LINC 2018 live case guide

CLINICAL DATA
- Severe claudication left calf, walking capacity 50 meters
- ABI left 0.62
- Thrombendatherectomy right groin 7/2016
- Minor stroke 2014

RISK FACTORS
- Art. hypertension, diabetes mellitus type 2, nicotine abuse

PROCEDURAL STEPS
1. Left groin retrograde and cross-over approach
- 0.035" SupraCore guidewire 190 cm (ABBOTT)
- 7F–40 cm Balkin Up&Over sheath (COOK)
2. Guidewire passage and PTA
- Command 18 and Armada 18 balloon (ABBOTT) or
- 0.035" Radiofocus soft angled guidewire, 260 cm (TERUMO) and 4.0/120 mm Armada 35 balloon (ABBOTT)
- 6.0/40 mm Armada 35 balloon (ABBOTT)
- Conquest high pressure balloon on indicaiton (BARD)
3. Stenting
- 5.0 or 6.0/150 mm Supera Interwoven Selfexpanding Nitinol stent (ABBOTT)

CLINICAL DATA
- Restpain left foot, Rutherford class 4, ABI left 0.40
- PTA/ stenting left SFA 11/2016 and PTA left popliteal artery
- PTA/ stent right SFA 11/2015

RISK FACTORS
- Chronic renal failure, GFR 65 ml/min
- Nephrectomy left due to renal cell carcinoma 1994
- Art. hypertension, former smoker

PROCEDURAL STEPS
1. Right femoral access and cross-over approach
- 0.035" SupraCore guidewire 190 cm (ABBOTT)
- 6F–55 cm sheath (COOK)
2. Guidewire passage
- Command 18, 300 cm guidewire (ABBOTT)
- Armada 18 4.0/80 mm balloon (ABBOTT)
In case of failure to pass the CT from antegrade:
3. Retrograde approach via proximal anterior tibial artery
- 7 cm 21 Gauge needle (COOK)
- Command 18, 300 cm guidewire (ABBOTT)
- 0.018" 3.0/40 mm Armada 18 balloon (ABBOTT)
4. P TA and stenting
- Armada 18 5.0/50 mm balloon (ABBOTT)
- Supera Interwoven Nitinol Stent 5.0/80 mm (ABBOTT)

CLINICAL DATA
- Severe claudication left, walking-capacity 120 meters
- Rutherford class 3, ABI left 0.53

RISK FACTORS
Minor stroke 2009, art. hypertension, former smoker, diabetes mellitus type 2

PROCEDURAL STEPS
1. Left femoral access
- 7F 25 cm Radiofocus Introducer (TERUMO)
- 0.035" SupraCore guidewire 300 cm (ABBOTT)
Left brachial approach:
- 7F 90 cm Check-Flo Performer (COOK)
2. Antegrade and retrograde guidewire passage
brachial:
- 5F Judkins Right diagnostic catheter 125 cm (CORDIS/ CARDINAL HEALTH)
from femoral:
- 5F Multipurpose diagnostic catheter 80 cm (CORDIS/ CARDINAL HEALTH)
- 0.035" stiff angled glidewire, 260 cm (TERUMO)
3. Predilatation and stenting of the aorto-iliac bifurcation
- Ultraverse or Dorado balloon (BARD)
- LifeStream covered stent 7/58 bilateral common iliac arteries in kissing-technique (BARD)
- Covera Plus vascular covered stent for the external iliac artery (BARD)

CLINICAL DATA
- Severe claudication right calf, walking capacity 10 meters
- ABI right 0.35
- Rutherford class 3

RISK FACTORS
- Congesitve heart failure, EF 40%
- Chronic renal failure, GFR 50 ml/min
- Art. hypertension, diabetes mellitus type 2, former smoker

PROCEDURAL STEPS
1. Left groin retrograde and cross-over approach
- 0.035" SupraCore guidewire 190 cm (ABBOTT)
- 6F–40 cm Balkin Up&Over sheath (COOK)
2. Guidewire passage
- 0.035" Radiofocus soft angled guidewire, 260 cm (TERUMO)
- CXI support catheter, 0.035" 135 cm (COOK)
In case of failure to pass the CT from antegrade:
3. Retrograde approach via distal SFA
- 9 cm 21 Gauge needle (COOK)
- 0.018" V-18 Control guidewire, 300 cm (BOSTON SCIENTIFIC)
- 0.018" CXI support catheter 90cm (COOK)
4. Angioplasty
- Advance balloon 5.0/100 mm (COOK)
- Advance Enforcer 6.0/40 mm in case of focal residual stenosis (COOK)
5. Stenting
- Zilver PTX stent 6.0/140 mm (COOK)

CLINICAL DATA
- Severe claudication left calf, walking capacity 150 meters
- ABI left 0.67, Rutherford class 3
- Failed recanalization-attempt left SFA 11/2017

RISK FACTORS
Art. hypertension, former smoker, diabetes mellitus type 2

PROCEDURAL STEPS
1. Right femoral access and cross-over approach
- 0.035" SupraCore guidewire 190 cm (ABBOTT)
- 6F–40 cm Balkin Up&Over sheath (COOK)
2. Guidewire passage
- 0.035" Radiofocus soft angled guidewire, 260 cm (TERUMO) and
- QuickCross support catheter, 0.035" 135 cm (SPECTRANETICS - PHILIPS)
3. PTA and stenting on indication
- SeQuent Please DCB 5.0/150 mm (B.BRAUN)
- VascuFlex Multi-LOC (B.BRAUN)

CLINICAL DATA
- Restpain right foot, livedo forefoot right, ABI 0.0, Rutherford class 4,
- PTA/ stenting right iliac and left SFA 3/2016, CAD, PTCA 2/2015,
- Hypertensive and ischemic cardiomyopathy, NYHA II

RISK FACTORS
Art. hypertension

PROCEDURAL STEPS
1. Right groin retrograde and cross-over approach
- IMA 5F diagnostic catheter (CORDIS/ CARDINAL HEALTH)
- 0.035" soft angled Radiofocus guidewire, 190 cm (TERUMO)
- 0.035" SupraCore guidewire 190 cm (ABBOTT)
- 7F 55 Check-Flo Performer sheath, Raabe Modification (COOK)
2. Antegrade guidewire passage
- 0.035" Stiff angled glidewire, 260 cm (TERUMO)
- CXC 0.035" support catheter, 135 cm (COOK)
3. Retrograde guidewire passage
Access via the proximal anterior tibial artery:
- 7 cm 21 Gauge needle (COOK)
- Command 18 guidewire, 300 cm (ABBOTT)
- 4Fr-10cm Radiofocus Introducer (TERUMO)
- Pacific Plus 4.0/40 mm balloon, 90 cm (MEDTRONIC)
4. PTA and stenting
- 6.0/20mm Admiral Xtreme balloon (MEDTRONIC)
- 7.0/20 Conquest non-compliant high pressure balloon (BARD)
In case of inability to open the balloons fully:
- Implantation of a Viabahn 7.0/100 mm (GORE)
- Relining with Supera Interwoven Nitinol stent (ABBOTT)

CLINICAL DATA
- Critical limb ischemia with chronic ulceration right heel, Rutherford class 5
- Restpain during night
- ABI right 0.33
- Failed recanalization-attempt of the posterior tibial artery elsewhere 1/2018
- PTA of the popliteal artery right 7/2017

RISK FACTORS
- Diabetes mellitus type 2, CAD, PTCA 7/2017
- Hypertensive cardiomyopathy, chronic renal failure, GFR 55ml/min
- Art. hypertension

PROCEDURAL STEPS
1. Antegrade approach right groin
- 6F-55 cm Flecor Shetah (COOK)
2. Guidewire passage into the anterior tibial artery and placement
- 0.018" V-18 Control guidewire, 300 cm (BOSTON SCIENTIFIC)
- 4m Spider filter (MEDTRONIC)
3. Atherectomy of the popliteal artery
- JetStream atherectomy device (BOSTON SCIENTIFIC)
4. Guidewire passage of the posterior tibial artery
- 0.014" PT2 guidewire, 30 cm (BOSTON SCIENTIFIC)
- 0.014" Coyote balloon (BOSTON SCIENTIFIC)
5. PTA with DCBs of the popliteal and posterior tibial artery
- Ranger DCB balloon 2.0 – 4.0 mm diameter (BOSTON SCIENTIFIC)

