Table 6

Extracranial Carotid and Vertebral Artery Disease Elements and Definitions

Element NameDefinition
Patient History
 AsymptomaticIndicate if the patient is asymptomatic. No prior stroke or TIA
 SymptomaticIndicate the onset and duration of symptoms.
 Previous strokePrevious stroke is defined as an acute loss of neurological function caused by an ischemic or hemorrhagic event with residual symptoms for at least 24 h or symptoms for <24 h with evidence of acute infarction (e.g., by CT or MRI).
If present, record stroke type:
  • Ischemic

  • Intracerebral hemorrhage

  • Subarachnoid hemorrhage

  • Unknown

If ischemic, list the most likely etiologies:
  • Large-artery atherosclerosis of the extracranial vessels (e.g., carotid)

  • Large-artery atherosclerosis of the intracranial vessels (e.g., middle cerebral artery stenosis)

  • Cardioembolism

  • Small-vessel occlusion (lacunar)

  • Ischemic stroke of other determined etiology (e.g., arterial dissection)

  • Ischemic stroke of undetermined etiology

 Transient ischemic attack (TIA)Documented history of TIA consisting of a transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction
Note the following:
  • Right retinal

  • Right hemispheric

  • Left retinal

  • Left hemispheric

  • Vertebrobasilar

  • Unknown distribution

Date of first and most recent episode
 ASA gradeChoose 1 of the following:
  • Grade I: Normal, healthy

  • Grade II: Mild systemic disease that does not limit activity

  • Grade III: Severe systemic disease that limits activity but is not incapacitating

  • Grade IV: Incapacitating systemic disease that is constantly life threatening

  • Grade V: Moribund; not expected to survive 24 h with or without surgery

 History of dementiaHistory of dementia, Alzheimer's disease, chronic confusion (at least 1 mo in duration), or senility
Year of onset (first diagnosis) may be helpful.
 SeizuresIndicate if the patient has a documented history of epilepsy.
 HemorrhageIndicate if the patient has a hemorrhage. Choose all that apply:
  • Intraparenchymal

  • Intraventricular

  • Subarachnoid

  • Subdural

 Cause of carotid/vertebral stenosisSelect any of the following that apply
  • Atherosclerosis

  • FMD

  • Dissection

  • Vasculitis (Takayasu's or giant cell arteritis)

  • Irradiation

  • Restenosis following CEA

  • Restenosis following CAS

  • Restenosis following vertebral angioplasty/stenting

Anatomic High-Risk Conditions
 Previous neck radiationIndicate if the patient had previous radiation therapy to the neck before the current admission or procedure.
 Previous neck surgery (other than CEA)Indicate if the patient had a previous extensive (i.e., radical) neck dissection (other than CEA) before the current admission or procedure.
 Previous carotid interventionYes or no. If yes, within <30 d, 31–180 d, or >180 d?
Note:
  • Right CEA

  • Right CAS

  • Left CEA

  • Left CAS

 Previous vertebral interventionYes or no. If yes, within <30 d, 31–180 d, or >180 d?
Note:
  • Left

  • Right

  • Proximal

  • Distal

 Previous ipsilateral CEAYes or no
 Tracheostomy presentIndicate if the patient has an open tracheostomy at the time of the current procedure.
 Cranial nerve palsy (32,33)Indicate if patient has a history of cranial nerve palsy/palsies. Choose 1 of the following:
  • Yes

    • If yes, indicate all nerves involved:

