Carey P - AIMRADIAL 2013 - Legal aspects

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

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Carey P - AIMRADIAL 2013 - Legal aspects

  1. 1. Patrick Carey, atty Legal Aspects of Radial and Femoral Approaches AimRADIAL2013 New York City, NY, USA, 26-28 Sep 2013
  2. 2. Legal Aspects of Radial and Femoral Approaches LAWS APPLICATION OF MEDICINE ↓ AMISTAD STORY ↓ BEST STORY WINS ↓ KNOW YOUR AUDIENCE ↓ JURY PERSPECTIVE OF SOC – DUE DILIGENCE ↓ JURIES ARE COMMON SENSE VISUAL LEARNERS AimRADIAL2013 New York City, NY, USA, 26-28 Sep 2013
  3. 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. 4. Legal Aspects of Radial and Femoral Approaches AimRADIAL2013 New York City, NY, USA, 26-28 Sep 2013
  5. 5. Legal Aspects of Radial and Femoral Approaches PCI - RADIAL VS. FEMORAL APPROACH ↓ NOW MAY REQUIRE ANALYSIS ↓ WHAT APPROACH IS IN THE BEST INTEREST OF THE PATIENT – YOUR RECOMMENDATION? ↓ 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. 6. Legal Aspects of Radial and Femoral Approaches DR. DID YOU PERFORM AN ALLEN’S TEST ↓ DID YOU DOCUMENT YOUR FINDINGS ↓ WHY DID YOU NOT CONSIDER RADIAL APPROACH? AimRADIAL2013 New York City, NY, USA, 26-28 Sep 2013
  7. 7. Legal Aspects of Radial and Femoral Approaches INCREASED RISK OF HARM STANDARD AimRADIAL2013 New York City, NY, USA, 26-28 Sep 2013
  8. 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. 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. 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. 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

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