CLINICAL DATA
- Critical limb ischemia, small interdigital ulceration
- Rutherford class 5, ABI left 0.56
- CAD, MI and PTCA 2007
- Spinal surgery 2006

RISK FACTORS
Art. hypertension

PROCEDURAL STEPS
1. Right femoral access and cross-over approach
- 6F 45 cm cross-over sheath Fortress (BIOTRONIK)
2. Recanalisation left SFA
- 0.018" Advantage glidewire (TERUMO)
- 0.018" CXI support catheter (COOK)
Back-up material:
- Connect 250T CTO-wire (ABBOTT)
- Outback reentry system (CORDIS/ CARDINAL HEALTH)
3. PTA
- Passeo 18 Ballon 5 x 150 mm (BIOTRONIK)
- 5 mm Passeo 18 Lux DCB (BIOTRONIK)
4. Stenting on indication, spot-stenting
- Pulsar 18 stent (BIOTRONIK)

CLINICAL DATA
- Restenosis left ICA, TEA left 2013, asymptomatic
- TEA right 3/2015, minor stroke 5/2006 right hemispheric
- Congestive heartfailure, EF 45%, NYHA II
- Chronic renal insufficiency, GFR 67ml/min
- COPD

RISK FACTORS
Art. hypertension, nicotin abuse

PROCEDURAL STEPS
1. Right groin acces
- 8F 25 cm Radiofocus introducer (TERUMO)
- 5F Judkins Right diagnostic catheter (CORDIS/ CARDINAL HEALTH)
- 0.035" soft angled glidewire, 190 cm (TERUMO)
- 0.035" SupraCore 190 cm guidewire (ABBOTT)
2. Cerebral protection
- MoMa proximal protection system, Mono-Balloon (MEDTRONIC)
3. Predilatation and stenting
- 3.5/20 mm MiniTrek Monorail balloon (ABBOTT)
- 8/30 mm CGuard stent (INSPIRE-MD)
4. Postdilatation
- Paladin® Carotid Post-Dilatation balloon with integrated embolic protection (CONTEGO MEDICAL)
5. Aspiration and declamping with the Paladin filter in place
6. Retrieval of the Paladin system

CLINICAL DATA
- Severe claudication right calf, walking capacity 40 meters
- ABI right 0.47, Rutherford class 3
- PTA/ stenting left SFA 12/2017
- CAD, MI 8/2016, PTCA
- Ischaemic cardiomyopathy, EF 47%
- Pace-maker 5/2016

RISK FACTORS
- Art. hypertension, former smoker

PROCEDURAL STEPS
1. Left groin retrograde and cross-over approach
- IMA-diagnostic 5F catheter (CORDIS/ CARDINAL HEALTH)
- 0.035" angled soft Radiofocus guidewire, 190 cm (TERUMO)
- 0.035" SupraCore guidewire, 190 cm (ABBOOTT)
- 7F 55 cm Flexor Check-Flo introducer, Raabe Modifcation (COOK)
2. Passage of the distal SFA-CTO
- 0.018" Connect 250 T guidewire, 300 cm (ABBOTT)
- 0.018" QuickCross support catheter 135 cm (SPECTRANETICS)
3. Angioplasty
- 6.0/60 mm Lithoplasty balloon (SHOCKWAVE MEDICAL)
- 6.0/80 mm iLuminor DCB (iVASCULAR)

CLINICAL DATA
- PAOD Rutherford 3, walking capacity 50 m right, ABI right 0.6, left 0.8
- PTA/stent of the left SFA 01/2018, of the left CIA 11/2011
- CEA left 2008, AMI 1998, CABG 02/2017

RISK FACTORS
Arterial hypertension, former smoker, hyperlipidemia, renal impairment

ANGIOGRAPHY
During PTA left: severely calcifed occlusion of the right SFA

PROCEDURAL STEPS
1. Left groin retrograde and cross-over approach
- IMA-diagnostic 5F catheter (CORDIS/CARDINAL HEALTH)
- 0.035" angled soft Radiofocus guidewire, 190 cm (TERUMO)
- 0.035" SupraCore guidewire, 190 cm (ABBOOTT)
- 6F Balkin Up&Over sheath, 40 cm (COOK)
2. Passage of the occlusion right SFA
- 0.035" Radiofocus angled stiff guidewire, 260 cm (TERUMO)
- 0.035" CXC support catheter, 135 cm (COOK)
In case of failure guidewire passage from antegrade:
3. Retrograde approach via distal SFA
- 7 cm 21 Gauge needle (COOK)
- 0.018" V-18 Control guidewire, 300 cm (BOSTON SCIENTIFIC)
- 4F-10 cm Radiofocus introducer (TERUMO)
- Pacific Plus 4.0/40 mm balloon, 90 cm (MEDTRONIC)
4. PTA and treatment with DCB
- 6.0/40 mm Advance Enforcer balloon (COOK)
- Luminor DCB 6.0/120 mm (iVASCULAR)
5. Stenting on indication
- 7/150 mm iVolution Self-Expanding stent (iVASCULAR)

CLINICAL DATA
- PAOD Rutherford 5, D3-ulcerations and rest pain at night, walking capacity 10 m
- PTA of the left popliteal artery 01/18

RISK FACTORS
- Diabetes mellitus type 2, arterial hypertension, former smoker
- ABI right 0.7, left 0.5

ANGIOGRAPHY
During PTA 01/18: occlusion of ATP and ATA

PROCEDURAL STEPS
1. Left groin antegrade approach
- 6F 55 cm Flexor Check-Flo sheath, Raabe Modification (COOK)
2. Guidewire passage of the occlusion PTA with DCBs
- 0.014" Command ES guidewire, 300 cm (ABBOTT)
- 0.018" 90 cm Seeker support catheter (BARD)
- 0.014" Ultraverse balloon (BARD)
- Lutonix-BTK DCB (BARD)
3. In case of dissections after DCB, provisional placement of nitinol "tacks"
- Tack Endovascular System (Intact Vascular)

CLINICAL DATA
- PAOD Rutherford 3, walking capacity 10–15 m, ABI right 0.55, left 0,8
- PTA/stenting of left SFA and BTK 12/2107

RISK FACTORS
- Arterial hypertension, hyperlipidemia, diabetes mellitus type 2 with neuro- and angiopathy

PROCEDURAL STEPS
1. Left groin and cross-over approach
- Judkins Right 5F diagnostic catheter (CORDIS/CARDINAL HEALTH)
- 0,035" SupraCore guidewire 30 cm (ABBOTT)
- 6F–40 cm Balkin Up&Over sheath (COOK)
2. Guidewire passage of the occlusion
- 0.035" Halfstiff Terumo 260 cm (TERUMO)
- 0.035" QuickCross support catheter, 135 cm (SPECTRANETICS-PHILIPS)
3. PTA with scoring ballon
- 4/40 mm AngioSculpt PTA scoring balloon (SPECTRANETICS-PHILIPS)
4. PTA with DCBs
- Stellarex 5.0/120 mm DCBs (SPECTRANETICS-PHILIPS)

CLINICAL DATA
- Progressive asymptomatic AAA, diameter max. 59 mm
- Coiling of 3 lumbar arteries L2-L3 1/2018
- PAOD Rutherford 3, PTA left EIA 11/2007 and left SFA 2010

RISK FACTORS
Artrial hypertension, hyperlipidemia, nicotine abuse (30Y) and renal impairment

PROCEDURAL STEPS
1. Bifemoral percutaneous approach in local anaesthesia
- Preclosing with 2 Proglide closure devices both sides (ABBOTT)
2. Guidewire positioning
- Lunderquist GW 180 cm (COOK)
3. Implantation of a bifurcational stentgraft
- Ovation Stentgraft (ENDOLOGIX)
Cannulation of the contralateral limb:
- 5F Amplatz Left diagnostic catheter (CORDIS/CARDINAL HEALTH)
- 0.035" soft angled short Radiofocus glidewire (TERUMO)
4. PTA
- Proximal seal: Reliant balloon (MEDTRONIC)
- Graft-bifurcation: 12/40 mm Admiral balloon (MEDTRONIC)

