A case of critical ischemia of the lower limbs: critical elements and possible medico-legal implications
Keywords:
ischemia, lower limbs, medical malpractice, complication, amputation.Abstract
Peripheral arterial disease (PAD) is an atherosclerotic process that causes stenosis and occlusion of non-cerebral and non-coronary arteries. Critical ischemia of the lower limbs is the most advanced and severe state of arterial disease. The purpose of this work is to underline the importance of a timely diagnostic-therapeutic framework in case of critical ischemia of the lower limbs, through a precise, coordinated, and multidisciplinary teamwork. A significant example is represented by the presentation of a clinical case that came to our observation following a request for compensation and which required an adequate evaluation in the medical-legal field.
This work will make possible to clarify any profiles of medical professional responsibility, with specific reference to the predictability and preventability of the unfavorable events that have occurred, and which have led to a progressive worsening of the patient's clinical condition, which then resulted in the amputation of the lower limb, associated to organic deterioration and progressive complete permanent disability. In these cases, the collection of semeiological data must be careful, meticulous, and completed by suitable instrumental investigations. These data, with the exhaustive compilation of the medical record, play a decisive role even in the presence of adverse events and/or infrequent complications, in order to demonstrate from a medico-legal point of view that despite the implementation of all precautions codified by the specialized discipline, the adverse event, however foreseeable, is not always concretely preventable and therefore avoidable, being included in the non-negligent "complication" and not necessarily attributable to professional responsibility.
References
Basile G, Ghezzi M, Rinaldi LF, Brioschi C, Passeri A, Giorgetti A, et al. Spinal cord ischemia complicating treatment of abdominal aortic aneurysms: a legal overview. Acta Biomed. 29 June 2022;93(S1): e2022181.
Mehlsen J, Wiinberg N, Joergensen BS, Schultz-Larsen P. High prevalence of peripheral arterial disease in patients with previous cerebrovascular or coronary event. Blood Press. October 2010;19(5):308–12.
Hirsch AT, Criqui MH, Treat-Jacobson D, Regensteiner JG, Creager MA, Olin JW, et al. Peripheral arterial disease detection, awareness, and treatment in primary care. JAMA. 19 September 2001;286(11):1317–24.
Norgren L, Hiatt W, Dormandy J, Nehler M, Harris K, Fowkes F. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). Journal of vascular surgery. January 2007 ;45 Suppl S. https://pubmed.ncbi.nlm.nih.gov/17223489/
Peach G, Griffin M, Jones KG, Thompson MM, Hinchliffe RJ. Diagnosis and management of peripheral arterial disease. BMJ. 14 August 2012;345: e5208.
Huang CL, Wu IH, Wu YW, Hwang JJ, Wang SS, Chen WJ, et al. Association of lower extremity arterial calcification with amputation and mortality in patients with symptomatic peripheral artery disease. PLoS One. 2014;9(2): e90201.
Layden J, Michaels J, Bermingham S, Higgins B, Guideline Development Group. Diagnosis and management of lower limb peripheral arterial disease: summary of NICE guidance. BMJ. 8 August 2012;345: e4947.
Setacci C, de Donato G, Teraa M, Moll F, Ricco J, Becker F, et al. Chapter IV: Treatment of critical limb ischaemia. European journal of vascular and endovascular surgery: the official journal of the European Society for Vascular Surgery. December 2011;42 Suppl 2. https://pubmed.ncbi.nlm.nih.gov/22172473/
Sultan S, Tawfick W, Hynes N. Ten-year technical and clinical outcomes in TransAtlantic Inter-Society Consensus II infrainguinal C/D lesions using duplex ultrasound arterial mapping as the sole imaging modality for critical lower limb ischemia. J Vasc Surg. April 2013;57(4):1038–45.
Kopp R, Weidenhagen R, Hornung H, Jauch KW, Lauterjung L. [Acute limb ischemia from the general surgeon’s point of view. How much knowledge of vascular surgery is necessary?]. Chirurg. December 2003;74(12):1090–102.
Rutherford RB, Baker JD, Ernst C, Johnston KW, Porter JM, Ahn S, et al. Recommended standards for reports dealing with lower extremity ischemia: revised version. J Vasc Surg. September 1997;26(3):517–38.
Duval S, Keo HH, Oldenburg NC, Baumgartner I, Jaff MR, Peacock JM, et al. The impact of prolonged lower limb ischemia on amputation, mortality, and functional status: the FRIENDS registry. Am Heart J. October 2014;168(4):577–87.
Rutherford RB. Clinical staging of acute limb ischemia as the basis for choice of revascularization method: when and how to intervene. Semin Vasc Surg. March 2009;22(1):5–9.
Anderson JL, Halperin JL, Albert NM, Bozkurt B, Brindis RG, Curtis LH, et al. Management of patients with peripheral artery disease (compilation of 2005 and 2011 ACCF/AHA guideline recommendations): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. February 2013;127(13). https://pubmed.ncbi.nlm.nih.gov/23457117/
Park SJ, Hwang JC, Cho HR, Park HJ, Kim SJ, Park BW. Role of surgical treatment for peripheral arterial disease in endovascular era. J Korean Surg Soc. June 2013;84(6):353–9.
Eiberg JP, Grønvall Rasmussen JB, Hansen MA, Schroeder TV. Duplex ultrasound scanning of peripheral arterial disease of the lower limb. Eur J Vasc Endovasc Surg. October 2010;40(4):507–12.
Basile G, Ghezzi M, Brioschi C, Rinaldi LF, Marone EM. Legal aspects of lower limbs acute ischemia - Minerva Forensic Medicine 2021 June-September;141(2-3):51-6. DOI: 10.23736/S2784-8922.21.01808-2
Italian Journal of Vascular and Endovascular Surgery 2015 September;22(3 Suppl 2) - Minerva Medica - Journals https://www.minervamedica.it/en/journals/vascular-endovascular-surgery/issue.php?cod=R46Y2015S02
2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS) | European Heart Journal | Oxford Academic: https://academic.oup.com/eurheartj/article/39/9/763/4095038
Dormandy J, Belcher G, Broos P, Eikelboom B, Laszlo G, Konrad P, et al. Prospective study of 713 below-knee amputations for ischaemia and the effect of a prostacyclin analogue on healing. Hawaii Study Group. Br J Surg. January 1994;81(1):33–7.
Mätzke S, Lepäntalo M. Claudication does not always precede critical leg ischemia. Vasc Med. 2001;6(2):77–80.
Downloads
Published
Issue
Section
License
Copyright (c) 2022 Giuseppe Basile, Quirino Alessandro Petrucci, Marcello Ghezzi, Federico Amadei, Luca Bianco Prevot, Riccardo Accetta, Stefania Fozzato
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Transfer of Copyright and Permission to Reproduce Parts of Published Papers.
Authors retain the copyright for their published work. No formal permission will be required to reproduce parts (tables or illustrations) of published papers, provided the source is quoted appropriately and reproduction has no commercial intent. Reproductions with commercial intent will require written permission and payment of royalties.
How to Cite
