LINC 2015 live case guide

CLINICAL DATA
Claudication intermittens bilateral,
150 meter walking capacity, calf-pain left > right
Art. hypertension, former smoker

ABI
Left 0,52; right 0,66

DUPLEX
Severely calcified SFA bilateral

ANGIOGRAPHY
Short occlusion distal SFA left, severe calcification

PROCEDURAL STEPS
1. Right groin retrograde cross-over approach
- 6F Balkin Up&Over 40 cm sheath (COOK)

2. Passage of the occlusion
- 0.035" stiff angled Terumo guidewire, 300 cm (TERUMO)
- Armada 35 5/120 mm Balloon (ABBOTT)
- Exchange to a 0.018" SteelCore guidewire (ABBOTT)

3. Stenting
- SUPERA Interwoven Nitinol-Stent (ABBOTT)

CLINICAL DATA
Severe claudication left leg, walking capacity 150 meters
PTA of the right external iliac artery in 12/2014
Thrombendartherectomy left groin 2012
Failed recanalization-attempt lef SFA elsewhere 11/2014
Art. hypertension, hyperlipoproteinemia

ABI
Left 0.67

ANGIOGRAPHY
During PTA right iliac artery: mid SFA-occlusion left, good run-off

PROCEDURAL STEPS
1. Right groin retrograde cross-over approach with 6F sheath
- 6F Balkin Up & Over Contralateral Flexor Check-Flo Performer 40 cm (COOK)

2. Passage of the occlusion
- 0.035" Seeker supportcatheter, 135 cm (BARD)
- 0.035" angled stiff glidewire 260 cm (TERUMO)
- I n case of failure retrograde approach via the distal SFA

3. PTA
- Vascutrak 5.0/250 mm Balloon (BARD)
- Lutonix Drug-Coated Balloon 6.0/150 mm (BARD)

4. Stenting on indication
in case of dissection:
- INTACT VASCULAR Tack Endovascular Stapler™ (INTACT VASCULAR)

CLINICAL DATA
Severe claudication left leg, walking capacity 150 meters
PTA of the right external iliac artery in 12/2014
Thrombendartherectomy left groin 2012
Failed recanalization-attempt lef SFA elsewhere 11/2014
Art. hypertension, hyperlipoproteinemia

ABI
Left 0.67

ANGIOGRAPHY
During PTA right iliac artery: mid SFA-occlusion left, good run-off

PROCEDURAL STEPS
1. Right groin retrograde cross-over approach with 6F sheath
- 6F Balkin Up & Over Contralateral Flexor Check-Flo Performer 40 cm (COOK)

2. Passage of the occlusion
- 0.035" Seeker supportcatheter, 135 cm (BARD)
- 0.035" angled stiff glidewire 260 cm (TERUMO)
- I n case of failure retrograde approach via the distal SFA

3. PTA
- Vascutrak 5.0/250 mm Balloon (BARD)
- Lutonix Drug-Coated Balloon 6.0/150 mm (BARD)

4. Stenting on indication
in case of dissection:
- INTACT VASCULAR Tack Endovascular Stapler™ (INTACT VASCULAR)

CLINICAL DATA
Severe claudication left calf
Stenting left iliac arteries and patch-plastic left groin 2008
Unsuccessful recanalization attempt left SFA, failed guiewire-access
into the SFA-occlusion 11/2014
Arterial hypertension, diabetes mellitus type 2, smoker
Renal insufficiency (GFR 56ml/min)

ABI
Left 0.46

ANGIOGRAPHY
Long occlusion left SFA, ostial stenosis of the deep femoral artery patent stents left iliac arteries.

PROCEDURAL STEPS
1. Right groin retrograde cross-over approach
- 7F Balkin Up & Over 40 cm sheath (COOK)

2. Retrograde access: puncture of the occluded mid SFA left
- 18 Gauge 7 cm needle
- 0.035" stiff angled guidewire 30 cm (TERUMO)
- 6Fr 10 cm sheath (TERUMO)
- 5F Judkins Right diagnostic catheter (CORDIS)
- 0.018" Connect 250 T Guidewire 300 cm (ABBOTT)
- In case of failure exchange to 0.014" Floppy ES 300 cm guidewire (ABBOTT).
- Outback Reentry catheter (CORDIS)

3. Balloon-angioplasty and stenting
- After snaring of the retrograde guidewire PTA with Savvy 5/120mm Balloon (CORDIS)
- Smart Control Selfexpanding stent (CORDIS)
- In case of bleeding at the retrograde access-site or groin-patch: Viabahn 7/100 mm covered stentgraft (GORE)

CLINICAL DATA
Severe claudication intermittens right leg
walking-capacity 200 meters
PTA with drug-eluting balloons left SFA 11/2014
Diabetes mellitus type 2, hyperlipidaemia

ABI
Right 0.66

ANGIOGRAPHY
10 cm long occlusion mid SFA right

PROCEDURAL STEPS
1. Left groin retrograde cross-over approach
- 6F Balkin Up & Over 40 cm sheath (COOK)

2. Passage of the occlusion
- 0.035" CXI-support-catheter, straight tip, 135 cm length (COOK)
- 0.018" Connect Flex guidewire, 300 cm (ABBOTT)

3. Balloon-angioplasty and stenting
- Advance 18 5.0/120 mm balloon (COOK)
- Zilver-PTX 6.0/100 mm (COOK)

CLINICAL DATA
PAOD with claudication intermittens and restpain at night left leg
PTA right SFA with drug-eluting balloons 12/2014
Thrombendartherectomy left common femoral artery 10/2014
Arterial hypertension
Hyperlipoprotaeinemia
Smoker

ABI
Left 0.61

ANGIOGRAPHY
During PTA right leg: long SFA-occlusion, moderate calcification

PROCEDURAL STEPS
1. Right groin retrograde cross-over approach
- 6F Balkin Up & Over 40 cm sheath (COOK)

2. Guidewire passage
- 0.035" QuickCross support-catheter 135 cm (SPECTRANETICS)
- 0.035" TERUMO glidewire angled stiff, 300 cm (TERUMO)
- 0.018" Victory 30g, 300 cm (BOSTON SCIENTIFIC)

3. Predilatation and drug-eluting balloon treatment
- Pacific 5/120 mm balloon (MEDTRONIC)
- In.Pact 5.0/120 mm drug-coated balloon (MEDTRONIC)

4. Stenting on indication
- Complete 6.0/150 mm Selfexpanding Nitinol-stent (MEDTRONIC)

CLINICAL DATA
Restpain right leg, Rutherford class 4
History of surgical aorto-biiliac prosthesis 1972, report can not be found
Minor stroke 2011 before CEA of carotid artery stenosis right, art. hypertension

ABI
Right 0.4

CT
Severe calcification of the aortic bifurcation, 32 mm aneurysm left common iliac artery
Former aortoiliac bypass can not be seen on CT

PROCEDURAL STEPS
1. Retrograde access both common femoral arteries
- 7F-10 cm sheath (TERUMO)
Left brachial access:
- 5F diagnostic pigtail-catheter (CORDIS)
- 0.035" soft angled short glidewire (TERUMO)
- 0.035" SupraCore Guidewire 300 cm (ABBOTT)
- 6F-90 cm Check-Flow Performer Sheath (COOK)

2. Guidewire passage of the iliac occlusion right
via brachial access:
- 5F-125 cm Judkins Right diagnostic catheter (CORDIS)
- 0.035" stiff angled TERUMO glidewire, 260 cm (TERUMO)
- or 0.018" Connect 300 cm guidewire (ABBOTT)
- Snaring of the wire into the retrograde sheath and passage of the contralateral common iliac artery occlusion via the brachial access.

