Found 23 Results Sorted by Case Date
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California – Interventional Radiology – Pain And Cold Foot After Arteriogram, Angioplasty, And Atherectomy



On 6/26/2015, a patient presented to an interventional radiologist’s outpatient clinic for a left lower extremity arteriogram and intervention for a thrombosed left lower extremity bypass graft, originally placed in 2007.  The patient had an extensive medical history including a renal transplant, diabetes, right leg amputation, and multiple revascularization procedures, including prior thrombectomies of the left lower extremity graft.

The patient reportedly had pain both at rest and with activity, and had a cold left leg prior to and immediately before the procedure.  In order to improve blood flow in the patient’s left leg, the interventional radiologist performed an arteriogram, angioplasty, tPA administration, atherectomy, and stent placement within the left lower extremity, including an attempt to revascularize the native superficial femoral artery.

Images show an initially thrombosed femoral artery to popliteal bypass graft and deep femoral artery.  Further images show balloons inflated in various parts of the graft and native arteries.  Final images show flow through a patent common femoral artery (CFA), bypass graft, and peroneal and anterior tibial arteries.  The deep femoral artery appeared occluded shortly beyond its origin.

After the procedure, a nurse noted the patient’s foot was cold.  The interventional radiologist also assessed the patient post-procedure and found the foot to be cold, both two (2) and four (4) hours post-procedure.  The interventional radiologist recommended to the patient that she travel to the emergency department of a university hospital.

The patient was then driven by her companion two hours to the emergency department, where she was assessed by an ED physician and a vascular surgeon.  She was taken to the operating room where she underwent surgery, which included a left leg above-the-knee amputation and a deep femoral artery thrombectomy.

The Board stated that the standard of care for an interventional radiologist when performing an intervention is to recognize complications and to take appropriate steps to manage them.  Although the patient’s foot was reportedly cold and painful immediately post-procedure, it can take some time for the foot to warm, and pain could be caused by reperfusion.  However, it is clear that two to four hours after the procedure, the interventional radiologist recognized that the patient’s leg had not improved and was worsening and that further care was needed.  Thus, when it became clear to the interventional radiologist that the foot was not improving, he recommended that the patient seek more treatment.

The records of the interventional radiologist’s care of the patient were inadequate in that they do not state whether the patient’s clinical status post-procedure was worse than before the procedure.  A post-procedure pulse examination was lacking which would have helped in determining the patient’s clinical status.

The patient reported to the ED physician that the pain began after the procedure and steadily worsened, which indicates that the patient rethrombosed her bypass graft and deep femoral artery (source of collateral flow) immediately.  This event should have been recognized by the interventional radiologist.

However, the interventional radiologist’s documentation for this patient was inadequate and sparse.  The medical records lacked documentation of the change in the patient’s status post-procedure, the discussion with the patient leading up to the discharge from his center, and the patient’s disposition.  The interventional radiologist discharged the patient to her own care directly from his clinic instead of calling Emergency Medical Services (EMS), which indicates that the interventional radiologist failed to recognize the gravity of what was occurring.

His conduct did not ensure that the patient would be attended continuously until definitive treatment was given.  The patient arrived at the emergency department at approximately 8:00 p.m., two hours after the patient was discharged from the interventional radiologist’s clinic.

Had the process of discharge and transfer occurred earlier, it is possible that the outcome could have been different.  The interventional radiologist failed to communicate with the ED physician ahead of the patient’s arrival.  The interventional radiologist gave the patient a CD of the procedure, a copy of the medical records, and his phone number, as an attempt of communicating with the emergency department personnel regarding the events that occurred at the interventional radiologist’s clinic.

However, the interventional radiologist failed to telephone the ED physicians at the emergency department to give a verbal report on the patient and to provide a more informative transition and preparation for continued care.  In expecting the practitioners at the emergency department to call the interventional radiologist to gain more information, the interventional radiologist improperly sought to shift his responsibility to provide needed information about the patient to the staff at the emergency department.

