CASE REPORT FORM BIOSCIENCE LESION FORM
CASE REPORT FORM BIOSCIENCE LESION FORM
CASE REPORT FORM BIOSCIENCE LESION FORM
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Database provided by<br />
© CTU and Cardiology Bern<br />
<strong>CASE</strong> <strong>REPORT</strong> <strong>FORM</strong><br />
<strong>BIOSCIENCE</strong><br />
<strong>LESION</strong> <strong>FORM</strong><br />
Pseudonym<br />
Date of Birth<br />
Date of Inclusion<br />
<strong>BIOSCIENCE</strong> Lesion,<br />
CRF Version 2.3<br />
May.2012<br />
1<br />
Database © Cardiobase<br />
CTU and Cardiology Bern, Switzerland<br />
and 2mt, Ulm, Germany
<strong>LESION</strong> <strong>FORM</strong> Lesion No: . . . . . . . . . .<br />
1. Identification of Lesion<br />
1.1 CASS number _______<br />
2. Characteristics of lesion<br />
2.1 Restenotic lesion yes no<br />
2.2 Total occlusion<br />
Yes, < 3 months old (including acute occlusion, e.g.STEMI)<br />
Yes, > 3 months old<br />
No<br />
2.3 Evidence of thrombus yes no<br />
If yes, specify:<br />
Thrombus categories to be assessed after initial guidewire passage<br />
Grade 1: Definite thrombus with greatest diameter 1/2 of<br />
vessel diameter but
3. Catheter size<br />
Catheter size diagnostic<br />
4F 5F 6F 7F<br />
Catheter size intervention<br />
4F 5F 6F 7F<br />
4. Access site radial femoral<br />
5.1 Specify Characteristics of Intervention<br />
Only dilatation yes no<br />
If only dilatation, with drug-eluting balloon? yes no<br />
5.2 Overview of present treatment<br />
Stent<br />
Nr.<br />
Type of stent<br />
Implantation<br />
pressure<br />
Unit<br />
Stent length<br />
(mm)<br />
Stent Diameter<br />
(mm)<br />
bar<br />
1<br />
bar<br />
2<br />
bar<br />
3<br />
bar<br />
4<br />
bar<br />
5<br />
5.2.1 Total number of stents implanted in this lesion ______<br />
<strong>BIOSCIENCE</strong> Lesion,<br />
CRF Version 2.3<br />
May.2012<br />
3<br />
Database © Cardiobase<br />
CTU and Cardiology Bern, Switzerland<br />
and 2mt, Ulm, Germany
5.2.2 Lesion treatment<br />
lesion pre-dilated<br />
direct stenting<br />
post-dilatation<br />
5.3 Overlapping stents implanted yes no<br />
if no, go to 4.6<br />
5.4 Treatment of a bypass lesion yes no<br />
5.4.1 Type of graft if no, go to 5.5<br />
Saphenous vein graft<br />
arterial graft<br />
5.4.2 Location of treated lesion<br />
Anastomosis<br />
Ostium<br />
Shaft<br />
5.5 Treatment of a bifurcation (including left main) yes no<br />
If yes, specify<br />
5.5.1 Side branch stenting yes no<br />
<strong>BIOSCIENCE</strong> Lesion,<br />
CRF Version 2.3<br />
May.2012<br />
4<br />
Database © Cardiobase<br />
CTU and Cardiology Bern, Switzerland<br />
and 2mt, Ulm, Germany
5.6 Post-procedural outcome<br />
5.6.1 Residual stenosis post-procedure (%) ______<br />
Determined by QCA Visual assessment<br />
5.6.2 Timi flow pre ______<br />
5.6.3 Timi flow post ______<br />
<strong>BIOSCIENCE</strong> Lesion,<br />
CRF Version 2.3<br />
May.2012<br />
5<br />
Database © Cardiobase<br />
CTU and Cardiology Bern, Switzerland<br />
and 2mt, Ulm, Germany
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