3. After Guidewire-passage PTA via the femoral access bilateral
- Admiral 6/40 mm-balloon, 90 cm (MEDTRONIC)

4. Stenting
- via left groin: Sinus aortic stent 24-80 mm (OPTIMED)
Implantation of covered stents into the aortic bifurcation:
- 9/59 mm Lifestream covered stents (BARD)
- 9/100 mm Fluency covered stent right external iliac artery (BARD)

CLINICAL DATA
Critical limb ischemia left with toe-ulcerations Dig 2 and 3
PTA and stenting left SFA and failed recanalization attempt
left tibioperoneal trunk 1/2015
Diabetes mellitus type 2, arterial hypertension
CAD with PTCA 11/2013
Former smoker, renal insufficiency with GFR 55ml/min

ANGIOGRAPHY
During PTA of left SFA: Occlusion of the tibioperoneal trunk the peroneal and anterior tibial artery

PROCEDURAL STEPS
1. Left antegrade access
■ 5F – 55 cm Ansel Sheath (COOK)
Retrograde access to the posterior tibial artery:
■ 7 cm 21 Gauge needle (COOK)
■ 0.018" Connect Guidewire 300 cm (ABBOTT)
■ 0.018" CXC Support-Catheter 90 cm (COOK)

2. Guidewire exchange
■ After retrograde guidewire-passage and snaring from antegarde exchange to 0.014" PT2 Guidewire 300 cm (BOSTON SCIENTIFIC)

3. PTA and stenting
■ MiniTrek RX 4/20 mm PTCA Balloon (ABBOTT)
■ Cre8 4.0/48 mm Drug-Eluting Stent (ALVIMEDICA)

CLINICAL DATA
Severe claudication left calf, walking capacity 50 meters
PTA of a restnosis of the SFA-ostium left with drug.-coated ballon 12/2014
Stenting left SFA / popliteal artery 10/2013
Thrombendartherectomy left groin /2013
CAD and PTCA LAD 9/2013
Arterial hypertension, diabetes mellitus, type 2, former smoker

ABI
Left 0.43

ANGIOGRAPHY
In-Stent occlusion distal SFA and P1/P2 popliteal artery left
P3-segment significantly stenosed

PROCEDURAL STEPS
1. Left antegrade approach
- 7F 55 cm Ansel sheath (COOK)

2. Guidewire passage
- 0.035" QuickCross support-catheter 90 cm (SPECTRANETICS)
- 0.035" Half stiff J-angled 300 cm (TERUMO)
- exchange to 0.014" Floppy ES Guidewire 300 cm (ABBOTT)

3. Filter-protection
- WirionTM EPD-System (GARDIA MEDICAL)

4. Laser-atherectomy
- 7F Tandem Booster-Laser (SPECTRANETICS)

5. PTA with drug-coated balloons
- LegFlow OTW Drug-Coated Balloon (CARDIONOVUM)

CLINICAL DATA
Left CLI (non healing forefoot wound)
SFA TFT DES 8/2010
SFA TFT Peroneal DEB 7/2011
SFA Rotarex Peroneal POBA 4/2014
SFA TFT Peroneal DEB 5/2014
Failed retrograde DP 9/2014

RISK FACTORS
DM hypertension, CAD EF 45%, hyperlipidemia, smoker

PROCEDURAL STEPS
1. Antegrade 7F access
- Retrograde posterior tibial vein (PTV) access (Ultrasound guided) micropuncture followed by COOK 5F x 45 cm Ansel sheath

2. Antegrade LimFlow ‘Send’ Catheter 7F

3. Retreograde LimFlow ‘Receive’ Catheter 5F

4. Align and Crossover

5. Predilatation crossover point

6. Stent from TFT to PTV
- Atrium 5 mm x 38 and Viabahn 5 mm

7. Percutaneous Reverse Valvulotome

CLINICAL DATA
Severe claudication left calf
Stenting of the SFA left 2009 (Samba-stent)
Thrombenarthererctomy left groin 2010
PTA of the right SFA / stenting 1/2015
CAD, multiple PTCAs
Chronic heart failure (NYHA II)
Chronic renal insufficiency (GFR 70ml/min)
Art. hypertension, diabetes mellitus type 2

ABI
Left 0.64; right 0.82 (post stenting)

ANGIOGRAPHY
During PTA right SFA: in-stent reocclusion and severe calcification left SFA

PROCEDURAL STEPS
1. Right groin and cross-over access
- 7F 40 cm balkin Up & Over sheath (COOK)

2. Guidewire passage
attempt to pass the occlusion from antegrade
- QuickCross 0.035" 135 cm Supportcatheter (SPECTRANETICS)
- 0.035" stiff angled glidewire, 260 cm (TERUMO)

3. In case of failure retrograde stent-puncture
- 7 cm 18 Gauge needle and
- QuickCross 0.035" 135 cm Supportcatheter (SPECTRANETICS)
- 0.035" stiff angled glidewire, 260 cm (TERUMO)
- Snaring of the guidewire from above

4. PTA
- Armada 35 5.0/120 mm Ballon (ABBOTT)
- Potentially high-pressure balloon: Conquest 6/20 mm (BARD)

5. Stenting
- Supera interwoven nitinol-stent (ABBOTT)

CLINICAL DATA
Acute onset of severe claudication right and left calf 1-2 months ago (right > left)
Eversionatherectomy of a symptomatic internal carotid artery stenosis right 12/2014
Arterial hypertension, diabetes mellitus type 2, former smoker

ABI
Right 0.55; left 0.57

ANGIOGRAPHY
Bilateral occlusion of the SFA, non calcification
Thrombotic subtotal occlusion of the right carotid artery before surgery

PROCEDURAL STEPS
1. Right femoral retrograde and cross-over access
- 8F 40 cm Balkin Up & Over sheath (COOK)

2. Guidewire passage
- 0.018" CXI angled support-catheter 135 cm (COOK)
- 0.018" V-18 COntrol Guidewire, 300 cm (BOSTON SCIENTIFIC)

3. Thrombectomy
- Rotarex 8F Thrombectomy Catheter (STRAUB MEDICAL)

4. PTA and stenting on indication
- if residual thrombus: local thrombolysis with Actilysis
- if residual arteriosclerotic lesions: balloon-angioplasty/stenting
- Lutonix drug coated balloon 5.0/150 mm (BARD)
- Epic-Stent 6.0/150 mm (BOSTON SCIENTIFIC)

CLINICAL DATA
Severe claudicatio with worsening 3 months ago
Stenting of the SFA left 12/2013
CAD and PTCA 11/2014
Art. hypertension, diabetes mellitus type 2, former smoker

ABI
Left 0.62

ANGIOGRAPHY
During coronary angiography: In-stent reocclusion left with stent-fractures.

PROCEDURAL STEPS
1. Right femoral retrograde and cross-over access
- 8F 40 cm Balkin Up & Over sheath (COOK)

2. Guidewire passage
- 0.035" stiff angled glidewire, 260 cm (TERUMO)
- Judkins Right 5F diagnostic catheter (CORDIS)
- Exchange to 0.018" guidewire coming with the Rotarex-catheter (STRAUB MEDICAL)

3. Thrombectomy
- 8F Rotarex-Thrombectomy (STRAUB MEDICAL)

4. PTA with drug-eluting balloons
- In-Pact Pacific 5.0/120 mm (MEDTRONIC)

5. Stenting of areas with stent-fracture
- Supera Interwoven Nitinol Stent 5.0/100 mm (ABBOTT)

CLINICAL DATA
Critical ischemia with ulcerations right forefoot (Dig 3 and 4 and lateral)
PTA of a SFA-stenosis 12/2014 with drug-eluting balloon
CAD with CABG 2008
Diabetes mellitus type 2, art. hypertension

ABI
Right 0.2

ANGIOGRAPHY
5 cm occlusion of the proximal peroneal artery and long tibial occlusions (ATA and PTA).

PROCEDURAL STEPS
1. Right antegrade access
- 5F 55 cm Ansel Sheath (COOK)

2. Guidewire passage of the occlusion(s)
- 0.014" PT2 guidewire, 300 cm (BOSTON SCIENTIFIC)
- Amphirion Deep Balloon 2.5/120 mm - 120 cm (MEDTRONIC)
In case of failure exchange to:
- 0.018" V-18 Control guidewire 300 cm (BOSTON SCIENTIFIC)
- supported by TrailBlazer 0.018" 90 cm (COVIDIEN)

3. PTA and drug administration
- Amphirion Deep 2.5/120 mm Balloon (MEDTRONIC)
- BullFrog Micro-infusion catheter for administration of Dexamethason into the arterial wall (MERCATOR MedSystems)

CLINICAL DATA
Critical ischemia with ulcerations right forefoot (Dig 3 and 4 and lateral)
PTA of a SFA-stenosis 12/2014 with drug-eluting balloon
CAD with CABG 2008
Diabetes mellitus type 2, art. hypertension

ABI
Right 0.2

ANGIOGRAPHY
5 cm occlusion of the proximal peroneal artery and long tibial occlusions (ATA and PTA).