The interventional radiologist failed to maintain documentation regarding the change in the patient’s status post-procedure, the discussion leading up to the discharge from his center, and the patient’s disposition.  He stated that he was not sure if he documented these events, and if he did, he sent them with the patient.  Documentation sent with the patient has since been lost.  Documentation of a change in the patient’s clinical status was lacking.  The medical records lacked documentation of what was discussed regarding the patient’s disposition and where she was told to go for further care.

The Board judged the interventional radiologist’s conduct to have fallen below the standard of care for the following reasons:

1) The interventional radiologist failed to offer to transport the patient by ambulance or EMS services to ensure that she would be attended continuously until definitive treatment was given. His failure to do so indicates that he failed to understand the gravity of the situation which was occurring.

2) The interventional radiologist failed to adequately communicate with the emergency department, to call ahead of time to inform them that the patient was in transit, and to inform them of the circumstances.

3) The interventional radiologist failed to maintain adequate and accurate records.

The Board issued a public reprimand.

State: California


Date: December 2017


Specialty: Interventional Radiology, Vascular Surgery


Symptom: Extremity Pain


Diagnosis: Acute Ischemic Limb, Post-operative/Operative Complication


Medical Error: Diagnostic error, Delay in proper treatment, Underestimation of likelihood or severity, Failure of communication with other providers, Lack of proper documentation


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Vascular Surgery – Arteriogram Performed On A Patient’s Right Leg Instead Of The Left Leg



On 8/15/2016, a patient presented to a vascular surgeon with peripheral vascular disease, a non-healing ulcer on his left third toe tip, and diminished arterial blood flow in both legs.

Based on his initial evaluation, the vascular surgeon determined that a left leg arteriogram was necessary.

On 8/18/2016, the patient’s family consented to a left leg arteriogram and the vascular surgeon pre-operatively marked the patient’s left and correctly performed a timeout.

After the vascular surgeon performed the timeout, he performed a right leg arteriogram instead of the planned left leg arteriogram.

The Board judged the vascular surgeon’s conduct to be below the minimal standard of competence given that he performed a wrong-site procedure by performing an arteriogram on the patient’s right leg (wrong site) instead of the patient’s left leg (correct site).

It was requested that the Board order one or more of the following penalties for the vascular surgeon: permanent revocation or suspension of his license, restriction of practice, imposition of an administrative fine, issuance of a reprimand, probation, corrective action, payment of fees, remedial education, and/or any other relief that the Board deemed appropriate.

State: Florida


Date: October 2017


Specialty: Vascular Surgery


Symptom: N/A


Diagnosis: Cardiovascular Disease


Medical Error: Wrong site procedure


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



North Carolina – Vascular Surgery – Abdominal Aortic Aneurysm 8.3 cm In Size With Large Type I Endoleak



On 3/31/12, a 76-year-old male with a history of heart disease, chronic obstructive pulmonary disease (COPD), prior endovascular repair of a large abdominal aortic aneurysm (AAA) in 2010 at an outside hospital (OSH) presented to the VA Medical Center emergency department with complaints of back, flank, and hip pain.

On 4/1/12 in the early morning, the patient had a CT scan with contrast which revealed an 8.3 cm AAA with large Type I endoleak.  There was retroperitoneal stranding consistent with an aneurysm rupture.  At 7:45 a.m., these findings were communicated to the emergency department physician.

At 8:00 a.m., the patient was evaluated by a vascular surgeon.  Based on the vascular surgeon’s interpretation of the CT films and the patient’s clinical presentation, the vascular surgeon recommended admission for observation with a follow-up consultation with orthopedic surgery and interventional radiology.

The patient was admitted to the medical ward for the next three days during which he continued to have severe ongoing pain that was managed with pain medications.

