Malpractice Allegations Against Vascular Surgeons:Prevalence, Risk Factors, and Impact on Surgeon Wellness

OBJECTIVES

The contemporary medicolegal environment has been linked to procedure overuse, healthcare variation, and higher costs. For physicians accused of malpractice, there is also a personal toll. The objective of this study was to evaluate the prevalence of and risk factors for involvement in medical malpractice lawsuits among US vascular surgeons, and to examine the association between these allegations with surgeon wellness.

METHODS

In 2018, the Society of Vascular Surgery (SVS) Wellness Task Force conducted a confidential survey of active members using a validated burnout assessment (Maslach Burnout Index) embedded into a questionnaire. This survey included questions related to medical errors and malpractice litigation. De-identified demographic, personal, and practice-related characteristics were assessed in respondents who reported malpractice allegations in the preceding two years, then compared to those without recent medicolegal litigation. Risk factors for malpractice allegations were identified (chi-square, Kruskal-Wallis tests), and the association between malpractice allegations with wellness was examined. Multivariate logistic regression models were developed to identify independent risk factors for malpractice accusations.

RESULTS

Of 2905 active SVS members, 871 responses from practicing vascular surgeons were analyzed. 161 (18.5%) were named in a malpractice lawsuit within two years. Malpractice allegations were significantly associated with surgeon burnout [OR 1.47 (1.01, 2.15), p=0.041], but not with self-reported depression or suicidal ideation. The nature of malpractice claims included procedural errors (23.1%), failure to treat (18.8%) and error/delay in diagnosis (16.9%). 20% of claims were settled prior to trial and 19% were dismissed. Defendant vascular surgeons reported a "fair" resolution in 26.4% of closed cases. By unadjusted analysis, factors significantly associated with recent malpractice claims included mean age (51.7+/-10.0 vs. 49.3+/-11.2; p=0.0044) and mean years in practice (18.0+/-10.7 vs. 15.2+/-11.8; p=0.0007). Multivariate analysis revealed independent variables associated with malpractice allegations, including on-call frequency (p=0.0178), recent medical errors (p=0.0189), and male surgeons (p=0.045).

CONCLUSIONS

Malpractice allegations are common for vascular surgeons and are significantly associated with surgeon burnout. Nearly 20% of survey respondents reported being named in a lawsuit within the preceding two years. Our findings underscore the need for SVS initiatives to provide counseling and peer support for vascular surgeons facing litigation.

When is embolic protection needed in lower extremity interventions and how should it be done

Distal embolization (DE) during lower extremity arterial intervention is a potentially devastating complication which could lead to limb loss. The use of a distal embolic protection device (EP) may prevent significant DE during intervention. Studies investigating the incidence and impact of DE suggest that it is a rare event with low impact on clinical outcomes. The use of EP during peripheral interventions has only been studied in uncontrolled small series with no comparison to unprotected interventions. In spite of the absence of good quality studies, there may be situations where EP is helpful. These situations may be when lesions or devices are particularly prone to produce emboli. The EP device may produce its own serious complications which must be considered prior to their use. In addition these devices are fairly expensive, a factor that needs to be considered when deciding to employ EP. A simple direct comparison of EP vs. no EP during lower extremity intervention could answer many clinical questions surrounding this controversy.

Endovascular repair of para-anastomotic aneurysms of the aorta and iliac arteries: preferred treatment for a complex problem

PURPOSE

Standard surgical repair of para-anastamotic aneurysms (PAAs) of the abdominal and thoracic aorta and the iliac arteries has been associated with high morbidity and mortality rates. We reviewed our continuing experience with endovascular repair of these lesions to determine whether this approach is favorable and durable.

METHODS

All patients with PAAs of the aorta or iliac arteries who underwent endovascular treatment of their lesions between August 1993 and July 1999 were prospectively followed up, and data on age, previous aortic pathology and surgery, size of PAA, time to diagnosis, and symptoms at presentation were recorded. Preoperative, intraoperative, and postoperative imaging studies were analyzed. All patients had endovascular stent-grafts placed under digital fluoroscopic guidance in the operating room. Data on intraoperative and postoperative complications, mortality, and endoleaks were reviewed.

