National Vascular Registry Bypass Patient Details Patient Consent* 2 Not Required If patient not consented: Date consent recorded / / (DD/MM/YYYY) Do not record NHS number, NHS number* name(s) or postcode. Date of birth* / / (DD/MM/YYYY) If consent not required: Sex* 1 Male 2 Female Ignore consent date. Last name First name Postcode* Admission Details Admission date* / / (DD/MM/YYYY) Mode of admission* 1 Elective 2 Non-elective Hospital code* Local ID* Procedure type Pre-populated drop down menu on NVR audit site Bypass Pre-operative: Pathway Referring Specialty* 1 Primary care 2 Medical specialty 3 Emergency Department 4 Other surgical specialty 5 MDT diabetic foot clinic * Mandatory fields Date of release 26/01/2016 Bypass: 1 of 7
Anaesthetic Assessment (for Elective Pathway only) Investigation after preop anaesthetic assessment* 1 No additional investigation /intervention 2 Referral to another specialty 3 Further investigations required 4 Optimization in drug therapy Indications Side of indication* 1 Right 2 Left 3 Bilateral Presenting problem* 1 Acute limb ischemia 2 Chronic limb ischemia 3 Neuropathy 4 Tissue loss 5 Uncontrolled infection 6 Trauma 7 Aneurysm Fontaine score on admission* 1 1 No symptoms 2 2 Intermittent claudication 3 3 Nocturnal and/or resting pain 4 4 Necrosis and/or gangrene in the limb Right / Left Bilateral Previous ipsilateral treatment* Previous contralateral treatment* If presenting problem is trauma or aneurysm, the following questions do not need to be answered: Fontaine score Ipsilateral ankle compressible pre-op Pre-op ipsilateral ABPI Contralateral ankle compressible pre-op (if symptoms are bilateral) Pre-op contralateral ABPI (if symptoms are bilateral) Ipsilateral ankle compressible at discharge Ipsilateral ABPI at discharge Contralateral ankle compressible at discharge (if symptoms are bilateral) Contralateral ABPI at discharge (if symptoms are bilateral) * Mandatory fields Date of release 26/01/2016 Bypass: 2 of 7
Risk Scoring Comorbidities* Please select as many options as applicable. ne 1 Diabetes 2 Hypertension 3 Chronic lung disease 4 Ischaemic heart disease 5 Chronic heart failure 6 Chronic renal disease 7 Stroke Smoking status* 1 Current or stopped 2 Ex-smoker 3 Never smoked within 2 months White cell count* Sodium* Potassium* Creatinine* Albumin Haemoglobin* (x10 9 /l) (mmol/l) (mmol/l) (µmol/l) (g/l) (g/dl) Abnormal ECG* rmal 1 Abnormal ASA Grade* 1 1 Normal 2 2 Mild disease 3 3 Severe, not life-threatening 4 4 Severe, life-threatening 5 5 Moribund patient Pre-operative ne 4 ACE inhibitor / ARB medication* 1 Anti-platelet 5 Antibiotic prophylaxis 2 Statin 6 DVT prophylaxis 3 Beta blocker Right / Left Ipsilateral Ankle Compressible Ipsilateral Preoperative Ankle brachial pressure index* Bilateral Contralateral Ankle Compressible Contralateral Preoperative Ankle brachial pressure index* * Mandatory fields Date of release 26/01/2016 Bypass: 3 of 7
Procedure Date/Time start / / (DD/MM/YYYY); : (HH:MM) Anaesthetic type* 1 Local anaesthetic 4 GA plus regional anaesthetic 2 Regional anaesthetic 5 GA plus peripheral nerve blockade 3 General anaesthetic 6 Regional plus peripheral nerve blockade Angioplasty Angioplasty Stent Lesion Outcome Aorta 1 2 10 <10 St/An S R F Right leg Angioplasty Stent Lesion Outcome Common iliac 1 2 10 <10 St/An S R F External iliac 1 2 10 <10 St/An S R F Common femoral 1 2 10 <10 St/An S R F Profunda femoral 1 2 10 <10 St/An S R F Superficial femoral 1 2 10 <10 St/An S R F Popliteal 1 2 10 <10 St/An S R F Tibial / pedal 1 2 10 <10 St/An S R F Within bypass 1 2 10 <10 St/An S R F graft Left leg Angioplasty Stent Lesion Outcome Common iliac 1 2 10 <10 St/An S R F External iliac 1 2 10 <10 St/An S R F Common femoral 1 2 10 <10 St/An S R F Profunda femoral 1 2 10 <10 St/An S R F Superficial femoral 1 2 10 <10 St/An S R F Popliteal 1 2 10 <10 St/An S R F Tibial / pedal 1 2 10 <10 St/An S R F Within bypass 1 2 10 <10 St/An S R F graft Key: Occlusion 10cm, Occlusion < 10cm, Stenosis/Aneurysm Success, Residual stenosis, Failure * Mandatory fields Date of release 26/01/2016 Bypass: 4 of 7
Bypass Right inflow 0 Axillary artery Right outflow Left inflow 0 Axillary artery Left outflow Right endarterectomy Left endarterectomy Right leg graft 1 Autologous vein 2 Biologic prosthetic 3 Prosthetic 4 Vein and prosthetic Left leg graft 1 Autologous vein 2 Biologic prosthetic 3 Prosthetic 4 Vein and prosthetic Right graft why not vein 1 No ipsilateral vein 2 No leg or arm vein 3 Surgeon choice Left graft why not vein 1 No ipsilateral vein 2 No leg or arm vein 3 Surgeon choice Operator Vascular specialist 1* Anaesthetist 1* Vascular specialist 2 Anaesthetist 2 Vascular specialist 3 Vascular specialist 4 * Mandatory fields Date of release 26/01/2016 Bypass: 5 of 7
Post Operative Number of vessels with continuous run-off to foot Right Leg Left Leg 0 0 1 1 > 1 > 1 Not imaged Not imaged Destination after surgery* 1 Ward 2 Level 2 (HDU/PACU) 4 Level 3 (ICU) 5 Died in theatre Note: If Died in theatre is selected, the remaining questions in the post-operative section will not show Critical care stay* (Number of days) Further unplanned lower limb surgery* 0 None 1 Angioplasty without stent 2 Angioplasty with stent Please select as many 3 Lower limb bypass options as applicable. 7 Minor amputation (below ankle) 8 Major amputation (above ankle) 9 Other Note: if Major amputation (above ankle) is selected, the rest of this bypass record will not be entered, and a linked amputation record will be started. Readmission to a higher level of care* Postoperative complications* Please select as many options as applicable. ne 1 Cardiac (MI / NSTEMI / heart failure) 2 Respiratory 3 Cerebral (stroke) 4 Renal failure 5 Haemorrhage 6 Limb ischemia * Mandatory fields Date of release 26/01/2016 Bypass: 6 of 7
Discharge Discharge status Alive on discharge* Date discharged/died* / / (DD/MM/YYYY) Ipsilateral artery patent at discharge Wound healed at discharge Right / Left Ipsilateral Ankle Compressible Ipsilateral Ankle brachial pressure index at discharge Bilateral Contralateral Ankle Compressible Contralateral Ankle brachial pressure index at discharge Follow Up Readmission to hospital within 30 days 0 No Reason for NO follow up Date clinic appointment attended 1 Died prior to planned follow-up after discharge 2 Moved out of area 3 Did not attend 4 Other / / (DD/MM/YYYY) (Only if follow up occurred) If you have any queries please contact us on 020 7869 6621 and nvr@rcseng.ac.uk * Mandatory fields Date of release 26/01/2016 Bypass: 7 of 7