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Sizing Sheet and Order Form
Anatomical Measurements:
Aneurysm Neck Diameter:
Min Max
Maximum Aneurysm Diameter:
Min Max
Diameter at AorticBifurcation:
Min Max
Right Common Iliac Diameter:
Min Max
Right External Iliac Diameter:
Min Max
SMA to Distal Renal:
Aneurysm Neck Length:
Diameter at Cannulation Socket:
Min Max
Distance From Bifurcation:
mm
Left Common Iliac Diameter:
Min Max
Left External Iliac Diameter:
Min Max
Ipsilateral Side
Right Left
Distal Renal
Right Left
Neck Angulations:
Peri-renal Angulation: °
Infra-renal Angulation:°
Suggested C-Arm Angulation
CC: ° RAO: ° LAO: °
Thrombus and Calcification:
None Partial Circ.
Thrombus Neck
L. Iliac
R. Iliac
Calcification Neck
L. Iliac
R. Iliac
Implant Sizes: Please note that all listed diameters are INTERNAL. The Outside diameters are 1mm larger than the listed size.
Main Body:
Contralateral Leg: Listed length is the working length. The length in parentheses applies only when L1=81mm. The actual length of the stent is 40mm longer than the stated working length.
It is the responsibility of the physician approving this form to assess the suitability of the device in relation to the IFU, if the product is used outside the indications and criteria stipulated within the IFU, this is regarded as off label usage for which Lombard Medical cannot be held accountable. By signing this document, I confirm my full understanding of the above statement.
Sizing approved/signed by physician
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