California – Vascular Surgery – “Severe Stenosis” Reported For 26-54% Occlusion Of The Right Internal Carotid Artery

A 74-year-old female patient was reported by a vascular surgeon in a preoperative history and physical as suffering from “some near syncopal events.”  On one of these occasions, 12/2/2009, she fell and struck her head. She underwent a CAT scan that showed a left frontal hematoma. On 12/8/2009, a CDUS was performed and the radiologist reported 26-54% stenosis in the right internal carotid artery and 65-66% stenosis in the right carotid bulb.  The velocity was within normal range. No stenosis percentage was reported for the left internal carotid artery. As regards to the left carotid bulb, the radiologist reported “mild plaque formation.”

On 1/8/2010, the vascular surgeon performed a right CEA on the patient.  In his preoperative history and physical of the same date, he reported that the patient’s 12/8/2009 CDUS “showed mild left internal carotid artery stenosis but rather severe right internal carotid artery stenosis of about 80%.”  In his operative report, the vascular surgeon reported that the CDUS “demonstrated severe stenosis in the right internal carotid artery. However, irregular plaque may be as tight as 80%.”

The vascular surgeon committed gross negligence in his care of the patient in the following respects: the vascular surgeon’s performance of a right CEA on the patient was not indicated given that the patient was asymptomatic and had normal carotid artery velocities.  Based on the CDUS report, the patient had minimal stenosis of 26-54% of the right internal carotid artery. The vascular surgeon’s reporting in the medical records that the 12/8/2009 CDUS showed that the patient had “severe stenosis” and “about 80%” stenosis of the right carotid artery was false, misleading, an inaccurate medical record, and false representation.

For this allegation as well as others, the Medical Board of California ordered that the vascular surgeon’s license be revoked and be placed on probation for five years. During this time, he was to attend a PACE program, a medical record keeping course, a CME education course, be assigned a practice monitor, and was prohibited from engaging in the solo practice of medicine as well as supervising physician assistants.

State: California

Date: December 2016

Specialty: Vascular Surgery

Symptom: Syncope

Diagnosis: Cardiovascular Disease

Medical Error: Unnecessary or excessive treatment or surgery, Lack of proper documentation

Significant Outcome: N/A

Case Rating: 2

Link to Original Case File: Download PDF

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