CLINICAL DATA
- PAOD Rutherford 3, walking capacity 150 m, ABI left 0,6
- PTA/stent right EIA 12/2017, PTA/stent left SFA 08/2016
- CAD, PTCA 06/2016

RISK FACTORS
Hyperlipidemia, nicotine abuse (20PY), arterial hypertension

ANGIOGRAPHY
During PTA right 12/2017: IRS left SFA

PROCEDURAL STEPS
1. Right groin and cross-over approach
- Judkins Right 5F diagnostic catheter (CORDIS/CARDINAL HEALTH)
- 0,035" SupraCore guidewire 30 cm (ABBOTT)
- 7F-40 cm Balkin Up&Over sheath (COOK)
2. Guidewire passage of the in-stent reocclusion
- 0.035" Halfstiff Terumo 260 cm (TERUMO)
- 0.035" QuickCross support catheter, 135 cm (SPECTRANETICS-PHILIPS)
- Exchange to a 0.014" Floppy ES guidewire 300 cm (ABBOTT)
3. Laser atherectomy
- 7F Excimer laser with Turbo Elite 2.3 mm cathether (SPECTRANETICS-PHILIPS)
4. PTA with DCBs
- Stellarex 6.0/120 mm DCBs (SPECTRANETICS-PHILIPS)

CLINICAL DATA
- Severe claudication left calf, walking capacity 150 meters, ABI 0.5, Rutherford class 3
- PTA / stenting right SFA 9/2017 elsewhere
- CAD with MI and PTCA 2002, TIA 9/2017

RISK FACTORS
Art. hypertension, diabetes mellitus type 2, nicotine abuse

PROCEDURAL STEPS
1. Right groin and cross-over access
- IMA-diagnostic 5F catheter (CORDIS/ CARDINAL HEALTH)
- 0.035" angled soft Radiofocus guidewire, 190 cm (TERUMO)
- 0.035" SupraCore guidewire, 190 cm (ABBOOTT)
- 6F Balkin Up&Over sheath, 40 cm (COOK)
2. Guidewire passage
- 5.0/100 mm Sterling OTW balloon, 90 cm (BOSTON SCIENTIFIC)
- 0.018" Victory guidewire, 18 gramm, 300 cm (BOSTON SCIENTIFIC)
3. Atherectomy for vessel-preparation
- Diamondback 360 Peripheral Orbital Atherectomy system (CSI CARDIOVASCULAR SYSTEMS)
- VANGUARD IEP peripheral balloon with integrated embolic protection (CONTeGO MEDICAL)
4. Direct stenting
- Eluvia drug-eluting stent (BOSTON SCIENTIFIC)

CLINICAL DATA
- Critical limb ischemia left, ulcerations dig 2/3 left, restpain
- Previous femoro-popliteal bypass surgery left (in-situ) 2007 with bypass-thrombectomy 2017
- Congestive heartfailure, NYHA III
- Paroxysmal atrial fibrillation
- COPD

RISK FACTORS
Art. hypertension, nicotine abuse

PROCEDURAL STEPS
1. Left groin and cross-over approach
- Judkins Right 5F diagnostic catheter (CORDIS/CARDINAL HEALTH)
- 0,035" SupraCore guidewire 30 cm (ABBOTT)
- 6F-40 cm Balkin Up&Over sheath (COOK)
2. Guidewire passage
- 0.035" stiff, angled glidewire, 260 cm (TERUMO)
- 0.035" Seeker support catheter, 135 cm (BARD)
3. Angioplasty
- VascuTrak 5.0/300 mm balloon (BARD)
- Lutonix GEOALIGN marking system DCB 6.0/120 mm (BARD)
4. Stenting on indication
- LifeStent (BARD)

CLINICAL DATA
- Critical limb ischemia, ulcerations left foot
- Congestive heart-failure, EF 35%, NYHA II

RISK FACTORS
Diabetes mellitus type 2, art. hypertension, current smoker

PROCEDURAL STEPS
1. Transbrachial approach
- 6F 90 cm Check-Flo performer sheath (COOK)
- 5F 125 cm diagnostic Judkins Right catheter (CORDIS/ CARDINAL HEALTH)
- SupraCore 300 cm 0.035" guidewire (ABBOTT)
2. Passage of the occlusions
- Stiff angled 0,035" guidewire, 260 cm (TERUMO)
- Together with 5F-125 cm Judkins Right catheter
3. Bilateral groin access
- 7F 10 cm Radiofocus sheath (TERUMO)
- Snaring of the antegrade guidewire form above into the groin-sheath or
- Into 6F-Judkins-Right guiding catheter (CORDIS) inserted from below
4. PTA via the groin access bilateral
- SupraCore 300 cm 0,035" guidewire (ABBOTT)
- Admiral balloon 6.0/120 mm bilateral (MEDTRONIC)
5. Implantation of covered stents
- Viabahn 8.0/150 mm in kissing-technique (GORE)
- Reinforcement with balloon-expandable stents at the aortic bifurcation:
- Palmaz Genesis 8.0/79 mm balloon-expandable stents in kissing-technique (CORDIS)
- Bigraft covered stent for the medial sacral artery (BENTLEY)

CLINICAL DATA
- Severe claudication left leg, walking capacity 200 meters
- ABI left 0.53, Rutherford class 3, CAD

RISK FACTORS
Art. hypertension, diabetes mellitus type 2, current smoker

PROCEDURAL STEPS
1. Right groin and cross-over approach
- Judkins Right 5F diagnostic catheter (CORDIS/ CARDINAL HEALTH)
- 0,035" SupraCore guidewire 30 cm (ABBOTT)
- 7F-40 cm Balkin Up&Over sheath (COOK)
2. PTA of the CFA left
- Admiral balloon 7.0; 8.0/20 mm (MEDTRONIC)
3. Stenting
- 7.0/40 or 8.0/40 mm Supera Interwoven Nitinol stent (ABBOTT)

CLINICAL DATA
- PAD Rutherford 4 right, rest pain at night, walking capacity 10 m
- Femoro-popliteal bypass right 2008 and recurrent reocclusion 2017 (11/17)
- Failed recanalization attempt of the right popliteal 01/18

RISK FACTORS
Former smoker, arterial hypertension, renal impairement, atrial fibrillation

ANGIOGRAPHY
Occluded femoro-popliteal bypass right and severly calcified popliteal occlusion right

PROCEDURAL STEPS
1. Antegrade access right groin
- 6F 90 cm Check-Flow Performer (COOK MEDICAL)
2. Antegrade guidewire passage
in casse of failure retrograde approach via the anterior tibial artery
- 2.9F sheath (pedal puncture set) (COOK)
- 0.014" CTO-Approach 25 gramm guidewire, 300 cm (COOK)
- 0.018" CXI support catheter 90 cm (COOK)
- Advance Micro-Balloon 3.0/120 mm, 90 cm (COOK)
3. PTA of the popliteal artery occlusion
- Pacific Plus 4.0/40 mm balloon, 90 cm (MEDTRONIC)
4. Stenting
- 5.0/100 mm Supera Interwoven Self-expanding Nitinol stent (ABBOTT)

CLINICAL DATA
- PAOD Rutherford 3, walking capacity 10 m
- CAD; CABG MV-Reconstruction, 2010
- NSTEMI 11/2107 with CPR, PTCA 11/17, ICM (LV-EF 40%)

RISK FACTORS
Diabetes mellitus type 2, arterial hypertension, hyperlipidemia

PROCEDURAL STEPS
1. Left groin retrograde and cross-over approach
- IMA diagnostic 5F catheter (CORDIS/CARDINAL HEALTH)
- 0.035" angled soft Radiofocus guidewire, 190 cm (TERUMO)
- 0.035" SupraCore guidewire, 190 cm (ABBOOTT)
- 6F Balkin Up&Over sheath, 40 cm (COOK)
2. Passage of the occlusion right SFA
- 0.035" Radiofocus angled stiff guidewire, 260 cm (TERUMO)
- 0.035" CXC support catheter, 135 cm (COOK)
- Exchange to 0.018" SteelCore guidewire (ABBOTT)
3. PTA and stenting on indication
- Legflow drug-coated balloon (CARDIONOVUM)
- VascuFlex Multi-LOC (B.BRAUN)

