Patient. Clinical data Indications: Operation date. Comorbidities: Patient code Birth date: / /

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1 Patient Patient code Birth date: / / Sex: Male Height (cm): Female Weight (kg): Risk Factors: Family history of coronary disease: Hypertension Dyslipidemia Peripheral disease Diabetes Comorbidities: No Smoker No NID ID COPD End stage renal failure Prior stroke Patient in randomised trial No, other reasons Doctors comment about the patient: Clinical data Indications: Angina pectoris: Yes, patient enrolled No, not fulfilling inclusion/exclusion criteria No, patient refusal No, patient too symptomatic, physician choice No, patient referred for PCI No, trial not started yet in my unit Stable angina No Unstable angina Acute MI Dyspnea None Previous MI none I II III CCS: I II III IV NSTEMI STEMI ECG CTO related lesion: Normal Questionable Non Q-Wave Q-Wave Proof of ischemia: Not done Multi Slice CT Negative Uncertain Positive Baseline creatinine: Creatinine measure: Mg/dl mmol/l LV global EF: >=50% Segmental regional<br/>wall normal >=35%<50% <35% motion<br/>cto related lesion: hypokinetic akynetic diskinetic Presence of viable<br/>myocardium 2D-echocardiography Myocardial scintigraphy MRI / / Current smoker Ex-smoker IV MI territory of CTO Previous CABG CABG territory of CTO PCI territory of CTO (if Previous PCI reocclusion after previous PCI) Clinical data: Operation date

2 Anatomy No of vessel disease<br/>(including CTO): CTO Artery: to vessel: LMT LAD LCX RCA SB BP-Arterial BP-Venous CTO location: In stent CTO ostial proximal mid distal More than one segment Bifurcation involvement: Occlusion duration characteristics Visual estimation vessel<br/>diameter (mm): Collaterals filling: Proximal tortuosity: Stump: LAD LCX RCA Occlusion duration (month): Undetermined Likely (clinically confirmed) Certain (angiographically confirmed) Visual estimation CTO<br/>length (mm): Collateral circulation none ipsilateral retrograde ipsilateral&retrograde Straigh (<70 1 bend) Slight (>70 1 bend) Calcification: None Mild (spots) Moderate (2 bends >70 or 1 bend >90 ) Moderate (<=50% RLD) Severe (2 bends >90 or 1 bend >120 ) Severe (>50% RLD) Not applicable Distal opacification: Tapered stump Good (as proximal) Blunt stump Faint (less than proximal) No stump Not visible CC0 CC1 CC2

3 Procedure params Previous attempts No: Same operator Radial access Contralateral injection Guiding catheter<br/>size (F): Corsair Tornus Other dedicated devices Other device: Recanalization approach: Wire method: Single wire Parallel wire Step up step down STAR IVUS IVUS used: to identify entry point for re-entry for reverse CART Anterograde Anterograde recanalized Retrograde Retrograde result Retrograde method: Externalization TouchingWire WireCrossing Pathway Wires and Balloons Wires: CART ReversedCART Septal Epicardial Bypass Collateral not crossed Lesion not crossed by wire Lesion not crossed by device Retrograde successful Total No of guide wires: Wire crossed correctly Wire to begin: Other wire to begin: Wire finally successfully crossing: Other wire successful: Stiffness: Tapered Wire type: Balloons: Soft (<=1g) Intermediate (>1 & <=3g) Moderate (>3 & <9g) Stiff (>=9g) Wire hydrophilic: Non polymer Hydrophilic Polymer Total No of balloons: Anchoring balloon Balloon crossed Balloon crossing primarily: No of OTW: No of Microcatethers: Balloon crossed Balloon crossed device assisted Balloon failed Other balloon: No of Monorail: Non Hydrophilic

4 Stents Bifurcation stenting: DES Stents: Number: Max diameter (mm): BioMatrix Cypher Endeavor Nobori Promus Taxus Xience Other brand: BMS Stents: Number: Max diameter (mm): Drug eluting balloons: Number: Brand: Result Single stenting Double stenting Final stenosis (%): Failure mode: Wire not crossable Final runoff Procedural time (mins): Dye (ml): Patient dose exposure (mgy): Cathlab complications < TIMI0/1 TIMI2 TIMI3 Total length (mm): Total length (mm): Max diameter (mm): Fluoroscopic time (mins): Area dose product (CGY*cm2): Balloon not crossable Stent not crossable Persistent dissection No/slow flow Coronary perforation Death No MI No Procedure related Q-Wave Non procedural Non Q-Wave Stent trombosis with abrupt Stent thrombosis closure Stroke No coronary perf. No Non hemorragic Perforation minor Hemorragic PE - w.o. tamponade PE - with tamponade PE - Surgical intervention Dissection/thrombus of donor artery (contralateral) vascular complications Hb reduction of > 3 g/dl Surgical intervention required Transfusion of > 2 units of blood Prolonged hospital stay > 3 days Emergency re-pci Emergency CABG

5 Follow up Followup period: In hospital (<30 days) Symptoms improved 24-h post creatinine: Post creatinine measure: Mg/dl mmol/l contrast induced nephropathy<br/>(creatinine increase by<br/>0.5 mg/dl or >25%) Death No non fatal MI No Cardiac Q-MI Non cardiac Non Q-MI Re-revascularization No LST: No CABG(TVR) Possible LST re-pci(tvr) Definite LST Stent thrombosis No Re-hospitalization No Possible Procedure related Likely Non procedure related Certain Angiography: Restenosis (>50%) Reoclusion Stroke CCS: I II III IV

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