Data Collection for Medicare Facilities Performing Carotid Artery Stenting with Embolic Protection in Patients at High Risk for

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Date of
Record
procedure
#
mm/dd/yyyy
1
2
3
4
5
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10
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44
45

Patient SSN

Last nsme

First
name

Medicare ID

Date of Birth
mm/dd/yyyy

Gender
1=male
2=female

46
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Patient is
symptomatic
1=yes 2=no

Patient has
angina
1=yes 2=no

Patient has
contralateral
occlusion
1=yes 2=no

Patient meets high
surgical risk criteria
1=yes 2=no {see
Appendix)

CHF class (use
Arabic digits)

Modified Rankin
scale score if
patient had stroke

Lesion location
left=1 right=2
both=3

Location of stent
left=1 right=2
both=3

Location of lesion
within carotid ICA=1
CCA=2 both=3

% stenosis by
angiography

% stenosis of 2nd
lesion by angiography
(if applicable)

Device manufacturer
Guidant=1 Cordis=2
Abbott=3 Other=4

Embolic protection
used 1=yes 2=no

Any
complications
1=yes 2=no