On 4/4/12, the patient had a precipitous decline in his clinical status with severe hemodynamic compromise.  A repeat CT scan demonstrated a ruptured AAA with aortocaval fistula.  The patient was taken to the operation room where the vascular surgeon performed an open repair of the aortocaval fistula and ruptured AAA.  However, the patient suffered extensive operative blood loss, perioperative myocardial infarction, and neurological injury.

The patient survived the procedure but remained critically ill.  Over the next several days, the patient improved to a certain degree, but it was felt that the patient had suffered brain injury with little chance for meaningful recovery.

On 4/9/12, supportive measures were withdrawn, and the patient died.

In January 2017, the Board received information regarding a medical malpractice lawsuit settlement payment related to the care provided by the vascular surgeon to the patient.

The Board obtained the patient’s records and sent them to a qualified independent medical expert for review.  The independent medical expert judged the vascular surgeon’s conduct to be below the minimum standard of competence given failure to adequately diagnose and aggressively treat the patient’s symptomatic, ruptured AAA despite evidence of the patient’s life-threatening condition.

The vascular surgeon was reprimanded.

The Board reported the Consent Order to the Federation of State Medical Boards.and the National Practitioner Data Bank.

State: North Carolina


Date: July 2017


Specialty: Vascular Surgery, Emergency Medicine


Symptom: Back Pain, Pelvic/Groin Pain


Diagnosis: Aneurysm, Post-operative/Operative Complication


Medical Error: Delay in proper treatment


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



California – Vascular Surgery – CEA Performed On A 91-Year-Old Patient With Intermittent Syncopal Episodes



On 10/7/2010, a vascular surgeon saw a 91-year-old male patient for an evaluation of left internal carotid artery stenosis.  He lived independently and was quite physically active. An echocardiogram was taken in 2007 that confirmed the patient had atrial fibrillation.  He complained of intermittent syncopal episodes for 1-2 years. A CDUS taken 7/2/2010 revealed 10% narrowing of the proximal right internal carotid artery and 60% of the left.

The vascular surgeon wrote to one of the patient’s physicians that the CDUS showed “an irregular 60-69% stenosis.”  He also wrote “[Patient] is neurologically intact. He does describe though syncopal episodes whenever he lifts his left arm over his head.  He has a strong radial pulse and no blood pressure discrepancy between the left and right arm and I cannot elicit any vertebral steal syndrome, but he states that this has happened 6 or 7 times this year and with the known carotid artery stenosis, I am recommending that he undergo a carotid endarterectomy.”

The patient chose to have a CEA.  In his preoperative history and physical, the vascular surgeon reported that the July CDUS showed “50-69% left internal carotid artery stenosis.  With this being a borderline stenosis, he was followed but since the symptoms are so dramatic and so consistent he was then referred for vascular surgical evaluation and recommended for admission and surgery at the time.”

The vascular surgeon performed left CEA on 10/29/2010.  He noted the same preoperative and post-operative diagnoses: “Symptomatic left internal carotid artery stenosis.”  The procedure went well, and the patient was discharged on 10/31/2010.

The vascular surgeon’s care of the patient constituted gross negligence and the failure to maintain adequate records in the following aspects: he inaccurately and inconsistently reported the patient’s carotid duplex results, which constituted inadequate and inaccurate medical records; his performance of a carotid endarterectomy on the patient was not indicated given that he was 91 years old, had medical comorbidities, had moderate carotid artery stenosis, and was asymptomatic; and the vascular surgeon’s attribution of the patient’s syncopal events to carotid artery stenosis without obtaining a full workup or evaluation of his syncopal events was below the standard of care.

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: Cardiac Arrhythmia


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


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



California – Vascular Surgery – Second CEA Finds Neointimal Hyperplasia And Results In Complications



An 80-year-old male patient first presented to a vascular surgeon on 3/4/2010 for a consultation.  He had a previous history of stroke and left CEA eight years prior. The patient did not report any transient ischemic attacks, syncope, or new weaknesses.  The patient had residual weakness in his right arm, but otherwise functioned well.