PROCEDURAL STEPS
1. Right antegrade access
- 5F 55 cm Ansel Sheath (COOK)

2. Guidewire passage of the occlusion(s)
- 0.014" PT2 guidewire, 300 cm (BOSTON SCIENTIFIC)
- Amphirion Deep Balloon 2.5/120 mm - 120 cm (MEDTRONIC)
In case of failure exchange to:
- 0.018" V-18 Control guidewire 300 cm (BOSTON SCIENTIFIC)
- supported by TrailBlazer 0.018" 90 cm (COVIDIEN)

3. PTA and drug administration
- Amphirion Deep 2.5/120 mm Balloon (MEDTRONIC)
- BullFrog Micro-infusion catheter for administration of Dexamethason into the arterial wall (MERCATOR MedSystems)

CLINICAL DATA
Incidental finding of an abdominal aneurysm
Since 2 years recurrent abdominal pain

RISK FACTORS
Art. hypertension, smoker

CT
57 mm abdominal aneurysm, neck-kink of 60Æ

PROCEDURAL STEPS
1. Proglide closure-device preloading both groins
- 9F – 10 cm sheath both groins (TERUMO)

2. Implantation of the main body
- 0.035" Lunderquist 180 cm guidewire via right groin (COOK)
- Aorfix abdominal endovascular stentgraft (LOMBARD MEDICAL)

3. Cannulation of the contralateral limb
- Amplatz left I diagnostic catheter 5F (CORDIS)
- 0.035" soft angled TERUMO guidewire (TERUMO)
- 0.035" Lunderquist 180 cm guidewire via right groin (COOK)

4. Implanation of the contralateral limb (LOMBARD MEDICAL)
- PTA of the graft with a Reliant-balloon (MEDTRONIC) via 12F 12 cm sheaths (COOK)

CLINICAL DATA
Criticl limb ischemia, ulceration left lower leg and Dig 2
CLI right leg with heel-ulceration
PTA right SFA 1/2015
PTA left SFA 2011 for CLI-treatment
Atrial fibrillation
CAS left ICA 4/2006

ANGIOGRAPHY
During treatment of CLI right leg: 10 cm long distal SFA-occlusion left
Below-the-knee peroneal artery patent

ABI
0.34

PROCEDURAL STEPS
1. Right groin retrograde access and cross-over sheath placement
- IMA 5F diagnostic catheter (CORDIS)
- 0.035" soft angled TERUMO glidewire (TERUMO)
- 0.035" SupraCore 190 cm (ABBOTT)
- 6F 55 cm Ansel Sheath (COOK)

2. Guidewire passage and balloon-angioplasty
- 0.018" Connect 300 cm Guidewire (ABBOTT)
- supported by CXC 0.018" Catheter, 135 cm (COOK)
In case of failure exchange to:
- 0.018" Connect 250 T Guidewire, 300 cm (ABBOTT)

3. Balloon-angioplasty and stenting
- Pacific 5.0/80 mm Balloon, 135 cm (MEDTRONIC)
- Tigris GORE Vascular Stent 6.0/100 mm stent (GORE)

CLINICAL DATA
Severe claudicatio both legs right > left, worsening 1 month ago
CAD, intermittend atrial fibrillation
Art. hypertension, diabetes mellitus type 2

CT
Occlusion right common iliac artery, partially thrombotic.

PROCEDURAL STEPS
1. Bilateral retrograde groin access
- 7F 25 cm sheath (TERUMO)

2. Passage of the occlusion from antegrade and retrograde
Left:
- SOS-catheter 5F (COOK)
- 0.035" stiff straight TERUMO 260 cm (TERUMO)
Right:
- 0.018" Connect Flex 300 cm (ABBOTT)

3. Guidewire exchange to
- 0.035" SupraCore Guidewire (ABBOTT)

4. Predilatation right
- 5.0/40 mmm Armada 35 balloon (ABBOTT)

5. Implantation of covered stents in kissing-technique
- Advanta V-12 (MAQUET GETINGE GROUP)

CLINICAL DATA
Severe claudication right calf
PTA and stenting left SFA 12/2014
Art. hypertension, diabetes mellitus type 2
Renal insufficiency (GFR 65ml/min), former smoker
CAD with PTCA 11/2013

ANGIOGRAPHY
During PTA left SFA: long SFA-occlusion right.

ABI
Right 0.56

PROCEDURAL STEPS
1. Left femoral retrograde and cross-over access
- 6F 40 cm Balkin Up & Over sheath (COOK)

2. Guidewire passage of the SFA-occlusion
- 0.035" stiff angled glidewire, 260 cm (TERUMO)
- 0.015" Seeker Support-Catheter, 135 cm (BARD)
- Exchange to a 0.018" guidewire SteelCore 300 cm (ABBOTT)

3. PTA
- Vascutrak Balloon 5.0/250 cm (BARD)
- Lutonix 5.0/150 mm drug-coated balloon (BARD)

4. Stenting on indication
- LifeStent selfexpanding Nitinol-stent (BARD)

CLINICAL DATA
Critical limb ischemia with ulceration dig 5 right
PAOD with stenting right SFA 11/2010 and restenosis 12/2014
PTA with drug-eluting balloons 12/2014
Failure to pass the TTF-occlusion from antegrade 12/2014

ANGIOGRAPHY
12/2014: calcified TTF-occlusion, stenosis of the proximal peroneal artery

PROCEDURAL STEPS
1. Antegrade access right groin
- 5F 55 cm Ansel Sheath (COOK)

2. Guidewire passage
retrograde access via the peroneal artery:
- 7 cm 21 Gauge puncture needle (COOK)
- 0.018" V-18 Control Guidewire 300 cm (BOSTON SCIENTIFIC)
- Seeker 0.018" 90 cm support-catheter (BARD)

3. Guidewire exchange
After snaring of the guidewire from antegrade PTA of the lesion:
- Exchange to a 0.014" guidewire (Floppy ES ABBOTT)
- Vascutrak 3.5/40 mm Balloon (BARD)
- Lutonix Drug-Coated Balloon 3.5/120 mm (BARD)

CLINICAL DATA
Progression of an abdominal aneurysm to 55mm
CAD with PTCA 2008
Mitral valve moderate insufficiency
Art. hypertension, diabetes mellitus type 2

CT
55 mm abdominal aneurysm with irregaular neck, thrombus

PROCEDURAL STEPS
1. Proglide closure-device preloading both groins
- 9F – 10 cm sheath both groins (TERUMO)

2. Implantation of the main body
- 0.035" Lunderquist 180cm guidewire via right groin (COOK)
- Ovation abdominal endovascular stentgraft (TRIVASCULAR)

3. Cannulation of the contralateral limb
- Amplatz left I diagnostic catheter 5F (CORDIS)
- 0.035" soft angled TERUMO guidewire (TERUMO)
- 0.035" Lunderquist 180 cm guidewire via right groin (COOK)

4. Implanation of the contralateral limb (TRIVASCULAR)
- PTA of the graft with a Reliant-balloon (MEDTRONIC) via 12F 12 cm Sheaths (COOK)

CLINICAL DATA
Recurrent ulceration left foot, claudication intermittens, walking capacity 100 meters
PTA of SFA-stenosis left 12/2014
ABI > 1.3
Diabetes mellitus type 2, art. hypertension
Liver-transplantation 2009, chronic renal insufficienc (GFR 35ml /min)

PARTIALLY CO2-ANGIOGRAPHY
Short occlusion of the poplteal artery left (P2-segment).

DUPLEX
Popliteal artery diameter 1.6 cm

PROCEDURAL STEPS
1. Antegrade access left groin
- 7F 55 cm Ansel Sheath (COOK)

2. Guidewire passage
- 0.018" Victory 18gr 300 cm guidewire (BOSTON SCIENTIFIC)
- Balloon for support: Pacific 5.0/40 mm (MEDTRONIC)

3. Implantation of a stentgraft / stent
- Viabahn 6.0/50 mm (GORE)
- Supera 5.0/80 mm Interwoven Nitinol-stent (ABBOTT)

CLINICAL DATA
PAOD with rest-pain left leg, Rutherford class 4, and
Claudicatio intermittens left calf, walking capacity 100 meters
Failed antegrade recanalization attempt
Diabetes mellitus type 2, former smoker

ANGIOGRAPHY
10 cm distal SFA-occlusion left, moderat calcification

PROCEDURAL STEPS
1. Right femoral retrograde and cross-over access
- 6F 40 cm Balkin Up & Over sheath (COOK)

2. Guidewire passage from antegrade
- 5F Multipurpose diagnostic catheter 100 cm (CORDIS)
- 0.035" straight stiff TERUMO glidewire, 260 cm (TERUMO)
- in case of second failure: retrograde approach via the proximal anterior tibial artery 7 cm 21 Gauge needle (COOK)
- 0.018" V-18 Conrol Guidewire 300 cm (BOSTON SCIENTIFIC)
- 0.018" QuickCross 90 cm Supportcahteher (SPECTRANETICS)

3. After snaring of the guidewire from antegrade PTA
- Ultraverse 18 Balloon (BARD) and
- Luminor Drug-coated balloon (iVASCULAR)

4. Stenting on indication
- Supera Interwoven Nitinol-Stent (ABBOTT)

CLINICAL DATA
PAOD with severe claudication and restpain during night left foot
PTA / stenting of the popliteal artery left elsewhere and failure to recanalize the tibioperoneal trunk
Art. hypertension, CAD with CABG 2008, Polymyalgia rheumatica

ANGIO
During first rezanalization attempt: perforation after attempt to pass the tibioperoneal trunk occlusion.

