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Product evaluation and Feedback form (DES)
Product Name
Lot/Batch No.
Serial No.
Stent Size (Diameter & Length) mm
Qty.:
Hospital Name & Address
Interventional Cardiologist
Date of Procedure
Telephone
Email
Patient Information:
Age:
Sex:
Male
Female
Please tick anatomical location of the stenosis:
1. RCA proximal
2. RCA mid
3. RCA distal
4. Right posterior descendens
5. Main stem
6. LAD proximal
7. LAD mid
8. LAD distal
Vessel / Position of Stenosis
9. First Digonal
10. Second digonal
11. Cricumflex proximal
12. Obtuse margina
13. Circumflex Distal
14. Postero-lateral from LCX
15. Postero -descendens from LCX
16. Postero-lateral from RCA
Please indicate lesion characteristics:
Lesion Type (Please Tick):
A
B1
B2
C
Lesion Morphology:
Lesion Type:
Eccentric
Concentric
Diffuse
Focal
Others
Lesion calcification:
Severe
Moderate
Little/none
Unknown
Vessel angulation:
<45°
45°-90°
> 90°
Type of stent thrombosis:
Acute
Sub-acute
Late
Very late
Target vessel stenosis:
Chronic total occlusion:
Yes
No
In stent Restenosis lesion:
Yes
No
Ostial or Bifurcation lesion:
Yes
No
Comparison with routinely used competitor DES:
Please rate your perception of the clinical challenge of this procedure
Extremely Challenging
Moderately Challenging
Not Challenging
Please rate the product performances:
Deliverability
Excellent
Good
Satisfactory
Fair
Poor
Stent Visibility
Excellent
Good
Satisfactory
Fair
Poor
Flexibility
Excellent
Good
Satisfactory
Fair
Poor
Stent Shortening
Excellent
Good
Satisfactory
Fair
Poor
Crossability
Excellent
Good
Satisfactory
Fair
Poor
Deflation time
Excellent
Good
Satisfactory
Fair
Poor
Conformability
Excellent
Good
Satisfactory
Fair
Poor
Pre-dilatation Stent
Excellent
Good
Satisfactory
Fair
Poor
Pushability
Excellent
Good
Satisfactory
Fair
Poor
Post-dilatation Stent
Excellent
Good
Satisfactory
Fair
Poor
Inflation time
Excellent
Good
Satisfactory
Fair
Poor
Inflation & Deflation Data:
Max. Inflation Pressure
Number of Inflation (n):
Used in Multiple lesion?
Yes
No
Inflation time
Deflation Time
Overall Performance
Better
Same
Poor
If Overall performance is rated “Poor”, could you please explain the reason:
Any Adverse Events/Complications
I further acknowledge the data privacy along with this report:
Name:
Telephone
Email:
SUBMIT
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Time 7:30 pm
DEBTalks
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