Carotid Stenting Procedure Note (CAS/TCAR)

Date: [Procedure date]
Time: [Start time] – [End time]
Location: [OR / Hybrid OR / Cath lab / IR suite]
Primary Operator: [Name, credentials]; Assistant(s): [Names and roles]
Anesthesia: [General / MAC / Local]; Airway at end: [Extubated / Intubated / LMA]

Procedure

Procedure type: [Transfemoral Carotid Artery Stenting (CAS) / TransCarotid Artery Revascularization (TCAR)] (If converted from planned approach, specify initial plan and reason for conversion.)
Laterality: [Right / Left]
Target vessel segment(s): [Common carotid artery (CCA) / Carotid bulb / Cervical internal carotid artery (ICA)]
Pre-procedure diagnosis: [Diagnosis]
Post-procedure diagnosis: [Diagnosis]

Indications and Clinical Context

Indication category: [Symptomatic carotid stenosis / Asymptomatic carotid stenosis]
Qualifying event: [Stroke / TIA / Amaurosis fugax]; Onset: [Time from event to procedure] (Include only for symptomatic patients.)
Imaging basis for stenosis: [Duplex / CTA / MRA / Diagnostic angiography]; Percent stenosis: [Percentage]; Measurement method: [NASCET / ECST / Other] (Use NASCET for ICA lesions when applicable.)
Rationale for stenting over endarterectomy: [Hostile neck / Prior CEA / Prior neck radiation / High carotid bifurcation / Unfavorable arch anatomy / Medical comorbid risk]
Baseline focused neurologic exam: [Mentation, speech, facial symmetry, gross motor function] (Note any pre-existing deficits.)

Pre-Procedure Verification

Consent: [Obtained from patient / Obtained from surrogate] (Key risks discussed: stroke, death, MI, access complications, contrast reaction, dissection, embolization; include cranial nerve injury for TCAR.)
Time-out: Completed, verifying patient identity, procedure, laterality, allergies, and antiplatelet status.
Antiplatelet therapy: [Agent(s), dose(s), timing relative to procedure] (If dual therapy not per protocol, document reason and alternate plan.)

Access and Monitoring

• (Transfemoral CAS) Arterial access: [Right / Left] [Common femoral artery / Radial / Brachial]; Technique: [Ultrasound-guided / Micropuncture / Landmark]; Sheath size: [French size]
  Aortic arch approach: [Catheter type and technique] (Note difficult or variant arch anatomy if encountered.)
• (TCAR) Surgical exposure: [Right / Left] neck; CCA access technique: [Description]; Venous access for flow reversal: [Right / Left] femoral vein, Sheath size: [French size] (Note anatomic constraints if present: short CCA, high bifurcation, prior neck surgery.)
• Hemodynamic monitoring: [Standard monitors / Arterial line]; Neurologic monitoring: [Awake neuro checks / EEG / Cerebral oximetry (NIRS)] (If monitoring limited, specify reason.)

Anticoagulation

Anticoagulant: [Heparin / Bivalirudin]; Dose: [Dose and units]; Timing: [Timing relative to lesion manipulation]
ACT monitoring: Baseline [Value] | Target [Range] | Peak [Value and time] | Additional boluses: [Yes with details / None]
(If protocol deviation occurred, document rationale.)

Lesion Characterization

Target lesion: [Laterality] [Segment: CCA / Bulb / Cervical ICA]; Pre-treatment stenosis: [Percentage] by [NASCET / Other method]
Estimated lesion length: [Length in mm]; Relation to bifurcation: [At / Proximal to / Distal to]
Morphology: Calcification: [None / Mild / Moderate / Severe] | Ulceration: [Present / Absent] | Suspected thrombus: [Present / Absent] | Tortuosity: [None / Mild / Moderate / Severe]
Intracranial angiography: [Patency, collaterals, and relevant findings] (Include only if performed.)

