LINC 2016 live case guide

RISK FACTORS
Arterial hypertension (controlled),
hyperlipidemia (LDL 141mg/dl, Chol. 227mg/dl, HDL 49 mg/dl)

PROCEDURAL STEPS
1. Transfemoral retrograde approach
- 8F short sheath (TERUMO)
- Diagnostic 5F catheter Weinberg shape (COOK)
- TERUMO stiff angled 0.035" wire into left ECA

2. Exchange to
- Vista Brite Tip IG guiding catheter MPA1 shape into left CCA (CORDIS)

3. Distal protection
- Filter Wire EZ (BOSTON SCIENTIFIC) into distal ICA left

4. Stenting
- Roadsaver Carotid Micromesh stent (TERUMO) 8 x 25 mm

5. Carotid postdilatation
- 5 x 20 mm Paladin balloon with integrated embolic protection (40 micron pore size) (CONTEGO-MEDICAL)

6. Paladin filter closure and combined filter/balloon-system removal
- Removal of the distal EPD-Filter Wire EZ
- Removal of guiding catheter (wire controlled)

7. Closure of puncture site
- Angioseal 8F
Transfer patient ICU

New patient! Information will follow in due time. Thank you for your understanding.

CLINICAL DATA
Bilateral severe claudication left > right since years,
recently deterioration of walking distance and lesion
at the the dorsal side of the 2nd toe

RISK FACTORS
Hyperlipidemia, former smoker, controlled hypertension,
MRA with BTK vessel occlusions
ABI at rest: 0.5 left, 0.64 right

ABI at rest
Left 0.5, right 0.64

PROCEDURAL STEPS
1. Antegrade access left CFA
- 4F Fortress sheath (BIOTRONIK)

2. Approaching the lesion
- 0.014" wire approach, Advantage wire (TERUMO)
- Backup with CXI support catheter (COOK)

3. PTA and stenting of the occluded tibioperoneal trunc
- 3.0 x 38 mm Cr8 BTK Stent (ALVIMEDICA)

4. Recanalisation of the anterior tibial artery
- Primary PTA 2.5 x 200 mm Coyote balloon (BOSTON SCIENTIFIC)

CLINICAL DATA
PAD Rutherford 3 left calf,
PTA and stenting right SFA occlusion 1/2016

RISK FACTORS
Arterial hypertension, hyperlipidemia

ABI
Right 0.75, left 0.63

PROCEDURAL STEPS
1. Transfemoral retrograde approach
- 6F cross over sheath (Fortress, BIOTRONIK)

2. Recanalisation left SFA occlusion
- 35" TERUMO Stiff wire and glidecath catheter

3. PTA
- Passeo 18 (BIOTRONIK)

4. SFA stenting
- Pulsar 18 (BIOTRONIK)

5. PTA
- DEB Passeo 18 Lux

6. Closure of puncture site
- Angioseal 6F if possible

CLINICAL DATA
PAD Rutherford 3 right calf,
former Stenting of the left common iliac and external iliac artery,
former PTA and Stenting left SFA

ABI
Right 0.73; left 0.91

RISK FACTORS
Hypercholesterinemia ( Chol.282 mg/dl, LDL 174, HDL 55)
Arterial Hypertension

PROCEDURAL STEPS
1. Transfemoral retrograde approach
- 7F cross over sheath (TERUMO)
- 35" TERUMO stiff guidewire

2. Embolic protection
- Filter Wire EZ (BOSTON SCIENTIFIC)

3. Artherectomy
- Jetstream XC 7F, 120 cm (BOSTON SCIENTIFIC / BAYER)

4. PTA
- DEB Ranger 5 x 60 and 6 x 40 mm (BOSTON SCIENTIFIC)

4. Closure of puncture site
- Starclose 6F

CLINICAL DATA
Iliac vein thrombosis left side in 2013 treated with anticoagulation
Iliac vein thrombosis left side 06/2015
Mechanical compression of the left iliac vein (ostheosynthesis L4/5)

PRESENT STATE
Venous claudication (painfree walking distance 500 m)
Swelling (2 cm plus in thigh circumference) despite compression therapy
No skin changes
No varicose veins

DUPLEX
Postthrombotic changes in iliac and femoral veins

CT
Mechanical compression of the left iliac vein through ostheosynthetic material

PROCEDURAL STEPS
1. Venous access with ultrasound guidance in left popliteal
- 10F sheath