A CDUS on 2/11/2010 revealed 50% to 69% stenosis of the right internal carotid artery and 80% to 90% restenosis of the left internal carotid artery, with peak velocities over 600 cm/sec.  The vascular surgeon noted that he discussed the option of carotid stenting with the patient, but that the patient wanted to have a second CEA. The vascular surgeon did not obtain any additional imaging studies.

On 3/19/2010, the vascular surgeon performed a “re-do” left CEA on the patient.  He noted that it was a long and difficult operation. Instead of plaque, which can be removed, the vascular surgeon found neointimal hyperplasia, which cannot.  A classic CEA was therefore not performed; instead, the vascular surgeon widened the artery using a patch angioplasty.

There was no indication in the patient’s medical record that an assistant was present for surgery.  The vascular surgeon did not obtain a complete study following the procedure. At 10:30 p.m., the vascular surgeon made the first post-operative note containing status information, such as that the procedure was a left CEA re-do, with a Dacron patch repair with no complications.  He also noted that the patient’s right arm was slightly weaker than his left from an old stroke, and that “this is his baseline.” At 11:30 p.m., approximately one hour after the surgery, the vascular surgeon noted that the patient was slow to wake in the recovery room; had occasional left arm and leg movement, but the right side was quiet; that he was not yet responding to verbal commands; and that he had an interrupted breathing pattern.  These observations were consistent with a stroke. The vascular surgeon testified that he consulted with a neurologist and intensivist (the physician assigned to the intensive care unit, or ICU) in the early morning hours, and it was decided that the patient would remain in the ICU and receive intravenous heparin (a blood thinner) with the hope of dissolving the clot that was blocking the flow to the brain and preventing further clot formation.  The vascular surgeon, however, did not document a treatment plan and made no further chart notes until the following day.

Another physician ordered a CT imaging study at 4:35 a.m., the next morning, which showed an occluded left carotid artery.  A CDUS taken 3/20/2010 showed complete occlusion of the left common and internal carotid arteries. A CT scan of the patient’s head on 3/21/2010 showed a massive stroke.  The patient died on 3/23/2010. The vascular surgeon’s operative report stated that it was dictated on 4/7/2010.

The vascular surgeon committed gross negligence and the failure to maintain adequate and accurate records in the following respects: he did not obtain appropriate imaging studies, such as a CT angiogram, prior to performing the CEA; he did not provide proper counseling to the patient prior to surgery; intraoperatively, the vascular surgeon failed to obtain and document a completion imaging study in the operating room at the conclusion of the operation; postoperatively, when it was observed that the patient had neurologic deficits, the vascular surgeon failed to properly evaluate, diagnose, or exclude a technical problem, and the standard of care is to manage the problem immediately, with either urgent carotid duplex study or re-exploration of the carotid; and his failure to dictate his operative report in a timely manner, his failure to document the presence of an assistant during the procedure, his failure to document a completion study, and his failure to document a treatment plan when neurological deficits were observed constituted unprofessional conduct.

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: Weakness/Fatigue


Diagnosis: Ischemic Stroke, Post-operative/Operative Complication


Medical Error: Failure to order appropriate diagnostic test, Failure to examine or evaluate patient properly, Failure of communication with patient or patient relations, Delay in proper treatment, Lack of proper documentation, Procedural error


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



California – Vascular Surgery – Patient Undergoes Left CEA And Then Right CEA Resulting In Complications



A 66-year-old woman saw a vascular surgeon for a consultation in 2010.  She had a prior history of stroke. On 8/13/2010, the vascular surgeon performed a left CEA.  On 10/5/2010, he performed an abdominal aortic and bilateral iliac balloon angioplasty. The patient was a continuing patient of the vascular surgeon, and he asserted that he knew her well.

