Case Archive
General, Vascular Surgery
Ref. # 13008

A 75 year old Tennessee man, a lifelong smoker, had a history of severe cardiovascular and peripheral vascular disease. He had had a myocardial infarction followed by a triple vessel coronary artery bypass. He was also status post-operative aortobifemoral bypass, right profundaplasty with patch angioplasty and right femoropopliteal bypass graft. One year after these procedures, he presented to the local ER complaining of a recent onset of lower right leg pain that began while he was golfing. The attending physician, an internist, performed a physical exam and noted the leg was warm with some tenderness and no evident edema. A venous doppler study was negative for deep venous thrombosis. Radiology reported a decrease in the arterial supply to the right leg. The diagnosis was muscular pain and generalized arterial sclerosis with reduced flow due to proximal vascular disease. The patient was discharged and instructed to keep the leg level or slight elevated, using warm, moist compresses and Advil or Tylenol for pain. Five days later the patient presented to a major medical center and was diagnosed by his vascular surgeon with severe right leg ischemic pain due to graft occlusion of one-week duration. An arteriogram showed no revascularizable vessels and the patient underwent an above-the-knee amputation. A medQuest general surgeon, whose practice includes vascular surgery, opined the internist negligently failed to pursue an arterial vascular cause of the leg pain despite his awareness of the patient's history and the available venous doppler studies. There was a failure to obtain a specific history of the pain, which would have entailed inquiring about ischemic or night pain, associated hypesthesia or loss of function, or temperature changes. There was no documentation of the presence or absence of peripheral pulses. No vascular consultation was sought. In the absence of trauma and venous thrombosis, standard of care required a prompt arterial doppler study or arteriogram. With prompt diagnosis of impending femoropopliteal bypass graft occlusion, the patient's leg would have been saved.

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