PROCEDURAL STEPS
1. Antegrade approach left groin
- 5F 55 cm Ansel Sheath (COOK)

2. Retrograde guidewire passage
- 7 cm 21 Gauge needle to puncture the posterior tibial artery
- 0.018" V-18 control guidewire 300 cm (BOSTON SCIENTIFIC)
- 3F pedal sheath (COOK)
- 0.018" CXI-support-catheter 90 cm (COOK)
- potentially exchange to a 0.014" CTO-guidewire Winn 200 T (ABBOTT))

3. PTA
- Advance Micro 3.0/40 mm 90 cm Balloon (COOK) from retrograde

4. Stenting
- After guidewire-passage from antegrade after predilatation from retrogarde implanatation of a Xience Prime 3.5/38 mm drug-eluting stent (ABBOTT)

CLINICAL DATA
Acute type-B-dissection 12/2014
Art. hypertension
Smoker

CT
Enlargement of the descending thoracic aorta of 1.1 cm within 1 month.

PROCEDURAL STEPS
1. Percutaneous access right groin
- Preclosing with Proglide both sides (ABBOTT)
- 0.035" Lunderquist guidewire 260 cm (COOK)
- Calibration-pigtail catheter left groin
- Temporary pacemaker via right groin for rapid pacing
- IVUS (VOLCANO)

2. Implantation of a TAG thoracic stentgraft (GORE)

CLINICAL DATA
Severe claudication left calf, walking capacity 50 meters
Bilateral iliac artery PTA 2014
CAD with MI and PTCA 2000
Art. hypertension, diabetes mellitus type 2

ABI
Left: 0.62

ANGIOGRAPHY
During PTA right iliac arteries: severe calcification left SFA, short distal occlusion.

PROCEDURAL STEPS
1. Left antegrade approach
- 6F 10 cm sheath (TERUMO)

2. Guidewire passage
- 0.018" Victory 18g guidewire 300 cm (BOSTON SCIENTIFIC)
- QuickCross 0.018" 90 cm support-catheter (SPECTRANETICS)

3. PTA
- AngioSculpt 5/80 mm (SPECTRANETICS)
- Drug-coated balloon treatment
- Drug-coated balloon PTA

4. Stenting on indication

CLINICAL DATA
Critical limb ischemia, restpain and minor ulcerations forefoot right
Art. hypertension, CAD with PTCA 2003
Aortic valve replacement 2013, chronic heart failure, NYHA II-III
Atrial fibrillation, chronic renal insufficiency GFR (62 m/min)

ANGIOGRAPHY
During first rezanalization attempt: occlusion of the distal SFA, popliteal artery and tibioperoneal trunk

PROCEDURAL STEPS
1. Antegrade approach right groin
- 5F 55 cm Ansel Sheath (COOK)

2. Guidewire passage
- V-18 Control Guidewire (BOSTON SCIENTIFIC)
- PPS Arrow Catheter (ARROW)

3. In case of failure to pass the guidewire from antegrade
- Retrograde approach via the dorsalis pedis artery: 7 cm 21 Gauge needle
- 0.018 Connect Guidewire 300 cm (ABBOTT)
- 3F pedal sheath (COOK)

4. Guidewire passage from retrograde
- 0.018" CXI angled support-catheter 90 cm (COOK) potentially exchange to
- 0.014 Hydro-ST Guidewire 300 cm (COOK) and
- Advance Micro Balloon 3.0/120 mm (COOK)
- LegFLow Drug-Coated Balloon (CARDIONOVUM)

5. Stenting on indication

CLINICAL DATA
Critical limb ischemia with ulceration of the lower calf and forefoot
Chronic heart failure with NYHA II-III
Art. hypertension, diabetes mellitus type 2, former smoker

ABI
Left 0.45

DUPLEX
CFA-stenosis and SFA-occlusion

ANGIOGRAPHY
CFA-stenosis, PFA-stenosis and SFA-occlusion

PROCEDURAL STEPS
1. Right groin access and cross-over approach to left
- 7F 40 cm Balkin Up & Over sheath (COOK)

2. Filter-protection of the deep femoral artery
- Spider Filter 7 mm (COVIDIEN)

3. Atherectomy of the CFA and PFA
- TurboHawk (LX-M) (COVIDIEN)

4. Guidewire passage of the SFA-occlusion
- 0.035" TrailBlazer 135 cm supportcatheter (COVIDIEN)
- 0.035" stiff angled glidewire 260 cm (TERUMO)
- Exchange to the Spider-Filter 7 mm (COVIDIEN)

5. Atherectomy of the SFA
- TurboHawk (COVIDIEN)

6. PTA with drug-coated balloons
- Luminor 35 (iVASCULAR)

CLINICAL DATA
Critical limb ischemia, ulceration left plantar forefoot
Failed antegrade recanalization attempt 1/2015
Chronic renal failure, GFR 54 ml/min
Hyperlipoproteinemia, art. hypertension

ANGIOGRAPHY
During first rezanalization attempt: occlusion of the distal SFA, poplieal artery and tibioperoneal trunk

PROCEDURAL STEPS
1. Antegrade approach left groin
- 6F 40 cm Balkin Up & Over sheath (COOK)
- retrograde access via the peroneal artery: 7 cm 21 Gauge needle
- 0.018" V-18 Control Guidewire 300 cm (BOSTON SCIENTIFIC)
- QuickCross 0.018" 90 cm (SPECTRANETICS)

2. Passage of the occlusion from antegrade and retrograde with CART-technique
- antegrade Pacific 4.0/80 mm Balloon (MEDTRONIC)
- retrograde V-18 Control Guidewire (BOSTON SCIENTIFIC)

3. PTA
- GPS Arrow catheter
- Dorado balloon 5/120mm (BARD)
- Drug-coated balloon treatment: Luminor (iVASCULAR)

4. Stenting on indication
- Supera Interwoven Nitinol-Stent 5/150 mm (ABBOTT)

CLINICAL DATA
PAOD with rest pain and severe claudicatio left
Former smoker
Art. hypertension

ABI
Left 0.2

DUPLEX
Severe PAOD with chronic occlusion externa iliac artery both sides, occlusion left common and superficial femoral artery, severely calcified.

PROCEDURAL STEPS
1. Thrombendartherectomy left common femoral artery

2. Transbrachial guidewire passage through the left external iliac artery
- 6F-90 cm Check-Flow Performer Sheath (COOK)
- 5F Judkins Right diagnostic catheter 125 cm (CORDIS)
- 0.035" stiff angled glidewire 260 cm (TERUMO)

3. PTA of the iliac occlusion left after snaring of the guidewire into the left groin sheath
- Admiral 6.0/80 mm-Balloon (MEDTRONIC)
- 7.0/10 mm Complete stent (MEDTRONIC)

4. Guidewire passage of the SFA occlusion from left antegrade through the CFA-patch and potentially retrograde via the distal SFA

5. PTA and stenting of the SFA
- Armada 5.0/120 mm Balloon (ABBOTT)
- Supera 5.0/200 mm Interwoven Nitinol-stent (ABBOTT)

CLINICAL DATA
Subclavian steal with right arm exercise induced dizziness
Failed recanalization attempt due to severe iliac artery kinking
Art. hypertension, diabetes mellitus

RISK FACTORS
RR-difference right to left arm: > 30 %

ANGIOGRAPHY
During first recanalization attempt: right vertebral retrograde flow, occlusion of the right subclavian artery.

PROCEDURAL STEPS
1. Access via right brachial artery and right femoral artery
- brachial: 6F 55 cm Ansel Sheath (COOK)
- femoral: 8F Judkins Right Guiding-Catheter (CORDIS)
- Potentially stabilization of the guiding-catheter with a Filterwire EZ in the internal carotid artery right (BOSTON SCIENTIFIC).

2. Bidirectional attempt to pass the occlusion
- Judkins Right 5F diagnostic catheter 100 and 125 cm(CORDIS)
- 0.018" Connect Flex 300 cm or Connect 250 T 300 cm guidewire (ABBOTT)

3. PTA
- Predilatation with Sterling 5/40 mm Balloon (BOSTON SCIENTIFIC)

4. Stenting
- Omnilink 8/29 mm balloon-expandable stent (ABBOTT)

CLINICAL DATA
CLI patient , wound right dig ped I, CTO of the tibioperoneal trunc, recanalisation of the SFA in cross-over technique 12/2014 with stenting, but still not complete healing

RISK FACTORS
Abdominal aortic aneurysm 4,0 cm, CAD, CABG in 1999, art. hypertension, hyperlipidaemia, IDDM.