On 12/16/2010, the patient saw the vascular surgeon for a follow-up examination, and a CDUS taken on 12/10/2010 was discussed.  The report showed 70-80% stenosis in the patient’s right internal carotid artery. The vascular surgeon wrote to the patient’s physician that the report showed “progressive stenosis of the right side, now approaching 80%.”  She was asymptomatic. He recommended a right CEA, and the patient agreed.

The vascular surgeon performed a right CEA on 1/31/2011-2/1/2011.  In one operative report, in the Indication section, the vascular surgeon wrote that the patient had multiple cardiovascular problems, including bilateral carotid disease.  She had a previous stroke that involved weakness of her left arm and leg. Symptoms mostly had resolved over the years. She more recently had a left carotid endarterectomy for severe internal carotid artery stenosis and now was brought in for elective right carotid endarterectomy for a greater than 80% right internal carotid artery stenosis.  The procedure went well, but postoperatively, the patient evidenced a neurological deficit. A CDUS was obtained that showed compromised flow. The vascular surgeon undertook a re-exploration that was very difficult. He found the patient’s artery to be “friable;” it was very fragile, thin, and falling apart. He used a saphenous vein from her left ankle to replace a segment of the artery and inserted a self-expanding stent.

The vascular surgeon did not obtain a completion study after the procedure.  In another operative report in the Indications section, the vascular surgeon wrote that the patient experienced a good post-operative result from the left CEA and that “She also now has a progressing, now about 80%, right carotid stenosis.”  On 2/2/2011, the patient died following a stroke. In a death summary, the vascular surgeon wrote that the patient had “progressive stenosis now of the right side….”

The vascular surgeon’s care of the patient constituted gross negligence, and the failure to maintain adequate and accurate records in the following respects: he inaccurately and inconsistently reported the patient’s carotid duplex results, including the degree of stenosis; he inaccurately reported that the patient’s carotid duplex showed progressive stenosis of the right carotid artery; and postoperatively, the vascular surgeon failed to obtain a completion imaging study in the operating room at the conclusion of the second operation, which is an extreme departure from the standard of care.

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: Weakness/Fatigue


Diagnosis: Ischemic Stroke, Post-operative/Operative Complication


Medical Error: Procedural error, Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Lack of proper documentation


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



California – Vascular Surgery – CEA Performed Due To Conflicting CDUS And MRA Results Interpretation



A vascular surgeon first saw a 71-year-old female patient on 8/18/2010.  She reported having two episodes of slurred speech within a 3-week period.  Each episode lasted between 10-30 minutes. Slurred speech is a symptom of carotid artery disease.

There were two reports of imaging studies in the record.  A CDUS was taken 8/10/2010, and the radiologist reported “significant calcified atherosclerotic plaque with moderate to moderately severe stenosis of the proximal left internal and proximal left external carotid arteries.  Might consider obtaining a CTA of the carotid arteries for further evaluation.” An MRA of the carotid arteries and an MRA of the head without contrast were taken on 8/13/2010. The same radiologist reported as her relevant impression, “40-50% narrowing of the left carotid bulb with mild narrowing of the proximal left internal carotid artery.”

In a consult letter dated 8/18/2010, the vascular surgeon wrote to the referring physician that the MRA showed “about a 60% left internal carotid artery stenosis and very irregular plaque.”  He recommended proceeding with a left CEA. In a history and physical authored by the vascular surgeon dated 8/20/2010, he reported that “the MRA was done on 8/13/2010, and this demonstrated…a moderate left internal carotid artery stenosis with lots of irregularities of this plaque.  The left internal carotid artery is about….” The vascular surgeon performed a left CEA on 8/24/2010. In his operative report, he wrote that testing had showed “stenosis of 60%-70% left internal carotid artery.”

