En 腔静脉支架植入术知情同意书.doc

Modern Hospital GuangzhouInformed Consent of Superior/Inferior Vena Cave Balloon Dilatation (+Stent Implantation) Patient name：Sex：Age：Case No：Brief description of disease and treatment recommendationsI am aware that I have been diagnosed with and recommended to undergo under anesthesia. Superior/Inferior vena cave stenosis or occlusion could lead to venous return obstacle. Superior vena cave lesion could lead to head and neck swelling. Inferior vena cave could lead to hepatic congestion, portal hypertension and return obstacle of veins of lower extremity etc. Main symptoms are abdominal distension, ascites, edema of both lower extremities and venous ulcer etc.Other Potential risks and handling:I have been informed that this procedure carries potential risks. However, certain uncommon risks are not included hereinto. The method of surgery should be individualized based on medical condition. I have been informed that I am entitled to discuss with my physician regarding the surgery and any associated special questions. 1I understand that all anesthetic procedures carry potential risks. 2I understand that all drugs might cause unwanted side effects, including mild symptoms such as nausea and rashes, serious anaphylactic shock, and even life-threatening events.3I understand the risks associated with this procedure and corresponding measures taken:Common risks for interventional diagnosis and treatment1）Anesthetic accident; Cardiovascular and cerebrovascular accidents (myocardial infarction, cerebral infarction, cerebral hemorrhage etc.); arrhythmia could be life-threatening. 2）Various infections during perioperative period, including puncture wound infection, implanted stent infection, lung infection, urinary system infection etc. ;3）X-ray-related damages;4）Hemorrhage, local hematoma of puncture site, false aneurysm, angiorrhexis of vascular approach or operation target; thoracic or celiac hemorrhage or posterior peritoneum hemorrhage; intervention-related damages lead to visceral hemorrhage (for example alimentary tract hemorrhage or urinary tract hemorrhage and intracranial hemorrhage etc.); severe cases can be addressed in a shock even death;5）Damage: Puncture could lead to arteriovenous fistula; peripheral nerve injury causes nerve irritation symptoms, temporary or permanent dysneuria; damage of surrounding organs could lead to certain symptoms; Catheter and guide wire damaging blood vessels could lead to plaque rupture, aortic dissection, angiorrhexis etc.6）Embolism: embolism of blood vessels of systemic organs or extremities could lead to certain ischemic symptoms, dysfunction or afunction;7）Contrast agents (or embolic agents) and intra-operative medications could lead to toxic and side effects, for example damaging kidney function and causing kidney failure; Drug allergy could lead to allergic shock etc.8）Knotting, angulation, fracture of catheter and guide wire and unable to remove them, which causes embolization etc; functional impairment of related organs and unexpected accidents of instrument and material etc lead to failure of interventional therapy or other accidents, which probably requires one-stage or two-stage open operation;9）Anatomic structure, leision feature or technical condition etc cause failure or discontinuation of interventional therapy, but the medical expenses are still borne by the patient;10) Postoperative deep venous thrombosis of lower limb; concurrence of pulmonary embolism and possibility of endangering life;11) Symptoms can not be relieved or even get worse after interventional therapy;12) Other accidents.Risks for this procedure: specific method will be decided based on actual circumstance during operation.1) Blood vessels are damaged during operation, which leads to massive hemorrhage, hemorrhage of thoracic and abdominal cavity, cardiac tamponade, retroperitoneal hemorrhage and shock and endangers patients life;2) Elastic recoil of local lesion after operation; residual stenosis; restenosis of immediate and long-term; another interventional therapy will be needed in case of serious cases;3) Postoperative local thrombosis of immediate and long-term or intimal hyperplasia; restenosis or obstruction; further treatment leads to concurrence fatal pulmonary embolism and endanger patients life;4) Stent blocking hepatic vein and renal vein opening could lead to thrombosis, congestion of related organs and dysfunction etc;5) Intra-operative or postoperative stent shifting of immediate and long-term, deformation or fracture, falling off into right atrium etc; operation or interventional therapy will be needed in severe cases;6) Stent damaging blood vessel of immediate and long-term after operation, massive hemorrhage, hemorrhagic shock, which threaten patients life;7) Postoperative primary disease and symptoms are not relieved or even progressed;8) Other accidents.9)4. I understand that if I have hypertension, heart disease, diabetes, hepatic and renal inadequacy and phlebothrombosis etc or if I am a smoker, the abovementioned risks might increase, or patients condition gets worse during or after operation; cardio-cerebralvascularaccident or even death might happen;5. I understand that due to inappropriate position or non-compliance of doctors recommendation, effects of the treatment might be affected.Special risks or major high-risk factorsI understand that the following special complications or risks may occur under current medical condition, apart from the forementioned situations: Appropriate measures will be taken in the case of the risks and accidents as described above. Choices of the patients informed consent l I have been informed of the method of surgery, complications and risks that may occur during surgery and postoperatively, and other possible treatment options. All questions regarding this procedure have been properly answered. l I agree that adjustments to scheduled method of surgery are allowed during surgery based on the medical condition. l I understand that this procedure requires the collaborative efforts by several physicians. l I am not ensured a 100% success of this procedure.l I authorize affected organs, tissues and specimens as well as imaging data that are involved in this procedure can be handled by the physician, which include pathological and cytological examinations, scientific studies, medical waste disposal, etc. l For the best of knowledge, I have disclosed my medical condition to the physician in a tru