Case Report: Negligent decision to attempt high risk lytic (clot busting) therapy
(Excerpts taken with permission from Minnesota Trial Lawyer Association’s (MTLA) "Minnesota Case Reports”)
John Doe, age 42, had suffered an accidental gunshot wound to his right shoulder region when he was a child. The gunshot wound severed the right subclavian artery and surgeons placed a bypass graft from the innominate artery to the axillary artery to assure blood to flow to the right arm. The graft remained patent for several years until 2001, when Doe started experiencing symptoms of compromised blood flow to his right arm.
In May 2003, Doe’s vascular surgeon referred Doe to an interventional radiologist for angiogram and possible lytic (clot busting) therapy. Before meeting with Doe, the interventionalist reviewed a recent ultrasound report showing that the graft was 100% occluded from the point where the graft was attached to the axillary artery to some undetermined point near the innominate artery. The interventionalist met with Doe and explained that he would first do an angiogram to map the vessels in the region and then possibly attempt lytic therapy to dissolve the clot. The interventionalist admitted at deposition that he advised Doe that any clot disrupted during lytic therapy would flow through the graft to his right arm.
The angiogram showed that the occlusion in the graft was less than one inch from the innominate artery. Despite this, the interventionalist attempted lytic therapy. Lytic therapy required the interventionalist to use various instruments—guide wire, balloon catheter, and an infusion catheter—that he threaded through the aortic arch, into the innominate artery, and then into the graft so that he could ultimately place an infusion catheter into the clot and infuse tPA to the clot. These instruments disrupt pieces of clot, and in Doe’s case, the pieces of clot could not flow through the occluded graft to the arm. Pieces of disrupted clot backwashed into the innominate artery and flowed to Doe’s brain, causing an embolic stroke.
Plaintiffs’ experts opined that the defendant departed from accepted standards of care by attempting to perform lytic therapy under the circumstances here. The occlusion was too close to the innominate artery, and any disrupted clot ran an unacceptably high risk of backwashing into the innominate artery and flowing through the carotid and vertebral arteries to the brain. The defendant could not reasonably expect disrupted clot to flow to the arm, given that the graft was 100% occluded for an approximate length of seven inches.
At the time of the incident, Doe was married and employed as an architect in a national firm. He was a senior associate and likely would have become an associate vice president within a few years and possibly a full vice president by 2013. Post-stroke neuropsychological testing showed that Doe had an extremely high verbal IQ, but that he was significantly impaired in areas involving visual-spatial skills, executive functioning, and short-term memory. He suffered from depression. Doe also had medical issues including left-sided hemiplegia, left neglect and left field cut, history of post-stroke seizure, and neurogenic bladder. Defense experts agreed that Doe would never work as an architect, but contended that he could hold a number of skilled positions on a part-time basis.
Settlement discussions never occurred until a few weeks before trial. The case settled shortly before trial.
Settlement: $2.7 million
Case Name: John Doe v. Interventional Radiologist
Date of Disposition: Fall, 2005
Attorneys: John F. Eisberg
William J. Maddix