The vascular surgeon’s care for the patient constituted gross negligence in the following respects: the vascular surgeon’s performance of CEA on the patient was not indicated given the CDUS and MRA findings, which the vascular surgeon incorrectly reported as “about 60%” stenosis.  There was no basis from the inconclusive CDUS and MRA for a conclusion of 60%. The patient should have been managed medically, and that the performance of the CEA was an extreme departure from the standard of care. The vascular surgeon’s documentation of stenosis of “about 60%” without explanation for the basis for his disregard of the radiologist’s MRA findings constituted unprofessional conduct as well as a failure to maintain adequate and accurate records and false representations in the medical records.

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: N/A


Diagnosis: Cardiovascular Disease


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


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



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



California – Orthopedic Surgery – Significant Knee Pain After Meniscectomies



A 71-year-old woman with a history of diabetes, hypertension, and chronic back pain who had a prior history of left knee surgery as well as a rotator cuff report developed some right knee pain in January 2011 and was seen by an orthopedic surgeon in July 2011 because of persistent right knee pain.

The orthopedic surgeon saw her and noted that she had some degenerative changes in both knees and that she had knee pain on the right side that had been present without an injury.  He noted that her clinical exam actually showed the same tenderness in both the knee where she had the symptoms and the one where she did not.  A magnetic resonance imaging scan suggested some possible tears in the posterior horns of both menisci.  His initial choice was to do an arthroscopic procedure.

The surgery was scheduled and performed on 12/8/2011.  The orthopedic surgery performed total bilateral medial and lateral meniscectomies, even though the consent form only allowed him to operate on the bilateral medial meniscus.  The orthopedic surgeon’s documentation failed to justify the procedures and the consent form was inadequate.  Postoperatively, the patient developed significant pain in the knee and was seen back at the surgery center for a dressing change and the following day because of persistent pain.  There was documentation of multiple efforts to reach the orthopedic surgeon that were unsuccessful.  The patient eventually contacted the orthopedic surgeon and he told her to go to the emergency department.

The records at the emergency department show that on 12/10/2011, the ED physician noted a significant vascular problem in the right leg.  The ED physician spoke to the orthopedic surgeon.  The patient was then seen by a vascular surgeon who explored her popliteal area and discovered that she had a transection of the tibioperoneal trunk off the popliteal artery which also had an aneurysm.  The orthopedic surgeon never followed up once he knew there was a complication to assist in the management with his knowledge of the initial surgery.

The Board judged the orthopedic surgeon’s conduct as having fallen below the minimum level of competence given that the orthopedic surgeon performed total meniscectomies on the patient for what appeared to be isolated meniscal tears and once the orthopedic surgeon learned of the surgical complication, he failed to see the patient or discuss the case with a vascular surgeon.

The Board ordered the orthopedic surgeon to be placed on probation for four years with stipulations to complete 40 hours annually in any areas of deficient practice, to complete a medical record keeping course, to enroll in a clinical training program equivalent to the Physician Assessment and Clinical Education Program, and to undergo clinical monitoring.

State: California


Date: October 2016


Specialty: Orthopedic Surgery, Emergency Medicine, Vascular Surgery


Symptom: Extremity Pain


Diagnosis: Post-operative/Operative Complication, Cardiovascular Disease


Medical Error: Procedural error, Failure of communication with other providers, Failure of communication with patient or patient relations, Failure to follow up


Significant Outcome: Hospital Bounce Back


Case Rating: 3


Link to Original Case File: Download PDF



California – Vascular Surgery – Surgery For Ischemic Limb With Post-Operative Complications



On 1/27/2009, a 74-year-old female was brought to the emergency department by ambulance.  She was diagnosed with exacerbation of congestive heart failure and admitted to the intensive care unit (ICU) for further care.

Her past medical history was significant for severe coronary, peripheral, cerebrovascular, pulmonary, and renovascular occlusive disease.  The patient also had a history of previous myocardial infarction, hypertension, hyperlipidemia, and chronic obstructive pulmonary disease with more than twenty years of tobacco abuse.  The patient’s past surgical history was significant for heart bypass with porcine aortic valve replacement, carotid endarterectomy, left femoral endarterectomy, renal and iliac stent placements.  In the emergency department, it was noted that the patient had new onset of atrial fibrillation.