CLINICAL DATA
- Progressive thoracic AAA (max. diameter 67mm)
- Coiling of intercostal arteries to reduce the risk of spinal cord ischemia during TEVAR in two sessions (3 arteries)
- CAD

RISK FACTORS
Arterial hypertension, hyperlipidemia

PROCEDURAL STEPS
1. Bilateral femoral access
- Preloading of Proglide-Systems right (ABBOTT)
2. Positioning of guidewire
- LunderQuist 0.035" 260 cm (COOK)
3. Implantation of 2 thoracic stentgrafts
- Ankura thoracic graft (LIFE TECH)
- Stengraft from left subclavian artery to the celiac trunk

CLINICAL DATA
- PAOD Rutherford 3, painfree walking distance 50 m
- Stent-PTA right SFA 03/2017
- ABI right: 0,5, left: 1,0

RISK FACTORS
Smoker, arterial hypertension, diabetes mellitus type 2

DUPLEX
ISR-occlusion of the right SFA

PROCEDURAL STEPS
1. Left groin retrograde and cross-over approach
- IMA-diagnostic 5F catheter (CORDIS/CARDINAL HEALTH)
- 0.035" angled soft Radiofocus guidewire, 190 cm (TERUMO)
- 0.035" SupraCore guidewire, 190 cm (ABBOOTT)
- 6F Balkin Up&Over sheath, 40 cm (COOK)
2. Guidewire passage and thrombectomy
- Rotarex 6F (STRAUB MEDICAL)
3. Filter placement
- 6 mm Spiderfilter (MEDTRONIC) in PIII segment
4. PTA with DCBs
- Ranger DCB 5.0/120 mm (BOSTON SCIENTIFIC)

CLINICAL DATA
- POAD Rutherford 3, walking capacity 200 m
- sudden deterioration of symptoms
- ABI right 0.6

RISK FACTORS
Arterial hypertension, nicotine abuse (30PY)

ANGIOGRAPHY
Thrombotic iliac occlusion right

PROCEDURAL STEPS
1. Right femoral approach
- 7F 25 cm sheath (TERUMO)
2. Guidewire passage and thrombectomy
- Rotarex 8F (STRAUB MEDICAL)
3. Stenting
- LifeStream covered stent for the common iliac artery (BARD)
- Covera Plus self-expanding covered stent for the external iliac artery (BARD)

CLINICAL DATA
- PAOD Rutherford 3 left, painfree walking distance 150 m
- PTA/ stent of the right SFA 11/2017
- Pseudoxanthoma elasticum (vascular, ocular and cerebral affection)
- ABI right: 0.8; left: 0.3
- PTA/ stenting right SFA 11/2017

RISK FACTORS
Arterial hypertension, CAD, hyperlipidemia

ANGIOGRAPHY
During PTA right 11/17: occlusion of the left SFA and popliteal artery

PROCEDURAL STEPS
1. Right groin retrograde and cross-over approach
- IMA 5F diagnostic catheter (CORDIS/CARDINAL HEALTH)
- 0.035" soft angled Radiofocus guidewire, 190 cm (TERUMO)
- 0.035" SupraCore guidewire 190 cm (ABBOTT)
- 7F 55 Check-Flo Performer Sheath, Raabe Modification (COOK)
2. Antegrade guidewire passage
- 0.035" Stiff angled Glidewire, 260 cm (TERUMO)
- CXC 0.035" support catheter, 135 cm (COOK)
3. Retrograde guidewire passage
Access via the peroneal artery:
- 7 cm 21 Gauge needle (COOK)
- 0.018" V-18 Control guidewire, 300 cm (BOSTON SCIENTIFIC)
- 4F-10 cm Radiofocus Introducer (TERUMO)
- Pacific Plus 4.0/40 mm balloon, 90 cm (MEDTRONIC)
4. PTA and stenting
- 6.0/20 mm Admiral Xtreme balloon (MEDTRONIC)
- 7.0/20 Conquest non-compliant high pressure balloon (BARD)
- In case of inability to open the balloons fully implantation of a Viabahn 7.0/100 mm (GORE)
- Relining with Supera Interwoven Nitinol stent (ABBOTT)

CLINICAL DATA
- PAOD Rutherford 3 left, painfree walking distance 150 m
- PTA/ stent of the right SFA 11/2017
- Pseudoxanthoma elasticum (vascular, ocular and cerebral affection)
- ABI right: 0.8; left: 0.3
- PTA/ stenting right SFA 11/2017

RISK FACTORS
Arterial hypertension, CAD, hyperlipidemia

ANGIOGRAPHY
During PTA right 11/17: occlusion of the left SFA and popliteal artery

PROCEDURAL STEPS
1. Right groin retrograde and cross-over approach
- IMA 5F diagnostic catheter (CORDIS/CARDINAL HEALTH)
- 0.035" soft angled Radiofocus guidewire, 190 cm (TERUMO)
- 0.035" SupraCore guidewire 190 cm (ABBOTT)
- 7F 55 Check-Flo Performer Sheath, Raabe Modification (COOK)
2. Antegrade guidewire passage
- 0.035" Stiff angled Glidewire, 260 cm (TERUMO)
- CXC 0.035" support catheter, 135 cm (COOK)
3. Retrograde guidewire passage
Access via the peroneal artery:
- 7 cm 21 Gauge needle (COOK)
- 0.018" V-18 Control guidewire, 300 cm (BOSTON SCIENTIFIC)
- 4F-10 cm Radiofocus Introducer (TERUMO)
- Pacific Plus 4.0/40 mm balloon, 90 cm (MEDTRONIC)
4. PTA and stenting
- 6.0/20 mm Admiral Xtreme balloon (MEDTRONIC)
- 7.0/20 Conquest non-compliant high pressure balloon (BARD)
- In case of inability to open the balloons fully implantation of a Viabahn 7.0/100 mm (GORE)
- Relining with Supera Interwoven Nitinol stent (ABBOTT)

CLINICAL DATA
- POAD Rutherford 3, walking capacity 200 m, ABI right 0.43
- Asymptomatic high grade stenosis of brachiocephalic trunc

RISK FACTORS
Smoker (40PY), arterial hypertension, hyperlipidemia

PROCEDURAL STEPS
1. Left groin retrograde and cross-over approach
- IMA-diagnostic 5F catheter (CORDIS/ CARDINAL HEALTH)
- 0.035" angled soft Radiofocus guidewire, 190 cm (TERUMO)
- 0.035" SupraCore guidewire, 190 cm (ABBOOTT)
- 6F Balkin Up&Over sheath, 40 cm (COOK)
2. Passage of the occlusion right SFA
- 0.018" Advantage guidewire (TERUMO)
- 0.018" CXI support catheter (COOK)
3. Vessel preparation right SFA
- Sterling balloon (BOSTON SCIENTIFIC)
4. Primary stenting
- Eluvia DES (BOSTON SCIENTIFIC)
5. Postdilatation left SFA
- Mustang balloon (BOSTON SCIENTIFIC)

CLINICAL DATA
- PAOD Rutherford 5 left, forefeet ulcerations and infections, restpain at night, mediasclerosis
- Failed recanalization attempt 01/18 elsewhere
- CAD, AMI, PTCA 2012

RISK FACTORS
Arterial hypertension, hyperlipidemia

ANGIOGRAPHY
Popliteal and BTK occlusions left

PROCEDURAL STEPS
1. Left groin antegrade approach
- 6F 55 cm Flexor Check-Flo Sheath, Raabe Modification (COOK)
2. Guidewire passage, second attempt from antegarde
- 0.014" CTO Approach 25 gramm 300 cm (COOK)
- 0.018" CXI support catheter, 90 cm (COOK)
In case of failure of guidewire passage from antegrade:
3. Retrograde approach via the distal anterior tibial artery and PTA
- 2.9F sheath (pedal puncture set) (COOK)
- 0.014" Hydro-ST 300 cm guidewire (COOK)
- 0.014" CTO-Approach 25 gramm guidewire, 300 cm (COOK)
- 0.018" CXI support catheter 90 cm (COOK)
- Advance 3.0/120 mm, 90 cm (COOK)
4. PTA of the popliteal artery
- Advance LP balloon 0.018" (3, 4, 5 mm) (COOK)

