Endovascular Stent Graft {Serial/Lot Number}  
Model Number   Serial/Lot Number     Implant Date
{Filled in by server}   {Filled in by server}      
/
/
Manufacturer        
  {Product Family -Medtronic Only}

Implant Information
Aneurysm Type
Bifurcated
Thoracic
Iliac
Other

 
Procedure
First Implant Procedure
Second Implant Procedure
Third Implant Procedure

Configuration   Location
Bifurcated
Iliac
Aorto-Uni-Iliac
Conversion
Occluder
Thoracic
Cuff
 
Left Iliac
Right Iliac
Aortic
Thoracic