Addressograph

1. Addressograph Carotid Endarterectomy NVD Proforma To be completed by surgical team Date procedure undertaken ______________ Date admitted to hospital ______________ Medical Hx DM IHD CCF PVD Renal Dialysis Pre-op lowest systolic BP ____mmHg Pre-op lowest diastolic BP ____mmHg Date referred to team _____________ Date first seen by team ______________ Who referred ______________ Symptomatic stenosis Y / N Date of index event ______________ Symptoms Amaurosis fugax TIA Stroke Grade of ipsilateral stenosis ____% Grade of contralateral stenosis ____% Date of diagnostic duplex ______________ Pre-op duplex Y / N specify date ___________________ Date of most recent event ______________ Previous ipsilateral carotid surgery Y / N Pre-op creatinine ___________ On antiplatelet prior to CEA Y / N specify ___________________ Warfarin stopped Y / N Pre-op statin Y / N specify ___________________ Pre-op β-BlockerY / N specify ___________________ Delay in surgery > 2 weeks Y / N specify ___________________ Which carotid Rx R / L Procedure start time______________ Finish time______________ Anaesthetic GA / LA Shunt used Y / N Endaterectomy Standard / Eversion Patch Y / N Distal tacking sutures Y / N Complications Y / N specify ___________________ Cranial nerve injury Y / N specify ___________________ Did Px return to theatre Y / N specify ___________________ Return completed to vascular lab by 5pm on day of surgery