PROCEDURAL STEPS
1. Antegrade punctering of the right CFA, insertion of a 4F Fortress 45 cm sheath

2. Recanalisation of the tibioperoneal trunc
- 0.018" Advantage wire (TERUMO)

3. Predilatation
- Arrow GPS 3 x 40 mm balloon catheter (TELEFLEX)

4. Angiocontrol of the PTA result via balloon sideport

5. Secondary stenting
- 3.5 mm x 31 mm Cre8 BTK drug-eluting stent (ALVIMEDICA)

6. Manual compression

CLINICAL DATA
CAD
Art. Hypertension
Nephrectomy left side

PROCEDURAL STEPS
1. Percutaneous approach both groins
- Prostar XL (ABBOTT)
- 14F sheath (COOK)

2. Possibly predilatation of the iliacs

3. Placement of the "ultra low profile" Incraft bifurcated endograft (14F CORDIS) below the renal arteries

CLINICAL DATA
EVAR 2009 with Talent prothesis, in followup visits perstent Type II endoleak via lumbar arteries, axial aneurysm growth of 8 mm

RISK FACTORS
Hypertension, hyperlipidemia

PROCEDURAL STEPS
1. Left transbrachial approach
- 5F 90 cm shuttle sheath (COOK) to left common iliac artery

2. Cannulation of left hypogastric
- 0.035" Glidewire and 4F 120 cm Glidecath (TERUMO)

3. Cannulation of left ileolumbar artery
- 0.014" Choice PTII wire (BOSTON SCIENTIFIC)

4. Cannulation of endoleak
- 0.014" Echelon or 0.010 Marathon microcatheter (COVIDIEN)

5. Embolisation of Endoleak with alcohol-copolymer
- Onyx (COVIDIEN)

CLINICAL DATA
PAOD Rutherford 4, intermittend rest pain,claudication right calf at 20 meters
PTA and Stent right popliteal 2009, Stent left CIA 2/2011

RISK FACTORS
NIDDM, hypertension, hyperlipidemia

PROCEDURAL STEPS
1. Left femoral approach
- 5F 10 cm sheath (TERUMO)

2. Cross-over manoeuvre
- Insertion 6F 45 cm Destination sheath (TERUMO) via 0.035 Advantage wire (TERUMO)

3. True lumen recanalization right A. pop.
- Ocelot PIXL (AVINGER)

4. Directional atherectomy popliteal artery
- Turbohawk LSM (COVIDIEN)

5. Postdilation
- In.Pact paclitaxel eluting balloon (MEDTRONIC)

CLINICAL DATA
- Claudication left leg with pain free walking distance of 150m (Rutherford III)
- CVRF: hypertension, former smoker
- high grade stenosis promixal SFA
- 12 cm CTO distal SFA
- Mild Ca+

ABI LEFT
- 0.6

PROCEDURAL STEPS
- Crossed using the Ocelot Catheter (AVINGER, Redwood City, CA)
- Real time confirmation of true lumen crossing (avoided disruption of medial/adventitial border)
- Reduced fluoroscopy using only OCT for crossing)
- Cap to cap standalone crossing
- OCT guided Atherectomy using the Pantheris Catheter (not approved for sale, currently under FDA IDE Clinical Trials) (AVINGER, Redwood City, CA)
- Real time directional cutting targeting plaque
- Histology of plaque sample reveals 0% adventitia
- Reduced fluoroscopy using OCT for atherectomy
- Post Atherectomy DEB using In.Pact Admiral Balloon (MEDTRONIC, Minneapolis, MN)

POST PROCEDURAL ABI LEFT
- 1.2

CLINICAL DATA
Asymptomatic, 90% ICA stenosis, vmax in CCD 280cm/sec
Type III aortic arch

RISK FACTORS
Hypertension

PROCEDURAL STEPS
1. Femoral approach
- Cannulation of left common carotid artery with 6F 90 cm Shuttle sheath (COOK) in telescope technique with 5,4 VTEK Slipcath (COOK).

2. Passage of lesion
- Epifilterwire (BOSTON SCIENTIFIC)

3. Implantation of Roadsaver dual layer carotid stent (TERUMO)

4. Postdilation
- Sterling RX balloon (BOSTON SCIENTIFIC)

CLINICAL DATA
CAD 3VD
Art. Hypertension
Impaired renal function
DM 2

DUPLEX
Thoraco-abdominal aortic aneurysm 62mm
- Crawford Type IV with aneurysms of both common iliac arteries
- occlusion of the left hypogastric artery
- replaced infrarenal aorta

PROCEDURAL STEPS
1. Percutaneous approach both groins
- Prostar XL (ABBOTT)
- 14F (COOK) both groins

2. Left axillary access
- 5F TERUMO sheath,later 12/8F sheath

3. Placement of a CMD
- Zenith-endograft (COOK) with three branches

4. Implantation of the distal bifurcated endograft and a IBD on the right side

5. Closure of the groins

6. Cannulation of the SMA, renal arteries and the right hypogastric artery through the branches and implantation of the bridging stentgafts

CLINICAL DATA
Claudication (foot) Rutherford-Becker class 3
Recanalisation of the femoro-popliteal bypass (P I) 12/2014
Femoro-popliteal bypass (PTFE) 2008

RISK FACTORS
Hypertension, tobacco use

ABI AT REST
0.6/1.0

DUPLEX
Occlusion of the PTA/ATA

PROCEDURAL STEPS
1. Antegrade femoral access right groin
- 6F 11cm sheath (CORDIS)
- 5F STR guiding catheter (CORDIS)

2. Recanalisation of the posterior tibial artery
- 0.014" Pilot 150 wire (ABBOTT), 0.014" Extra-Support wire (ABBOTT)
- 0.014" Advantage (TERUMO), 2.0x120mm OTW Amphirion balloon (MEDTRONIC)

3. Atherectomy
- Phoenix 1.8 mm (VOLCANO)

4. (DE-) Postdilatation and stenting on indication
- 2.5x120 mm Lutonix 14 (BARD)

5. Optional: tibial access

CLINICAL DATA
Claudication Rutherford-Becker class 3
Recanalization and stenting of the left EIA and SFA 06/2013
Stenting of the right SFA 09/2013

RISK FACTORS
Tobacco use, hypertension, hypercholesterolemia

ABI AT REST
Right/left: 0.6/0.3

DUPLEX
Left leg: CIA, EIA, CFA, DFA without stenosis.
Origin of the SFA occluded. Detectable blood flow in the PA (I).

PROCEDURAL STEPS
1. Retrograde femoral access (cross-over)
- 6F and 8F Cross-over sheath Balkin (CORDIS)
- 0.035" stiff wire (TERUMO)

2. Recanalization of the SFA
- 0.018" Advantage (TERUMO), Quick-Cross support-catheter (SPECTRANETICS)

3. Laser procedure
- 2.0mm Elite Laser, Turbo-Tandem (SPECTRANETICS)
- Wirion filter (GARDIA MEDICAL)

4. DEB postdilatation
- 5 mm and 6 mm x 120 mm PacificInpact balloon

5. Stenting on indication

CLINICAL DATA
Claudication (left calf) Rutherford-Becker class 3
Coronary heart disease: DES RCX 02/2005; PCI RCA 09/2001

RISK FACTORS
Tobacco, hypertension, diabetes hypercholesterolemia

ABI AT REST
Right/left: 0.9/0.4

DUPLEX
Left leg: CIA, EIA, DFA without stenosis, distal part of the SFA incl. PA occluded
Detectable blood flow in the middle part of the PA and the tibio-peroneal trunc

PROCEDURAL STEPS
1. Antegrade femoral access
- 7F sheath (CORDIS)

2. Recanalization of the SFA/PA
- 4F vertebralis catheter (CORDIS)
- 0.035" wire (TERUMO)

3. Atherectomy
- Jetstream (BOSTON SCIENTIFIC)

4. Postdilatation
- 4/5 mm 120 mm DE-balloon angioplasty, Ranger (BOSTON SCIENTIFIC)

5. Stenting on indication

CLINICAL DATA
Claudication Rutherford-Becker class 3
Femoro-popliteal Bypass surgery 2005, re-occlusion of the Bypass 2006+2014
Recanalization+DEB+Stent of the SFA/PA 12/2014

RISK FACTORS
Tobacco use

ABI AT REST
Right/left: 0.5/1.1

DUPLEX
Bypass and PA without stenosis, occlusion of the PTA and ATA.

