Description of Event or Problem · 1
THE PATIENT UNDERWENT AN OFF-PUMP CORONARY ARTERY BYPASS (OPCAB) DUE TO TRIPLE VESSEL CORONARY ARTERY DISEASE. AS PART OF THE PROCEDURE, THE SURGEON USED THE PAS-PORT PROXIMAL ANASTOMOSIS SYSTEM (CLIP) WITH A SAPHENOUS VEIN GRAFT TO COMPLETE THE PROXIMAL ANASTOMOSIS OF A CORONARY ARTERY BYPASS. FOLLOWING DEPLOYMENT OF THE CLIP, THE SURGEON NOTED THE CLIP HAD PENETRATED THROUGH THE ANTERIOR WALL OF THE AORTA WHERE IT SHOULD HAVE BEEN AFFIXED, BUT RATHER WAS AFFIXED TO THE POSTERIOR WALL OF THE AORTA. BLEEDING WAS SEEN AT THE POSTERIOR WALL OF THE ASCENDING AORTA. THE SURGICAL STAFF MANUALLY STOPPED THE BLEEDING AND PLACED THE PATIENT ON CARDIOPULMONARY BYPASS TO REMOVE THE CLIP, REPAIR THE SITE OF BLEEDING, AND COMPLETE THE CORONARY ARTERY BYPASS SURGERY. SUBSEQUENTLY, BLEEDING WAS AGAIN NOTED FROM THE POSTERIOR WALL OF THE AORTA AND REQUIRED FURTHER REPAIR. THE PATIENT'S CONDITION BECAME UNSTABLE REQUIRING AN INTRA-AORTIC BALLOON PUMP AND PERCUTANEOUS CARDIOPULMONARY SUPPORT PRIOR TO COMPLETION OF THE SURGERY. ON (B)(6) 2020, THE PATIENT UNDERWENT FURTHER CHEST SURGERY FOR INCREASED BLEEDING FROM A SITE ASSOCIATED WITH USE OF A TEMPORARY PACEMAKER. NO BLEEDING WAS NOTED AT THE PREVIOUSLY REPAIRED AORTA. HOWEVER, THE PATIENT'S CONDITION DETERIORATED AND THE PATIENT SUBSEQUENTLY DIED DUE TO MULTI-ORGAN FAILURE.