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Evaluation and Feedback Form (PTCA Balloon Catheters)
Product Name
Lot/Batch No.
Serial No.
Balloon Size (Diameter & Length) mm
Qty.:
Hospital Name & Address
Interventional Cardiologist
Date of Procedure
Telephone
Email
Patient details:
Age:
Sex:
Male
Female
Medical History / Risk factors (if any):
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
Comparison with routinely used competitor BALLOON: Brand name competitor:
Please rate your perception of the clinical challenge of this procedure:
Extremely Challenging
Moderately Challenging
Not Challenging
Please indicates lesion characteristics:
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°
Target vessel stenosis:
Chronic total occlusion:
Yes
No
In stent Restenosis lesion:
Yes
No
Ostial or Bifurcation lesion:
Yes
No
Type of procedure:
Pre-dilation
Post-dilation
Please rate the product performances:
Trackability
Excellent
Good
Satisfactory
Fair
Poor
Inflation time
Excellent
Good
Satisfactory
Fair
Poor
Push-ability
Excellent
Good
Satisfactory
Fair
Poor
Raidopacity
Excellent
Good
Satisfactory
Fair
Poor
Cross-ability
Excellent
Good
Satisfactory
Fair
Poor
Balloon integrity
Excellent
Good
Satisfactory
Fair
Poor
Entry profile
Excellent
Good
Satisfactory
Fair
Poor
Deflation time
Excellent
Good
Satisfactory
Fair
Poor
Balloon Compliance
Excellent
Good
Satisfactory
Fair
Poor
Inflation & Deflation:
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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