Legal aspects of radial and femoral approaches: perspectives from the lawyer

1. Patrick Carey, atty
Legal Aspects of Radial and Femoral Approaches
AimRADIAL2013
New York City, NY, USA, 26-28 Sep 2013

2. Legal Aspects of Radial and Femoral Approaches
LAWS APPLICATION OF MEDICINE
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AMISTAD STORY
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BEST STORY WINS
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KNOW YOUR AUDIENCE
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JURY PERSPECTIVE OF SOC – DUE DILIGENCE
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JURIES ARE COMMON SENSE VISUAL LEARNERS
AimRADIAL2013
New York City, NY, USA, 26-28 Sep 2013

3. Legal Aspects of Radial and Femoral Approaches
SIMPLE APPROACH
Medicine continues to evolve
Physicians are required to evolve as
medicine changes & remain up to date
Medical studies & Journals are equally
available to lawyers as they are to
physicians
Are you “Up to Date”
Juries determine “Standard of Care” based
upon juror education through literature,
expert testimony & Anatomicals.
Insist upon the lawyer you want. Patients
pick their physician – you should be able
to select your legal counsel
AimRADIAL2013
New York City, NY, USA, 26-28 Sep 2013

4. Legal Aspects of Radial and Femoral Approaches
AimRADIAL2013
New York City, NY, USA, 26-28 Sep 2013

5. Legal Aspects of Radial and Femoral Approaches
PCI - RADIAL VS. FEMORAL APPROACH
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NOW MAY REQUIRE ANALYSIS
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WHAT APPROACH IS IN THE BEST INTEREST OF
THE PATIENT – YOUR RECOMMENDATION?
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DEPENDS UPON PATIENT PRESENTATION
MEDICAL HISTORY
COMORBIDITIES
DEMOGRAPHICS & OCCUPATION
Fred Astaire patient
Liberace patient
FEMORAL WON’T GO AWAY
AimRADIAL2013
New York City, NY, USA, 26-28 Sep 2013

6. Legal Aspects of Radial and Femoral Approaches
DR. DID YOU PERFORM AN ALLEN’S TEST
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DID YOU DOCUMENT YOUR FINDINGS
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WHY DID YOU NOT CONSIDER RADIAL APPROACH?
AimRADIAL2013
New York City, NY, USA, 26-28 Sep 2013

7. Legal Aspects of Radial and Femoral Approaches
INCREASED RISK OF HARM STANDARD
AimRADIAL2013
New York City, NY, USA, 26-28 Sep 2013

8. Legal Aspects of Radial and Femoral Approaches
51.7% of ER-related malpractice lawsuits in a study involved:
1. Misdiagnosis,
2. Delayed diagnosis or
3. Failure to diagnose
Cardiology - Physician Insurers Association of American (PIAA) registry,
Table 1. PIAA Registry: Closed Claims 1985-2009
AimRADIAL2013
New York City, NY, USA, 26-28 Sep 2013

9. Legal Aspects of Radial and Femoral Approaches
PATIENT SELECTION FOR TRANSRADIAL PCI APPROACH
Ideal patient characteristics include:
1. Hemodynamic stability,
2 age <70 years,
3 no history of prior ipsilateral brachial or TR procedure, and
4 a palpably large radial artery with a strong pulse & normal Allen’s Test (Document)
Relative contraindications to the radial approach include:
The absence of radial pulse,
An abnormal Allen’s test,
A severe vasospastic condition (such as Raynaud’s),
Planned or present arteriovenous shunt for dialysis, and
The potential use of the radial artery as a conduit for aortocoronary bypass.
AimRADIAL2013
New York City, NY, USA, 26-28 Sep 2013

10. Legal Aspects of Radial and Femoral Approaches
INFORMED CONSENT
Document Informed Consent
Vascular Complications Associated With Transradial Catheterization
Spasm
Bleeding
Hematoma
Compartment syndrome
Perforation, laceration, dissection
Evulsion of artery
Arterio-venous fistula
Pseudo-aneurysm
Subcutaneous granulomatous reaction (hydrophilic coating)
Cutaneous infection
Subacute and delayed occlusion
Digital ischemia
Accelerated atherosclerosis
Transient vocal cord paralysis
Mediastinal hematoma
Delayed reflex sympathetic dystrophy
AimRADIAL2013
New York City, NY, USA, 26-28 Sep 2013

11. Legal Aspects of Radial and Femoral Approaches
PERFORMANCE
Access on the first attempt is optimal
Repeated arterial trauma increases the risk for spasm,
Document careful vessel palpation and planning of arteriotomy puncture - critical to
successful TRA. The arteriotomy should be approximately 2 cm proximal to the radial
styloid in order to avoid the bifurcation and diminutive distal vessel.
Document - prophylactic use of pharmaceutical agents known to reduce vascular tone, such
as calcium channel blockers (e.g., Verapamil 2.5 mg) and/or nitrates (e.g., Nitroglycerin 0.1–
0.4 mg) are routinely utilized and are best given directly in the radial artery immediately
after vascular access.
Document – anticoagulation – Heparin - can be given either IV or intra-arterial.
Document – catheter selection & why
Document – perfusion following PCI completion
Document – Discharge instructions & Follow-up
Patient call – see the patient & document result.
- The non-compliant patient
8. Research articles Transradial Arterial Access for Coronary and Peripheral Procedures: Executive Summary by
the Transradial Committee of the SCAI - Ian Gilchrist, M.D. – Catherization and
Cardiovascular Interventions 00:000–000 (2011)
Medicolegal Characteristics of Cardiac Catheterization Litigation in the United States, 1985
to 2009 - Mladen I. Vidovich, MD – IN PRESS - (Am J Cardiol 2013;-:-e-)
AimRADIAL2013
New York City, NY, USA, 26-28 Sep 2013