      • Recurrent laryngeal or its parent nerve, the vagus nerve

      • Hypoglossal

      • Facial

      • Other

  • No

Comorbid Cardiopulmonary Conditions
 History of chronic lung diseaseHistory of chronic lung disease (e.g., chronic obstructive pulmonary disease, chronic bronchitis, emphysema, restrictive lung disease) or currently receiving long-term treatment with inhaled or oral pharmacological therapy (e.g., beta-adrenergic agonist, anti-inflammatory agent, leukotriene receptor antagonist, or steroid)
Year of onset (first diagnosis) may be helpful.
 On home oxygenIndicate if, before the current procedure, the patient has been receiving home oxygen therapy for treatment of chronic lung disease.
 NYHA class III or IV in last 6 wkIndicate if the patient's highest NYHA cardiac functional class has been class III or IV at any time within 6 wk before the current procedure. Patients in NYHA classes III and IV have anginal or heart failure symptoms at rest and/or resulting in marked limitation of physical activity. NYHA classes III and IV are formally defined as follows:
  • Class III: Patient has cardiac disease resulting in marked limitation of physical activity. Patient is comfortable at rest. However, less than ordinary physical activity (e.g., walking 1 to 2 level blocks or climbing 1 flight of stairs) causes fatigue, palpitations, dyspnea, or anginal pain.

  • Class IV: Patient has dyspnea at rest that increases with any physical activity. Patient has cardiac disease resulting in inability to perform any physical activity without discomfort. Symptoms may be present even at rest. If any physical activity is undertaken, discomfort is increased.

Note: For patients without cardiac disease or patients with NYHA class I or II, code No.
Patient Assessment
 Carotid bruitsIndicate if carotid bruits are present. Choose 1 of the following:
  • Yes

    • Left

    • Right

    • Bilateral

  • No

  • Not assessed

 Supraclavicular bruitsIndicate if supraclavicular bruits are present. Choose 1 of the following:
  • Yes

    • Left

    • Right

    • Bilateral

  • No

  • Not assessed

 NIH Stroke Scale scoreIndicate if the NIHSS was used. Choose 1 of the following:
  • Yes

    • Indicate scores done before the procedure, immediately after the procedure, before discharge, and other.

  • No

 Modified Rankin Stroke Scale scoreIndicate the patient's score:
 ScoreDescription
  0No symptoms at all
  1No significant disability despite symptoms; able to carry out all usual duties and activities
  2Slight disability; unable to carry out all previous activities but able to look after own affairs without assistance
  3Moderate disability; requiring some help but able to walk without assistance
  4Moderately severe disability; unable to walk without assistance and unable to attend to own bodily needs without assistance
  5Severe disability; bedridden, incontinent, and requiring constant nursing care and attention
  6Death
 Barthel IndexIndicate if the Barthel Index was measured. Choose 1 of the following:
  • Yes

    • Indicate scores done before the procedure, immediately after the procedure, before discharge, and other.

  • No

 Specific neurologic findingsIndicate the presence or absence of the following:
  • Hemiparesis

  • Upper motor neuron facial weakness

  • Lower motor neuron facial weakness

  • Dysphasia

  • Hemisensory loss

  • Visuospatial neglect

  • Branch retinal artery occlusion

  • Central retinal artery occlusion

  • Dysarthria

  • Gait ataxia

  • Disconjugate gaze

  • Tongue deviation

  • Nystagmus

Diagnostic Procedures
 Carotid Duplex Ultrasound
  Date of procedureIndicate the date of the procedure (mo/d/y).
  Location of measurementMeasure each of the following in the right CCA, right ICA, left CCA, and left ICA.
  Plaque characteristicsIndicate if any of the following are present:
  • No plaque

  • Homogeneous plaque (stable)

  • Heterogeneous plaque (unstable)

  • Surface irregularity

  Intima-media thicknessIndicate intima-media thickness in millimeters.
  CCA systolic velocityMeasure systolic velocity in proximal, mid, and distal segments of CCA.
Measure velocity in centimeters per second.
  CCA diastolic velocityMeasure diastolic velocity in proximal, mid, and distal segments of CCA.
Measure velocity in centimeters per second.
  ICA systolic velocityMeasure systolic velocity in proximal, mid, and distal segments of ICA.
Measure velocity in centimeters per second.
  ICA diastolic velocityMeasure diastolic velocity in proximal, mid, and distal segments of ICA.
Measure velocity in centimeters per second.
  Peak ICA: distal CCA systolic velocity ratioIndicate systolic velocity radio measured in centimeters per second. Choose 1 of the following:
  • <2.0

