Failure to Diagnose Aortic Dissection

An aortic dissection is a tear in the inner wall of the aorta, the body's largest artery. Blood enters the wall through the tear and separates its layers, creating a false channel that can rupture, obstruct branches to the brain, heart, kidneys, and limbs, or progress to fatal cardiac tamponade within hours.

Dissections are classified by anatomy. The Stanford system divides them into Type A, which involves the ascending aorta and is a surgical emergency, and Type B, which begins beyond the left subclavian artery and is typically managed with aggressive blood-pressure control and selective intervention. Both carry significant mortality if unrecognized.

The condition is uncommon but not rare in the patient populations where it matters most: middle-aged and older adults with hypertension, patients with connective tissue disorders, and those with a bicuspid aortic valve or family history of aneurysmal disease.

The literature has documented for decades that a substantial portion of aortic dissections are missed on first presentation. The reasons are clinical, not mysterious.

Dissection mimics more familiar conditions. The classic teaching of sudden "tearing" chest pain radiating to the back is present in only a fraction of cases. Many patients present with atypical features: stroke-like neurologic deficits, abdominal pain, syncope, leg ischemia, or what initially appears to be an acute coronary syndrome. Vital-sign asymmetry between arms is a finding that should prompt immediate consideration of dissection, yet it is often unmeasured or unrecorded.

The diagnosis is missed not because the disease is hidden, but because the clinician never considered it.

Anchoring, premature closure, and the gravitational pull of a working diagnosis (heart attack, musculoskeletal pain, anxiety, stroke) are recurring themes in cases where dissection was identified only at autopsy or after catastrophic deterioration.

Most missed dissections originate in the emergency department. The recurring fact patterns are familiar to physicians who review these matters.

• Triage histories that omit the abrupt, maximal-at-onset character of the pain.
• Failure to obtain bilateral upper-extremity blood pressures.
• Reliance on a normal electrocardiogram and troponin to "rule out" a cardiovascular emergency that is not coronary in origin.
• Discharge with a diagnosis of musculoskeletal pain, anxiety, or atypical chest pain without imaging capable of identifying dissection.
• Failure to escalate when the patient's pain, hemodynamics, or neurologic status do not fit the working diagnosis.

These failures are not always individual. They frequently reflect system breakdowns: crowded departments, shift handoffs, unclear ownership of the patient, and protocols that do not prompt the question: could this be a dissection?

Imaging is the path to diagnosis. CT angiography of the chest, abdomen, and pelvis is the most widely used modality; transesophageal echocardiography and MR angiography play defined roles in the right clinical context. The technology is broadly available. The question is whether it is ordered and interpreted in time.

Documented imaging failures include studies ordered without contrast where contrast was indicated, dissection flaps overlooked on otherwise reported scans, hematoma mistaken for atherosclerotic change, and findings communicated in a written report without a direct call to the treating clinician when the situation demanded one.

In some matters, the imaging actually identified the dissection, and the patient still deteriorated because the report was not read, not communicated, or not acted on with the urgency the finding required.

Untreated Type A dissection carries a mortality estimated at roughly one to two percent per hour in the early phase. Surgical repair, when accomplished promptly, transforms the prognosis. Hours matter. So do minutes.

The downstream consequences of a missed or delayed diagnosis are among the most severe in medicine: stroke, paraplegia from spinal-cord ischemia, bowel infarction, limb loss, end-organ failure, and death. Survivors frequently face long rehabilitation, permanent neurologic deficits, and a substantially changed life.

Professional society guidance, including the joint American College of Cardiology and American Heart Association guidelines on thoracic aortic disease, sets out a structured approach to risk-stratifying patients for acute aortic syndromes. The framework emphasizes a careful history (abrupt, severe, ripping or tearing pain), physical examination (pulse and pressure asymmetry, focal neurologic findings, new aortic insufficiency murmur), and a low threshold for advanced imaging in patients whose presentation cannot otherwise be explained.

Whether the standard of care was met in a specific case turns on what the clinician knew, when, what was done with that information, and whether the workup reflected the differential diagnosis a reasonable physician would consider.

These are not simple cases. They require qualified experts in emergency medicine, cardiology or cardiothoracic surgery, and frequently radiology and critical care. Causation is contested: the defense will argue that the dissection was unsurvivable regardless of when it was identified, and the plaintiff must establish, through qualified opinion, that timely recognition would more likely than not have changed the outcome.

The record review is intensive. Triage notes, nursing flow sheets, physician documentation, vital-sign trends, imaging studies and the radiologist's draft and final reports, communications between providers, and the entire sequence of the stay must be reconstructed with precision. Small entries, such as a single pressure reading or a single note about the character of pain, can carry significant weight.

Maryland malpractice procedure adds its own demands, including the certificate of qualified expert and the structured discovery the rules require. These matters are not pursued on speculation. They are pursued on the record.

A serious dissection case takes months of preparation before any meaningful position can be advanced. The medical records often run to thousands of pages. Imaging must be obtained, preserved, and shown to the right experts. Hospital policies and triage protocols are relevant. The chronology must be exact.

The practice does not accept these matters lightly. Mr. Russo evaluates each potential dissection case for medical merit, evidentiary support, and the resources required to litigate it to a meaningful resolution. Selective intake is what makes the depth of preparation possible.

Medical malpractice claims in Maryland are governed by the Health Care Malpractice Claims Act and proceed initially through the Health Care Alternative Dispute Resolution Office before they may be filed in circuit court. A certificate of a qualified expert and an accompanying report are required. Strict deadlines apply, and the discovery rule that governs when a claim accrues is fact-intensive in vascular cases where the consequences may have evolved over time.

Cases on the Eastern Shore most often proceed in the Circuit Courts for Wicomico, Worcester, Talbot, Queen Anne's, and Dorchester Counties. Matters with venue in the District of Columbia follow different procedural rules and are handled accordingly.

Families are usually not in a position to evaluate medical causation on their own. What they can do is preserve the record. Request complete medical records from every facility involved, including imaging on disc rather than reports alone. Write down the sequence of events while memory is fresh. Note the names of providers and the times of significant decisions if those details are available.

From there, a confidential conversation with counsel experienced in vascular malpractice can determine whether the facts warrant the expert review a serious case requires. The practice undertakes that conversation without obligation.