CLINICAL DATA
- POAD Rutherford 5, Dig. I ulceration left, restpain at night, walking capacity 20 m, ABI left 0.4
- PTA/stenting left SFA and left ATA 05/17
- CAD, CABG 2013

RISK FACTORS
Arterial hypertension, diabetes mellitus type 2, hyperlipidemia

PROCEDURAL STEPS
1. Left groin antegrade approach
- 6F 55 cm Flexor Check-Flo Introducer, Raabe Modifcation (COOK)
2. Guidewire-passage from antegrade
In case of failure retrograde approach via dorsal pedal artery:
- 2.9F sheath (pedal puncture set) (COOK)
- 0.014" CTO-Approach Hydro guidewire, 300 cm (COOK)
- 0.018" CXI support catheter 90 cm (COOK)
- Advance Micro-Balloon 3.0/120 mm, 90 cm (COOK)
3. In case of failure antegrade approach via posterior tibial artery
- 0.018" Command 18 guidewire, 300 cm (ABBOTT)
- 0.018" Quick-Cross support catheter (SPECTRANETICS-PHILIPS)
4. PTA
- 2.5/100 m Amphirion Deep ballon catheter (MEDTRONIC)

CLINICAL DATA
- PAOD Rutherford 6 left, forefeet ulcerations, ABI 0.3 left
- Renal imparement, kidney transplantation 2001, CAD

RISK FACTORS
Diabetes mellitus type 2 with neuro- and angiopathy, arterial hypertension, hyperlipidemia, former smoker

PROCEDURAL STEPS
1. Left antegrade access
- 6F 55 cm Flexor Check-Flo Introducer, Raabe Modification (COOK)
2. Guidewire passage of the ATA-CTO
- 0.014" Command ES guidewire, 300 cm (ABBOTT)
- 3.5/120 mm Armada 14 balloon (ABBOTT)
3. Arterial wall injection of dexamethason
- BullFrog Micro-Infusion-Device (MERCATOR MEDSYSTEMS)

CLINICAL DATA
- Progressive throraco-abdominal aneurysm after Type B-dissection (diameter max. 61mm)
- Adipositas, congestive heart failure, NYHA II-III

RISK FACTORS
Arterial hypertension, hyperlipidemia, adipositas

PROCEDURAL STEPS
1. Right groin access
- 6F 25 cm sheath (TERUMO)
- 6F MACH 1 LIMA guiding catheter (BOSTON SCIENTIFIC)
- 5F SOS diagnostic catheter (MERIT MEDICAL)
2. Cannulation and embolisation of segmental arteries
- 0.014 PT2, 300 cm guidewire (BOSTON SCIENTIFIC)
- 2.7F Progreat Microcatheter, 130 cm (TERUMO)
- 0.018" pushable microcoils (COOK)

CLINICAL DATA
- Chronic critical limb ischemia right forefoot, severe claudication right calf
- Rutherford class 5, ABI right 0.46
- PTA/stent of left SFA 12/2017, failed antegrade recanalisation attempt 01/2018 right
- TEA right groin 8/2017 and left 11/2017
- CAD, PTCA 2004

RISK FACTORS
Diabetes mellitus type 2, art. hypertension, hyperlipidemia, former smoker

PROCEDURAL STEPS
1. Left groin retrograde and cross-over approach
- IMA-diagnostic 5F catheter (CORDIS/ CARDINAL HEALTH)
- 0.035" angled soft Radiofocus guidewire, 190 cm (TERUMO)
- 0.035" SupraCore guidewire, 190 cm (ABBOTT)
- 7F Balkin Up&Over sheath, 40 cm (COOK)
2. Right SFA CTO puncture
- 18 Gauge 7 cm needle
- 0.035" stiff angled Glidewire, 190 cm (TERUMO)
- 6F – 10 cm Radiofocus-Introducer (TERUMO)
3. Passage of the CTO
Retrograde passage into the right CFA:
- Pioneer-Plus Reentry-system (philips)
- 0.014" Floppy ES guidewire, 300 cm (ABBOTT)
- Snaring of the retrograde guidewire into the the cross-over sheath
4. PTA/stenting
- Armada 35 5.0/100 mm balloon (ABBOTT)
- Distal and proximal: Zilver PTX-DES (COOK)
- SFA-ostium: Viabahn 7.0/250 mm (GORE)

CLINICAL DATA
- Pain and paresthesia right hand during elevation followed by dizziness and headache
- RR right: 110/ 60 mmHg ; RR left 140/80 mmHg

RISK FACTORS
Arterial hypertension, former smoker (40 py), hyperlipidema , diabetes mellitus Typ II

PRESENT STATE
- Subclavian-steal syndrome with retrograde flow in the vertebral artery
- No dysphagia

PROCEDURAL STEPS
1. Right brachial approach
- 5F 25 cm sheath (TERUMO)
2. Right femoral approach
- 7F 90 sheath, Flexor Check-Flo Introducer (COOK)
3. Passage of the lesion
- Snaring of the guide wire from femoral acces
4. Predilation
- 8 mm Admiral balloon (MEDTRONIC)
5. Implantation of a self-expanding nitinol stent from femoral
- Smart 10–12/60 mm stent (CORDIS)

CLINICAL DATA
- PAOD Rutherford 3, walking capacity 10 m left
- ABI left 0.53

RISK FACTORS
- Arterial hypertension, diabetes mellitus type 2, hyperlipidemia
- Chronic renal failure, GFR 40 ml/min/1.73 m2
- CAD: NSTEMI and CABG 2009
- Cerebral ischemia 1994
- COPD

PROCEDURAL STEPS
1. Brachial approach
- 6F 90 cm Check-Flo Performer (COOK)
2. Left femoral approach
- 7 25 cm sheath (TERUMO)
3. Guidewire passage
- 0.035" stiff angled Glidewire, 260 cm (TERUMO)
- Pacific 5.0/120 0mm-Ballon (MEDTRONIC)
4. Stenting
- LifeStream covered stent (common iliac artery) (BARD)
- Cover Plus covered stent (external iliac artery) (BARD)

b>CLINICAL DATA
- Incidental finding of a juxtarenal aortic aneurysm with progression to 75 mm max. diameter
- Coiling of intercostal and lumbar arteries before FEVAR to reduce the risk of spinal ischemia and prevent type II endoleak, coiling performed during production period of the custommade device

RISK FACTORS
- Arterial hypertension, diabetes mellitus Type 2
- chronic renal impairment, GFR 60 ml/min/1.73 m2

PROCEDURAL STEPS
1. Bilateral femoral access and left axillar percutaneous access
- Preloading of Proglide-Systems (ABBOTT) for all 3 access-sites
2. Implantation of the CMD thoracoabdominal stentgraft (JOTEC)
3. Implantation of E-ventus covered stents into the visveral arteries (JOTEC)
4. Implantation of the bifurcated component with extension into the common iliac arteries

CLINICAL DATA
- PAOD Rutherford 3, claudication, walking capacity 100 m left
- ABI left 0,68
- Stenting SFA left (Supera) 2017, DEB angioplasty SFA right 2017
- Angioplasty BTK arteries + stenting popliteal artery right 2014

RISK FACTORS
- Arterial hypertension, diabetes mellitus Type 2
- Chronic renal impairment, GFR 60 ml/ min/ 1.73 m2

PROCEDURAL STEPS
1. Left femoral retrograde and cross-over approach
- 7 F 55 cm Check-Flo Performer, Raab Modification (COOK)
2. Guidewire passage and filter positioning in the peroneal artery
- PT2 0.014" guidewire, 300 cm (BOSTON SCIENTIFIC)
3. Atherectomy and PTA with DCBs
- Jetstream SC (BOSTON SCIENTIFIC)
4. PTA with drug eluting balloons
- Lutonix drug-coated balloon (BARD)

