Avulsion of the left internal mammary artery graft after minimally invasive coronary surgery: fatal complication or medical error? A case report

Minimally invasive direct coronary artery bypass (MIDCAB) is performed through a left anterior mini-thoracotomy without the use of a cardiopulmonary bypass and offers greater potential for more rapid recovery, reduced pain and a decreased need for blood transfusion than conventional coronary artery bypass grafting. Few major complications of the MIDCAB procedure have been reported in the literature since the first intervention was performed in 1995, but the most serious one is avulsion of the left internal mammary artery (LIMA) graft near the site of anastomosis with the left anterior descending coronary artery. Forensic issues regarding the role of the surgeon in causing this life-threatening emergency condition have not been discussed. We report here the case of a 48-year-old man who died 18 days after a MIDCAB of massive thoracic bleeding due to the avulsion of the LIMA graft. We discuss the probable etiopathogenesis of this fatal complication from a forensic point of view

Intersecting fractures of the skull and gunshot wounds. Case report and literature review

When two fracture lines of a solid surface (ice, glass, eggshell, etc.) intersect, it is always possible to tell which one has been made first. Indeed pre-existing damage of the surface arrests all the fracture lines produced by subsequent impacts. This well-known principle (established by Puppe in 1903) has been largely used in glass fracture analysis, but can be applied also to the examination of skull fractures. It can help sequencing blunt force or gunshot injuries determining the direction of fire and differentiating entrance from exit wounds in the absence of specific distinguishing features (i.e., internal/external beveling of the skull or overlying skin indicators). In this context, we report the case of a 76-year-old man who shot himself in the mouth with a Walther PPK 7.65 handgun and highlight the utility of the application of both Puppe's Rule and Multislice Computed Tomography (MSCT) in the examination of gunshot wounds to the skull