Delayed Diagnosis Of Abdominal Aortic Aneurysm Leads To Fatal Infection

This case involves a 66-year-old female patient with a past medical history of an abdominal aortic aneurysm following a stent graft placement and a recent diagnosis of gout who presented to the emergency department with acute back pain. The emergency medicine physician diagnosed the patient with spinal gout, prescribed her prednisone, and discharged the patient home. The patient returned to the emergency department with worsening back pain and fever. She was admitted with a diagnosis of sepsis of unknown cause. The patient then awaited further diagnosis for 9 days before being emergently taken to the operating room for evacuation of a retroperitoneal hematoma, removal of her infected stent graft, and repair of an abdominal aortic aneurysm that had enlarged and leaked secondary to infection from the stent graft. In spite of emergent treatment, the patient expired. It was alleged that this delay in diagnosis caused the patient’s fatal outcome. An expert vascular surgeon was sought to review the medical records for causation and damages.

Question(s) For Expert Witness

1. Please describe your experience in treating patients with abdominal aortic aneurysms.

2. In your experience, how does endoleak or re-rupture of stented aortic aneurysm complicate operative repair?

3. How does unrecognized rupture or endoleak of stented aortic aneurysm affect patient outcome following emergency surgery?

Expert Witness Response E-017049

I treat many patients with complex abdominal aortic aneurysms as part of my regular practice and have published multiple peer-reviewed articles on this subject. An unrecognized rupture and/or endoleaks of previously repaired abdominal aortic aneurysms can be potentially fatal. The vascular surgery scientific literature is clear that ruptured abdominal aortic aneurysm repair is associated with significantly increased morbidity and mortality as compared to unruptured repair. Furthermore, in my experience, open and endovascular repair of a ruptured abdominal aortic aneurysm is much more technically difficult and results in a higher risk of complications. Definitive treatment of infected aortic stent grafts and mycotic aneurysms involves operative resection of the infected aneurysm and reconstruction of the arterial system in order to perfuse the abdominal organs and lower extremities. Reconstruction may be either extra-anatomic (axillo-bifemoral bypass) or in-line (direct reconstruction with a cryopreserved cadaveric aortic graft).