2. Wire crossage
- Terumo 0.035 stiff angled

3. Phlebography, IVUS

4. Predilatation
- Atlas Balloon 14 mm (BARD)

5. Implantation of dedicated Iliac vein stents
- Sinus-Obliquus 14–16 mm (OPTIMED),
- Sinus-XL Flex 14–16 mm (OPTIMED), or
- Vici 14–16 mm (VENITI)

6. High-pressure postdilation of stents
- Atlas Balloon 14 mm (BARD)

MEDICAL HISTORY
Ilio-femoro-popliteal thrombosis 1986 after severe car accident with polytrauma
Permanent neurocognitive deficits
Ongoing anticoagulation therapy

RISK FACTORS
Chronic venous insufficiency left leg with: venous claudication, varicose veins,
hyperpigmentation, leg swelling
Villalta-Score: 6 points

CT
May Thurner compression of the left common iliac vein

PROCEDURAL STEPS
1. Venous access with ultrasound guidance in left popliteal (10F sheath)

2. Wire crossage
- TERUMO 0.035 stiff angled

3. Phlebography, IVUS

4. Predilation
- Atlas Balloon 14 mm (BARD)

5. Implantation of dedicated Iliac vein stents
- Sinus-Obliquus 14–16 mm (OPTIMED),
- Sinus-XL Flex 14–16 mm (OPTIMED), or
- Vici 14–16 mm (VENITI)

6. High-pressure postdilation of stents
- Atlas Balloon 14 mm (BARD)

MEDICAL HISTORY
Ilio-femoro-popliteal thrombosis 1986 after severe car accident with polytrauma
Permanent neurocognitive deficits
Ongoing anticoagulation therapy

RISK FACTORS
Chronic venous insufficiency left leg with: venous claudication, varicose veins,
hyperpigmentation, leg swelling
Villalta-Score: 6 points

CT
May Thurner compression of the left common iliac vein

PROCEDURAL STEPS
1. Venous access with ultrasound guidance in left popliteal (10F sheath)

2. Wire crossage
- TERUMO 0.035 stiff angled

3. Phlebography, IVUS

4. Predilation
- Atlas Balloon 14 mm (BARD)

5. Implantation of dedicated Iliac vein stents
- Sinus-Obliquus 14–16 mm (OPTIMED),
- Sinus-XL Flex 14–16 mm (OPTIMED), or
- Vici 14–16 mm (VENITI)

6. High-pressure postdilation of stents
- Atlas Balloon 14 mm (BARD)

CLINICAL DATA
Past medical history: No personal or familiy history of DVT
Previously healthy
Chronic venous insufficiency left leg with:
Venous claudication (walking distance 600 m)
Leg swelling (thigh 7 cm plus)
No varicose veins or skin changes

DUPLEX/CT
Stenosis of the external iliac vein left side

PROCEDURAL STEPS
1. Venous access with ultrasound guidance in left popliteal (10F sheath)

2. Wire crossage
- TERUMO 0.035 stiff angled

3. Phlebography, IVUS

4. Predilation
- Atlas Balloon 14 mm (BARD)

5. Implantation of dedicated iliac vein stents
- Sinus-XL Flex 14 mm (OPTIMED), or
- Vici 14 mm (VENITI)

6. High-pressure postdilation of stents
- Atlas Balloon 14 mm (BARD)

MEDICAL HISTORY
Appendectomy and removal of ovarian cyst 1996
Laparoscopic adhesiolysis and tubal sterilisation 2005
Last menstrual cycle 03/2015
Recent gynecologic exam unremarkable

PRESENT STATE
Left sided abdominal dull pain, lower quadrant since 6 months
The pain is worse during defecation
No pain during or after sexual intercourse or during voiding
Pain dependence on position (no pain during bed rest, worse while standing and sitting)

CT
Prominent left-sided ovarian vein, varicose, parauterine veins

VENOGRAPHY
Refluxing left-sided ovarian vein, no reflux in hypogastric and right ovarian vein

PROCEDURAL STEPS
1. Venous access in right femoral vein (5F sheath)
2. Cobra 4F diagnostic catheter
3. Selective venography of distal left ovarian vein
4. Foam sclerotherapy of varicose uterine veins
5. Coil embolization of ovarian veins (0.018, 8-12 mm)

CLINICAL DATA
Past medical history:
Thrombosis of IVC and bilateral Iliac veins 08/2013 treated with anticoagulation
Varicocele, hemorrhoids
Thrombophilia testing negative
Failed endovascular recanalisation attempts in 2015 in two tertiary care hospital

