Vasular Graft {Serial/Lot Number}  
Valve Model Number   Date of Implant Size
{filled in by server}  
Vascular Graft Manufacturer

Implant Information
Aneurysm Type
Bifurcated
Thoracic
Iliac
Other

 
Implant
Primary
Secondary
(e.g. cuff placed to correct lead)
Tertiary

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