PROCEDURAL STEPS
1. Antegrade femoral access (cross-over)
- 6F sheath (TERUMO)

2. Recanalization of PTA
- 5F STR-catheter (CORDIS), 0.014" Pilot 50/150 wire (ABBOTT), 0.014" Advantage (TERUMO)
- 2.0 x 120 mm Amphirion-OTW (MEDTRONIC)

3. Predilatation
- 2.0 x 120 mm Amphirion-RX (MEDTRONIC)

4. Dilatation
- 2.5/3 x 120 mm Lutonix (DE-) balloon (BARD)

5. Optional
- DES, retrograde access, re-entry device

CLINICAL DATA
Past Medical History:
Iliac vein thrombosis left side in 2012 (May Thurner) treated with CDT (EKOS) and 2 overlapping stents in common and external iliac veins

VTE-RISK FACTORS
Chronic venous insufficiency (ulcer, varicose veins), smoking
Currently no anticoagulation therapy

PRESENT COMPLAINT
Chronic venous insufficiency left leg with:
Mild leg swelling (2 cm plus in thigh circumference) / No venous claudication
Hyperpigmentation, varicose veins

DUPLEX
Popliteal & femoral veins: patent / Common femoral vein: patent
External and common iliac veins: instent restenosis

PROCEDURAL STEPS
1. Local anaesthesia with standby

2. Venous access with ultrasound guidance in left popliteal (10F sheath)

3. Wire crossage
- 0.035" stiff angled (TERUMO)

4. Phlebography, IVUS

5. Predilatation
- Atlas Balloon 12–14 mm (BARD), Aspirex 10F (STRAUB MEDICAL) thrombectomy depending on thrombus load

6. Implantation of dedicated Iliac vein stents over TERUMO stiff angled wire 0.035"
- Sinus-Obliquus 14–16 mm (OPTIMED),
- Sinus-XL Flex 14–16 mm (OPTIMED)
- Vici 14–16 mm (Veniti)

7. High-pressure postdilation of stents
- Atlas Balloon 14–16 mm (BARD)

CLINICAL DATA
Past medical history:
Iliofemoral DVT left side in April 2014 treated conservatively
VTE-Risk factors: history of distal DVT right leg 2007
while on oral contraception and smoking
Currently on anticoagulation therapy, compression stockings

PRESENT COMPLAINT
Chronic venous insufficiency left leg with:
Moderate leg swelling despite compression therapy
Severe venous claudication

CT
No clear signs of May Thurner present / external iliac vein occlusion
Popliteal and femoral veins postthrombotic, common femoral and iliac veins occluded

PROCEDURAL STEPS
1. General anaesthesia, prone position, urinary catheter

2. Venous access with ultrasound guidance in left popliteal
- 7F destination sheath

3. Wire crossage
- TERUMO 0.035" stiff angled, 4F Berenstein catheter, torque device

4. Phlebography, IVUS

5. Predilation
- Atlas Balloon 12–14 mm (BARD)

6. Implantation of dedicated Iliac vein stents over TERUMO stiff angled wire 0.035"
- Sinus-Obliquus 14–16 mm (OPTIMED),
- Sinus-XL Flex 14–16 mm (OPTIMED)

7. High-pressure post-dilation of stents
- Atlas Balloon 14–16 mm (BARD)

CLINICAL DATA
Past medical history:
Bilateral iliofemoral DVT involving infrarenal VCI 2001 treated conservatively
VTE-Risk factors: oral contraception, Faktor V Leiden
Currently no anticoagulation therapy, compression stockings
Endometriosis, WPW syndrome

PRESENT COMPLAINT
Chronic venous insufficiency both legs with:
Mild leg swelling, Moderate venous claudication, cramps
Severe pelvic congestions syndrome with abdominal and back pain, depending on menstrual cycle.

DUPLEX
Popliteal & femoral veins & external iliac veins: patent
Iliac veins and IVC: postthrombotic high velocity flow without modulation
MR venography: postthrombotic changes of IVC and left common iliac vein, right ovarian vein ectasia.

CT
Right ovarian vein (10 mm), postthrombotic infrarenal IVC

PROCEDURAL STEPS
1. General anaesthesia, supine position, urinary catheter

2. Venous access in both common femoral (10F) and right jugular veins (6F)

3. Wire crossage IVC from both femoral veins
- TERUMO 0.035" stiff angled, 4F Berenstein catheter, torque device

4. Phlebography, IVUS

5. Right ovarian vein venography & embolization from jugular access
- pushable Nester coils (COOK)

6. Predilation IVC
- Atlas Balloon 14–18 mm (BARD)

7. Implantation of dedicated vein stents over TERUMO stiff angled wire 0.035" in IVC and kissing stents iliac veins
- Sinus-XL 18–22 mm (OPTIMED) for IVC,
- Sinus-XL Flex 14–16 mm (OPTIMED) for iliac veins

8. High-pressure postdilation of stents
- Atlas Balloon 14–18 mm (BARD)

CLINICAL DATA
Multifocal hepatocellular carcinoma ED: 07/14
Child A liver cirrhosis
After 1. DEB-TACE (3 ml 75 μm Tandem loaded with 150 mg doxorubicin
plus 11 μml unloaded Embozene 250 μm; CELONOVA, USA) 11.12.2014
Today: 2. DEB-TACE of the first cycle

PROCEDURAL STEPS
1. Transfemoral approach right groin

2. Short 4F sheath Radifocus (TERUMO)

3. 0.035" 180 cm J-wire

4. 4F 110 cm 4F Sidewinder Typ I (CORDIS)

5. 2,8F Microcatheter Progreat (TERUMO)

6. Embolisation
- 75μm Tandem DEB-particles (CELONOVA); loaded with 150 mg of doxorubicin

CLINICAL DATA
Asymptomatic progressive AAA 53 mm

RISK FACTORS
Art. hypertension, history of smoking

PROCEDURAL STEPS
1. Fusion imaging (2D-3D registration)
- Artis Zeego/Leonardo (SIEMENS)

2. Bifemoral cut-down

3. Guidewire positioning
- Lunderquist GW 180 cm (COOK)

4. Implantation of a bifurcated stentgraft
- Endurant II (MEDTRONIC)

5. Postdilation
- Reliant balloon (MEDTRONIC)

6. Contrast enhanced Dyna-CT
- Artis Zeego/Leonardo (SIEMENS)

CLINICAL DATA
Asymptomatic progressive AAA 53 mm

RISK FACTORS
Art. hypertension, history of smoking

PROCEDURAL STEPS
1. Fusion imaging (2D-3D registration)
- Artis Zeego/Leonardo (SIEMENS)

2. Bifemoral cut-down

3. Guidewire positioning
- Lunderquist GW 180 cm (COOK)

4. Implantation of a bifurcated stentgraft
- Endurant II (MEDTRONIC)

5. Postdilation
- Reliant balloon (MEDTRONIC)

6. Contrast enhanced Dyna-CT
- Artis Zeego/Leonardo (SIEMENS)

CLINICAL DATA
Pat. on waiting list for LTx
Cryptogenic liver cirrhosis, child A
Refractory ascites
Previous episode of hep. encephalopathy

PROCEDURAL STEPS
1. Transjugular venous access right side
- 9F 20 cm sheath (Arrows)

2. Puncture attempt: right liver vein --> right PV
- TIPS-set (OPTIMED) 30Æ or 60Æ angled

3. 0.035" superstiff wire (BOSTON SCIENTIFIC)

4. Predilatation
- 8 x 80 mm MARS® balloon (OPTIMED)

5. 10F Sheath (Checkflow, COOK) 38-45 cm, straight / angled

6. Stentgraft implantation
- Viatorr®-Stentgraft (GORE)

7. Planning
- Puncture: right LV right PV
- Needle type: 30Æ angled
- Shunt: 10 mm Viatorr (GORE) 10/6/2 or 10/7/2

CLINICAL DATA
Asymptomatic AAA 54 mm!
Asymptomatic aneurysm of the left common iliac artery 26 mm
Left SFA occlusion

RISK FACTORS
Art. hypertension, history of smoking

PROCEDURAL STEPS
1. Bifemoral cut-down

2. 8F sheath placement (TERUMO)

3. Fusion imaging for endograft navigation using 2-D – 3-D registration

4. Guidewire insertion (TERUMO)
- Lunderquist GW 180 cm (COOK)

5. Stentgraft positioning and deployment
- 2 Nellix systems (ENDOLOGIX)

6. Endobag prefilling with saline, angiography

7. Endobag filling with polymer

8. Optional secondary fill

CLINICAL DATA
Asymptomatic AAA 54 mm!
Asymptomatic aneurysm of the left common iliac artery 26 mm
Left SFA occlusion

RISK FACTORS
Art. hypertension, history of smoking

PROCEDURAL STEPS
1. Bifemoral cut-down

2. 8F sheath placement (TERUMO)

3. Fusion imaging for endograft navigation using 2-D – 3-D registration

4. Guidewire insertion (TERUMO)
- Lunderquist GW 180 cm (COOK)

5. Stentgraft positioning and deployment
- 2 Nellix systems (ENDOLOGIX)

6. Endobag prefilling with saline, angiography

7. Endobag filling with polymer

8. Optional secondary fill

CLINICAL DATA
DM, neurovasculopathy

RISK FACTORS
Right pre-tibial II-III D lesion, right foot rest pain. TcPO2: 17 mmHg
Hypertension
Ischemic heart disease (previous PTcA)

PROCEDURAL STEPS
1. Right Groin antegrade US guided approach
- 6F 11 cm sheath (TERUMO)

2. Antegrade wiring of AT and arch
- 4F BER 2, 100 cm (CORDIS)
- 0.014" Pilot 200, 300 cm (ABBOTT)

3. Antegrade passage of the PT/lateral plantar occlusion
- 4F BER 2 100 cm (CORDIS), V18 CW (BOSTON SCIENTIFIC)

4. Wires rendez-vous through arch and lateral plantar artery

5. Predilatation
- Armada XT, 1,5 mm x 20 mm (ABBOTT)

6. Definitive dilatation
- Armada 14, 2,5 mm x 200 mm (ABBOTT)

CLINICAL DATA
DM, neurovasculopathy

RISK FACTORS
I° toe gangrene and calcanear Tuc 1 c lesion; TcPO2: 8 mmHg.
Hypertension, dyslipidemia
Ischemic heart disease (previous PTcA)

PROCEDURAL STEPS
1. Antegrade US guided left groin approach
- 6F 11 cm sheath (TERUMO)
- 4F 110 cm Flexor sheath (COOK) option

2. Antegrade/retrograde trans tarsal loop passage of the PT occlusion
- 0.018" V18 300 cm (BOSTON SCIENTIFIC)
- Pilot 200, 300 cm (ABBOTT)

3. Wires rendez-vous

4. Predilatation
- Ultraverse 1.5 mm x 20 mm (BARD)
- Ultraverse 2.0 mm x 300 mm (BARD)

5. Definitive dilatation
- Lutonix 2.5 mm x 150 mm (BARD)

CLINICAL DATA
DM, neurovasculopathy

RISK FACTORS
Right CLI, diffuse onycodisthrophia, I° and II° TUC 1c, TcPO2=22 mmHg
Hypertension, dyslipidemia, ischemic heart disease, CAF, previous left CFA surgical endoatherectomy

PROCEDURAL STEPS
1. Right groin US guided antegrade approach
- 6F 11 cm sheath (TERUMO)

2. Antegrade passage of the distal AT/dorsalis paedis occlusion
- 4F Ber 2, 100 cm (CORDIS),
- 0.018" 300 cm V18 CW (BOSTON SCIENTIFIC)
- 0.014" 300 cm V14 (BOSTON SCIENTIFIC)
- retrograde distal I° digital puncture after failure
- arch evaluation and possible trans-loop retrograde lateral plantar recanalization

3. Predilatation
- Coyote ES 1.5 mm/2 mm x 20 mm

4. Definitive dilatation
- Coyote 2.5 mm x 200 mm

CLINICAL DATA
Unusual presentation in 2008 with supra-renal IVC thrombosis and extensive right lower extremity DVT
Suprarenal IVC filter placed
Successfully treated by catheter directed thrombolysis and placement of tandem 12mm diameter, 90mm long Wallstent
Patient could not tolerate balloon dilatation beyond 10 mm
Fully anticoagulated
Lost to follow up; represented in 2013 with varicose veins RLE. CEAP 4

PROCEDURAL STEPS
1. General anaesthetic, urethral catheter, supine position

2. Mid thigh femoral venous access
- 5F sheath; ascending venography
- R IJV access; 55cm long sheath; 8F
- 5000u IV Heparin
- Upsize to 10F sheath R FV

3. Attempt to cross occluded stent in R EIV from below and if necessary above
- Stif glidewire; back end stiff glidewire; centring balloon technique CTO wire (Asahi Astata 30g with 2.5 mm balloon to back it up).
- IF we get across; attempt to clear out stent with Rotarex (STRAUB MEDICAL).

4. Exchange for a 180cm Amplatz wire
- Pre dilate lesion with a high pressure balloon (BARD Atlas).
- Stent lesion with a dedicated venous stent
Veniti Vici 16 mm diameter, 120 mm long

5. Repeat balloon dilatation to nominal diameter of stent
- Confirm full stent expansion by IVUS (VOLCANO) and cone beam CT (SIEMENS).
- Completion venography

6. Radiofrequency ablation
- IF ALL ABOVE SUCCESSFUL then; radiofrequency ablation to R GSV throughout its length (ClosureFast, COVIDIEN).

7. Remove sheaths
- Class 2 thigh high compression stockings (Jobst) for 6 weeks.
- Full anticoagulation
- Overnight thigh high sequential compression device (COVIDIEN).
- Colour Doppler US day 1; CTV at 6/52

CLINICAL DATA
Noticed development of vulval varices after birth 2nd child and became much worse after third. Uncomfortable. Unpleasant.

PROCEDURAL STEPS
1. Local anaesthetic, no sedation

2. S upine position

3. R IJV access

4. S elective catheterisation right ovarian, left ovarian and bilateral internal iliac veins

5. Combination of foam sclerosant and coil (COOK) embolisation

6. Deliberate dissection orifice right ovarian vein!!

CLINICAL DATA
2008: CABG
2009: Adenocarcinoma right colon (pT3N1): resection + adj. chemo smoking

PRESENT STATE
Claudication right > left after 100 m since 6 months
DUS: Bilateral SFA occlusion
CT angio

PROCEDURAL STEPS
1. Left CFA retrograde access

2. Crossover procedure
- RIM Catheter (COOK) + Roadrunner Uniglide 0.035"/260 cm stiff curved (COOK)

3. Flexor sheath 6F, 45 cm (COOK)

4. Roadrunner Uniglide 0.018"/260 cm (COOK) + 0.018" curved CXI Catheter 90 cm (COOK)

5. Recanalization
- by preference intraluminal (Plan B: subintimal)

6. Predilatation
- Advance 18LP balloon (COOK)

7. Popliteal artery
- DCB Advance PTX 0.018" balloon (COOK)

8. SFA
- Zilver PTX stent (COOK)

CLINICAL DATA
1992: Aortobifemoral bypass
2003: left CAS
severe COPD
smoking, hypercholesterolemia, arterial hypertension

PRESENT STATE
claudication right leg since 6 months, 50 m
DUS: bilateral SFA occlusions
MR angio

PROCEDURAL STEPS
1. Right CFA access anterograde
- 6F BriteTip Sheath (CORDIS) 12 cm

2. Predilatation
- Passeo-18 (BIOTRONIK)

3. Dilatation
- DCB Passeo-Lux 0.018" (BIOTRONIK)

4. Stenting
- Pulsar-18 (BIOTRONIK)

CLINICAL DATA
PTCA in 2007
COPD
Hypercholesterolemia, ex-smoker

PRESENT STATE
Claudication in both legs with 100 m walking distance since 3 months.

DUPLEX
Weak monophasic signals in both groins with on the left side complete absence of flow.

PROCEDURAL STEPS
1. Left brachial access
- 6F GlideWire 0.035" curved stiff (TERUMO)
- Internal mammaria catheter 5F (CORDIS)
- Destination 6F 90 cm (TERUMO)

2. PLAN A: Anterograde recanalization
- GlideWire 0.035"/280 cm curved stiff (TERUMO), alternative: Advantage GlideWire 0.018" (TERUMO)
- supported by CXI 0.035"/0.018" 150 cm (COOK)

3. PLAN B: Retrograde recanalization with SFA puncture(s)

4. Predilatation
- Armada 0.035" (ABBOTT VASCULAR)

5. Stenting
- Supera VMI (ABBOTT VASCULAR)

CLINICAL DATA
2008: PTA+S right CIA & EIA, left SFA
prostatic cancer, treated with radiotherapy
8/JAN/15: PTA+S left EIA & SFA
hypercholesterolemia, smoking

PRESENT STATE
Rest pain (Rutherford 4) right angiography

PROCEDURAL STEPS
1. Left CFA access, 6F

2. Crossover procedure
- RIM Catheter (COOK) + GlideWire 0.035" (TERUMO)
- Destination 7F 45 cm sheath (TERUMO)

3. In-stent recanalization
- GlideWire 0.035"/0.018" (TERUMO)
- Berenstein 4F 100 cm (CORDIS) CXI 0.035"/0.018" catheter (COOK)

4. Predilatation
- Armada 0.035" (ABBOTT VASCULAR)

5. Stenting
- Viabahn Endoprosthesis (GORE)

6. Left CIA stenosis stenting
- BeGraft balloon-expandable stent-graft (BENTLEY INNOMED)

CLINICAL DATA
46-year-old gentleman with a history of chronic DVT for several years, first seen in June 2013. He has persistent progressive symptoms with left leg swelling and ankle pain, despite reliable use of graded compression stockings and other conservative measures. This is interfering with his work as an electrician. His medications are aspirin 81 mg only.

