title: Litigation in nontraumatic aortic diseases--a tempest in the malpractice maelstrom.
abstract: OBJECTIVE
  Physicians are vulnerable to highly litigated thoracic aortic diseases. On the basis of a review of litigated cases, we aim to determine legally protective strategies for physicians and methods to improve treatment.
  
  
  METHODS
  Thirty-three nontraumatic, thoracic aorta-related legal cases were analyzed.
  
  
  RESULTS
  Twenty-three patients (69.7%) had dissections (21 ascending, 2 descending), 8 (24.2%) had aneurysms and 2 had miscellaneous other phenomena (1 coarctation and 1 iatrogenic descending aortic rupture). The adverse event was death in 30 (90.9%) patients and paraplegia or stroke in 3 (9.1%). Allegations included: failure/delay in diagnosis (19), delay in surgery (4), error in surgical technique (5), failure to prevent paraplegia (2) and miscellaneous (3). Medical treatment was retrospectively judged suboptimal in 22 cases (66.6%) for reasons consonant with allegations.
  
  
  CONCLUSIONS
  Aortic disease can be diagnostically elusive, as 'the great masquerader'. Emergency physicians must maintain a high index of suspicion for aneurysm and dissection. The D-dimer test can effectively rule out aortic dissection. 'Triple rule-out' CT scans should be performed liberally. CT scan readers must remember to evaluate the aorta. Operating room administrators must be aware that postponing a scheduled thoracic aortic case may result in interim rupture and consequent litigation. With virulent thoracic aortic diseases, adverse outcome itself does not imply substandard care.
authors.affiliation: Section of Cardiothoracic Surgery, Yale University School of Medicine, New Haven, Conn. 06510, USA. john.elefteriades@yale.edu
authors.forename: John A
authors.initials: JA
authors.lastname: Elefteriades
authors.forename: Peter W
authors.initials: PW
authors.lastname: Barrett
authors.forename: Gary S
authors.initials: GS
authors.lastname: Kopf
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001018:Aortic Diseases / Q000175:diagnosis* / Q000601:surgery*; D006801:Humans; D008318:Malpractice / Q000331:legislation & jurisprudence*; D008875:Middle Aged; D013903:Thoracic Surgery; D016896:Treatment Outcome; D014481:United States