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Comprehensive Vascular and Endovascular Care

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Comprehensive Vascular and Endovascular Care


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26850 Providence Parkway
Suite 405
Novi, MI   48374
Phone: 248-465-4820
Fax: 248-662-3018
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Providence Medical Building
22250 Providence Drive
Suite 555
Southfield, MI   48075
Phone: 248-424-5748
Fax: 248-443-1706
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Sclerotheraphy Consent

Sclerotherapy Informed Consent

 

This form is designed to provide you with information you need to make an informed decision on whether or not to have sclerotherapy performed. If you have any questions or do not understand any potential risks, please do not hesitate to ask us.

 

WHAT IS SCLEROTHERAPY?
Sclerotherapy is a popular method for eliminating varicose veins and superficial telangiectasias (“spider veins”) in which a solution, called a sclerosing agent, is injected into the veins.

DOES SCLEROTHERAPY WORK FOR EVERYONE?
The majority of persons who have sclerotherapy performed will be cleared or at least see improvement.  Unfortunately, however, there is no guarantee that sclerotherapy will be effective in every case.  Approximately 10% of patients who undergo sclerotherapy have poor to fair results (“poor results” means that the veins have not totally disappeared after six treatments).  In very rare instances the patient’s condition may become worse after sclerotherapy treatment.

HOW MANY TREAMENTS WILL I NEED?
The number of treatment needed to clear or improve the condition differs from patient to patient, depending on the extent of varicose and spider veins present.  One to six or more treatments may be needed; the average is three to four.  Individual veins usually require one to three treatments.

WHAT ARE THE MOST COMMON SIDE EFFECTS?
The most common side effects experienced with sclerotherapy treatment includes the following:

  1. Itching. Depending in the type of solution used, you may experience mild itching along the vein route.  This itching normally lasts 1 to 2 hours but may persist for a day of so.
  2. Transient hyperpigmentation.  Approximately 10% of patients who undergo sclerotherapy notice discoloration (light brown streaks) after) after treatment.  In almost every patient the veins become darker immediately after the procedure.  In rare instance this darkening of the vein persists for 4 to 12 months.
  3. Sloughing. Sloughing occurs in less than 1% of the patients who receive sclerotherapy.  Sloughing consists of a small ulceration at the injection site that heals slowly over 1 to 2 months.  A blister may form, open, and become ulcerated.  The scar that follows should return to a normal color.  This occurrence usually represents injection into or near a small artery and is not preventable.
  4. Allergic reactions. Very rarely a patient may an allergic reaction to the sclerosing agent used.  The risk of an allergic reaction is greater in patients who have a history of allergies.

NOTE: Patients must read and sign a new consent form every 6 months

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Patient initial

 

*Copyright Dermatology Associates, San Diego County, Inc 1994

 

 

SCLEROTHERAPY: INFORMED CONSENT FORM

  1. Pain. A few patients experience moderate to severe pain and some bruising, usually at the site of the injection.  The veins may be tender to the touch after treatment, and an uncomfortable sensation may run along the vein route.  This pain is usually temporary, in most cases lasting 1 to at most 7 days.
  1. Telangiectatic matting. This refers to the development of new tiny blood vessels in the treated vessel.  This temporary phenomenon occurs 2 to 4 weeks after treatment and usually resolves within 4 to 6 months.  If occurs in up to 18% of women receiving estrogen therapy and in 2% to 4% of all patients.
  1. Ankle swelling. Ankle swelling may occur after treatment of blood vessels in the foot or ankle.  If usually resolves in a few days and is lessened by wearing the prescribed support stockings.
  1. Phlebitis. Phlebitis is a rare complication, seen in approximately 1 out of every 1000 patients treated for varicose veins greater than 3 to 4 mm in diameter.  The possible dangers of phlebitis include the possibility of a pulmonary embolus (a blood clot to the lungs) and post phlebitis syndrome, in which the blood clot is not carried out of the legs, resulting in permanent swelling of the legs.

WHAT ARE THE POSSIBLE COMPLICATIONS IF I DO NOT HAVE SCLEROTHERAPY PERFORMED?
In cases of large varicose veins (greater than 3 to 4 mm in diameter), spontaneous phlebitis and/or thrombosis may occur with the associated risk of possible pulmonary emboli.  Additionally, large skin ulcerations may develop in the ankle region of patients with long-standing varicose veins with underlying venous insufficiency.  Rarely these ulcers may hemorrhage or become cancerous.

ARE THERE OTHER TYPES OF PROCEDURES TO TREAT VARICOSE VEINS AND TELANGIECTASIAS?  WHAT ARE THEIR SIDE EFFECTS?
Because varicose and telangiectatic leg veins are not life threatening conditions, treatment is not mandatory in every patient. Some patients may get adequate relief of symptoms from wearing graduated support stockings.  Ambulatory phlebectomy is a procedure in which certain type of veins can be removed through small surgical incisions.  The complications of this procedure are similar to those of sclerotherapy with the addition of small surgical scars that naturally occur with this procedure.

Vein stripping and/or ligation may also be used to treat large varicose veins.  This procedure may require a hospital stay and usually is performed while the patient is under general anesthesia.  Risks of vein stripping and/or ligation include permanent nerve paralysis in a small percentage of patients, possible pulmonary emboli, infection, and permanent scaring.  General anesthesia has some associated serious risks, including the possibility of paralysis brain damage, and death.

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Patient initial

 

 

WHAT IF I EXPERIENCE A PROBLEM AFTER RECEIVING SCLEROTHERAPY?
If you notice any type of adverse reaction, please call the doctor immediately.

COMMENTS : ___________________________________________________________________________________

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BY MY INITIAL, I ACKNOWLEDGE THAT I HAVE RECEIVED A COPY OF THIS SCLEROTHERAPY INFORMED CONSENT FORM.


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Patient initial

 

 

 

BY SIGNING BELOW, I ACKNOWLEDGE THAT I HAVE READ THE FOREGOING INFORMED CONSENT FORM AND THAT THE DOCTOR HAS ADEQUATELY INFORMED ME OF THE RISKS OF SCLEROTHERAPY TREATMENT, ALTERNATIVE METHODS OF TREATMENT, AND THE RISKS OF NOT TREATING MY CONDITION, AND IN HEREBY CONSENT TO SCLEROTHERAPY TREATMENT PERFORMED BY DR. _______________

Date____________________ Time _______________am/pm

 

______________________________            _______________________________
Patient Signature                                             Patient Representative*

(*If patient is a minor or is incompetent, signature of Parent or Legal Guardian is required)

 

________________________________        _______________________________
Witness                                                           Relationship to Patient