CLINICAL DATA
DM, hypertension, hyperlipidemia

PRESENT STATE
Right foot: 3c TUC I°toe and 2c Tuc 2° and 3°

PROCEDURAL STEPS
1. US guided antegrade 6F 11 cm sheath
2. CO2 angiography
3. 4F Ber and V18 gw antegrade intraluminal recanalization attempt of pedal through AT
4. Second 0,014" gw in PT and lateral plantar artery antegrade recanalization attempt; retrograde distal PT if failure
5. POBA, Jetstream atherectomy (BOSTON SCIENTIFIC), Ranger DEB (BOSTON SCIENTIFIC) discussion
6. US closure device deployment (6F Angio-Seal)

CLINICAL DATA
- DM, previous SFA stenting (2001)
- re-treated with directional atherectomy for IS restenosis 2017

PRESENT STATE
Ulcerations in IV and V toes TUC 2C right foot

PROCEDURAL STEPS
1. Right US guided antegrade 6F 11 cm sheath deployment
2. CO2 angiography
3. AT antegrade 0,014" CTO gw intraluminal attempt, retrograde when failure; antegrade PT subintimal attempt
4. AT Predilatation, Phoenix debulking atherectomy (Philips), Stellarex DEB (SPECTRANETICS-Philips); PT POBA
5. US guided closure device deployment (Angio-Seal)

CLINICAL DATA
DM, dyalisis, kidney transplant, ischemic heart disease

PRESENT STATE
Bilateral CLI with left toes gangrenes

PROCEDURAL STEPS
1. Retrograde access right CFA
- 6F long sheath deployment and retrograde left P3 puncture + 6F 11 cm sheath
2. Presto technique for SFA and popliteal artery
- Balloon P3 aemosthasis
3. Antegrade BTK and BTA reacanalization attempt
4. Discussion for debulking and DEB
5. Closure device

CLINICAL DATA
DM, hypertension

PRESENT STATE
- Right CLI in previous 2°-3°-4°-5° amputation
- plantar 2CTUC

PROCEDURAL STEPS
1. US guided antegrade Right CFA puncture and 6F 11 cm sheath deployment
2. CO2 angiography
3. Antegrade AT recanalization (V18 cw + 4F BER2) antegrade lateral plantar and arch recanalization (0,014 Command)
4. Discussion for DEB/POBA
5. US guided closure device deployment (Angio-Seal)

CLINICAL DATA
- Claudication Rutherford-Becker class 3
- DCB angioplasty and stenting of the left popliteal artery 2014
- Stenting of the right CIA and CIE 2017

RISK FACTORS
Hypertension, tobacco use, diabetes, hypercholesterolemia

PRESENT STATE
- ABI at rest: 0.7
- Duplex ultrasound/angiography: 80% stenosis of the left CFA

PROCEDURAL STEPS
1. Femoral access (cross-over)
- 0.035" wire (TERUMO)
- 7/8F 45 cm sheath (COOK)
2. Directional atherectomy
- 0.0014" wire (TERUMO)
- Spider filter (MEDTRONIC)
- TurboHawk/ HawkOne (MEDTRONIC)
3. Post-dilatation
- DCB (MEDTRONIC)
4. Stenting on indication

CLINICAL DATA
- PAOD Fontaine IIb, Rutherford 3
- Recanalisation right SFA and proximal popliteal artery 12/2017
- Recanalisation right popliteal and posterior tibial arteries 06/2014
- Persistant CTO left CIA and bilateral IIA stenoses

RISK FACTORS
Smoking, hypertension, diabetes mellitus, hypercholesterolemia

PRESENT STATE
- Buttock, thigh and calf claudicatio left side
- ABI: 0.8 / 0.4
- MRA 2014: CTO of left CIA, high grade stenosis of bilateral IIA

PROCEDURAL STEPS
1. Bilateral retrograde femoral access
- Right side 45 cm, left side 11 cm
2. First crossing approach from contralateral side
- 6F IMA- or 5 F SOS-catheter
3. Additional retrograde crossing attempt in order to avoid impacting the left IIA origin (CART technique)
4. Predilatation of left CIA
5. Stent implantation left CIA
6. Stent implantation left IIA (right side on indication)
- Promus Stent (BOSTON SCIENTIFIC)

CLINICAL DATA
- PAOD Fontaine IV, Rutherford 5 left leg
- Chronic bilateral venous insufficiency
- Intermittant atrial fibrillation
- Unsuccessful recanalisation attempt of left PTA and ATA 04/2017
- Chronic kidney diseases NKF III - IV (GFR 23–35 ml/min)

RISK FACTORS
Diabetes mellitus, obesity

PROCEDURAL STEPS
1. Left antegrade femoral access, 6F
2. 5F STR guiding catheter (CORDIS)
3. Balloon guided antegrade crossing attempt
- 0.014'' Advantage wire (TERUMO) or 0.014'' Victory 14 wire (BSC)
4. Predilatation on indication
5. Optional atherectomy
- Rotablator (BSC)
6. Drug coated balloon angioplasty
- Lotus (Acotec)
7. Stenting on indication

CLINICAL DATA
- PAOD Rutherford 3
- Severe claudication right calf, walking capacity 50 meters
- Recanalisation, rtPA-thrombolysis and stent implantation right prox-dist SFA 04/2011
- Recanalisation and stent implantation right distal SFA 11/2004
- Fogarty thrombectomy right distal SFA 2004
- Testicular cancer, semicastratio and radio-chemotherapy 2003-2004
- ABI: right 0.6 after excercise test 0.4

RISK FACTORS
Nicotine abuse (25 PY) to 2006, hypercholertinemia

DUPLEX
Long instent reocclusion of right SFA

PROCEDURAL STEPS
1. Left femoral retrograde and cross over approach
- 6F 45 cm sheath
2. 0.035" or 0.018" Terumo GW, supported by vertebral catheter, 5F
3. Rotarex thrombectomy
- 6F (STRAUB MEDICAL)
4. Predilatation on indication (Cutting balloon)
5. Drug-coated balloon angioplasty

CLINICAL DATA
- PAOD Fontaine IIb/ Rutherford 3
- Recanalisation right EIA, CFA & DFA with persistant SFA occlusion 11/2017
- Infrarenal AAA
- ABI: 0.6/ 0.4

RISK FACTORS
Hypertension, ex-smoker, hypercholesterolemia

MRA
Occlusion of left CIA, EIA, CFA and SFA

PROCEDURAL STEPS
1. Retrograde right femoral access (45 cm sheath)
2. Retrograde puncture distal left SFA
3. Primarily retrograde recanalisation attempt
- 0.018'' or 0.035'' Glidewire (TERUMO)
4. Stenting of iliac vessels
5. DCB angioplasty of femoral arteries with stenting on indication
- BioMimics (Veryan) or Supera (ABBOTT VASCULAR)

CLINICAL DATA
- Claudication Rutherford-Becker 3
- Unsuccessful recanalisation right popliteal artery with perforation 12/2017

RISK FACTORS
Hypertension, tobacco use, hypercholesterolemia

PRESENT STATE
- ABI: 0.3
- Duplex ultrasound/ angiography: Occlusion of the right popliteal artery

PROCEDURAL STEPS
1. Femoral access (cross-over)
- 0.035" wire (TERUMO)
- 6F 45 cm sheath (COOK)
2. Retrograde puncture ATA vs. ATP
3. Recanalisation attempt
- 0.018" wire (BOSTON SCIENTIFIC, TERUMO)
- 3 x 40 mm balloon (BOSTON SCIENTIFIC)
4. Pre-dilatation
- DCB vs. POBA (MEDTRONIC, BOSTON SCIENTIFIC)
5. Stenting on indication
- Supera (ABBOTT)

CLINICAL DATA
- CRF: art. hypertension, hyperlipidemia
- PAOD with bilateral iliac stenting in 2013
- CHD with CABG and ischemic cardiomyopathy
- Stenting of right carotid artery 12/2107

IMPORTANT ITEMS
- Known carotid artery disease since 2012
- Yearly DUS surveillance and since Dec. 2017 treatment was initiated by vascular surgeon
- Vascular surgeon referred the patient for bilateral CAS