  • 2.0–4.0

  • >4.0

  Degree of stenosisIndicate range of stenosis:
  • Normal

  • 1%–49%

  • 50%–69%

  • 70%–99%

  • Complete occlusion

  Carotid stent stenosisIndicate the range of stenosis after carotid stenting:
  • Normal

  • 1%–49%

  • 50%–69%

  • 70%–99%

  • Complete occlusion

  Carotid bifurcation locationIndicate the location of carotid bifurcation. Choose 1 of the following:
  • Normal

  • High

  Vertebral artery flow directionIndicate the direction of artery flow for the right and left vertebral artery. Choose 1 of the following:
  • Forward

  • Reversed

  • No flow detected

 CT Angiography
  Date of procedureIndicate the date the procedure was performed (mo/d/y).
  RadiologistLast name, first, middle
  Location of measurementMeasure each of the following in the right CCA, right ICA, left CCA, and left ICA.
  Luminal diameter of CCAMeasure diameter in millimeters.
  Luminal diameter of ICAMeasure diameter in millimeters.
  Degree of stenosisUse the NASCET method for measurement of stenosis defined by the formula
% stenosis=100×(1−minimum luminal diameter at the lesion site)/diameter of nontapering segment of distal ICA
  Nonobstructed diameter of ICAMeasure diameter in millimeters.
  Plaque characteristicsIndicate if any of the following are present:
  • Calcifications

  • Ulceration

  • Tandem lesion

  Intracranial atherosclerotic diseaseIndicate if intracranial atherosclerotic disease (>50% stenosis) is present in the distribution in either the right or left ICAs: Yes or no.
  Other vascular abnormalityIndicate if another vascular abnormality is present, including aneurysm, AVM, etc.
 Magnetic Resonance Angiography
  Date of procedureIndicate the date of the procedure (mo/d/y).
  Location of measurementMeasure each of the following in the right CCA, right ICA, left CCA, and left ICA.
  Diameter of CCAMeasure diameter in millimeters.
  Diameter of ICAMeasure diameter in millimeters.
  Degree of stenosisUse the NASCET method for measurement of stenosis defined by the formula
% stenosis=100×(1−minimum luminal diameter at the lesion site)/diameter of nontapering segment of distal ICA
  Nonobstructed diameter of ICAMeasure diameter in millimeters.
  PlaqueIndicate if any of the following are present and describe:
  • Fibrous cap thickness in millimeters

  • Fibrous cap disruption

  • Intraplaque lipid content

  • Intraplaque hemorrhage

  Tandem lesionIndicate yes or no.
  Other vascular abnormalityIndicate if another vascular abnormality is present, including aneurysm, AVM, etc.
  Intracranial atherosclerotic diseaseIndicate if intracranial atherosclerotic disease (>50% stenosis) is present in the distribution of either the right or left ICA: Yes or no.
Invasive Therapeutic Procedures: Carotid and Vertebral Artery Stenting
 Date of procedureIndicate the date the procedure was performed (mo/d/y).
 Target carotid vesselIndicate whether the target vessel is the right or left carotid artery for the current procedure: Right or left.
 Target vertebral arteryIndicate whether the target vessel is the right or left vertebral artery for the current procedure: Right or left.
 Is the current procedure part of a clinical trial?Yes or no. If yes, note trial type:
  • Postmarket surveillance

  • Premarket approval

  • IDE

  • Other (specify)

