Vascular Quality Initiative - Carotid Artery Stent Last Name First Name Middle Initial Date of Birth Medical Record Social Security General Information Patient Data Zip/Postal Code Gender Male Female Ethnicity Not Hispanic or Latino Hispanic or Race White Black or African American Height inches or cm Latino Asian More than 1 race American Indian or Alaskan Native Weight lbs or kg Native Hawaiian or other Pacific Islander /other Admission Data Visit code (not required) Admit Date Discharge Date Primary Physician Surgery Date Did Primary Physician bill to Medicare Part B? No Yes Assistant Medicare Health Insurance Claim Discharge Status Home Rehab Unit Nursing Home Dead Other Hospital Skilled Nursing Facility If dead, date of death Transferred from? No Hospital Rehab Unit Demographics Smoking Never Prior (>1 yr) Hypertension No Yes (>=140/90 or history) Current (within 1 yr) Diabetes None Diet Oral Meds Beta Blockers No Op Day only Insulin Pre-op 1-30 days Chronic > 30 days Intolerant CAD None hx MI but no sx CABG/ None <5yr >=5yrs ago Symptoms Stable Angina Unstable PTCA Angina or MI < 6 mos CHF None Asymp, hx CHF COPD No Not Treated On Meds Mild Severe On Home Oxygen Dialysis No Functioning Transplant Creatinine mg/dl OR umol/l On Dialysis Stress Test Not Done Normal Pre-adm Living Home Nursing Home (+)ischemia (+)MI (+)both
ASA 1=Normal/healthy 2=w/Mild Systemic dx Pre-op Hemoglobin g/dl OR g/l Class 3=w/Severe Systemic dx 4=w/Severe Systemic dx That's Constant Threat to Life 5=Moribund/not Expected to Survive w/o Op Previous Arterial Bypass No Yes CEA No Yes Aneurysm Repair No Yes PTA/Stent No Yes Major Amp No Yes Pre-Op Medications ASA No Yes Intolerant Plavix No Yes Intolerant Statin No Yes Intolerant History Symptoms: Ocular Ipsilat Asymptomatic Ocular Contralat Asymptomatic Cortical Ipsilat Asymptomatic Cortical Contralat Asymptomatic If Ocular Ipsilat, Ocular Contralat, Cortical Ipsilat or Cortical Contralat equals minor or major stroke: Rankin Score 0 1 2 3 4 5 Vertebrobasilar Asymptomatic Non-Specific No Yes Previous Ipsilat CEA No Yes Previous Contralat CEA No Yes Previous Ipsilat Carotid Stent No Yes Ipsilat Stroke on CT/MRI? No Yes Medical High Anatomic Not done Risk No Yes High Risk No Yes Refused for Surgery No Yes Pre-op: Duplex No Yes MRA No Yes CTA No Yes Arteriogram No Yes
ICA Stenosis: Ipsilateral <50% >50% Contralateral <50% >50% >60% >70% >60% >70% >80% Occluded >80% Occluded Procedure Urgency Elective Site IR Anesthesia Local General Urgent Cardiac Cath Emergent OR, fixed OR, mobile Side Right Left Lesion Atherosclerosis Lesion Length mm Type Re-Stenosis Dissection Trauma Other Stenosis by % Second Stenosis No Yes If yes, Second Angiography Stenosis Severity % Upper Extent C1 C2 Approach Femoral Prophylactic Antibradyarrhythmic No Yes of Lesion C3 C4 Trans-Carotid (Location) C5 C6 Brachial Heparin No Yes Protamine No Yes Contrast Volume ml Bradyarrhythmia No Yes Protection No Yes Requiring Tx Device Failure Neurologic No Yes If Neurologic Change is Decreased LOC Seizure Change Yes, Neuro Change Type Stroke Other Lesion(s) Treated CCA Only Bifurcation or ICA Only CCA + Bifurcation or ICA Heart Rate: On Arrival in OR bpm Highest intra-op bpm Common Carotid Artery Pre-dilate Before Protection Device No Yes Protection Device None Angioguard Accunet Filterwire Percusurge Retrograde Flow Neuroshield Other Emboshield Spider Technical Failure No Yes If Technical Failure is Yes, Cause of Failure Can't Canulate CCA + Sheath Can't cross lesion Other If Technical Failure is No: Pre-dilate Before Stent No Yes Stent Type Wall Precise Acculink Other Xact Nexstent Vivexx Stent Diameter mm Tapered No Yes Stent Length mm of Stents Post Dilate No Yes Balloon Diameter mm (largest size used during procedure)
Bifurcation or ICA Pre-dilate Before Protection Device No Yes Protection Device None Angioguard Accunet Filterwire Percusurge Retrograde Flow Neuroshield Other Emboshield Spider Technical Failure No Yes If Technical Failure is Yes, Cause of Failure Can't Canulate CCA + Sheath Can't cross lesion Other If Technical Failure is No: Pre-dilate Before Stent No Yes Stent Type Wall Precise Acculink Other Xact Nexstent Vivexx Stent Diameter mm Tapered No Yes Stent Length mm of Stents Post Dilate No Yes Balloon Diameter mm (largest size used during procedure) Post-Op Data Ipsilat Neurological Event No Time of Onset Intra-op < 6 hrs post-op >= 6 hrs post-op Contralat Neurologic Event No Time of Onset Intra-op < 6 hrs post-op >= 6 hrs post-op 2b3a Inhibitor Post-op No Yes Reperfusion Symptoms None Seizure or Hemorrhage Myocardial Infarction No Troponin Only Dysrhythmia (new) No Yes EKG or Clinical CHF No Yes Access Site Cx No Minimal Hematoma/PA Hematoma/PA Req. Transfusion Required Operation IV Med Required For: Arterial Occlusion Hypertension No Yes Hypotension No Yes Discharge Medications: ASA No Yes Intolerant Plavix No Yes Intolerant Statin No Yes Intolerant Beta-Blocker No Yes Intolerant Other Antiplatelet No Yes Intolerant v1.12
Vascular Quality Initiative - Carotid Artery Stent Follow-Up Last Name First Name Middle Initial Date of Birth Medical Record Social Security Visit code (not required) Zip/Postal Code Physician Procedure: Carotid Artery Stent Surgery Date Side: General Information Date of Contact Contact By Face to Face Current Smoking No Phone Yes No Follow-up Possible Current Living Status Home Date of Death Cause Operation Related Nursing Home Non-Related Dead Unsure Current Medications ASA No Plavix No Coumadin No Beta Blocker No Statin No Yes Yes Yes Yes Yes Intolerant Intolerant Intolerant Intolerant Intolerant Carotid Artery Stent Ipsilat Neurological Event No Date of Event: Contralat Neurologic Event No Date of Event: Duplex CEA Site <50% >50% >60% >70% >80% Occluded Not Done CAS Site Re-intervention No Yes If Yes, Date of PTA/Stent: CAS Site Endarterectomy No Yes If Yes, Date of Procedure: v1.12