RESULTS

From August 1993 to July 1999, 28 patients (20 men, 8 women) had 35 PAAs of the aorta or iliac arteries. There were 5 thoracic aortic, 12 abdominal aortic, and 18 iliac artery PAAs. Three patients had a contained rupture of their PAA. All patients who had originally undergone reconstruction for occlusive disease had lesions consistent with false aneurysms, whereas 73% of the aortic or iliac PAAs in patients originally treated for aneurysm disease appeared to be true aneurysms. Thirty-four of 35 PAAs were successfully excluded with stent-grafts (97%). There was one death at 30 days (3.6%) in a patient who was successfully treated endovascularly for a contained rupture of a thoracic PAA. There were four major postoperative complications (14.2%) in the 28 patients who were treated. One patient had continued perfusion of a thoracic aortic PAA (type I endoleak). The in-hospital length of stay after endovascular repair of PAA was 4 days (range, 1-18 days). The mean follow-up period was 21 months (range, 1-68 months).

CONCLUSION

Endovascular repair of aortic and iliac artery PAAs is technically feasible and provides a high rate of lesion exclusion. Morbidity and mortality rates appear lower than those reported for open surgical repair. These patients can typically be discharged by the second postoperative day. Endovascular therapy for stable ruptured PAAs can be successfully performed and should be considered as an option only when appropriate devices and expertise are available. For uncomplicated PAAs of the aorta and iliac arteries, endovascular therapy may be more favorable than surgical repair.

Anatomic exposures in thoracoabdominal aortic surgery

Thoracoabdominal aortic aneurysm repair requires exposure of long segments of the aorta. This often results in large, debilitating incisions that can compromise pulmonary physiology significantly and result in severe pain. Preoperative preparation and positioning of the patient as well as careful planning of the incision based on the individual's anatomy are required for successful aortic exposure. Alternative approaches such as varying the skin incision location and performing submuscular dissection can reduce postoperative discomfort. Rib resection and double thoracotomy may be needed to expose enough aorta to allow safe proximal and distal control. Improved understanding of the pathophysiology of postoperative complications may alter the approach to aortic and visceral vessel exposure and reattachment. In addition, endovascular technology continues to advance, allowing for more applications in thoracic aortic disease. A combined open and endovascular approach to thoracic aortic aneurysms may minimize the morbidity and mortality by decreasing the physiologic insult normally incurred by long thoracoabdominal incisions.

Tolerance induction permits the development of graft-versus-host disease: donor-mediated attack following small bowel transplantation in mixed chimeras

The induction of tolerance to organ allografts would eliminate acute and chronic rejection as well as the need for nonspecific immunosuppression. We have shown that tolerance induced through the creation of mixed allogeneic bone marrow chimeras allows for the long-term engraftment of cardiac and small bowel allografts across strong multiple major histocompatibility barriers. The possibility that tolerance might render the host susceptible to graft-versus-host disease (GVHD) has not been investigated in this or other models of tolerance. To test this possibility chimeras were created by transplantation of T-cell depleted ACI and Lewis bone marrow into lethally irradiated Lewis rats. Chimerism was determined post bone marrow transplant (BMTx) by flow cytometry of lymphocytes from reconstituted animals. ACI/Lew chimeras (ALC), Lewis/ACI F1 (LACF1), and Lewis (LEW) rats all received heterotopic ACI vascularized small bowel grafts. A second group of chimeras received small bowel grafts from ACI rats pretreated with low dose irradiation to eliminate T-cells from the graft. LEW-->LEW small bowel isografts were also performed. Animals were examined for evidence of GVHD by clinical signs and histologic examination of biopsied tissues. GVHD was quantified using the popliteal lymph node enlargement assay. All LACF1 rats developed severe lethal GVHD following ACI small bowel transplant. Bone marrow chimeras, ALC (n = 6), developed fatal GVHD in a similar fashion after receiving a small bowel transplant. LEW-->LEW isografts and chimeras receiving bowel from irradiated ACI rats survived long term without GVHD while ACI-->LEW allogeneic transplants all underwent acute rejection. GVHD or its absence was confirmed histologically. Popliteal lymph node enlargement indices reflected the presence of GVHD in the chimeras (1.87) and LACF1 (5.4) receiving allografts, but not in isografts or chimeras receiving irradiated allogeneic transplants. Analysis of cytokines in the tongues of rats undergoing GVHD showed elaboration of Th1 type proinflammatory cytokines which was not seen in isografted rats or rats receiving preirradiated small bowel. These results demonstrate that tolerance induction through mixed chimerism results in susceptibility to small bowel induced GVHD. Preirradiating the donor bowel prior to SBTx can prevent GVHD.