PRESENT STATE
Bilateral venous claudication
Lumbar pain, bilateral swelling despite compression therapy, varicose veins
Currently no anticoagulation therapy
CT: postthrombotic IVC, large hemiazygos vein,
Failed endovascular treatment

PROCEDURAL STEPS
1. Bilateral common femoral vein access, right jugular vein access with ultrasound guidance (10F sheath)

2. Wire crossage
- TERUMO 0.035 stiff angled

3. Phlebography, IVUS

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

5. Implantation of dedicated Iliac vein stents
over TERUMO stiff angled wire 0.035":
- IVC stents: Sinus XL 22 mm (OPTIMED),
- Kissing Iliac vein stents: Sinus-XL Flex 14–16 mm (OPTIMED)

6. High-pressure post-dilation of stents
- Atlas balloon 14–18 mm (BARD)

CLINICAL DATA
Asymptomatic infrarenal AAA with progressively increasing diameter
Femorotibial bypass on the right side 2006
Lower extremity chronic venous disorders CEAP C4 on both sides
PTCA 2006

RISK FACTORS
Type 2 diabetes, arterial hypertension, hyperlipidemia,
65-pack-year cigarette smoking history

PROCEDURAL STEPS
1. Percutaneous femoral access in both groins
- Local anaesthesia, retrograde puncture of the CFA on both sides
- 0.035" Radiofocus M stiff guidewire, 180 cm (TERUMO)
- Preclosure of the access sites using ProGlide devices (ABBOTT)

2. Implantation of the INCRAFT®AAA Stent Graft System (CORDIS, CARDINAL HEALTH)
- the delivery system (14-F OD) with the main body inside up to the lower accessory right renal artery, deployment of the main body
- Implantation of the contralateral and then the ipsilateral iliac stentgraft (12-F OD)

3. Sealing ot the percutaneous access sites in both groins
- ballon dilatation of the main body and the iliac limbs: Reliant balloon (MEDTRONIC)
- control angiogram, then withdrawing the delivery system respectively the 12F sheath
- advancing and tying the knots using the knot pusher of the ProGlide system

CLINICAL DATA
Asymptomatic for cerebrovascular events. Recent successful PTA to left ICA
(December 2015), angiography showed rapid progression of right ICA disease.

RISK FACTORS
Diabetes, smoking, hypertension
Severe asymptomatic right ICA stenosis

ANGIOGRAPHY
80% right ICA stenosis (progressed from 50% one year ago)

PROCEDURAL STEPS
1. Right femoral approach

2. MOMA positioning for proximal cerebral protection (MEDTRONIC)

3. Wire crossing during endovascular clamping

4. Direct stenting with an Xact-Stent (ABBOTT)

5. Postdilation with Maverick XI Balloon (BOSTON SCIENTIFIC)

6. Debris (if any) aspiration and declamping

CLINICAL DATA
Severe bilateral claudication
Previous right SFA and popliteal artery PTA with DEB (December 2015)

RISK FACTORS
Smoking, hypertension
Previous CABG (LIMA to LAD) in 2000
Severe left leg claudication

ANGIO
Left SFA long occlusion

PROCEDURAL STEPS
1. Contralateral (right) femoral access and placement of a cross-over sheath
- 6F 45 cm Destination sheath (TERUMO)

2. Crossing the occlusion
- 0.035'' Glidewire (TERUMO)

3. Lesion predilatation
- 4.0/120 mm Pacific balloon (MEDTRONIC)

4. Dilatation
- 5.0/120 mm Admiral Inpact balloon (MEDTRONIC)

5. Spot stenting if needed

New patient! Information will follow in due time. Thank you for your understanding.

New patient! Information will follow in due time. Thank you for your understanding.

New patient! Information will follow in due time. Thank you for your understanding.

CLINICAL DATA
2007 CAS Right
Since 3 months bilateral claudication left > right after <100 m (Rutherford 3)
Good CFA pulses
No popliteal/distal pulses

RISK FACTORS
Diabetes mellitus type 2, arterial hypertension
Hypercholesterolemia

ANGIOGRAPHY
MR Angio lower limbs

PROCEDURAL STEPS
1. Right CFA access - crossover
- 0.035", 260 cm Glide wire (TERUMO)
- RIM catheter (COOK MEDICAL)
- Destination 6F, 45 cm (TERUMO)

2. Recanalization
- 0.018", 260 cm Advantage (TERUMO)
- CXI catheter 0.018", 150 cm (COOK MEDICAL)

3. Predilatation
- Advance 18 LP, 5 mm (COOK MEDICAL)

4. Stenting
- ZILVER PTX (6 mm – 120 mm) (COOK MEDICAL)

5. Post-dilatation
- Advance 35 LP 6 mm (COOK MEDICAL)

6. Assistance GE Healthcare
- Vessel assist – "Center Line Tracking"

7. Plan B
- Distal puncture + retrograde/bidirectional recanalization

New patient! Information will follow in due time. Thank you for your understanding.

