An aortic dissection is pretty much what it sounds like: a tear in the artery. An aortic dissection results from trauma or a tear that occurs in the inner layer of the aortic wall, resulting in bleeding into the wall of the aorta, and has a high mortality rate.
An aortic dissection involving the ascending aorta (in the upper chest) is a highly lethal condition, classically associated with the onset of back pain and high blood pressure, particularly intra-scapular and shoulder pain.
Aortic dissection is twice as frequent as the second most common grave danger to the aorta, the abdominal aortic aneurysm. Still, many patients survive both an abdominal aortic aneurysm and an aortic dissection, particularly when the doctor spots the problem before they blow the aorta open. But, all too frequently, aortic dissections are missed and lead to wrongful death medical malpractice lawsuits.
Our lawyers handle these cases. If you think you have a potential wrongful death medical malpractice claim for someone you loved because the ER doctor or another doctor failed to diagnose an aortic dissection, call 800-553-8082 to discuss your potential malpractice case or get a free online case evaluation.How Do Aortic Dissections Occur?
Aneurysms are slow to develop, taking years, and are often asymptomatic (without symptoms). Symptoms may develop suddenly if an aneurysm ruptures (tears open). Symptoms of rupture include severe, sudden or constant pain in the abdomen or back that may radiate to the groin, legs or buttocks; clammy skin; nausea; vomiting; rapid heart rate; and shock.Types of Dissections and Risk Factors
Aortic dissection is the most common emergency involving the aorta, and most commonly occurs in patients aged 50 to 70 years. Prevalence of aortic dissection is estimated to be approximately 2 in 10,000 people. Though rare in children, it has been associated with coarctation of the aorta (a congenital birth defect).
Aortic dissection may be classified using the Stanford classification as Type A (beginning in the ascending part of the aorta, DeBakey type I or II) or Type B (starting in the descending part of the aorta, DeBakey type III). The DeBakey classification system is as follows:
- Type I: aorta, aortic arch, and descending aorta (30%).
- Type II: ascending aorta only (20%).
- Type III: descending aorta distal to left subclavian (50%).
Though the exact cause of aortic dissection is not currently known, several risk factors, both congenital and acquired, have been identified including:
- Bicuspid aortic valve
- Coarctation (narrowing) of the aorta
- Connective tissue disorders
- Ehlers-Danlos syndrome
- Heart surgery or procedures
- High blood pressure (80% of patients having an aortic dissection have high blood pressure)
- Marfan syndrome
- Pregnancy (approximately 50% of all cases of aortic in women <40 years are associated with pregnancy, most occurring in the third trimester or early postpartum)
- Pseudoxanthoma elasticum
- Trauma (blunt chest trauma, i.e. hitting the steering wheel of a car during a car accident)
- Vascular inflammation resulting from conditions such as arteritis and syphilis
No doubt, diagnosis of an aortic dissection is the big leagues: incompetent doctors are not going to catch it. Putting the risk Getting it right requires a high degree of suspicion as symptoms can vary. Good patient medical history and physical examinations in addition to ECG (electrocardiography), imaging, and laboratory studies are essential in diagnosing aortic dissection. Symptoms are usually sudden and include severe chest pain.
The pain may be sharp, stabbing, ripping or tearing, and felt below the chest bone, then moving to the back or under the shoulder blades, shoulder, neck, jaw, or abdomen. As the aortic dissection rupture worsens, the pain may move to the arms and legs.
Besides pain, patients may experience confusion or disorientation, dizziness, fainting, nausea and vomiting, sweating, decreased movement or sensation in other parts of the body, dry mouth or skin, shortness of breath, difficulty breathing when lying flat, or a rapid or weak pulse. Other symptoms include low blood pressure or variation between blood pressure measurements between left and right arms and legs.
Aortic dissections may be evident through aortic angiography, chest x-rays, MRI, CT scan, echocardiogram or ultrasonography. The starting point is a CT scan which is usually the starting point because it is a very accurate test for diagnosing aortic dissection.
So what is a doctor required to do? The standard of care when diagnosing a patient complaining of an acute onset of severe chest or upper back pain/shoulder requires that the doctor order a chest CT scan to rule out potentially fatal conditions. High blood pressure readings would further increase the likelihood of an aortic dissection
Quick diagnosis is imperative to reduce the risk of mortality as the risk of death increases with each passing hour. It is such a serious concern because 20% of patients may die before reaching the hospital, and diagnosis is not made until autopsy in 15% of all cases. In the absence of surgery, 80% of patients will die within two weeks and 40% within 24 hours. Although surgery can result in an 80% chance of survival, aortic surgery comes with a risk of mortality in the region of 25%.
