36C10X19Q0200-009.pdf

Patient: Provider: Case ID:

This document is confidential and privileged under the provisions of 38 U.S.C. § 5705, and its implementing regulations. This material cannot be disclosed to anyone without authorization as provided for by that law or its regulations. The statute provides for fines up to $20,000 for unauthorized disclosures.

Protected Peer Review Case

VISN #: Case ID:

Facility: Station #:

Patient Name: Patient SSN:

Facility Case ID: Type of Review:

Request

Practitioner to be reviewed: Credentials:

MD/DO

Service/Specialty: Setting:

Vascular Surgery

Period to be reviewed:

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Instructions to Reviewer (extracted from the spreadsheet or other documentation provided by VISN):

One document named provided to reviewer - Anesthesia Report

FACILITY CONCERN: male s/p open L carotid-subclavian bypass and TEVAR on . Shortly after arriving in the SICU post-operatively he was noted to have an expanding hematoma in the left neck; he complained of SOB and was intubated for airway protection.

He was taken to the OR emergently for evacuation of left neck hematoma on . On

, he was found to have an acute MI. Echocardiogram prior to discharge showed a drop in EF from 60-65% to 35%. Was choice of surgery, preoperative work-up, and performance of surgery timely and appropriate?

Patient: Provider: Case ID:

This document is confidential and privileged under the provisions of 38 U.S.C. § 5705, and its implementing regulations. This material cannot be disclosed to anyone without authorization as provided for by that law or its regulations. The statute provides for fines up to $20,000 for unauthorized disclosures.

Recognition and communication of critical clues to patient’s clinical condition.

Timely initiation of appropriate actions during periods of clinical deterioration.

Health record documentation.

Supervision of health profession trainees.

Please summarize your assessment of this case giving your rationale for the level of care selected above. Please include any comments that you think are relevant to your findings and include references or other resources that were used in making your final determination.

The CD provided by the VA facility with relevant images were reviewed.

The pre-operative work-up was within standard. The indications for surgery in this patient were questionable, although not outside the standard. Factors that would mitigate against surgery include the patient’s age, pre-operative "moderate to high" cardiac risk and need for

SCA coverage in the presence of a LIMA graft. This was therefore an anatomic and physiologic high risk situation and treatment of an asymptomatic PAU in an elderly high risk patient was not a treatment many surgeons would choose. That being said, the choice was not a violation of the standard provided the risks of the surgery were clearly spelled out to the patient. While there are data to indicate complication rates are increased when concurrent bypass and EVAR is performed versus staging procedures, the decision to combine the procedures was within the standard.

There were two technical errors in this case. The most obvious was failure to achieve hemostasis at the operative site requiring re-exploration. This was a technical error. Less obvious but more consequential was the compromise of the LIMA graft by the Amplatzer plug. This was evident on the final runs and led to a STEMI with reduction of EF from 60-

35%. Amplatzer plugs have some advantages, however one cannot completely predict the length to which they will deploy. More controlled occlusion could be achieved by either use of multiple small coils stacked on each other and restricted to the proximal SCA or surgical ligation of the SCA proximal to the LIMA after bypass. There was no evidence from the images that the surgeon sought to identify the LIMA by retrograde selective catheterization so that he could accurately deploy an occlusion device. This was the cause of the major morbidity in this case.

Most experienced and competent clinicians might have managed the case differently but remains within the standard of care.

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Specialty: Date Completed: