Misdiagnosis of Thoracic Aortic Emergencies Occurs Frequently Among Transfers to Aortic Referral Centers: An Analysis of over 3700 patients
George Arnaoutakis1, Edgar Aranda-Michel2, Yancheng Dai2, Reed Holmes1, Thomas Beaver1, Derek Serna-Gallegos3, Tomas Martin1, Forozan Navid3, Ibrahim Sultan3.
1University of Florida, Gainsville, FL, USA, 2University of Pittsburgh, Pittsburgh, PA, USA, 3University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
OBJECTIVE: Acute aortic syndromes (AAS) are prone to misdiagnosis by facilities with limited diagnostic experience. Prior studies have focused on single institution experience. We evaluated regional variability in these misdiagnosis trends among patients transferred to different regional quaternary care centers with presumed AAS.
METHODS: Two institutional aortic center databases were retrospectively reviewed for emergency transfers in patients with diagnosis of acute aortic dissection (AAD), intramural hematoma, penetrating aortic ulcer, thoracic aortic aneurysm, or aortic pseudoaneurysm between 2008 and 2020. Transferring diagnoses versus actual diagnoses were reviewed using physician notes and radiology reports. Misdiagnoses were confirmed by a board-certified cardiothoracic surgeon.
RESULTS: A total of 3,772 inpatient transfers were identified, of which 1,762 patients were classified as emergency transfers. Mean age was 64 years (58% male). Patients were transferred from 203 different medical centers by ground (51%) or air (49%). Differences in transfer diagnosis and actual diagnosis were identified in 188 (10.7%) patients. Of those, incorrect classification of Type A vs B dissections was identified among 23% while 30% of patients with a referring diagnosis of an AAD did not have one. 14% transferred for contained/impending rupture did not have signs of rupture. All misdiagnoses were secondary to misinterpretation of imaging, with motion artifacts (n=32, 17%) and post-surgical changes (n=44, 23%) being common sources of diagnostic error.
CONCLUSIONS: Misdiagnosis of AAS commonly occurred in patients transferred to two separate large aortic referral centers. While diagnostic accuracy may be improving, there are opportunities for improved physician awareness through standardized web-based imaging education
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