CLINICAL DATA
History: 2007 CAS Right
Since 3 months bilateral claudication left > right after <100 m (Rutherford 3)
Good CFA pulses
No popliteal/distal pulses

RISK FACTORS
Diabetes mellitus type 2, arterial hypertension, hypercholesterolemia
MR Angio lower limbs

PROCEDURAL STEPS
1. Left CFA access
- Glidewire 0.035" (TERUMO)
- RIM Catheter (COOK MEDICAL)
- Fortress 6F, 45 cm (BIOTRONIK)

2. Recanalisation
- Advantage 0.018", 260 cm (COOK MEDICAL)
- CXI Catheter 0.018", 150 cm (COOK MEDICAL)

3. Predilatation
- Passeo 18 Lux 6 mm (BIOTRONIK)

4. Stenting
- Pulsar 18 6 mm (BIOTRONIK)

5. Postdilatation
- Passeo 18 6 mm (BIOTRONIK)

6. GE Healthcare
- Vessel Assist - Center Line Tracking

CLINICAL DATA
History: 2008 CAS right, 2010 PTAS popliteal right, 2010 CEA left, 2011
PTCA + CABG, 2015 PTRA bilateral
Present State: non-healing ulcer left leg since 1 month

RISK FACTORS
Insuline dependent diabetes mellitus
Arterial hypertension, hypercholesterolemia
MR Angio lower limbs

PROCEDURAL STEPS
1. Right CFA access - crossover
- 0.035", 260 cm glidewire (TERUMO)
- RIM catheter (COOK)
- Destination 6F, 45 cm (TERUMO)

2. Recanalization
- 0.018", 260 cm Advantage (TERUMO)
- CXI catheter 0.018", 150 cm (COOK)

3. Predilatation
- Armada 0.018", 5 or 6 mm (ABBOTT VASCULAR)
- Angiosculpt 5 or 6 mm (SPECTRANETICS)

4. Stenting
- Supera VMI (5 or 6 mm) (ABBOTT VASCULAR)

5. Postdilatation
- Armada 0.018", 5 or 6 mm (ABBOTT VASCULAR)

6. Assistance GE Healthcare
- Vessel assist - "Center Line Tracking"

7. Plan B
- Distal puncture + retrograde / bidirectional recanalization

CLINICAL DATA
History: 2001 PTAS bilateral SFA, 2011 PTA ATI left, 2011 PTA ISR
Stenosis right SFA, 2014 DCB right SFA ISR + poplitea
Present state: Recurrent claudication < 100m (Rutherford 3)
CT Angio Lower Limb

RISK FACTORS
Diabetes mellitus, hypercholesterolemia, smoking

PROCEDURAL STEPS
1. Left CFA Access
- 0.035" Glide wire (TERUMO)
- RIM Catheter (COOK MEDICAL)
- Destination 6F, 45 cm (TERUMO)

2. Recanalization
- 0.018", 260 cm Advantage (TERUMO)
- CXI Catheter 0.018", 150 cm (COOK MEDICAL)

3. Predilatation
- Armada 0.018", 5 or 6 mm (ABBOTT VASCULAR)

4. Stenting
- Viabahn 5 or 6 mm, 250 mm (GORE)

5. Postdilatation
- Armada 0.018", 5 or 6 mm (ABBOTT)

6. Plan B
Direct Stent Puncture right SFA + Retrograde / Bidirectional Recanalization

PRESENT STATE
First DVT in 2009 – just post partum – see CT
Waited 9 months, attempted endovascular reconstruction – failed.
Has had 2 more children.
Symptoms: weight gain, 50 m claudication up hill, heavy dead tired leg.