DUPLEX
PSV right 377 cm/s, left 420 cm/s

PROCEDURAL STEPS
1. Transfemoral access
- 8F short sheath (TERUMO)
2. Intubation of LCC
- Berenstein 4F catheter (4F, TEMPO AQUA, CARDINAL HEALTH)
3. Placement of guiding sheath
- 8F CBL or Simmons 8F guiding sheath (VISTA BRITE TIP IG, CARDINAL HEALTH)
4. Wiring with Filter Wire
- EZ Distal EPD (BOSTON SCIENTIFIC)
5. Predilation of left ICA
- 3 x 20 mm Maverick balloon (BOSTON SCIENTIFIC)
6. Stenting
- 9 x 30 mm Carotid Wallstent (BOSTON SCIENTIFIC)
7. Postdilation
- Paladin 5 x 20 mm balloon with integrated filter protection (CONTEGO MEDICAL)
8. Removal of guiding catheter and sheath
9. Vessel closure
- Angioseal 8F (TERUMO)

CLINICAL DATA
- PTA of left SFA & recanalisation of tibioperoneal trunk and ATA 2013
- Stenting of left SFA 2016 (re-occlusion)
- Stenting, scoring PTA and DEB of right SFA 2017

RISK FACTORS
- Impaired renal function CKD III
- Hyperlipidemia, art. hypertension, diabetes mellitus

PRESENT STATE
- Severe claudication, walking distance <80 meters
- ABI 0.5 left. 0.71 right

PROCEDURAL STEPS
1. Antegrade access
- 5 F Terumo Destination 45 cm
2. Crossing of the lesion
- Advantage 0.018" wire (TERUMO) with CXI Support (COOK)
3. PTA of TB-trunk
- 3.0 x 40 mm balloon
4. Stenting
- Cr8-BTK (Alvimedica) if needed (after exchange to 0.014" wire)
5. PTA of ATP and peroneal artery
- 2.5 mm balloon
6. Recanalisation of ATA and PTA
- 2.5 mm x 200 mm balloon

CLINICAL DATA
- Severe claudication right leg
- 12 cm long SFA occlusion
- Recanalisation of left SFA with focal stent and DEB 11/2017

RISK FACTORS
Art hypertension, hyperlipidemia, former smoker

PRESENT STATE
- Ablatio mammae left 1997
- ABI: 0.57 right

PROCEDURAL STEPS
1. Antegrade access 5F right common femoral
2. Wire passage
- 0.018" Advantage (TERUMO) with CXI 0.018" support (COOK)
- Back-up wire: Connect 0.018" 250T (ABBOTT VASCULAR)
3. PTA
- Passeo 18 4 mm balloon (BIOTRONIK)
- Passeo 18 LUX DEB 5 mm balloon (BIOTRONIK)
4. Stenting
- Pulsar 18 5 x 150 mm stent on demand following REACT strategy (BIOTRONIK)
5. Manual compression
6. If antegrade recanalisation fails retrograde access via ATA

CLINICAL DATA
- Known vascular history with previous LICA PTA in 2015
- No history of chest pain, referred progressively deteriorating symptoms of claudication from October '17, now severely impairing his quality of life

RISK FACTORS
- Hypertension, previous history of smoking, hypercholesterolemia
- Severe claudication (20 mt), erectile dysfunction
- pronounced flow demodulation in both common femoral arteries

PROCEDURAL STEPS
1. Radial access for angiographic evaluation
2 . Bilateral femoral access
3. Right common iliac artery lesion crossing
- 0.018'' 300 cm wire or Terumo soft 0,035'' hydrophilic wire
4. Kissing stenting with balloon-expandable stents
- Assurant-Cobalt stents (MEDTRONIC)
5. Postdilation as required

CLINICAL DATA
- In November '17 major stroke with right-sided hemiparesis
- Progressive full recovery in the subsequent 30 days

RISK FACTORS
- Hypertension, hypercholesterolemia
- Asymptomatic (recent stroke)

DUPLEX
Left internal carotid tight disease with soft/ mixed plaque determining significant flow acceleration

PROCEDURAL STEPS
1. Femoral access
2. Proximal protection
- MOMA 9F (MEDTRONIC)
3. Lesion crossing with 0.014'' wire
4. Direct stenting
- 'Double mesh' stent C-Guard (INSPIRE MD)
5. Postdilation
- 5.0 mm Maverick XL balloon (BOSTON SCIENTIFIC)
6. Debris aspiration (if any)

CLINICAL DATA
- Previous left SFA PTA (plain balloon) for severe claudication in February 2017
(final angio attached).
- Asymptomatic till mid November when he started complaining left leg pain for walking distances > 200 mt (very active lifestyle)

RISK FACTORS
- Hypertension
- Severe claudication (walking distance 200 mt)

DUPLEX
Evidence of proximal SFA occlusion with flow demodulation in popliteal artery
1. Right femoral access
2. Cross-over approach
- Terumo Destination 6F 45 cm long sheath
3. Lesion crossing
- 0.018'' wire, 0.035'' hydrophilic wire (TERUMO)
4. Atherectomy for lesion preparation
- HawkOne System (MEDTRONIC)
5. Balloon dilatation
- 5.0 and 6.0 mm In.Pact Admiral drug-eluting balloons (MEDTRONIC)
6. Further postdilatation with long balloons, if needed

CLINICAL DATA
- Known history of dilated cardiomyopathy (EF 35%).
- Severe COPD.
- Previous PTA to RICA in 2016.
- In November 2017 sudden onset of right-sided hemyparesis with dysartria, full recovery after 24 hours.

RISK FACTORS
- Hypertension
- Currently asymptomatic (previous stroke in Novmber 2017)

DUPLEX
Severe LICA disease (fibro-calcific disease)

PROCEDURAL STEPS
1. Femoral access
2. Proximal protection
- MoMa proximal protection system (MEDTRONIC)
3. Direct stenting with 'closed-cell' stent
- Carotid Wallstent (BOSTON SCIENTIFIC)
4. Postdilatation
- 5.0 mm Maverick XL balloon (BOSTON SCIENTIFIC)
5. Debris aspiration (if any)

CLINICAL DATA
- HCC-lesion in liver segment 3 in alcoholic liver cirrhosis
- BCLC B
- 12/2014 atypical liver resection Seg 7 (G2,pT3a, R0)
- 09/2016 microwave ablation seg 6
- 10/2016 microwave ablation seg 8

PRESENT STATE
- MELD score:6
- CHILD-PUGH: A
- No ascites

PROCEDURAL STEPS
1. Pre-ablation imaging like CT (contrast enhanced)
2. Local anesthesia, analgosedation
3. One antenna is placed directly into the lesion
- EMPRINT CA15L2, Short percutaneous Antenna with thermosphere technology (COVIDIEN)
- Generator: EMPRINT (COVIDIEN)

CLINICAL DATA
- 54 year old patient with HCC lesions in liver segments 8, 8/5 and 6
- 12/2017: TACE

RISK FACTORS
liver cirrhosis, hepatitis B, BCLC-Stage-B, Type 2 diabetes mellitus, hypertension

PROCEDURAL STEPS
1. Right retrograde access
- 5F sheath Introducer 2® (TERUMO)
2. Catheterization and DSA of celiac trunk plus indirect porotgraphy
- 5 F Side-Winder catheter (TERUMO)
- 0.035'' angled guidewire (TERUMO)
3. Selective catheterization of segmental and subsegmental branches of the hepatic artery in depending on location, size, and arterial feeding vessel of the target tumor
- 2.8F coaxial microcatheter system Progreat (TERUMO)
4. Chemoembolization with mitomycin C and lipiodol
5. Puncture site closure with a percutaneous closure device
- 6F Angio-Seal™ VIP (ST. JUDE Medical)

CLINICAL DATA
Alcoholic liver cirrhosis with portal hypertension, including refractory ascites and variceal bleeding