 AnesthesiaIndicate if the patient received general anesthesia, local anesthesia, or no anesthesia during the current procedure. If >1 method was used, code it General.
 Procedure Indications and Anatomic Variables
  Target lesion symptomatic within past 6 moIndicate if the patient has had neurologic symptoms related to the target lesion in the past 6 mo.
  Restenosis in target vessel after prior CASNote if the indication for the current procedure is restenosis in the target carotid artery that was previously treated with angioplasty and/or a stent. Carotid artery restenosis is defined as >50% diameter stenosis at or adjacent to the site previously treated with balloon angioplasty or a stent.
  Restenosis of target vessel after prior CEANote if the indication for the current procedure is restenosis in the target carotid artery that was previously treated with carotid artery endarterectomy. Restenosis is defined as renarrowing within or adjacent to a prior endarterectomy site, evidenced by >50% diameter stenosis.
  Carotid lesion difficult to access surgicallyIndicate if the lesion is difficult to access surgically for CEA.Yes or noNote: Lesions that are difficult to access include those that are high in the neck (e.g., at or above the level of C2) and those that are within the proximal one half or one third of the CCA, at or below the clavicle, rendering endarterectomy either difficult or impossible.
  Vertebral lesion difficult to access surgicallyIndicate if the lesion is difficult to access surgically.Yes or no
  Aortic arch typeIndicate the patient's aortic arch type configuration. The 3 types of aortic arch are based on the relationship of the innominate artery to the aortic arch. The more inferior the origin of the target artery (i.e., type II or III aortic arch), the greater the difficulty in gaining access to the carotid artery.
Category:
  • Type I

  • Type II

  • Type III

  Contrast volumeIndicate the volume of iodinated contrast injected during the procedure in milliliters.
  Fluoroscopy timeIndicate the total fluoroscopy time recorded during the procedure to the nearest 0.10 min. The time recorded should include the total time for the procedure.
  Contralateral carotid occlusionIndicate if there is known 100% occlusion of the patient's contralateral carotid artery.
  Contralateral vertebral occlusionIndicate if there is known 100% occlusion of the patient's contralateral vertebral artery.
  Bovine archIndicate if the patient's aortic arch is bovine, in which the right brachiocephalic and left carotid arteries share a common trunk from the aortic arch.
  Procedure arterial access siteIndicate the primary arterial access site used to perform the CAS procedure.
Note the location:
  • Femoral

  • Direct carotid puncture

  • Direct vertebral puncture

  • Brachial

  • Radial

  • Axillary exposure

  • Carotid cut down

  • Vertebral cut down

  Arterial access closure methodList methods and devices in chronological order of closure. Indicate the method used to achieve hemostasis. Methods should include devices and nondevices such as manual compression.
  Tandem lesionsIndicate if there is evidence of tandem lesions. Choose 1 of the following:
  • Yes

    • Specify location(s)

  • No

  Intracranial stenosisIndicate if there is evidence of intracranial lesions. Choose 1 of the following:
  • Yes

    • Specify location(s)

  • No

  Other intracranial pathologyIndicate if there is evidence of other intracranial pathology. Choose 1 of the following:
  • Yes

    • Specify type

  • No

 Lesions and Devices
  Target lesion locationList the following:
  • Isolated CCA

  • Isolated ICA

  • Bifurcation

  • Vertebral ostia

  • Vertebral artery ostia

  • Midcervical vertebral

  Visible thrombus presentIndicate if the target lesion contains thrombus as assessed by baseline angiography and implied by the presence of filling defect.
  UlcerationIndicate if the target lesion is ulcerated as assessed by baseline angiography.
  CalcificationIndicate if calcification is present. If present, specify the location.
Choose 1 of the following:
  • None