Embolic Protection

• Strategy: [Distal filter / Distal occlusion balloon / Proximal occlusion / Flow reversal (TCAR)]
• Device: [Manufacturer, model, size]; Deployment location: [Vessel segment or landmark]
• (TCAR) Flow reversal: Start: [Time] | Stop: [Time] | Total duration: [Minutes]; Adequacy: [Adequate / Limited with reason]; Circuit issues: [None / Description of troubleshooting]
• (Transfemoral EPD) Deployment: [Successful / Limited with details]; Retrieval: [Successful / Limited with details]; Debris captured: [Yes / No]; Device-related issues: [None / Spasm / Dissection / Other]
• (If no protection device used, document explicit rationale: anatomic limitation, device failure, inability to cross.)

Intervention

Crossing strategy: [Wire type and technique]; Lesion crossed without predilation: [Yes / No]
Predilation: [Balloon type, diameter × length, inflation pressure and duration] (Include only if performed.)
Stent deployment: [Manufacturer and type], [Diameter × length]; Landing zones: [Proximal and distal reference]; Deployment accuracy: [Optimal / Adjusted]
Postdilation: [Balloon size, inflation parameters] (Include only if performed.)
Completion angiography: Residual stenosis [Percentage] | Flow [TICI grade or descriptive] | Dissection: [Present / Absent] | Thrombus: [Present / Absent] | Distal emboli: [Present / Absent]
Additional interventions: [Dissection treatment / Thrombus aspiration / Additional stenting / Vasodilators for spasm] (Include only if required.)

Hemodynamic Events

Events: [None significant / Bradycardia / Asystole / Hypotension / Hypertension]
Timing: [Phase of procedure when event occurred]
Treatment: [Atropine / Glycopyrrolate / Vasopressors / IV fluids / Temporary pacing / Antihypertensives] with [Doses if applicable]
Outcome: [Resolved / Ongoing at end of case]
(This section must be explicitly documented; if no events, state "No significant hemodynamic events.")

Neurologic Assessment

• Pre-procedure baseline: [Reference to focused exam above or restate key findings]
• Intra-procedure monitoring: [Method used]; Changes observed: [None / Description with onset, symptoms, duration, actions taken, and resolution status]
• Post-procedure exam: [Alertness, follows commands, speech, motor function] (If intubated or sedated, note exam limited and document pupils and purposeful movement.)

Devices

• Stent(s): [Manufacturer, type, diameter × length] (Lot and serial number if available.)
• Embolic protection device: [Manufacturer, model, size]
• Balloon(s): [Type, diameter × length]
• Sheath(s): [Arterial site and French size; venous site and French size if applicable]
• Closure device: [Type and size] (Include only if used.)

Case Totals

Contrast: [Type] [Volume in mL]
Fluoroscopy: [Time in minutes] and/or [Radiation dose metrics]
Estimated blood loss: [Volume] (Include only if clinically significant.)
IV fluids/blood products: [Type and volume] (Include only if administered.)

Complications

[No immediate complications / Description of complication(s) with management and outcome] (Complications to consider: stroke or TIA symptoms, distal embolization, dissection, perforation, access site hematoma, cranial nerve injury for TCAR, allergic reaction, device failure.)

Closure and Disposition

• (Transfemoral CAS) Access closure: [Closure device type / Manual compression]; Hemostasis: [Achieved / Ongoing with plan]; Distal pulses: [Present / Diminished / Absent with action taken]
• (TCAR) Carotid arteriotomy closure: [Technique]; Neck hemostasis: [Adequate / Measures taken]; Drain: [None / Type placed]; Venous sheath removal: [Immediate / Delayed with plan]
• Condition at end: [Hemodynamically stable / Unstable with details]; Airway: [Extubated / Intubated]; Disposition: [PACU / ICU / Stepdown] to [Receiving service]

Post-Procedure Plan

• Antiplatelet therapy: [Agent(s) and dose(s)]; Start/resume: [Timing]; Planned DAPT duration: [Duration] (If concurrent anticoagulation indicated, specify coordinated strategy.)
• Blood pressure goals: [Target range and treatment thresholds]
• Neurologic checks: [Frequency] with [Escalation criteria]
• Access site monitoring: [Instructions] (For TCAR, include neck and cranial nerve checks.)
• Activity restrictions: [Bedrest duration, head-of-bed position, lifting limits, ambulation timing]
• Follow-up imaging: Carotid duplex at [Timeframe]; Clinic follow-up: [Service] at [Timing]

(Populate only fields supported by source documentation. If a section is not applicable, indicate "Not performed" or omit per local documentation standards.)