
ruptured after being heparinized
for atrial fibrillation
DY
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Legal Considerations in Acute Aortic Diseases 335
18 70s/M Ascending aneurysm
(?iatrogenic
dissection)
Operated urgently—aortic
replacement
Improper postoperative care D Y
19 40s/M Type A Dissection
(s/p AVR X 2)
Abdominal symptoms
(nausea, vomiting).
Pancreatitis by enzymes
Failure to diagnose (not until
post-mortem)
DY
20 30s/F Type A Dissection Chest pain 6 days post-
partum. Bicuspid aortic
valve
Failure to diagnose (not until
post-mortem). Repeated r/o
pulmonary embolism. Unaware
of phenomenom of peri-
pregnancy dissection
DY
21 60s/M Thoracoabdominal
aneurysm
Gut ischemia after
difficult operation
(atheroembolism)
Improper conduct of operation D N
22 30s/M Type A Dissection Acute GI symptoms Failure to diagnose D Y
23 40s/M Type A Dissection Syncope, chest pain,
bradycardia
Failure to diagnose (not until
post-mortem)
DY
24 Teens/M Type A Dissection
(following prior
aortic root operation)
Chest pain upon exertion Inadequate pre-operative care.
Died on OR table
DN
25 20s/F Type A Dissection Chest pain two days after
delivery of child
Failure to diagnose (not until
postmortem). Rx’d for flu
DY
26 50s/M Type A Dissection Iatrogenic dissection
during coronary
angioplasty
Improper surgical conduct (ligated
innominate artery)
A
(Severe
CVA)
Y
(Continued )
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336 Elefteriades
Table 1 Individual Nontraumatic Thoracic Aortic Cases Reviewed (Continued )
Patient
no.
Age
(decile)/sex
Aneurysm or dissection
(plus location) Onset of symptoms Malpractice claim
Alive (A)
or dead (D)
Meritorious
(Yes/No)
27 70s/F Ascending aneurysm Postoperative AI, requir-
ing early re-operation.
Subsequent death
Improper surgical conduct
(causing early AI)
DY
28 30s/M Ascending aneurysm Months of feeling unwell,
with heartburn
Two month delay in cardiology
consultation to f/u on diastolic
murmur. Died of apparent
rupture between echo/cath and
surgical consultation.
DY
29 20s/M Type A Dissection Two weeks nausea,
vomiting, feeling ill. No
chest pain
Delay in diagnosis (repeated ER
visits, diagnosed as “asthma,
bronchitis”). Massive cardio-
megaly when CXR ultimately
done. Dissection of 10 cm aorta
and massive AI found. Died of
pulmonary edema
DY
30 40s/F Type A Dissection Sudden onset of abdomi-
nal
pain/nausea/vomiting
Failure to make diagnosis (until
post-mortem).
CT scan mis-read.
DY
Abbreviations: AVR, aortic valve replacement; CHF, congestive heart failure; CXR, chest X-ray; CT, computed tomography; ER, emergency room; IABP, intro-aortic
balloon pump; OR, operating room.
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Legal Considerations in Acute Aortic Diseases 337
(ascending) and two Type B (descending)], and two involved miscellaneous other
phenomena (one coarctation and one iatrogenic descending aortic rupture).
It is noteworthy that two cases involved peripartum aortic dissection in
young, childbearing women.
Of the 30 patients, 27 had died at the time the suit was filed, and of the remain-
ing three, two had paraplegia and one had a major cerebrovascular accident.
The allegations centered around the following issues:
1. Failure to make a diagnosis or delayed diagnosis in 17
a. eleven failure to make antemortem diagnosis and
b. six delay in diagnosis,
2. Delay in surgical therapy in four,
3. Error in surgical technique in four,
4. Failure to prevent paraplegia in two, and
5. Miscellaneous in three (failure to restrict activities, improper preopera-
tive care, improper postoperative care).
The physicians being sued were often multiple and included emergency
physicians, radiologists, cardiac surgeons, vascular surgeons, cardiologists, internists,
and obstetrician–gynecologists.
FINDINGS
The reviewing physicians felt that medical care delivered was suboptimal in 21
cases and satisfactory in nine. This designation was not based on legal definitions
of standard of care, but rather on whether or not retrospective case review revealed
substantive diagnostic or therapeutic instances where care could have been
improved.
In this review, it was found that litigation for nontraumatic thoracic aortic
diseases involved the following categories of alleged malpractice, in decreas-
ing order of frequency: failure-to-diagnose (or delay in diagnosis), delay in
surgical therapy, error in surgical technique, failure to prevent paraplegia, and
miscellaneous.
