Vertebral Artery Occlusion Procedure Record Form
Document all essential details of a vertebral artery occlusion procedure accurately and completely.
Patient Full Name
*
First Name
Last Name
Date of Procedure
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Referring Physician
*
Indication/Diagnosis
*
Please Select
Vertebral artery dissection
Aneurysm
Tumor embolization
Traumatic injury
Other
Side of Occlusion
*
Left
Right
Bilateral
Method/Technique Used
*
Coil embolization
Balloon occlusion
Vascular plug
Liquid embolic agent
Other
Complications (if any)
*
None
Arterial perforation
Thromboembolism
Dissection
Other
Immediate Outcome
*
Successful occlusion
Partial occlusion
Failed procedure
Operator Name
*
Additional Notes
Submit Record
Should be Empty: