Deceased
Adrian Charles Wilfred Van Die
Demographics
50y, male
Coroner
Coroner L E Campbell
Date of death
2015-04-18
Finding date
2018-11-26
Cause of death
Multi-organ failure caused by low flow ischaemia of coeliac artery and superior mesenteric artery territory viscera, due to obstruction of the coeliac, renal and superior mesenteric arteries by an Intra-Aortic Balloon Pump
AI-generated summary
Adrian Van Die, a 50-year-old with severe ischaemic cardiomyopathy, underwent coronary artery bypass grafting with intra-aortic balloon pump (IABP) support. The first IABP ruptured intraoperatively and was replaced. The replacement balloon, though appropriately sized according to standard algorithms, was ultimately too long for this patient and obstructed his coeliac, renal, and superior mesenteric arteries, causing progressive visceral ischaemia. Early post-operative signs of organ hypoperfusion were difficult to recognise in the context of expected severe post-operative cardiac dysfunction. The coroner found no adverse findings against the treating team, as the procedure followed accepted practice and the complication was rare. Clinical lesson: IABP balloon sizing algorithms, while evidence-based, may not account for individual anatomical variation; heightened vigilance for early ischaemic injury signs is warranted despite diagnostic difficulty in complex cardiac surgical patients.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Clinical conditions
Procedures
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