  • Mild

  • Moderate

  • Severe

  Lesion lengthIndicate the length of the target lesion in millimeters as assessed by baseline angiography.
  Minimal luminal diameterIndicate the MLD of the target lesion in millimeters as assessed by baseline angiography. The MLD is defined as the minimum luminal diameter derived from the angiographic view that shows the tightest point of the stenosis.
  Diameter of distal ICAIndicate the diameter of the nontapering distal segment of the ICA for NASCET measurement at the intended landing zone of the distal edge of the stent (where the vessel is no longer tapered and the walls become parallel).
Note: NASCET was a randomized clinical trial that compared the safety and efficacy of CEA to medical therapy for the prevention of stroke in symptomatic patients.
  Preprocedure percent stenosis of the carotid arteryIndicate the percent stenosis preprocedure, which is calculated as follows:
  • 1. When the tightest stenosis is in the ICA or at the carotid bifurcation, use the NASCET method. Percent diameter stenosis is calculated as 1−(minimum luminal diameter at the lesion site/diameter of nontapering segment of the distal ICA). The nontapering site is where the walls of the ICA become parallel.

  • 2. Do not use the NASCET method if the distal lumen collapses from a low-flow situation. In such cases, enter 99% because the stenosis may be graded as a near-occlusion.

  • 3. For stenosis localized to the CCA, percent diameter stenosis is calculated as 1−(minimum luminal diameter/diameter of the adjacent normal segment of the CCA).

  Preprocedure percent stenosis of the vertebral arteryIndicate preprocedure percent stenosis calculated as follows:
When the tightest stenosis is in the cervical vertebral artery (origin to dural entry), percent diameter stenosis is calculated as 1−(minimum luminal diameter of the nontapering segment of the distal vertebral artery). The nontapering site is where the walls of the vertebral artery become parallel.
  Lesion treatment incomplete or abortedIndicate if the lesion treatment was incomplete or aborted: Yes or no. If yes, note the reason(s):
  • Failure to gain vascular access

  • Unable to cross with guidewire

  • Unable to cross with balloon

  • Unable to deploy stent

  • Arrhythmia

  • Failure to confirm significant stenosis

  • Difficult to access because of tortuosity

  • Cardiac ischemia

  • Hypotension

  • Hypertension

  • Unable to deliver stent

  • Acute neurological event

  • Other

  Embolic protection attemptedIndicate if the operator tried to use an EPD:
  • Yes

  • Indicate if predilatation was done before balloon or stent.

  • List EPD devices in chronological order.

  • Note if successfully deployed.

  • No

If yes, indicate if predilatation was done before balloon or stent.
  • Yes

  • No

If yes, list EPD devices in chronological order.
  PredilatationIndicate if predilatation was performed before the attempted stent implantation or after EPD: Yes or no
  Stents implantedWere stents implanted? Yes or no. If yes, list stents in chronological order with the following information:
  • Stent

  • Brand

  • Model

  • Manufacturer

  Stents taperedYes or no
  Stent(s) diameterIndicate the diameter of the stent. If a tapered stent was used, indicate the smallest diameter of the tapered stent in millimeters.
  Stent(s) lengthIndicate the length of the stent in millimeters.
  Stent(s) malpositionIndicate if the stent was deployed in a location or position other than that for which it was intended.
  Postdilatation performedWas postdilatation performed? Yes or no. If yes, note the following:
  • Nominal balloon diameter in millimeters

  • Maximum inflation pressure in atmospheres

  Final MLDIndicate the final residual lumen diameter in millimeters.
  Final percent stenosis for carotid arteryIndicate percent stenosis postprocedure, calculated as follows:
  • 1. For an ICA site, use NASCET methodology. Percent diameter stenosis is calculated as 1−(minimum residual luminal diameter within the treated site/diameter of the nontapering segment of the distal ICA). The nontapering site is where the walls of the ICA become parallel.

  • 2. For a lesion and interventional site localized to the CCA, percent diameter stenosis is calculated as 1−(minimum residual luminal diameter/diameter of the adjacent normal segment of the CCA).

