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Iatrogenic vascular injuries with lethal outcome
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
2013 (English)In: World Journal of Surgery, ISSN 0364-2313, E-ISSN 1432-2323, Vol. 37, no 8, 1981-1987 p.Article in journal (Refereed) Published
Abstract [en]

Objectives

The aim was to study the nature of iatrogenic vascular injuries (IVIs) associated with postoperative death within 30 days. Patients who had undergone vascular surgery for IVIs and were reported prospectively to the Swedish national vascular registry during 1987-2008 were identified. They were cross-checked with the national population registry. Those who died within 30 days of surgery were studied regarding case records and death certificates. A total of 56 patients with postoperative death within 30 days after IVI were identified. Among them, 52 case records were retrieved (93 %). In 24 cases the IVIs were caused by puncture during endovascular procedures (13 hemorrhage, 11 occlusive thrombosis), 11 by penetrating trauma during open surgery, 6 by occlusion after external compression, 6 by percutaneous accidental arterial puncture. Main symptoms were peripheral ischemia (19/52, 37 %), external bleeding (14, 27 %), and hypovolemic shock without external bleeding (10, 19 %). Main specialties involved were interventional radiology (n = 18), general surgery (n = 9), and interventional cardiology (n = 8). Overall, 22 (42 %) were avoidable, and only 13 (25 %) underwent autopsy. Within 2 weeks, 36 patients (69 %) were dead. Also, there was a higher proportion with uncertain correlation between IVI and death. Interventional radiology, general surgery, and cardiology are the main specialities involved in IVIs with lethal outcome. Not all fatalities after IVI are attributable to the injury itself, but almost half of the injuries were considered avoidable.

Methods

Patients who had undergone vascular surgery for IVIs, and were reported prospectively to the Swedish national vascular registry 1987–2008 were identified. They were cross-checked with the national population registry and those who died within 30 days of surgery were studied regarding case-records and death certificates.

Results

Fifty-seven patients with postoperative death within 3o days after IVI were identified and of those 53 case records were retrieved (93%). In 24 cases the IVIs were caused by puncture during endovascular procedures (13 hemorrhages, 11 occlusive thrombosis), eleven by penetrating traumas during open surgery, six were occlusions after external compression, six were percutaneous accidental arterial punctures. Main symptoms were peripheral ischemia (n=19/53, 36%), external bleeding (n=14, 26%), hypovolemic chock without external bleeding (n=10, 19%). Main specialties involved were interventional radiology (n=20), general surgery (n=9) and interventional cardiology (n=8). Twenty-two (41%) were avoidable, only 13 (25%) underwent autopsy. Within two weeks 34 (70%) were dead. After two weeks there was a higher proportion with uncertain correlation between IVI and death.

Conclusion

Interventional radiology and general surgery and cardiology are the main specialities involved in IVIs with lethal outcome. All fatalities after IVIs are not attributable to the injury itself, but almost half of the injuries were considered avoidable.

Place, publisher, year, edition, pages
2013. Vol. 37, no 8, 1981-1987 p.
Keyword [en]
Iatrogenic injury, vascular surgery, postoperative mortality, lethal injuries, medical errors
National Category
Surgery
Research subject
Surgery
Identifiers
URN: urn:nbn:se:uu:diva-194349DOI: 10.1007/s00268-013-2061-2ISI: 000322023600033PubMedID: 23640723OAI: oai:DiVA.org:uu-194349DiVA: diva2:605037
Available from: 2013-02-12 Created: 2013-02-12 Last updated: 2017-12-06Bibliographically approved
In thesis
1. Iatrogenic Vascular Injuries
Open this publication in new window or tab >>Iatrogenic Vascular Injuries
2013 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Iatrogenic vascular injuries (IVIs) and injuries associated with vascular surgery can cause severe morbidity and death. The aims of this thesis were to study those injuries in the Swedish vascular registry (Swedvasc), the Swedish medical injury insurance where insurance claims are registered, the Population and Cause of death registries, and in patient records, in order to explore preventive strategies.

Among 87 IVIs during varicose vein surgery 43 were venous, mostly causing bleeding in the groin. Among 44 arterial injuries, only 1/3 were detected intraoperatively. Accidental arterial stripping predominated, with poor outcome. Four patients died, all after venous injuries.

IVIs increased over time, and constitute more than half of the vascular injuries registered in the Swedvasc. Lethal outcome was more common (4.9%) among patients suffering IVIs than among non-iatrogenic vascular injuries (2.5%). Risk factors for death were age, diabetes, renal insufficiency and obstructive lung-disease.

Fifty-two patients died within 30 days after IVI. The most common lethal IVIs were puncture during endovascular procedures (n=24, 46%), penetrating trauma during open surgery (11) and occlusion after compression (6). Symptoms were peripheral ischemia (n=19), external bleeding (14), and hypovolemic chock without external bleeding (10). Most died within two weeks (n=36, 69%). After >2 weeks the IVI as a cause of death was uncertain.

Among 193 insurance claims after vascular surgery during 2002-2007, nerve injuries (91) and wound infections (22) dominated. Most patients suffered permanent injuries, three died. Patients with insurance claims were correctly registered in the Swedvasc in 82%.

In 32 cases of popliteal artery injury during knee arthroplasty symptoms were bleeding (n=14), ischaemia (n=7) and false aneurysm formation (n=11). Only twelve injuries (38%) were detected intraoperatively. Patency at 30 days was 97%, but only seven (22%) patients had complete recovery. Six of those had intraoperative diagnosis of popliteal injury and immediate vascular repair.

In conclusion, registration of IVIs is increasing and outcome is often negatively affected by diagnostic and therapeutic delay. Not all fatalities after IVIs are attributable to the injury itself. The most common causes of insurance claims after vascular surgery were nerve injuries, and 82% were correctly registered in Swedvasc.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2013. 63 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 867
Keyword
vascular injuries, vascular surgery, vascular trauma, injury, medical error, patient safety, postoperative death, postoperative mortality, patient insurance, varicose veins
National Category
Surgery
Research subject
Surgery
Identifiers
urn:nbn:se:uu:diva-194346 (URN)978-91-554-8597-9 (ISBN)
Public defence
2013-04-12, Auditorium Minus, Museum Gustavianum, Akademigatan 3, Uppsala, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2013-03-22 Created: 2013-02-12 Last updated: 2013-04-02Bibliographically approved

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Rudström, HåkanBergqvist, DavidBjörck, Martin

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