Hematologist Opines on Fatal Carotid Endarterectomy

A middle-aged woman underwent a series of carotid endarterectomy procedures to correct a narrow carotid artery and reduce her risk of stroke. When her blood began to clot during one of the procedures, her surgeon claimed that she must have a previously unknown clotting problem. Despite this realization, the patient tragically passed away during the procedure, causing her family to sue for negligence in all aspects of the operation. Allegedly, no blood work was ever ordered for the patient prior to surgery, which left the trial requiring an expert in hematology to study the patient’s medical records and discuss what potential abnormal blood coagulant she may have had.

Question(s) For Expert Witness

  • 1. Based on this patient’s history, what records and clinical signs would you be look for to diagnose a clotting disorder?
  • 2. Are there clotting disorders that would likely go undiagnosed until 54 years of age?

Expert Witness Response E-044372

I have over 30 years experience in hematology practice with a focus on bleeding and clotting disorders. In order to diagnose a clotting disorder based on this patient’s history, I would look at a personal or family history of thrombosis or ischemia. Generally, inherited causes would not go undiagnosed until middle age, but acquired causes like cancer and autoimmune diseases present later in life.

Expert Witness Response E-052087

This patient scenario is one I see in my practice several times a year as an expert in hemostasis and thrombosis at a large referral-based academic center. I can say that history, lifestyle choices like smoking, and co-morbidities like hypercholesterolemia and diabetes are far more likely instigators of arterial events and more likely to present more than fifty years later then a primary blood disorder. However, yes, a middle aged woman could have a primary hypercoagulable state missed earlier in life. The major point of separation is whether the hypercoagulable state is primary to blood clotting defect or secondary to other medical conditions. Without blood tests to prove primary disorder, family history is helpful. Without any history or labs, then it comes down to how strong the secondary risk factors are, and whether they strong enough to explain the situation. Secondary risk could include damage done to a vessel with instrumentation.


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