Percutaneous Transluminal Coronary Angioplasty (PTCA)
You have been given information about your condition and the PTCA to be performed. This consent form is designed to provide a written confirmation of such discussions by recording some of the more significant medical information given to you. It is intended to make you better informed so that you may give or withhold your consent to the proposed procedure.
1. Condition: Dr. has explained to me that the following condition(s) exist in my case:
2. Proposed Procedure(s): I understand that the procedure proposed for evaluating and treating my condition is a PTCA.
Percutaneous Transluminal Coronary Angioplasty (PTCA)
What is PTCA and how is it performed?
Percutaneous Transluminal Coronary Angioplasty (PTCA) is a non-surgical treatment performed to is one of the most common non-surgical treatments for re-open obstructed blood vessels in that supply blood and oxygen to the heart. Under sedation, intravenous access is obtained in the groin or arm and a balloon-tipped catheter is guided through a small incision in the groin to the heart under X-ray guidance. Once the blockage is identified, the balloon is inflated to open up the clogged artery. and restore blood flow to the heart.
Why is the procedure done and what are the benefits?
When blood flow is blocked by an obstructed artery, a heart attack can result. PTCA is done to open the obstructed arteries and restore blood flow. Coronary artery disease is the narrowing of the vessels that supply blood and oxygen to the heart. This may be an alternative to a more invasive surgical procedure.
What to expect during the post-operative period?
After the procedure, your vital signs and the incision in the groin area will be monitored while you remain in bed. , closely. You may resume your diet right after the procedure but you must. until the catheter is removed. After 4-6 hours, the small, flexible catheter that was inserted for the procedure may be removed. This is to reduce the risk of bleeding from the blood-thinners that were given during the procedure and allow proper healing of the artery. Pain medication is given as needed.
By the next day you can gradually return to regular activity. You should drink lots of fluids and avoid driving, lifting heavy objects, and engaging in strenuous exercise or sexual activity for 24 hours after the procedure. Bruising and soreness at the incision is possible and normal.
Report undue pain, swelling or bleeding to your doctor. may require medical attention. Patients should discuss resuming all medications with their physician. Diabetics on glucophage are instructed to not resume this medication for 48 hours after the procedure. Patients are generally advised not to drive for 24 hours after the procedure is done. The results of the procedure will be discussed with you prior to discharge
What are the risks and complications of this procedure?
Just as there may be benefits to the procedure(s) proposed, medical and surgical procedures also involve risks. These risks include allergic reaction, bleeding, blood clots, infections, adverse side effects of drugs, heart attack, stroke and even loss of bodily function or life, as well as risks of transfusion reactions and the transmission of infectious disease, including hepatitis and Acquired Immune Deficiency Syndrome (AIDS), from the administration of blood and/or blood components.
There are particular risks and complications that are common for this procedure, and that these risks include, but are not limited to:
- Severe bruising/bleeding into the groin area: The risk is minimized by bed rest for 4-6 hours after the procedure, giving your artery time to heal.
- Superficial thrombophlebitis: irritation of the vein by the catheter.
- Hematoma: collection of blood under the skin (often where catheter was inserted).
- Changes in your heart rhythm: This can occur from the catheter irritating your heart.
- Allergic reaction or renal failure from the contrast dye used: Those with shellfish or iodine allergies have an increased risk of a reaction to the contrast dye used. The dye leaves the body from your kidneys. There is a small risk of kidney failure. It is important to stay well hydrated after the procedure.
- A tear or rupture of the artery that is being dilated: As the catheter is guided up to the heart, diseased vessels are stiffer with arteriosclerosis. The thin, flexible catheter can injure the blood vessels or the balloon can rupture the artery as it is being dilated.
- Possible formation of a blood clot in the artery that is instrumented and resultant heart attack: Call your doctor immediately if you have chest pain, extreme shortness of breath, dizziness, trouble speaking or swallowing, or paralysis in any part of your body during or after the test.
- Need for additional procedures: May increase the need for urgent bypass surgery. Also, opened areas may re-narrow, necessitating additional procedures.
- Endocarditis: infection or inflammation of the membrane that lines the heart.
- Cardiac tamponade: a collection of fluid in the space between the heart and the sac that surrounds it.
- Pneumothorax: build-up of air in the space between the lungs and the chest wall.
There is always a risk when being exposed to X-rays, although the benefits of this procedure likely outweigh any potential (and small) risk of the X-rays.
Before you agree to any operative procedure it is important to remember that each patient is different and that the outcome of any surgical procedure can never be guaranteed. You should understand that there may be complications that have not been mentioned and it is not possible to anticipate all complications or to answer each and every question.
Again, you should be aware that in the practice of medicine, unforeseen and unexpected risks or complications not previously discussed may occur. You should also understand that during the course of the proposed procedure(s) unforeseen conditions may be revealed requiring the performance of additional procedures, and such procedures may need to be performed.
Keep in mind that there is no substitute for an open and honest discussion with your own surgeon/physician regarding this procedure.
You should also be given any available treatment alternatives to this procedure by your doctor. Be sure to discuss any questions or concerns with your doctor.
3. Complications; Unforeseen Conditions; Results: I am aware that in the practice of medicine, other unexpected risks or complications not discussed may occur. I also understand that during the course of the proposed procedure(s) unforeseen conditions may be revealed requiring the performance of additional procedures, and I authorize such procedures to be performed. I further acknowledge that no guarantees or promises have been made to me concerning the results of any procedure or treatment.
4. Acknowledgments: The available alternatives, some of which include medication, the potential benefits and risks of the proposed procedure and the likely result without such treatment, have been explained to me. I understand what has been discussed with me as well as the contents of this consent form, and have been given the opportunity to ask questions and have received satisfactory answers.
5. Consent to Procedure(s) and Treatment: Having read this form and talked with the physicians, my signature below acknowledges that: I voluntarily give my authorization and consent to the performance of the abdominoplasty described above (including the administration of blood and disposal of tissue) by my physician and/or his/her associates assisted by hospital personnel and other trained persons as well as the presence of observers.
Patient (or person authorized to sign for patient) Date
Patient Social Security# Patient DOB
Witness Date