Graft versus host disease in rats made tolerant for organ allografts

Tolerance for organ allografts would eliminate acute and chronic rejection as well as the need for nonspecific immunosuppression. A potential hazard of tolerance is the susceptibility to graft vs host disease (GVHD) due to unresponsiveness to alloantigen. This study sought to determine if our model of tolerance induction results in susceptibility to GVHD. Chimeras were created by transplantation of T-cell depleted ACI and Lewis bone marrow into lethally irradiated Lewis rats. Chimerism was determined post-BMTx by flow cytometric analysis of recipient spleens for the presence of ACI cells. ACI/Lew chimeras (ALC), animals that reconstituted only with syngeneic (Lewis) marrow (so-called failed chimeras), and ACI/Lew F1 (LACF1) hybrid rats were all given 200 x 10(6) ACI splenocytes i.v. Animals were examined for evidence of GVHD. GVHD was quantified using the popliteal lymph node enlargement assay. All LACF1 (n = 6) rats developed severe lethal GVHD following ACI splenocyte injection. Similarly, ALC (n = 6) developed fatal GVHD. Animals that reconstituted only with syngeneic Lewis marrow (failed chimeras) showed no signs of illness. GVHD was confirmed histologically and immunohistochemically. Failed chimeras receiving ACI splenocyte challenge showed no evidence of GVHD histologically. Popliteal lymph node enlargement indices reflected the presence of GVHD in the chimeras and hybrids but not in the failed chimeras. We conclude that tolerance induction by mixed chimerism results in susceptibility to GVHD if enough donor lymphoid tissue is given to the host at the time of organ transplant. Animals that are not mixed chimeras (failed bone marrow transplant) rejected the allogeneic splenocytes as evidenced by their lack of disease. Tolerance may therefore make the host defenseless against fatal GVHD.

Induction of specific tolerance through mixed hematopoietic chimerism prevents chronic renal allograft rejection in a rat model

BACKGROUND

Chronic rejection is the leading cause of late graft loss in kidney transplantation. We tested the ability of mixed hematopoietic chimerism to prevent chronic renal allograft rejection in an established rat model and described possible mechanisms responsible for this tolerance.

METHODS

Mixed hematopoietic chimerism was established in lethally irradiated F-344 rats by reconstitution with Lewis bone marrow. Four groups (n = 5 each) received orthotopic kidney transplants: (1) allograft controls, (2) isograft controls, (3) experimental chimeras, and (4) specificity control. After 120 days kidney grafts were examined histologically, immunohistochemically, and for cytokine interferon-gamma, interleukin-2 (IL-2), IL-4, and IL-10 gene transcripts by means of reverse transcriptase polymerase chain reaction techniques.

RESULTS

Allograft control group exhibited severe parenchymal fibrosis; isograft control and chimera groups failed to develop this lesion. Immunohistochemical analysis revealed increased CD8+ lymphocytes and ED-1+ monocyte-macrophages infiltrating the tubulointerstitium of control allografts. Interferon-gamma and IL-2 were absent in isografts. IL-4 was absent and IL-10 was positive in all grafts. Chimeras promptly rejected third-party allografts.

CONCLUSIONS

Induction of specific tolerance through mixed hematopoietic chimerism prevents chronic renal allograft rejection. These results support the hypothesis of an immunologic basis of chronic rejection and advance previous observations that the induction of specific tolerance enables long-term solid organ transplantation without the use of immunosuppression.