PAOD REGISTRY CASE REPORT FORM
User Name:
Iware
Site No:
001
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patient List
Schedule Overview
Puncture site
Single access (Crossover or Antegrade)
Multiple accesses:
sheath:
Fr or
sheathless
Radial
Femoral
Brachial
distal SFA
PTA
ATA
Dorsal pedis
other
Right
Left
Result of diagnostic angiography:
(Diameter stenosis >50% with hemodynamic significance)
Numbers of disease vessels:
iliac
femoropopliteal
ATA
PTA
peroneal
Tibioperoneal trunk
Patency of below the ankle vessels:
DPA
Plantar artery
Nil
Target vessels
Right
Left
Iliac
CFA
SFA
Pop
PTA
Peroneal
ATA
TPT
Below the ankle lesions