  Final percent stenosis for vertebral arteryValue is dependent on the largest stenosis using essentially similar NASCET criteria for vertebral disease.
Invasive Therapeutic Procedures: Carotid Endarterectomy
 Date of procedureIndicate the date the procedure was performed (mo/d/y).
 OperatorLast name, first, middle
 Is the current procedure part of a carotid trial?Yes or no. If yes, note the type of trial:
  • Postmarket surveillance

  • Premarket approval

  • IDE

  • Other (specify)

 Target carotid vesselIndicate whether the target vessel is the right or left carotid artery for the current procedure:
  • Right

  • Left

  • Common

  • Bifurcation

  • Distal internal

 AnesthesiaIndicate if the patient received general anesthesia, local anesthesia, or no anesthesia during the current procedure. If >1 method of anesthesia was given, code it General.
 Endarterectomy techniqueStandard or eversion
 Procedure Indications and Anatomic Variables
  Target lesion symptomatic within past 6 moIndicate if the patient has had neurologic symptoms related to the target lesion in the past 6 mo.
  Target lesion symptomatic within past 3 moYes or no
  Target lesion symptomatic within past 6 wkYes or no
  Restenosis in target vessel after prior CEANote if the indication for the current procedure is restenosis in the target carotid artery that was previously treated with CEA. Restenosis is defined as renarrowing within or adjacent to a prior endarterectomy site, evidenced by >50% diameter stenosis.
  Contralateral carotid artery occlusionIndicate if there is known 100% occlusion of the patient's contralateral carotid artery.
  Contralateral carotid artery stenosisYes or no
  Spontaneous carotid artery dissectionIndicate if the patient has had a spontaneous carotid artery dissection before the current procedure: Yes or no.
If yes, note the location:
  • Common carotid

  • Carotid bifurcation

  • Distal internal

  Tandem lesionsYes or no. If yes, note the location.
  Intracranial stenosisYes or no. If yes, note the location.
  Other intracranial pathologyYes or no. If yes, note the type.
 Intraprocedural Information
  Patch utilizationStandard technique?
  • Yes

    • If yes, indicate the type of patch (e.g., Dacron, PTFE, bovine pericardium, vein).

  • No

  Thrombus present on direct visual inspectionIndicate if a thrombus (blood clot) was present on direct visual inspection intraoperatively during the CEA procedure.
  Monitoring technique usedNote the following:
  • Awake monitoring

  • Selective monitoring based on EEG, stump pressure, SSEP, motor-evoked potential, anatomic, or other factor (describe).

  Shunting usedIndicate if a shunt was used. If yes, note the following:
  • Selective shunt based on EEG, stump pressure, SSEP, motor-evoked potential, anatomic, or other factor (describe)

  • Was a shunt indicated but not technically possible?

  Surgical procedure terminatedIndicate if the CEA procedure was terminated: Yes or no. If yes, note the reason(s):
  • Hypotension

  • Hypertension

  • Nerve compromise

  • Excessive scar tissue

  • Carotid artery thrombosis

  • Difficulty with anesthesia

  • Difficulty with suction

  • ICA string sign or atresia

  • Cardiac instability

  • Inability to implement shunting

  • Excessive bleeding

  • Inability to access lesion because of anatomical lesions

  • Other (specify)

  Intraoperative completion evaluationCheck all that apply:
  • None

  • Standard Doppler

  • Arteriogram (include findings)

  • Duplex scan (include findings)

  Intraoperative complicationsIndicate any of the following:
  • Reopening of carotid artery (note indication and findings)

  • Technical difficulties (describe)

  Patient outcome
  • Normal neurologic exam

  • Deficit (describe)

 Medications
  Antiplatelet therapy, aspirinYes or no. If yes, note type.
  Contraindicated clopidogrelYes or no
  Contraindicated ticlopidineYes or no
  Contraindicated otherYes or no
  Intraoperative anticoagulationIndicate the drug and dose used
Procedural Outcomes
 Intraprocedural/intraoperative adverse eventsIndicate adverse event(s) that occurred during or after the procedure. Specify time of occurrence relative to procedure:
  • Abrupt closure

