Download Temporal Artery Biopsy - Meridian Surgery Center

Robert C Wright, MD, PS – Puyallup Washington
Informed Consent – Temporal Artery Biopsy
Your symptoms and physical exam suggest a disease of your blood vessels that could have potentially
devastating consequences, such as blindness. Your doctors would like a sample of an artery to prove the
presence of disease in your arteries, and request a biopsy of your temporal artery, located to the side of your
forehead.
Description of the Procedure
The operation may be performed under local anesthesia. A small incision is made above and along the
side of your ear on your temple. The temporal artery is identified and a segment is removed, tying off
the two remaining ends of the artery. The forehead wound is closed.
Risks/Complications of Procedure
Treatment risks fall into two categories; those that could happen during any operation under
anesthesia, and those specific for a biopsy. In any medical treatment, it is impossible to predict all the
things that could go wrong. Fortunately, complications are the exception rather than the rule. Every
reasonable effort is made to avoid complications. The most common possible complications are as
follows:
1.
Bleeding – this is a problem that could happen any time the skin is cut. The need for a blood
2.
transfusion is rare.
Infection – we take special care to prevent infection, but it is always a possibility. Vasculitis
increases the risk of a wound infection.
3.
4.
5.
6.
Reactions to medications – this could be many things, from a minor rash to possible death.
Reactions to anesthesia and surgery – this could show up as a heart attack, blood clots,
pneumonia, sore throat, or potential death (in rare cases).
Poor wound healing – breakdown of the incision.
Inability to identify the disease of the artery – most arterial diseases such as temporal arteritis
manifests as spotty areas in the blood vessels. Thus, it is possible that you can have arterial disease
that just will not show up. Also, the biopsy specimen may not show the disease if you have been on
steroids for more than a week.
Anticipated Recovery/Expected Rehabilitation
Recovery is quite variable, depending on the individual. Under most circumstances, you should be able to
return to work the next day. Sutures are usually removed (if necessary) in seven to fourteen days.
(see other side)
Consent for Treatment
I understand my condition to be an arterial disease, and am aware of its risks if undiagnosed and
untreated. I have read and understand the above explanation of the procedure being proposed. My
surgeon has answered my questions, and I choose to proceed with surgery.
I understand that every operation may yield unexpected findings. I give the surgeon permission to act on
his best judgment in deciding to remove or biopsy tissues that appear to be diseased, understanding that
complications may arise from that action.
I understand that the proposed operation is diagnostic only, and is used solely to guide your physicians in
your treatment. It is possible that the results of the biopsy may be misleading or inconclusive. No
absolute guarantee can be offered.
HIPAA: Before and after surgery, unless otherwise requested in writing by you, visitors whom you invite
to attend the surgery will be informed of the surgical finding, your surgical status, and anticipated
recovery issues for effectiveness of communications. Because of the anesthetic, you may or may not
remember these important details.
PRINT NAME__________________________________________________________________________
SIGNATURE ______________________________________________ DATE _________________
WITNESS ________________________________________________ DATE _________________
SURGEON ________________________________________________ DATE _________________
RELATIONSHIP TO PATIENT IF SIGNATURE OF LEGAL GUARDIAN ________________________________
I waive the right to read this form, and do not want to be educated and informed of treatment risks;
nonetheless I understand the need for this surgery and grant permission to the surgeon to proceed on my
behalf.
SIGNATURE _____________________________________________________ DATE ______________
rev 11/04/pjd