RISK FACTORS
Underlying May Thurner

PROCEDURAL STEPS
1. Prep
- R IJV; left groin and thigh; right groin

2. UltraSound (SIEMENS) guided access to left profunda and RIJV (COOK Micropuncture set)
- 10F sheath (COOK) to neck; 5F sheath BRITE TIP (CORDIS) left PFV
- 5000u IV Heparin
- Triforce (COOK MEDICAL) to gain access to and attempt to cross left iliac venous occlusion

3. Wires
- Hydrophilic 0.035" wire (MERIT MEDICAL)/stiff
hydrophilic 0.035" wire (MERIT MEDICAL)/
Roadrunner 0.035" wire (COOK MEDICAL)
- Asahi Astante 0.014" 30g tip CTO wire with back up 2.5 mm balloon
- Possibly snare (AndraSnare, ANDRAMED) if needed/
Lunderquist 0.035" wire 260 cm (COOK MEDICAL) once across

4. Balloon predilatation
- BARD Atlas 16/14 mm
to minimum 16 atm x 30s each zone

5. Stenting
- BARD Venovo 16/14/12 from low IVC down
to either low CFV or else into PFV

6. Postdilatation
- BARD Atlas again to same pressures and diameters
- IVUS (VOLCANO / PHILIPS) to confirm stent apposition and identify any intra-luminal debris
- Cone Beam CTV (SIEMENS) to confirm stent apposition

7. Aftercare
- Thigh high class 2 compression stockings (JOBST)
- Pneumatic compression boots (COVIDIEN / MEDTRONIC) x 24h until US performed
- Colour doppler US day 1 post op CTV direct at 6/52

New patient! Information will follow in due time. Thank you for your understanding.

New patient! Information will follow in due time. Thank you for your understanding.

CLINICAL DATA
Three children, haemorrhoids and vulval varicosities
during pregnancy
Varicose veins left posterior thigh and calf
treated by foam and RFA in June 2015
At clinical follow-up 6 weeks satisfactory
At 6 months ALL recurred

IMAGING
Mildly enlarged L ovarian vein
Tight left common iliac vein compression on MRV
CDUS – large varicose veins posterior thigh and
upper calf - extend close to introitus

PROCEDURAL STEPS
1. GA
- R I JV access
- Selective catheterisation of L ovarian vein: both internal iliac veins;
possibly right ovarian V
- Coils (COOK MEDICAL) +/– EMBA medical "hourglass"
- Foam (Sclerovein 3% diluted 3:1 with air)

2. IVUS to examine is iliac vein compression syndrome real

3. I f IVCS suggests it is real the predilate to 16 mm BARD Atlas

4. Stenting if IVCS is real
- COOK Zilver Vena 16 mm/VENITI Vici 16 mm/Wallstent 16 mm
- OPTIMED Sinus Venous/Obliquus 16 mm

5. Postdilate to 16 mm

6. Foam sclerotherapy and RFA to thigh veins

7. Transvaginal US to confirm ablationof all veins at 6/52

New patient! Information will follow in due time. Thank you for your understanding.

CLINICAL DATA
Asymptomatic infrarenal aneurysm (50mm), diagnosed in 12/2015

RISK FACTORS
COPD GOLD III
1-vessel coronary artery disease
Hx of smoking (50py)
Hx of art. hypertension
ABI 1.0 palpable pulses

PROCEDURAL STEPS
1. Percutaneous access both sides
Perclose ProGlide (ABBOTT)

2. Sheath insertion
DrySeal sheath (GORE)

3. Fusion Imaging
Prototype syngo X Workplace with AAA Guidance software (SIEMENS)
- Segmentation of the contrasted aorta
- Selection of operative landmarks (Renal artery ostia, hypogastric artery ostia)
- 2D-3D registration
- Fusion imaging overlay

4. Implantation of endoprosthesis
GORE C3-Exluder
- Main body: 28/145/14
- Contralateral leg: 16/16/95

5. Completion angiography

6. Contrast enhanced cone beam CT (Dyna CT)

CLINICAL DATA
Asymptomatic infrarenal aneurysm (50mm), diagnosed in 12/2015

RISK FACTORS
COPD GOLD III
1-vessel coronary artery disease
Hx of smoking (50py)
Hx of art. hypertension
ABI 1.0 palpable pulses

PROCEDURAL STEPS
1. Percutaneous access both sides
Perclose ProGlide (ABBOTT)

2. Sheath insertion
DrySeal sheath (GORE)

3. Fusion Imaging
Prototype syngo X Workplace with AAA Guidance software (SIEMENS)
- Segmentation of the contrasted aorta
- Selection of operative landmarks (Renal artery ostia, hypogastric artery ostia)
- 2D-3D registration
- Fusion imaging overlay

