Procedure Planning aFX™ endovascular aaa System - Endologix

Procedure Planning
Procedure Planning
AFX Endovascular AAA System
Patient ID #:
Physician:

Procedure Planning
Patient ID #:
Patient Initials:
Date of Birth:
Gender:
Physician:
Date Review w/Physician:
Date Prepared:
Prepared By:
Imaging Modality:
Contrast CT Scan Non-contrast CT Scan Angio MRI MRA Duplex Ultrasound
M2S
Other: ___________________________________________________________________
NOTICE: IMPORTANT INFORMATION FOR MEDICAL PROVIDERS
CAUTION: Individuals who are not medical practitioners and who do not have medical training took the anatomical measurements and
device selection recommendations, which are being provided on this form. It is required that you, as the patient’s physician, make your own
independent medical assessment of your patient’s anatomy and measurements, and that you exercise your own professional judgment in
determining whether the AFX system is of the appropriate type and size for use in your patient.
MM0187 Rev 03
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Procedure Planning
Aortic Neck Anatomy
D1 Proximal Neck Diameter: mm
D2 Distal Neck Diameter: mm
L1 Aortic Neck Length: mm
L2 Renal to Aortic Bifurcation Length: mm
L3 Distal Neck to Aortic Bifurcation Length: mm
D4 Aortic Bifurcation Diameter: mm
D5 Maximum Aneurysm Diameter: mm
D6 Minimum Suprarenal Aortic Diameter: mm
D1
D2
D6
L1
Iliac Anatomy
L4 Aortic Bifurcation to RT Hypogastric Artery Length: mm
L2
D5
L3
D7 RT Iliac Proximal Diameter: mm
D8 RT Iliac Distal Diameter: mm
L5 RT Common Iliac Landing Zone: mm
D9 Minimum Access Diameter (RT) mm
L5
D7
D4
D10
L7
L6 Aortic Bifurcation to LT Hypogastric Artery Length: mm
D10 LT Iliac Proximal Diameter: mm
D8
L4
L6
D11
D11 LT Iliac Distal Diameter: mm
L7 LT Common Iliac Landing Zone: mm
D12 Minimum Access Diameter (LT) mm
D9
D12
Angulation and Tortuosity
A1 Angle Proximal Neck to AAA Sac: Deg
A2 Angle Suprarenal to Proximal Neck: Deg
A3 C-Arm Correction Angle: Deg
NOTICE: IMPORTANT INFORMATION FOR MEDICAL PROVIDERS
CAUTION: Individuals who are not medical practitioners and who do not have medical training took the anatomical measurements and
device selection recommendations, which are being provided on this form. It is required that you, as the patient’s physician, make your own
independent medical assessment of your patient’s anatomy and measurements, and that you exercise your own professional judgment in
determining whether the AFX system is of the appropriate type and size for use in your patient.
MM0187 Rev 03
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Procedure Planning
Aortic Extension Options
Infrarenal Aortic Extension
Proximal Distal Covered Total
Diameter Diameter Length Length Model #
25 mm 25 mm 55 mm 55 mm A25-25/C55
25 mm 25 mm 75 mm 75 mm A25-25/C75
25 mm 25 mm 95 mm 95 mm A25-25/C95
28 mm 28 mm 55 mm 55 mm A28-28/C55
28 mm 28 mm 75 mm 75 mm A28-28/C75
28 mm 28 mm 95 mm 95 mm A28-28/C95
34 mm 34 mm 80 mm 80 mm A34-34/C80
34 mm 34 mm 100 mm 100 mm A34-34/C100
Suprarenal Aortic Extension
Proximal Distal Covered Total
Diameter Diameter Length Length Model #
25 mm 25 mm 75 mm 95 mm A25-25/C75-O20
25 mm 25 mm 95 mm 115 mm A25-25/C95-O20
28 mm 28 mm 75 mm 95 mm A28-28/C75-O20
28 mm 28 mm 95 mm 115 mm A28-28/C95-O20
34 mm 34 mm 80 mm 100 mm A34-34/C80-O20
34 mm 34 mm 100 mm 120 mm A34-34/C100-O20
Iliac Options
Flexible Limb Extension
Proximal Distal Total
Diameter Diameter Length Model #
16 mm 16 mm 55 mm I16-16/C55F SA
20 mm 13 mm 70 mm I20-13/C70F SA
20 mm 13 mm 88 mm I20-13/C88F SA
20 mm 20 mm 55 mm I20-20/C55F SA
Limb Extension
Proximal Distal Total
Diameter Diameter Length Model #
16 mm 16 mm 88 mm I16-16/C88 SA
20 mm 25 mm 55 mm IS20-25/C55 SA
20 mm 25 mm 65 mm IS20-25/C65 SA
Main Body Options
Body Limb Body Limb
Diameter Diameter Length Length Model #
22 mm 13 mm 40 mm 40 mm BA22-40/I13-40
22 mm 13 mm 60 mm 40 mm BA22-60/I13-40
22 mm 16 mm 70 mm 30 mm BA22-70/I16-30
22 mm 16 mm 90 mm 30 mm BA22-90/I16-30
22 mm 16 mm 60 mm 40 mm BA22-60/I16-40
22 mm 16 mm 80 mm 40 mm BA22-80/I16-40
22 mm 20 mm 70 mm 30 mm BA22-70/I20-30
22 mm 20 mm 90 mm 30 mm BA22-90/I20-30
22mm 20 mm 80 mm 40 mm BA22-80/I20-40
25 mm 13 mm 80 mm 40 mm BA25-80/I13-40
25 mm 16 mm 70 mm 30 mm BA25-70/I16-30
25 mm 16 mm 90 mm 30 mm BA25-90/I16-30
25 mm 16 mm 110 mm 30 mm BA25-110/I16-30
25 mm 16 mm 60 mm 40 mm BA25-60/I16-40
25 mm 16 mm 80 mm 40 mm BA25-80/I16-40
25 mm 16 mm 100 mm 40 mm BA25-100/I16-40
MM0187 Rev 03
Body Limb Body Limb
Diameter Diameter Length Length Model #
25 mm 16 mm 120 mm 40 mm BA25-120/I16-40
25 mm 16 mm 80 mm 55 mm BA25-80/I16-55
25 mm 20 mm 70 mm 30 mm BA25-70/I20-30
25 mm 20 mm 90 mm 30 mm BA25-90/I20-30
25 mm 20 mm 110 mm 30 mm BA25-110/I20-30
25 mm 20 mm 80 mm 40 mm BA25-80/I20-40
25 mm 20 mm 120 mm 40 mm BA25-120/I20-40
28 mm 16 mm 70 mm 30 mm BA28-70/I16-30
28 mm 16 mm 90 mm 30 mm BA28-90/I16-30
28 mm 16 mm 60 mm 40 mm BA28-60/I16-40
28 mm 16 mm 80 mm 40 mm BA28-80/I16-40
28 mm 16 mm 100 mm 40 mm BA28-100/I16-40
28 mm 20 mm 70 mm 30 mm BA28-70/I20-30
28 mm 20 mm 90 mm 30 mm BA28-90/I20-30
28 mm 20 mm 80 mm 40 mm BA28-80/I20-40
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