Endovascular Intervention Procedure Note (Lower-Extremity PAD)

Procedure Title: [Lower Extremity Angiography and Endovascular Intervention – Procedure Note]

Date: [Procedure date]

Start Time: [Start time]

Stop Time: [Stop time / not recorded]

Location: [Procedure location]

Primary Operator: [Name, credentials]

Additional Operators/Assistants: [Name(s) and role(s) / none]

Laterality: [right / left / bilateral] (required)

MRN/Encounter: [MRN and/or Encounter Number] (if available)

Indications and Diagnoses

[Clinical indication] (State the indication such as claudication, chronic limb-threatening ischemia, acute limb ischemia, tissue loss, rest pain, or abnormal noninvasive testing. Identify the target limb and vascular territory [aortoiliac / femoropopliteal / infrapopliteal-pedal]. If clinical severity classification is documented, include [Rutherford category] and/or [WIfI stage]; do not infer scores if not stated—use descriptive clinical severity instead.)

Pre-Procedure Diagnosis: [Clinical diagnosis based on history and noninvasive testing]
Post-Procedure Diagnosis: [Final angiographic diagnosis]

Pre-Procedure Verification

• [Informed consent obtained and documented] [yes / no—if no, state reason]
• [Correct patient, laterality, and planned access site verified] [yes / no—if no, explain]
• [Time-out performed immediately prior to access] [yes / no—if no, explain]
• [Antibiotic prophylaxis] [agent and dose / not given / not indicated per policy]
• [Pregnancy screening result] (Include only if applicable per institutional policy)

Sedation and Anesthesia

[Anesthesia type: local only / moderate sedation / MAC / general anesthesia] provided by [operator-directed / anesthesia team]. (If anesthesia team provided care, state type and refer to the anesthesia record for details.)

• Local anesthesia: [Agent and total volume at access site(s)]
• Moderate sedation (if operator-directed): Intraservice time: [start time] to [stop time] ([total minutes]). Independent trained observer present: [yes / no]

Vascular Access

(Document each access site. If access was converted after failed attempts, describe all attempts and the final successful access.)

[Access Site 1]

• Artery and laterality: [Artery name and side]
• Guidance: [ultrasound-guided / fluoroscopic landmarks / surgical cutdown] (If ultrasound-guided, state: vessel patency assessed, real-time needle entry visualized, images recorded.)
• Sheath: [Size Fr] × [Length cm]
• Anticoagulation: [Heparin with target ACT / alternative agent and target]
• Access attempts/conversions: [Attempts and sites tried, reason for conversion] (Include only if applicable)

[Access Site 2]

(Include only if additional access obtained.)

Diagnostic Angiography

Technique

Catheter positions and imaging runs: [Describe catheter positions and runs obtained: aortogram / pelvic / unilateral runoff / bilateral runoff / tibial-pedal views]. Contrast type: [iodinated / CO₂ / diluted iodinated]. Adjunct diagnostics: [pressure gradients measured / diagnostic IVUS / none]. (If no diagnostic angiography performed, state "No diagnostic angiography performed" with justification.)

Baseline Angiographic Findings

(Organize by limb based on laterality. For each segment, document lesion type, severity [% stenosis or occlusion], estimated length, and calcification [none / mild / moderate / severe]. Explicitly document normal findings in key segments. For segments not imaged, state "not imaged.")

Right Limb

(Include only if right limb imaged)

• Inflow: Distal aorta: [normal / lesion details / not imaged]; Common iliac: [normal / lesion details / not imaged]; External iliac: [normal / lesion details / not imaged]; CFA: [normal / lesion details / not imaged]; Profunda: [normal / lesion details / not imaged]
• Femoropopliteal: SFA proximal: [normal / lesion details / not imaged]; SFA mid: [normal / lesion details / not imaged]; SFA distal: [normal / lesion details / not imaged]; Popliteal: [normal / lesion details / not imaged]
• Infrapopliteal: Tibioperoneal trunk: [normal / lesion details / not imaged]; AT: [normal / lesion details / not imaged]; PT: [normal / lesion details / not imaged]; Peroneal: [normal / lesion details / not imaged]
• Pedal: Dorsalis pedis: [patent / diseased / occluded / not imaged]; Plantar arch: [intact / incomplete / not imaged]
• Tibial runoff: [0 / 1 / 2 / 3] vessels patent to ankle