On 1/27/2009, the patient complained of left arm pain.

On 1/28/2009, doppler and CT angiogram were performed.

On 1/28/2009, a vascular surgeon saw the patient to evaluate the patient’s left arm acute arterial occlusion.  “Thrombectomy +/- angioplasty” was recommended after cardiac clearance.

At 8:25 a.m. on 1/30/2009, surgery was performed.  Percutaneous thrombectomy with atherectomy, angioplasty, and stent placement were done in multiple arteries of the left upper extremity.  An Angio-seal closure device was used in the right femoral access site.  A 6 mm x 10 cm Viabahn stentgraft was placed into the brachial artery and a 7 mm x 29 mm Cordis Genesis stent was placed into the subclavian artery.  Clinically, the patient’s left hand was significantly worse after surgery and needed reexploration.

On 1/31/2009, the vascular surgeon recommended anticoagulation with heparin on and possible fasciotomy.  Fasciotomy of the left forearm was subsequently performed with no improvement.  The patient’s left forearm experienced clinical deterioration over the next few days.

On 2/2/2009, the patient was transferred to a different hospital by request of her family.  The patient was unstable and required a blood transfusion on arrival.  The patient’s left arm was non-viable, and no blood flow to the left forearm or hand was documented on angiography.

On 2/7/2009, the patient required an amputation just below the left elbow level.

After transfer to this different hospital, the patient also developed ischemic symptoms in both lower extremities.  An attempt at endovascular treatment was unsuccessful.

On 2/10/2009, she underwent open bilateral iliofemoral thromboembolectomies with patch angioplasties.  A malpositioned Angio-seal was found in the right common femoral artery.  This operation was successful and the patient had no further ischemic episodes.

The Board judged the vascular surgeon’s conduct to have fallen below the minimum level of competence for the following reasons:

1) Failing to appropriately assess and document the condition of the patient’s arm and hand.

2) Failing to create an appropriate treatment, plan.

3) Failing to adequately perform a physical exam on the patient.

4) Deferring surgery until 1/30/2009, and not heparinizing the patient while she was awaiting surgery.

5) Using atherectomy in the arm for acute arterial occlusion instead of thrombolysis.

6) Using a stentgraft in the brachial artery rather than suture repair and failing to remove the embolic material in the hand.

7) Delaying transfer of the patient to the other hospital, where thrombolytic therapy was available.

8) Failing to recognize the progressive ischemia of the patient’s hand during the post-operative period.

9) Delaying commencing heparin in the post-operative period.

10) Delaying fasciotomy and lack of re-exploration with palmar arch embolectomy or thrombolysis to address distal embolization in view of a dying hand.

11) Failing to acknowledge the patient’s dead hand, which was documented on her arrival to the other hospital.

12) Failing to recognize a persistent, progressive limb-threatening situation in the post-operative period.

13) Failing to recognize that the patient had right lower extremity ischemia, which is a known and accepted complication after intraluminal placement of the Angio-seal closure device.

14) Failing to adequately note the condition of the patient’s hand during the early post-operative period and whether there had been improvement and then deterioration.

15) Failing to document evidence that the patient’s hand was viable as suggested by the vascular surgeon.

16)  Failing to discuss all options and alternatives.

The Board issued a public reprimand with the stipulation for the vascular surgeon to enroll in a medical record keeping course.

State: California


Date: March 2016


Specialty: Vascular Surgery


Symptom: Extremity Pain


Diagnosis: Acute Ischemic Limb, Cardiovascular Disease, Post-operative/Operative Complication


Medical Error: Improper treatment, Delay in proper treatment, Underestimation of likelihood or severity, Lack of proper documentation


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 3


Link to Original Case File: Download PDF



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