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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