4. Implantation of endoprosthesis
GORE C3-Exluder
- Main body: 28/145/14
- Contralateral leg: 16/16/95

5. Completion angiography

6. Contrast enhanced cone beam CT (Dyna CT)

CLINICAL DATA
Small AAA 31 mm, left common iliac artery 31 mm
and left thrombosed internal iliac artery aneurysm 38 mm
Diagnosed in 9/2105 in an external institution, asymptomatic status

RISK FACTORS
Ascending aneurysm (46 mm)
Ectatic infrarenal aorta (31 mm)
Ectatic popliteal arteries (right 13 mm: left: 14 mm)
Hx of smoking (40 py)
Hx of art. hypertension
ABI 1,0 both sides with palpable pulses

PROCEDURAL STEPS
Ultrasound guided percutaneous access
- Perclose ProGlide (ABBOTT)

- Sheath insertion
- Wire change (guidewire - stiff wire)
- DrySeal sheath (GORE)

- Angiography and Fusion Imaging
- Prototype syngo X Workplace with AAA Guidance software (SIEMENS)

- Implantation of Endoprosthesis (GORE Excluder Leg Endoprosthesis 16/16/135)
- Ballooning

- Completion angiography
- Puncture site closure

- Contrast enhanced cone beam CT (Dyna CT)

CLINICAL DATA
Small AAA 31 mm, left common iliac artery 31 mm
and left thrombosed internal iliac artery aneurysm 38 mm
Diagnosed in 9/2105 in an external institution, asymptomatic status

RISK FACTORS
Ascending aneurysm (46 mm)
Ectatic infrarenal aorta (31 mm)
Ectatic popliteal arteries (right 13 mm: left: 14 mm)
Hx of smoking (40 py)
Hx of art. hypertension
ABI 1,0 both sides with palpable pulses

PROCEDURAL STEPS
Ultrasound guided percutaneous access
- Perclose ProGlide (ABBOTT)

- Sheath insertion
- Wire change (guidewire - stiff wire)
- DrySeal sheath (GORE)

- Angiography and Fusion Imaging
- Prototype syngo X Workplace with AAA Guidance software (SIEMENS)

- Implantation of Endoprosthesis (GORE Excluder Leg Endoprosthesis 16/16/135)
- Ballooning

- Completion angiography
- Puncture site closure

- Contrast enhanced cone beam CT (Dyna CT)

New case! Information will follow in due time. Thank you for your understanding.

CLINICAL DATA
CAD w 2 DES LAD 10/14, COPD
FEV1 0.9, NIDDM
Recent R hemispheric TIA X2 with L arm and leg weakness
R amarousis fugax 6 months ago

RISK FACTORS
Htn, dyslipidemia, former smoker
CDU: R PSV 447 cm/sec, EDV 179 cm/sec, ICA/CCA 6
CTA (shown): ≥ 80% high RICA stenosis

PROCEDURAL STEPS
1. 9F MoMa proximal embolic protection (MEDTRONIC)

2. Predilatation with 4.0/30mm Quantum (BOSTON SCIENTIFIC)

3. Implantaiton of a 8-10/40 Xact Stent (ABBOTT)

4. Postdilation with 5/20 Quantum (BOSTON SCIENTIFIC)

New patient! Information will follow in due time. Thank you for your understanding.

CLINICAL DATA
L subclavian AND LICA artery occlusions
Severe lifestyle-limiting R claudication @ 50'

RISK FACTORS
Current smoker, HTN, dyslipidemia

ABI
Right 0.50 → 0.16

CTA
≈ steep iliac bifurcation, R SFA/popliteal CTO

PROCEDURAL STEPS
1. Contralateral access
- 7F Ansel cross-over sheath (COOK)
cross CTO (tibial access prn)
- QUickCross catheter (SPECTRANETICS)
- 0.035" Glidewire (TERUMO)

2. PTA and DCB R SFA/popliteal
- Armada Balloon (ABBOTT)
- Lutonix DCB (BARD)

3. If dissections after DCB, provisional placement of nitinol "tacks"
(INTACTSOLUTIONS)

CLINICAL DATA
Juxtarenal aneurysm 59 mm max. below a left acc. RA

RISK FACTORS
CAD, art. hypertension, hypertensive heart disease, LE 12/15

PROCEDURAL STEPS
- Percutanous approach both groins Prostar XL (ABBOTT).
- Placement of 14F sheaths (COOK).
- Placement of Endurant bifurcated endograft (MEDTRONIC) just below the LRA.
- Cannulation of the lower left renal artery and placement of the sandwich graft (GORE-Viabahn).
- Extension of the the aortic endograft with an Endurant-tubegraft (MEDTRONIC) in order to complete the sandwich-repair.
- Closure of the groins.