There was an interesting new study of interest in the American Journal of Cardiology. The gist of it is that acute aortic syndrome (AAS), which includes acute aortic dissection, intramural hematoma, and penetrating ulcer of the aorta, is often confused with acute coronary syndrome (ACS), which includes myocardial infarction. This confusion has often led to malpractice because of the delayed diagnosis.
Further, this confusion results in inappropriate treatment such as anti-platelet, anti-thrombin, or fibrinolytic therapy. Exposing a patient with aortic dissection to such treatments can lead to hemodynamic instability among other problems. Hemodynamic instability before surgery for aortic dissection has been associated with negative outcomes. Use of fibrinolytics in patients with aortic dissection can lead to severe hemorrhagic complications and result in an estimated mortality rate of 71%. Sadly, this is about the same as the death rate if the patient had gone untreated.
In another study in the Journal of Cardiology, 109 emergency room patients who were eventually diagnosed with aortic dissection were examined. The failure to diagnose aortic dissection occurred in 16% of patients admitted to the emergency room. Other studies have estimated the rate of misdiagnosis of aortic dissection to be closer to 25-31% and are most commonly misdiagnosed as myocardial infarction.
The lack of or incomplete capture of medical history in the emergency room can lead to misdiagnosis. Clinical examination and chest radiography alone are insufficient to make a diagnosis of aortic dissection. Further, no specific blood tests are available, though there are some recently discovered markers that might soon be of more help. These challenges coupled with the fact that emergency departments see more patients presenting with myocardial infarction compared to those with acute coronary syndrome, in a ratio of nearly 2900 to 5, often lead to misdiagnosis and inadequate treatment of the patient which can put the patient at further risk for an adverse outcome.
Thankfully, mortality rates associated with an aortic dissection have been declining since the introduction of cardiopulmonary bypass in the 1950s and aortic arch repair in 1955. Further advances in diagnosis and reparative techniques, including stent placement and percutaneous aortic fenestrations, have helped further reduce mortality rates. Although mortality rates have declined in the past 60 years, the rate of death remains high - too high - and can be further improved by timely, correct diagnosis and proper management.Aortic Dissections Medical Malpractice Verdicts
These mistakes lead to aortic dissection medical malpractice lawsuits. This is a sampling of relatively recent plaintiffs' aortic aneurysm verdicts and settlements:
- 2018 New Jersey, $871,030 verdict: An adult female died at the age of 37 due to an undiagnosed aortic dissection while under the care and treatment of the defendants. The decedent's estate claimed that the defendant physician, and clinic vicariously, failed to properly and timely diagnose and treat her conditions, leading to her ultimate death. The estate claimed the defendants failed to provide the decedent with the adequate standard of care, deviated from accepted procedures and failed to refer her to a specialist for evaluation. The defendants denied liability. The jury determined the defendants to be 100 percent negligent and awarded the estate $871,030 for damages and funeral expenses.
- 2017, Utah $2,940,250 verdict: This case was filed under the estate of a man who died from an aortic dissection. The patient visited the defendant medical clinic, suffering from abdominal pain. He was seen by a physician's assistant, who diagnosed him as suffering from constipation. After a week of continuous pain, the decedent returned to the clinic and met with a different physician. He was again diagnosed him with abdominal pain and constipation, once again failing to be diagnosed with the actual medical issue. For a second time, no cardiac tests were administered. Four days after his second visit to the clinic, the decedent died of aortic dissection. The defendant was accused of breaching the standard of care by twice misdiagnosing decedent and failing to perform cardiac tests, such as a chest X-ray or an EKG, and failing to send him to the E.R., resulting in his death. The jury awarded $2,940,250 to the decedent’s widow.
- 2017 Massachusetts, $4,000,000 settlement: In this case, the plaintiff arrived at the emergency room with complaints of sudden left-sided chest pain that extended into her left arm and left side of her jaw. She came under the care of the defendant nurse practitioner and the defendant physician. The plaintiff had an abnormal EKG. At that time, based upon examination and test results, the differential diagnoses included acute myocardial infarction, anxiety, coronary artery disease, chest wall pain, costochondritis, mitral valve prolapse, myocarditis, aortic dissection, unstable angina, pneumonia, pneumothorax, pulmonary embolus, and stable angina. No chest CT scan was ordered. Hours later after being admitted, the plaintiff became diaphoretic and complained of burning in her legs with no feeling in her feet. A CT angiogram taken shortly thereafter showed a complete dissection of the plaintiff's thoracic aorta. She was airlifted to a tertiary care facility where she underwent surgery. She was deemed to have suffered spinal cord ischemia that resulted in paralysis. The plaintiff alleged that the defendants were negligent in failing to act quickly when an aortic dissection was a part of a differential diagnosis. As a result of the defendants' negligence, the plaintiff suffered spinal cord ischemia which resulted in the plaintiff's paralysis. The defendants denied the allegations of negligence and contended that there was insufficient time to transfer the patient to another facility. The parties agreed to resolve the plaintiff's claim for the sum of $4,000,000.