PROCEDURAL STEPS
1. US guided popliteal puncture
- Sono-site ultrasound, Micropuncture set (COOK)
- Upsize to 7F sheath (TERUMO)

2. Lesion crossing
- 0.035" Glidewire advantage (TERUMO)
- Glidecatheter

3. Balloon venoplasty
- Charger (BOSTON SCIENTIFIC) or Admiral (MEDTRONIC)

4. Positioning of EKOS thrombolytic infusion catheter (per chronic DVT trial)

CLINICAL DATA
73-year-old woman with known bilateral severe renal artery stenosis
from a CTA on 10/16/2013 with atrophy in the left kidney.
She has not had congestive heart failure.
She was a former smoker; stopped approximately two years ago.
She has a history of coronary artery disease with myocardial infarction
and coronary stents in 2012. She does not have dyslipidemia or diabetes.

Current blood pressure medications are clonidine 0.1 b.i.d., Toprol 12.5 daily,
and losartan/hydrochlorothiazide 50/12.5 daily. She also takes Zocor 40,
Plavix 75, and aspirin 81.

VITAL SIGNS
Blood pressure, was 178/67 mmHg in the right arm and 161/70 mm Hg in the left arm.

LABS
GFR 66 ml/min.1.73m2

PROCEDURAL STEPS
1. Right femoral puncture and insertion of 7F RDC guide sheath (CORDIS)

2. Selective catheterization of left renal artery
- Spartacore wire (ABBOTT)

3. Possible Buddy Wire and pressures
- Radi wire (VOLCANO)

4. Renal artery stenting
- Formula 414 stents (COOK)

CLINICAL DATA
Patient is a 57-year-old gentleman with history of hypertension sleep apnea and obesity who presented to emergency room for 3 days history of sudden onset severe left abdominal pain and worse during inspiration and sometimes radiating to his left shoulder. An abdominal CT scan showed a splenic infarct 2.5 cm celiac artery aneurysm.

RISK FACTORS
History of a cardiomyopathy with negative cardiac catheterization, nonischemic left bundle branch block, renal insufficiency Echocardiogram showed LVEF 40% without atrial or ventricular thrombus.

PROCEDURAL STEPS
1. US guided radial puncture
- Sono-site ultrasound, Micropuncture set (COOK)
- Adminstration of NTG and Verapamil
- Insertion of 6F Slender Sheath (TERUMO)
- Traverse arch, wire descending thoracic aorta and exchange for 5F Shuttle Sheath (COOK)

2. Select celiac access, subselect and coil proximal splenic artery
- Interlock coils (BOSTON SCIENTIFIC)

3. Possible subselect and coil embolize left gastric artery

4. Advance 0.018" Platinum plus wire into hepatic artery

5. Exclude celiac aneurysm with ICast stent grafts (Atrium) or Viabahn stent grafts (GORE)

CLINICAL DATA
PAOD Rutherford 3, claudication both legs
PTA and stenting at bi-lateral iliac arteries at 2009
Claudication appeared again early last year
Stenting for bi-lateral EIA and right SFA at 12/2014

RISK FACTORS
Ischemic heart disease, hypertension,
diabetes mellitus type 2, dyslipidemia,
CKD (hemodialysis dependent)

ABI
Right 1.15, left 0.87 (after EVT)

PROCEDURAL STEPS
1. Left common femoral access and ipsi-lateral antegrade approach
- 6F Guiding sheath, Parent-Plus 23 cm (MEDIKIT)

2. Retrograde puncture of the left distal SFA
- 20G Introducer Needle (MEDIKIT)
- Cruise 0.014" 225 cm (NEOS)
- Promenent-NEO2 60 cm (TOKAI MEDICAL PRODUCTS)

3. Antegrade wiring
- 0.014" Harberd (Asahi Intec) supported by Prominent-NEO 135 cm

4. Retrograde wiring
- 0.014" Chevalier floppy (CORDIS Endovascular)
- Wire rendez-vous technique within SFA-CTO

5. PTA / stenting from antegrade
- Coyote 3.0 x 220 mm (BOSTON SCIENTIFIC)
- Sterling 5.0 x 220 mm (BOSTON SCIENTIFIC)
- Smart Control (CORDIS)

CLINICAL DATA
POAD Rutherford 3, claudication left carf at less than 100 meters
Stenting for left SFA and PTA for left POP 1/2014
Claudication appeared again at 12/2014

DUPLEX
Dyslipidemia, diabetes mellitus type 2
ABI: right 1.15, left unmeasureable
CT images of left femoral artery

PROCEDURAL STEPS
1. Left common femoral access and ipsi-lateral antegrade approach
- 6F Guiding sheath, Parent-Plus 23 cm (MEDIKIT)

2. Retrograde puncture of the left distal PTA
- 20G Introducer Needle (MEDIKIT)
- Cruise 0.014" 225 cm (NEOS)
- Promenent-NEO2 60 cm (TOKAI MEDICAL PRODUCTS)

3. Antegrade wiring
- 0.035" Redifocus small-J (TERUMO) supported by 4F angiographic catheter (CORDIS)
- 0.014" Astatto XS9-12 (Asahi Intec) supported by Prominent-NEO 135cm (TOKAI MEDICAL PRODUCTS)

4. Retrograde wiring
- 0.014" Chevalier floppy (CORDIS Endovascular)
- Wire rendez-vous technique within CTO lesion

5. Thrombus aspiration
- TVAC aspiration catheter (NIPRO)
- Distal protection by external pressure cuff

6. PTA/stenting from antegrade
- Coyote 3.0 x 220 mm (BOSTON SCIENTIFIC)
- Sterling 5.0 x 220 mm (BOSTON SCIENTIFIC)
- Smart Control, if necessary (CORDIS)

CLINICAL DATA
PAOD Rutherford 2, claudication right calf at 300 meters

RISK FACTORS
Old cerebral infarction

ABI
Right 0.69, left 0.92

PROCEDURAL STEPS
1. Right common femoral access and ipsi-lateral antegrade approach
- 6F guiding sheath, Parent-Plus 23 cm (MEDIKIT)

2. Antegrade wiring
- 0.014" Halberd (ASAHI INTEC) supported by Prominent-NEO 135 cm (TOKAI MEDICAL PRODUCTS)
- 0.014" Astato XS9-12 (ASAHI INTEC)

3. Retrograde wiring
- 0.014" Cruise (Neos) supported by Prominent 135 cm (TOKAI MEDICAL PRODUCTS)
- Guidewire rendez-vous technique within SFA-CTO

4. PTA/Stenting from antegrade
- Coyote 3.0 x 220 mm (BOSTON SCIENTIFIC)
- Sterling 5.0 x 220 mm (BOSTON SCIENTIFIC)
- Smart control, if necessary (CORDIS)

CLINICAL DATA
04/12 TIA (Dysarthria and right arm paresis)

RISK FACTORS
Hypertension, former smoker, hyperlipidaemia, diabetes mellitus

PROCEDURAL STEPS
1. Femoral access: Navigation of a diagnostic catheter into the left ECA
- 5F JB1 diagnostic catheter, 100 cm (CORDIS)
- 0.035" TERUMO angled guide-wire, 260 cm (TERUMO)

2. Introduction of the cerebral protection device and endovascular clamping
- 8F - 11 cm introducer (CORDIS)
- 0.035" E-Wire guide-wire, 260 cm (JOTEC)
- Endovascular Clamping Device – MoMa 8F (MEDTRONIC)

3. Passing of the left ICA lesion and stenting
- 0.014" Choice Pt Extra stiff guide-wire, 190 cm (BOSTON SCIENTIFIC)
- 3.5/20 mm Falcon Bravo RX PTA Balloon Catheter (MEDTRONIC)
- 40 mm Adapt RX Carotid Stent (BOSTON SCIENTIFIC)

4. Postdilatation
- 5.0/20 mm Falcon Bravo RX PTA Balloon Catheter (MEDTRONIC)

5. Left brachial access: Navigation of a diagnostic catheter into the left ECA
- 7F – 45 cm introducer (CORDIS)
- 7F VERT diagnostic catheter, 100 cm (TERUMO)
- 0.035" Teruma angled guide-wire, 260 cm (TERUMO)

6. Passing of the left subclavian artery lesion and stenting
- 70/20 mm Powerflex Pro OTW PTA ballon catheter (CORDIS)
- Stent Genesis 90 x 29 7F OTW (CORDIS)

CLINICAL DATA
Asymptomatic expanding aneurysm sac after EVAR without apparent endoleak secondary to sac hygroma

RISK FACTORS
Hypertension, COPD, hyperlipidaemia, former smoker

PROCEDURAL STEPS
1. Cut down bilateral common femoral arteries
- DrySeal Introducer 18F (WL GORE)
- DrySeal Introducer 20F (WL GORE)
- 0.035" E-Wire guide-wire, 260 cm (JOTEC)

2. Endograft relining
- Endurant proximal cuff 28 x 45 mm (MEDTRONIC)
- Endurant iliac limb externsion 16 x 16 x 120 mm 14F (MEDTRONIC)
- Endurant iliac limb externsion 16 x 20 x 120 mm 16F (MEDTRONIC)

3. Latex balloon accomodation
- Reliant balloon (MEDTRONIC)