The seriousness of these cases is apparent in the sobering fact that, of the
30 patients, 27 were dead at the time of the lawsuits and the remaining three
were permanently impaired by paralysis or stroke. This statistic underscores the
highly lethal nature of thoracic aortic aneurysm and dissection. Mistakes, delays,
and failure to include aortic diseases in the differential diagnosis can easily result
in patient mortality or devastating debility.
Of all types of aortic disease resulting in lawsuits, Type A dissection
predominates by a wide margin, accounting for 60% of our reviewed cases.
Helpful corollaries can be drawn from the observation in this study of the
existence of several major patterns—both clinical and legal—for these aortic-
related lawsuits. These patterns will be examined individually, category by
category.
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338 Elefteriades
Failure to Diagnose (or Delay in Diagnosis)
Relative Infrequency of Aortic Dissection
Aortic dissection is relatively uncommon compared to other causes of chest pain,
especially myocardial infarction. It is not surprising that this less common etiology
of chest pain is not always paramount in the consciousness of emergency and
primary care physicians responsible for screening the enormous numbers of
patients who present with chest complaints. In fact, it has been estimated that, on
the front lines, a physician will, on average, see 80 patients with acute coronary
syndrome before encountering one with aortic dissection (12). In fact, over one
and one-half million patients are admitted to hospital per year in the United States
with chest pain. The emergency physician carries the burden of sifting out among
this massive group of patients those with the relatively uncommon phenomenon
of acute aortic dissection (13).
The “Great Masquerader”
Aortic dissection is known as “the great masquerader”—for good reason. Aortic
dissection commonly extends from the top of the chest to the bottom of the abdo-
men—thus, gaining the capability to produce pain in the chest, the back, the
flanks, the abdomen, and even the pelvis. Aortic dissection can also, by virtue of
a false lumen bulging into the main arterial channel, occlude virtually each and
every branch of the aorta—from the coronary arteries to the brain and arm vessels,
to the spinal arteries to the visceral arteries to the leg vessels (Fig. 1). In view of
its protean manifestations it is not surprising that aortic dissection has come to be
known as the great masquerader—not only capable of producing chest symptoms,
but also stroke, paralysis, abdominal pain, nausea and vomiting, and limb ischemia,
among other symptoms and signs.
The difficulty of diagnosis of aortic dissection has been well documented in
the scientific literature. Nearly 20% of affected patients present without typical
signs and symptoms (i.e., without chest pain, malperfusion phenomena, cerebral
disturbances, or signs of cardiac compromise) (14–16). Furthermore, clinical
studies have documented that the diagnosis of aortic dissection is frequently
missed on initial evaluation and not made until postmortem examination in
27% to 55% of patients (12,16–19). In fact, the diagnosis of aortic dissection is
often made incidentally on an imaging study done for another reason (17). Thus,
in a context where atypical presentation and failure to diagnose are common, the
concept of “malpractice” in failing to diagnose aortic dissection becomes intrinsi-
cally suspect—especially, if one considers the common definition of malpractice
based on what can be expected of a physician of average ability and training. The
evidence cited in this paragraph argues for a high degree of leniency in the physi-
cian’s favor in determining departure from the standards of care in thoracic aortic
diseases. In fact, difficulty in diagnosis, delayed diagnosis, or failure to diagnose
are so common as to approach the “norm” for this disease, even in the best hands,
rather than the exception.
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Legal Considerations in Acute Aortic Diseases 339
Some quotations from the literature are in order to bring home the inherent
difficulty in diagnosing aortic dissection. Spittel (17) indicates that “with such
diverse clinical manifestations, the diagnosis of aortic dissection can be challenging,
and misdiagnosis commonly occurs.” Aortic dissection can be mis-diagnosed as,
among other entities, myocardial infarction, pericarditis, congestive heart failure,
pulmonary embolism, pneumothorax, lymphoma, and cholecystitis. Fradet (19)
indicates that “acute aortic dissection remains a challenge for the physician.”
For all these reasons, it is not surprising that failure to reach a diagnosis of
aortic aneurysm or dissection (or delay in diagnosis) was by far the most frequent
reason for aortic-related litigation in this series.
We have the following discrete suggestions to make, which promise not only to
decrease the likelihood of lawsuits, but also to enhance patient care and save lives:
1. Include aneurysm and dissection in the differential diagnosis. Aortic ane-
urysm and dissection must have a prominent place in the consciousness
Figure 1 Aortic dissection can affect virtually any branch or any organ of the body, leading to
potentially protean manifestations, and justifying the reputation as “the great masquerader.”