CLINICAL DATA
EVAR for AAA 2013 with bifurkated stentgraft, initial diameter of AAA 56 mm, in follow-up
CT-angiograms persisting Type II Endoleak via lumbar arteries and inferior mesenteric
artery (IMA). In 2015 enlargement of AAA to 70 mm in maximum axial diameter.

RISK FACTORS
Art. hypertension, former smoker, CHD

PROCEDURAL STEPS
1. Left transbrachial approach
- 6F 70 cm Raabe sheath (COOK) insertion into ostium of superior mesenteric artery

2. Cannulation of middle colic artery
- 0,035" Glidewire and 4F 120 cm Glidecath (TERUMO)

3. Cannulation of IMA and Endoleak
- 0,014" Choice PT II wire (BOSTON SCIENTIFIC)

4. Catheter insertion
- 0,014" Echelon or 0,010" Marathon microcatheter into Endoleak and following angiogram

5. Embolisation of Endoleak with alcohol-colymer
- Onyx 34/34L (MEDTRONIC)

6. After microcatheter removal final angiogram via IMA and hypogastric artery to confirm complete Endoleak embolisation

CLINICAL DATA
2013 Complex EVAR for aorto-biiliac AAA with Zentih bifurcated endograft and bilateral Zenith iliac-sidebranch endografts, 2013 embolisation of Type II Endoleak via AMI. In CT-angiogram aneurysm enlargement of left iliac aneurysm from initially 55mm to 65 mm and persisting type II EL via left deep circumflex iliac artery.

RISK FACTORS
Arterial hypertension, CHD, RCX-PTCA 2012, hyperlipidemia

PROCEDURAL STEPS
1. Access via retrograde left femoral puncture
- Insertion of 5F 10 cm sheath (TERUMO)

2. Cannulation of deep circumflex iliac artery
- 0,035 Glidewire and 4F 90 cm Glidecath (TERUMO)

3. Cannulation of Endoleak
- 0,014 Choice PT II wire (BOSTON SCIENTIFIC) via the pelvic collaterals

4. Catheter insertion
- 0,014" Echelon microcatheter (MEDTRONIC) into Endoleak and following angiogram

5. Embolisation of Endoleak
- Alcohol-colymer Onyx 34/34L (MEDTRONIC)

6. After microcatheter removal final angiogram via deep circumflex iliac artery to confirm complete Endoleak embolisation

CLINICAL DATA
66 mm rapid growing AAA

RISK FACTORS
Hypertension, obesity, hypercholesterinemia
Anxiety disorder Krea 0,9 mg/dl

PROCEDURAL STEPS
Percutanous approach both groins
- Prostar XL (ABBOTT)
- 14F sheath (COOK)

- Placement of a pigtail catheter via the left groin
- Lunderquist wire right side

- Placement of the main body through the right side directly below the renals - Treovance-Endograft (BOLTON-MEDICAL)
- Probing and positioning of the iliac limb extension contralateral
- Ipsilateral positioning of the iliac endograft

- Postballooning
- Final angiography
- Closing access with Prostar (preclose technique)

New patient! Information will follow in due time. Thank you for your understanding.

New patient! Information will follow in due time. Thank you for your understanding.

New patient! Information will follow in due time. Thank you for your understanding.

CLINICAL DATA
Juxtarenal growing aneurysm 62 mm
PAD with severe calcified and stenosed iliac arteries
Common ostium of the CT and SMA

