[20620735]
Patient had aaa repair. Aaa repaired with stent graft and cardiomem sensor placed by surgeon in aneurysm sac. It was noted at the end of the surgical procedure that a countable item was missing. An anterior and posterior x-ray taken of the abdomen. There were not any countable items in the abdominal cavity on x-ray. Patient had a post-op follow-up visit with the surgeon approximately a month later. Another abdominal film was taken. This film revealed a long object (~12 cm) resting next to the aneurysm area. Surgeon and radiologist reviewed the film, and they were unable to determine the identity of the object. The surgeon decided at this time to leave the retained object because it did not seem to be creating any problems for the patient. Patient returned to ed 26 days later with a ruptured aaa. Family made decision in the ed to not treat surgically. Patient was admitted to palliative care. Patient expired two days later. Autopsy performed and revealed retained device to be the tip of the cardiomem delivery catheter. Delivery catheter tip was sent for examination. Preliminary autopsy results revealed that a sharp bone spur on the patient's spine ruptured the posterior wall of the aneurysm, and the retained device was not the causative agent creating the aaa rupture. After autopsy results were returned to surgeon, he remembered that the first cardiomem delivery catheter was slightly bent and had to be exchanged during the procedure. It is believed that during the exchange, the catheter tip from the first cardiomem was unknowingly retained. The second cardiomem catheter was inserted without difficulty. Specific device information unknown.
Patient Sequence No: 1, Text Type: D, B5