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340 Elefteriades
of physicians on the front lines of chest pain evaluation— especially
emergency physicians and primary care doctors. The very process of
including these diseases in the differential diagnosis of chest or abdomi-
nal symptoms will suggest that studies be done to rule these diseases in
or out—the first step in preventing catastrophic oversight.
2. Perform simple pertinent blood tests, including a D-dimer. Creatine
phosphokinase isoenzyme and troponin levels are useful in ruling in or
out myocardial infarction. If these enzymes are negative, aortic disease
must rise in the differential diagnosis of acute chest pain (this is espe-
cially true if the electrocardiogram (EKG) fails to show suspicious ST
or T-wave changes of ischemia or infarction). The D-dimer is another
useful test. D-dimer is a degradation product of fibrin crosslinking in
clot. This test is sensitive for detecting on-going intravascular thrombo-
sis. Emergency physicians are familiar with ordering this test to rule out
pulmonary embolism. This test has a high sensitivity for that purpose.
Less well known is the fact that D-dimer is nearly invariably elevated in
acute aortic dissection. The sensitivity of this test is 99% (16). If the D-
dimer is negative, acute aortic dissection is essentially ruled out. This is
probably true because significant amounts of clot form quite quickly in
the false lumen of any dissection, liberating D-dimer. In fact, the degree
of elevation of D-dimer correlates with the longitudinal extent of the
dissection, suggesting that surface area for contact of the bloodstream
with the dissection plane determines D-dimer release. A large body of
knowledge has now accumulated supporting the application of D-dimer
in aortic dissection (20–23). In fact, bedside kits are now available (24).
A recent paper has shown an extremely high sensitivity and specificity
(90% and 97%, respectively) for aortic dissection of a test called smooth
muscle myosin heavy chain assay (25). However, this test is not widely
and immediately available in the clinical setting.
3. Image freely, including the “Triple Rule-Out.” In many of the cases we
studied, no imaging studies whatsoever were done, not even a chest
X-ray. Had imaging been done, the lawsuit would have been prevented
and, quite possibly, the patient’s life saved.
a. Chest X-ray. The chest X-ray can certainly provide useful clues—
such as prominence of the ascending aorta to the right of the upper
mediastinal contour, indistinctness of the aortic knob, and widening
or distortion of the descending aortic stripe. Also, pulmonary conges-
tion can be a helpful indicator of cardiac issues. We suggest this test
as a minimum in patients with chest, or even abdominal, symptoms.
b. Echocardiogram. The transthoracic echocardiogram is available on
an urgent basis in nearly all emergency rooms. This test is highly
sensitive for ascending dissection. It may show enlargement of the
ascending aorta, a dissection flap, or aortic insufficiency—all clues
to the existence of an aortic dissection.
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Legal Considerations in Acute Aortic Diseases 341
c. Computed tomography (CT) scan. In nearly all cases, had a CT scan
been done, the diagnosis would have been made and prompt, appro-
priate therapy begun. The CT scan is available in nearly all emer-
gency rooms on an immediate basis. For patients with unexplained
chest or abdominal symptoms, the CT scan can be remarkably
pertinent and helpful. We use the CT scan for a “Triple Rule-Out.”
The three conditions most threatening to the patient with unexplained
chest pain are aortic dissection, pulmonary embolism, and myocar-
dial infarction (Fig. 2). In the current era of 64-slice CT scanners,
all three diagnoses can effectively be ruled out within just a few
minutes by a chest CT scan (13). The CT scan is sensitive for detec-
tion of dissection, pulmonary embolism, and coronary artery calci-
fication. Absent any of these phenomena, the patient is unlikely to
be in acute jeopardy from his symptoms. Another advantage of the
Triple Rule-Out CT scan is that treatment with thrombolytic agents
for presumed myocardial infarction can be disastrous in a patient
who really has an aortic dissection (this occurred in one of the cases
in this series, contributing to a lethal outcome). Such inappropriate
thrombolysis can be prevented by the Triple Rule-Out CT scan.
4. Read the imaging studies correctly. In most of the cases with delay in
diagnosis, the chest X-ray, echocardiogram, and/or CT scan were read
incorrectly—because aortic dissection was not in the consciousness of
the reader (Fig. 3). It was not until another individual reviewed the
Figure 2 The “Triple Rule-Out” computed tomography scan that can be so useful in
diagnosing or ruling out the “big three” conditions that threaten the life of the chest pain
patient: coronary artery disease, pulmonary embolism, and aortic dissection. We strongly
recommend its use.
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