RISK FACTORS
Art. hypertension
CAD

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

2. Cut down left axillary artery and double puncture

3. Placement of two 7F Shuttle sheaths from above. Cannulation of both renal arteries with a 7F shuttle sheath (COOK)

4. Placement of Endurant bifurcated endograft (MEDTRONIC) just below the SMA

5. Placement of the chimney stent-grafts (Advanta-MAQUET) in both renal arteries

6. Closure of the groin

CLINICAL DATA
Thoracoabdominal aortic aneurysm
Narrow iliac arteries

RISK FACTORS
Art. hypertension
Panarteritis nodosa

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

2. Left axillary access 5F sheath via cut down

3. Placement of a LP-CMD - Zenith-endograft (COOK) with four branches and closure of the groins to avoid SCI

4. Cannulation of celiac trunk, SMA and renal arteries through the branches and implantation of the bridging stentgafts

5. Final angiography

6. Closure left axillary access

CLINICAL DATA
Thoracoabdominal aortic aneurysm
Narrow iliac arteries

RISK FACTORS
Art. hypertension
Panarteritis nodosa

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

2. Left axillary access 5F sheath via cut down

3. Placement of a LP-CMD - Zenith-endograft (COOK) with four branches and closure of the groins to avoid SCI

4. Cannulation of celiac trunk, SMA and renal arteries through the branches and implantation of the bridging stentgafts

5. Final angiography

6. Closure left axillary access

New patient! Information will follow in due time. Thank you for your understanding.

CLINICAL DATA
Subacute onset R leg pain 2 to 3 months, Rutherford Class II, Category III
US Duplex showed instent occlusion of RSFA
Failed R Fem pop bypass, multiple PTA and stenting of RSFA
at outside hospital, failed revascularization of RSFA due to stent fracture

RISK FACTORS
Hypertension, dyslipidemia, coronary artery disease,
polycythemia vera (ongoing work up)

PROCEDURAL STEPS
1. Left Common femoral access and up and over
- 7F Pinnacle destination sheath 45 cm, up and over (TERUMO)
- If necessary, R pedal posterior tibial retrograde access (4F COOK sheath) and direct stent access

2. Intra-luminal approach
- 0.014" 4 Fr Viance catheter, 150 cm (MEDTRONIC)
- 0.038" Vertip catheter, 125 cm (CORDIS / CARDINAL HEALTH)
- 0.014" Confianza wire, 300 cm (ABBOTT VASCULAR)

3. Thrombectomy
- Angiojet Rheolytic aspiration thrombectomy (BOSTON SCIENTIFIC) or
- PENUMBRA aspiration thrombectomy (PENUMBRA)

4. Filter placement
- exchanged with 0.014/Bare wire, 315 cm (ABBOTT VASCULAR)
- Emboshield filter 4/7 mm embolic protection system (ABBOTT VASCULAR)

5. PTA and Stenting as indicated
- INPACT drug coated balloons 6.0/120 mm (MEDTRONIC)
- Supera stenting 5.5/100 mm (ABBOTT VASCULAR)

CLINICAL DATA
PAD, Rutherford Class II, category III, claudication of L calf at 1 to 2 blocks,
ABI R LE - 0.5 and L LE - 0.6
Jet stream athrectomy, PTA and stenting of RSFA in 09/2015

RISK FACTORS
Hypertension, diabetes mellitus type II,
dyslipidemia, moderate aortic regurgitation

PROCEDURAL STEPS
1. Right common femoral access and cross over approach
- 7F Pinnacle destination sheath 45 cm up and over sheath (TERUMO)

2. Guidewire passage
- 0.014" Spartacore wire, 300 cm (ABBOTT VASCULAR)
- 0.038" Vertebral 135" Tempa Aqua catheter, 125 cm (CORDIS)

3. Filter placement
- exchanged with 0.014" Bare wire, 315 cm (ABBOTT VASCULAR)
- Emboshield filter 4/7 mm embolic protection system (ABBOTT VASCULAR)

4. Athrectomy and thrombectomy, if embolization occurs
- Jet stream Pathway rotational athrectomy 2.4/3.4 (BOSTON SCIENTIFIC)
- PENUMBRA aspiration thrombectomy (PENUMBRA)

5. PTA and stenting on indication
- IN-PACT drug coated balloons 6.0/120 mm (MEDTRONIC)
- SUPERA stenting 5.5/150 mm (ABBOTT VASCULAR)

CLINICAL DATA
89 yo male with ESRD on HD with dysfunctional LUE radio-cephalic fistula
at the wrist, decreased access flow rates greater than 25% drop
from 900 ml/min to 600 ml/min. Multiple prior interventions in the past
(beginning in 2009).
Most recent intervention 3 months prior.

RISK FACTORS
DM, CAD, DM

PROCEDURAL STEPS
1. US guided left radial artery access
- 4F or 6F slender sheath (TERUMO)

2. BOSTON SCIENTIFIC 018" V18 wire

3. BOSTON SCIENTIFIC Sterling 018" PTA catheter

New case! Information will follow in due time. Thank you for your understanding.

New patient! Information will follow in due time. Thank you for your understanding.

New patient! Information will follow in due time. Thank you for your understanding.