- 2017 Massachusetts, $900,000 settlement: In this wrongful death matter, the plaintiff alleged that the defendant radiologist was negligent during an angioplasty procedure which resulted in the patient suffering a fatal aortic dissection. The decedent came under the care of the defendant, an interventional radiologist, for the placement of rental artery stent due to moderate right and left renal artery stenosis. During the procedure, the defendant needed to exchange a short sheath for a long sheath. During this process, the defendant lost access to the lower pole artery and made several attempts to re-canalize the vessel which were unsuccessful. The patient began to complain of severe chest and back pain and it appeared that the patient suffered an aortic dissection. The procedure was stopped immediately and an abdominal aortogram revealed compression along the left lateral wall of the inferior aorta. A later CTA scan showed rapidly progressing extensive aortic dissection and dissection of the thoracic aorta extending to the root. The defendant was uncertain of how to proceed and consulted with other physicians before ultimately deciding to have the patient be med flighted to another facility. The patient coded shortly after that decision and died shortly thereafter. The plaintiff brought suit against the defendant alleging negligence. The defendant denied the allegations and disputed that there was a deviation from acceptable standards of care under the circumstances. The parties agreed to resolve the plaintiff's claim for the sum of $900,000.
- 2017, New Jersey $875,000 settlement: A man underwent a triple bypass procedure and was discharged from the hospital without any complications. Once he got home, the plaintiff contended he suffered an episode where he had sharp throat pain and briefly passed out. The patient was taken back to the hospital where he was diagnosed with pneumonia. The defendant gave the patient a trans-thoracic cardiogram which is an external procedure that only shows a small portion of the aorta. Afterward, the doctor let the man be discharged. Three days later, his aorta ruptures, suffers from profound brain damage and eventually dies. The estate of the decedent sued the defendant doctor on the claim of neglect for failure to use a trans-esophageal echocardiogram or MRI to properly diagnose his aortic dissection and failure to further analyze his results when they showed “suspicious artifacts” on his scan. The defendant denied liability and claimed there was no evidence of an aortic dissection on the echocardiogram so there was no reason to take further action. Both parties agreed to settle and the plaintiff was given $875,000.
- 2015, Ohio: $275,000 Settlement. A woman gets in a car accident and presents at OSU Wexner Medical Center complaining of chest pains following a car crash, home to wait for test results. The defendant doctor saw the reports and thought she might be suffering an aortic dissection. He could not get reach the woman, and she died. The defendants argued causation: she would have died anyway.
- 2012, Kentucky: $1,300,000 verdict, less 30% comparative fault. The tragic case of a 49-year-old woman who died waiting to go into surgery. The lawsuit by woman's husband claimed a doctor made no effort to rule out a thoracic aortic dissection in spite of the evidence. Had the doctor ordered a CT scan, he would have seen the dissection.
- 2011, Pennsylvania: $1,900,000 verdict. Wrongful death case involving a 31-year-old man who was admitted to the hospital with intense chest pain. He was treated and released and died three days later.
- 2011, Massachusetts: $1,750,000 settlement. Wrongful death of a 24-year-old man. A lawsuit brought against both the emergency room doctor for failure to diagnose and the radiologist who did not review all of the MRI films that showed the aortic dissection.
- 2007, Maryland: $500,000 settlement. Wrongful death and survival claim involving a 56-year-old man who presented to the emergency room hypertensive with complaints of near syncope, diaphoresis and back pain. A transesophageal echocardiogram test that confirmed the aortic dissection was not performed until the next day. At that point, the man was too far along and he died was his doctors planned emergency surgery.
Aortic aneurysms and aortic dissections can usually be treated when correctly diagnosed. But they are frequently missed by emergency room and primary care doctors and, too often become the subject of a wrongful death medical malpractice claim. If you think you have a potential wrongful death malpractice claim for someone you loved because a doctor misdiagnosed an aortic dissection, call 800-553-8082 to discuss your potential case or get a free no obligation case evaluation.
- Medical malpractice claims in Maryland: an overview
- Look at a sample aortic dissection lawsuit filed in Montgomery County against a radiologist
- Look at a sample aortic dissection lawsuit filed in Baltimore
- A look at emergency room malpractice cases in Maryland
- Settlement values of other emergency room malpractice and surgery cases