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embolization procedure
CRF #10
Site
Albany Medical Center (01)
UCSF (02)
LIJ/Northwell (03)
U Penn (04)
Yale (05)
Charlotte Radiology (06)
Patient Number
Please enter in three digit format (e.g., 001, 002, ..., 025)
Is this an original or revised submission?
Original
Revised
Name of the Person Entering Data into this CRF
First Name
Last Name
EMBOLIZATION PROCEDURE
Date of Embolization Procedure
MM
DD
YYYY
Attending Physician
Procedural Assistant
Serum Pregnancy Test
Positive
Negative
Arterial Access
Right Common Femoral Artery
Left Common Femoral Artery
Bilateral Common Femoral Artery
Left Radial Artery
UFE Procedure Start Time (Time of Time-Out)
Hour
Minute
Second
AM
PM
Sheath Size
No Sheath
4-French
5-French
6-French
7-French
Microcatheter
Yes
No
If "yes" for microcatheter, please specify the brand:
COMPLETE THIS SECTION IF EMBOZENE MICROSPHERES WERE USED
Technically Successful UFE
Yes
No
If Embozene Microspheres were used, specify the first size used.
500 Microns
700 Microns
900 Microns
Specify the volume (mL) of the first size of Embozene Microspheres used for embolization
If Embozene Microspheres were used, specify the second size used.
No Additional Sizes of Embozene Microspheres Were Used
700 Microns
900 Microns
Specify the volume (mL) of the second size of Embozene Microspheres used for embolization
If Embozene Microspheres were used, specify the third size used.
No Additional Sizes of Embozene Microspheres Were Used
900 Microns
Specify the volume (mL) of the third size of Embozene Microspheres used for embolization
COMPLETE THIS SECTION IF EMBOSPHERE MICROSPHERES WERE USED
Technically successful UFE
Yes
No
If Embosphere Microspheres were used, specify the first size used.
500-700 Microns
700-900 Microns
900-1200 Microns
Specify the volume (mL) of the first size of Embosphere Microspheres used for embolization
If Embosphere Microspheres were used, specify the second size used.
No Additional Sizes of Embozene Microspheres Were Used
700-900 Microns
900-1200 Microns
Specify the volume (mL) of the second size of Embosphere Microspheres used for embolization
If Embosphere Microspheres were used, specify the third size used.
No Additional Sizes of Embozene Microspheres Were Used
900-1200 Microns
Specify the volume (mL) of the third size of Embosphere Microspheres used for embolization
ADDITIONAL PROCEDURAL INFORMATION
Additional Vessels Embolized
Yes
No
If "yes" for additional vessels embolized, please specify which vessels were embolized.
Procedure End Time (Sheath Removal)
Hour
Minute
Second
AM
PM
Closure Device Utilized
Yes
No
If "yes" for closure device utilized, please specify which closure device was used.
Total Fluoroscopy Time (Minutes)
Cumulative Dose (mGy)
Dose Area Product
ADVERSE EVENTS
Intra-Procedural Adverse Event
If "yes," please complete an adverse event (AE) CRF for each event.
Yes
No
Attestation
*
I approve the data entered into this CRF and attest to its accuracy.
Date of Completion
MM
DD
YYYY
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