Left Limb

(Include only if left limb imaged)

• Inflow: Distal aorta: [normal / lesion details / not imaged]; Common iliac: [normal / lesion details / not imaged]; External iliac: [normal / lesion details / not imaged]; CFA: [normal / lesion details / not imaged]; Profunda: [normal / lesion details / not imaged]
• Femoropopliteal: SFA proximal: [normal / lesion details / not imaged]; SFA mid: [normal / lesion details / not imaged]; SFA distal: [normal / lesion details / not imaged]; Popliteal: [normal / lesion details / not imaged]
• Infrapopliteal: Tibioperoneal trunk: [normal / lesion details / not imaged]; AT: [normal / lesion details / not imaged]; PT: [normal / lesion details / not imaged]; Peroneal: [normal / lesion details / not imaged]
• Pedal: Dorsalis pedis: [patent / diseased / occluded / not imaged]; Plantar arch: [intact / incomplete / not imaged]
• Tibial runoff: [0 / 1 / 2 / 3] vessels patent to ankle

Intervention

(Repeat the following block for each treated lesion or vessel segment. Do not fabricate device sizes, lesion lengths, or residual stenosis values.)

[Intervention Target 1]

• Target: Limb: [right / left]; Vessel/segment: [vessel and segment]; Baseline: [stenosis / CTO / thrombus], [severity %], [length], [morphology: ostial / bifurcation / in-stent restenosis / severe calcification / other]
• Crossing strategy: Approach: [antegrade / retrograde / crossover]; Technique: [intraluminal / subintimal]; Wires/support catheters: [list]; Embolic protection: [device used / not used]
• Therapeutic devices:
  • Angioplasty: [Balloon type: plain / DCB / cutting / scoring]; [diameter × length]; [inflation pressure atm × duration sec]; [number of inflations]
  • Stent/Stent-graft: [Type/brand]; [diameter × length]; [number deployed]; Landing zones: [from–to]; Post-dilation: [yes/no]
  • Atherectomy: [Modality: directional / orbital / rotational / laser]; Device: [name]; [passes or treatment time]; Adjunct: [DCB / PTA / none]
  • Thrombectomy/Thrombolysis: [Device and passes / lytic agent and dose] (Include only if performed)
• Post-treatment result: Residual stenosis: [% or threshold]; Flow: [restored / improved / unchanged]; Complications: [none / dissection / perforation / embolization / spasm]; Bailout interventions: [none / describe]

[Intervention Target 2]

(Repeat block as needed for each additional lesion treated.)

Completion Angiography

Segments re-imaged: [list]. Final results: Inflow [describe], Femoropopliteal [describe], Tibial/Pedal [describe]. Final tibial runoff: [0 / 1 / 2 / 3] vessels to ankle. Pedal arch: [intact / incomplete / not imaged]. Untreated significant lesions: [none / list with rationale for deferral]

Hemostasis and Post-Procedure Exam

• Sheath removal: [Sheath size] removed at [time]; Closure: [manual pressure / closure device type]; Hemostasis achieved: [yes / no]
• Access-site events: [none / hematoma / bleeding / pseudoaneurysm / other]
• Distal perfusion: DP/PT: [pulses palpable / Doppler signals present / absent]; Foot: [warm with brisk capillary refill / other]; Compared to baseline: [improved / unchanged / worsened]

Procedural Totals

• Anticoagulation: [Agent and total dose]; ACT: [baseline / peak / end] (if measured)
• Intra-arterial medications: [Agent(s) and dose(s) / none]
• Contrast: [Agent type]; [Total volume mL]
• Radiation: Fluoroscopy time: [minutes]; Dose: [Reference air kerma mGy / DAP Gy·cm²] (if available)
• Estimated blood loss: [mL]
• Implants: [List stents/stent-grafts with identifiers / see implant log]

Complications

[None / List each complication with management and outcome]

Disposition and Plan

• Condition: [stable / guarded / critical]
• Disposition: [recovery area / inpatient unit / ICU / discharge]
• Activity: [Bedrest duration and restrictions]
• Neurovascular checks: [Frequency and duration]
• Antithrombotic regimen: [Agent(s), dose(s), duration] (Provide rationale if deviating from standard practice post-stent/DCB)
• Follow-up: [Clinic timing]; [Surveillance imaging]; [Wound care if applicable]; [Return precautions]