  • Spasm requiring treatment

  • Loss of external carotid

  • Distal intracranial embolization

  • Embolization (systemic)

  • Embolization (carotid)

  • Thrombosis

  • Occlusive untreated dissection

  • Arrhythmia requiring treatment

  • Hypotension requiring treatment

  • Hypertension requiring treatment

  • Stroke (ischemic, hemorrhagic, unknown type)

  • TIA

  • Amaurosis fugax

  • Seizure

  • Puncture site complications

  • Death (or death in lab)

  • Intubation or resuscitation

  • Stent malposition

  • Embolic protection retrieval

  • Intracranial hemorrhage

  • Other (specify)

 Results
  • Procedure technical failure—unable to deploy stent

  • Procedure terminated for stenosis <70%

  • Procedure terminated because of complication before deployment

  • Procedure technical success without complications

  • Procedure technical success with complications

 Acute occlusionIndicate if there is acute occlusion <24 h after the procedure.
 Residual stenosisNote:
  • Right

  • Left

  • Bilateral

 Right-side percent stenosisIndicate right-side percent stenosis.
 Left-side percent stenosisIndicate left-side percent stenosis.
 Stent migration/deformationStent located in planned landing zone with complete lesion coverage
 Distal embolizationOcclusion of cerebral arteries or periprocedural neurologic deficit resulting from dislodgment of atheromatous debris or thrombus from the procedural site
 Postprocedural complications in hospitalIndicate if any of the following occurred:
  • None

  • Arrhythmia requiring treatment

  • Hypotension requiring treatment

  • Hypertension requiring treatment

  • MI

  • New unstable angina

  • Electrocardiographic changes

  • Cardiac enzyme elevations

  • Pulmonary embolism

  • Stroke (ischemic, hemorrhagic, unknown type)

  • Deterioration in Modified Rankin Scale score

  • TIA

  • Amaurosis fugax

  • Seizure

  • Intracranial hemorrhage

  • Hyperperfusion syndrome

  • Other neurologic complication (specify)

  • Secondary carotid intervention (specify)

  • Vessel thrombosis or ischemia of extremity

  • Puncture site complications

  • Pseudoaneurysm

  • Pseudoaneurysm vascular repair

  • Hematoma (local or retroperitoneal) (indicate if transfusion required)

  • Other bleeding (indicate if transfusion required)

  • Access site infection

  • Creatinine increase >1.0 mg/dL

  • Hemodialysis

  • Pneumonia

  • Urinary tract infection

  • Sepsis

  • Death

  • Other (specify)

Patient Education/Counseling
 Medication instructionVerbal and written medication instructions provided to patient and/or family
 Recognition of new or worsening symptomsVerbal and written instructions provided to patient and/or family (by physician or nurse) regarding new or worsening symptoms and when to call the physician
 Diet counselingAdvice given or discussion held with the patient and/or family about diet counseling related to lowering cardiovascular risk. May include
  • Sodium restriction

  • Fluid restriction

  • Other (specify)

 Referral to dietician for diet counselingReferral to dietitian for weight management and/or advanced nutritional instruction
 Activity counselingAdvice given or discussion held with the patient and/or family about activity level and restrictions in activity and/or exercise recommendations.
 Smoking cessation counselingAdvice given or discussion held with the patient (by physician, nurse, or other personnel) about the importance of stopping smoking. May include
  • Counseling (may be basic or advanced)

  • Written materials

  • Referral to smoking cessation program

  • Drugs to assist for smoking cessation

 Plan for follow-up careDocumentation of plan for follow-up care with physician and/or nurse
Should include date of follow-up
 Patient referralPatient referred to other care such as neurology, neurosurgery, vascular surgery, cardiology clinic/office.
Transitional care (specify duration):
  • Home health care

  • Nurse case manager

  • Hospice or palliative care

  • Home telemonitoring

  • Ambulatory cardiac telemetric monitoring (e.g., mobile cardiac outpatient telemetry)

  • Period of time enrolled in the program and/or qualitative characterization of the level of the patient's success/participation in the program(s) may be specified.

 Discharge statusIndicate the following:
  • Discharge NIHSS score

  • Discharge Modified Rankin Scale score

  • Discharge Barthel Index

  • Cranial nerve injury

  • Technical defects requiring revision

  • Stroke (ischemic, hemorrhagic, unknown type)—note date

  • TIA (single or multiple)—note date

  • Amaurosis fugax

  • MI (Q wave or non–Q wave)—note date

Outcomes
 Time pointsIndicate the period at which outcome measures are assessed. Choose all that apply:
  • 1 mo

  • 3 mo

  • 6 mo

  • 1 y

 Follow-up visitDocumentation of follow-up evaluation for patients with established carotid/vertebral arterial disease should include
  • Patient history

  • Functional status

  • Physical examination

  • Laboratory or other tests

 Date of visitIndicate the date of visit (mo/d/y).
 Follow-up NIHSS(See scale above.)
 Repeat duplex ultrasound performedIndicate if repeat duplex ultrasound was performed in any of the following time frames:
  • Before discharge

    • Yes

    • No

  • 3 mo

    • Yes

    • No

  • 6 mo

    • Yes

    • No

  • Annually

    • Yes

    • No

 Right-side percent stenosisIndicate right-side percent stenosis.
 Left-side percent stenosisIndicate left-side percent stenosis.
 MRA or CTA performedIndicate if MRA or CTA was performed in any of the following time frames:
  • Before discharge

    • Yes

    • No

  • 3 mo

    • Yes

    • No

  • 6 mo

    • Yes

    • No

  • Annually

    • Yes

    • No

 Right-side percent stenosisIndicate right-side percent stenosis.
 Left-side percent stenosisIndicate left-side percent stenosis.
 Follow-up Modified Rankin Scale score(See scale above.)
 Follow-up Barthel Index(See scale above.)
 StrokeIndicate stroke type:
  • Ischemic

  • Hemorrhagic

  • Unknown

Indicate whether or not the patient was hospitalized.
 Reason for terminationIndicate the reason for termination.
 DeathNote the following:
  • Date

  • Cause

  • Date of the last visit in which the patient was evaluated

  • Death within 30 d of last visit

  • Death 30 d after last visit

 Repeat Hospitalization
  Date of admissionIndicate the date of admission (mo/d/y).
  Primary reason for readmissionStroke, TIA, MI, other
  Repeat duplex ultrasound performed?Yes or no
  Right-side percent stenosisIndicate right-side percent stenosis.
  Left-side percent stenosisIndicate left-side percent stenosis.
  Was repeated MRA, CTA, or conventional angiogram performed?Yes or no
  Target lesion revascularizationIndicate whether CAS was performed.
  Target vessel revascularizationIndicate whether CEA or CAS was performed.
  Stent patencyIndicate whether the stent is patent and if restenosis is present:
  • Right-side percent stenosis

  • Left-side percent stenosis

ASA indicates American Society of Anesthesiologists; AVM, arteriovenous malformation; CAS, carotid artery stenting; CCA, common carotid artery; CEA, carotid endarterectomy; CT, computed tomography; CTA, computed tomographic angiography; EEG, electroencephalogram; EPD, embolic protection device; FMD, fibromuscular dysplasia; ICA, internal carotid artery; IDE, investigational device exemption; MI, myocardial infarction; MLD, minimal luminal diameter; MRA, magnetic resonance angiography; MRI, magnetic resonance imaging; NASCET, North American Symptomatic Carotid Endarterectomy Trial; NIH, National Institutes of Health; NIHSS, National Institutes of Health Stroke Scale; NYHA, New York Heart Association; PTFE, polytetrafluoroethylene; SSEP, somatosensory evoked potential; and TIA, transient ischemic attack.