RISK FACTORS
Type 2 diabetes mellitus, hypertension

PROCEDURAL STEPS
1. Insertion of 10F sheath into the right jugular vein
- 10F x 17-3%4'' sheath super Arrow-Flex® Psi Set, 45 cm, and tisue dilatator (Arrow International)
- 0.035'' angled guide wire (TERUMO)
2. Access to the a hepatic vein (right or middle) by inserting a 5F multi-purpose catheter
- 5F MP A1 (CORDIS)
- 0.035'' angled guide wire (TERUMO)
3. Puncture of the portal vein under ultrasound or fluoroscopic control using a Tips puncture set
- Tips puncture set with a spezial nitinol guide wire; needle size: ø 1.8 mm x 580 mm, 60° curved (OPTI MED)
- 0.035'' straight guide wire (stiff type) (TERUMO)
4. Placement of stiff guide wire and a catheter into the portal venous system to produce a direct portogram and to measure the direct portal pressure
- 4F Berenstein catheter (ANGIO DYNAMICS)
- Haemofix-Monitorin Kit Art/Ven BSS
5. Dilatation of the parenchymateous tract using an angioplasty balloon
- 0.035'' Supra Core 35 (ABBOTT VASCULAR)
- 6F Armada 35 PTA catheter (ABBOTT VASCULAR)
- Inflation device (MERIT MEDICAL)
6. Placement of the 10F sheath into the portal mainstem
- 10 F Check Flo Performer® introducer (COOK)
7. Implantation the portovenous PTFE covered stent under fluoroscopic control
- VIATORR 10 mm x 8 cm/2 cm; 10F (GORE)
8. Dilatation of stent using an angioplasty balloon
- 0.035'' Supra Core 35 (ABBOTT VASCULAR)
- 6F Armada 35 PTA catheter (ABBOTT VASCULAR)
- Inflation device (MERIT MEDICAL)
9. Direct portography and measure the pressure gradients between the portal vein and the inferior vena cava
- 5F- MP A1 (CORDIS)
- F Check Flo Performer® introducer (COOK)
10. Placement of a central venous catheter in the superior vena cava or right atrium
- Mahurkar acute dual lumen catheter, 11.5F x 19.5 cm (COVIDIEN)

CLINICAL DATA
- 8 day history of low back and pelvic pain; 4 days history of leg pain
- Swollen, purple, tense; normal pulses

PRESENT STATE
- No prior history, no medications, no cancer
- Recently laid up with severe flu
- US diagnosed left Ilio-femoral deep vein thrombosis; confirmed on CT

PROCEDURAL STEPS
1. Prone position; US guidance
- 11F sheath; 5000u IV Heparin
2. Initial venograms; cross lesion with hydrophiic wire (MERIT MEDICAL); confirm position in IVC
3. Penumbra Indigo 8F Cat system 80 cm long
4. May or may not use Alteplase 5–20 mg
5. Repeat venography
6. Aspiration
- 7F Detachable Hub sheath (TERUMO) or 8F 45 cm Hockey Stick (CORDIS)
7. IVUS
- VOLCANO/ PHILIPS
8. Balloon
- Atlas 14–16 mm at high pressure (>20 atm) (BARD)
9. Venous Stent
- Zilver Vena 14/140 mm inferiorly (COOK); 16mm x 100 or 140mm superiorly; repeat balloon dilatation to nominal diameter stent
10. IVUS to confirm full stent expansion; minimal venography to finish; CDUS Day 1; pneumatic compression boots; Class 2 thigh high stockings x 6 weeks

CLINICAL DATA
- Swollen left leg 10 months after an IF DVT
- Initially presented April 2017 with acute L IFDVT
- Delayed diagnosis
- Attempted lysis treatment complicated by genuine anaphylactic reaction to iodinated contrast
- Abandoned
- CTV showed IVC to ankle DVT
- Transferred to Galway; 3 days CDT improved situation, did not stent
- Anticoagulated for 7 months; leg has improved; still some venous claudication
- MRV to follow: MRV shows chronic iliac occlusion IVC to L CFV
- We think CFV is good enough for inflow

PROCEDURAL STEPS
1. Access R IVJ; L FV or PFV General anaesthetic; supine, urethral catheter
- 10F 35cm sheath
- 8F Hockey stick
- 5f CXI catheter (COOK)
- Road runner wire (COOK) or Glide wire (MERIT MEDICAL)
2. Ideally cross from above and below; confirm position – multiple obliques
3. Predilatation @ 20atm
- 16 mm Bard Atlas CIV EIV
- 14 mm CFV 12 mm PFV
- or FV cephalad end
4. Stent choice
there is no right or wrong; no stent has a proven advantage over another – so: deploying from inferior to superior
- 14 mm Wallstent/ Veniti Vici/ Bard Venovo/Cook Zilver Vena/ OPTI MED Sinus Venous/ MEDTRONIC Abre; then 16 mm to CIV
5. Identifying the dominant inflow by IVUS is probably the key step to this case
6. Post stent dilatation; same size balloons to high pressure
7. Confirm full stent expansion with IVUS
8. Venography to finish
9. Pneumatic compression boots
(Tyco/COVIDIEN); Class 2 stockings; CDUS day 1; full anticoagulation before, during and after

CLINICAL DATA
- Leiomyosarcoma IVC resection 1996;
- IVC sewn graft;
- patient for years and discharged to GP;
- recent severe RTA;
- no head injury;
- mildly swollen legs but now more severe

CT
CT abdomen with IV contrast as shown

PROCEDURAL STEPS
1. Access
- 10F 35 cm sheaths above and below- RIJV + L CFV + R CFV
2. Support catheters
3. Hydrophilic catheters and wires
4. If successful in crossing, then CBCT (SIEMENS) to confirm all intra-luminal
5. Exchange to 260 Lunderquist wires (COOK)
6. Capturex from above to trap any debris
- Consider use of Aspirex (STRAUB) – I don't know how acute this is really
7. Attempt balloon dilatation
- Kissing 14 mm balloons (BARD ATLAS) entire length of occlusion
8. Kissing stents with high resistance to compression
- Veniti Vici 14/120 mm and or Sinus XL 24/80 to top end; distal extension to mid CIV or EIV bilaterally
9. Post stent implantation to same high pressure (>20 atm)
10. IVUS , venography and CBCT to finish
- Normally I wouldn't use this much radiation but this is a bit unusual!!!

CLINICAL DATA
- 3 prior renal transplants, current one is failing
- innumerable previous central lines for dialysis
- now has symptoms of SVC obstruction

PRESENT STATE
- Clinically sleeps with 4 pillows
- swollen face, lips, hoarse voice – CTV initially read as no obstruction – however at MDM complete obstruction noted
- Previous attempt to cross failed

PROCEDURAL STEPS
1. General anaesthetic; cardiothoracic back up; 6 units grouped and cross matched. Arterial line
2. Access above and below 14F sheaths
3. Get good support catheters up close to occlusion and obtain best oblique. Try to cross with a variety of wires including hyrdophilic; stiff hydrophilic; Road Runner (COOK); Asahi Astata 30g curved tip
4. If unsuccessful then, in best oblique; line up TIPS need or Trans-Septal needle with a snare- shoud we go from south to north or via versa??
5. If we get across then balloon dilatation- unlike in iliacs where we go straight to 16 mm we will start here with 4/6/8/10; probably use a covered stent? Viabahn 13 mm x 50 mm; possibly reinforce with a Venous Stent like Bard Venovo
6. Post dilate to 12/14 mm
7. CBCT and IVUS to finish

CLINICAL DATA
- Right arm AVF created 2010
- treatment resistant cephalic vein stenosis
- brachial artery to cephalic vein
- recurrent high venous pressures prolonged bleeding – has been dilated every 6 weeks to 3/12 – we are looking for a bit more durability

PRESENT STATE
End stage renal disease

PROCEDURAL STEPS
1. Right arm AVF access using micropuncure set and then a pursestring suture
2. Cross lesion using hydrophilic wire and then stiff wire into IVC
3. Predilate with high pressure balloon to 10mm (its usual size)
4. Covera stent graft (BARD) to cover the lesion and avoid covering much of subclavian vein beyond
5. 3000u IV Heparin
6. Purse-string suture
7. Dialysis following day

CLINICAL DATA
- PAOD Rutherford 3, walking distance 200 meters

RISK FACTORS
- Arterial hypertension, current smoker, thromendatherectomy right CFA 12/2017

DUPLEX
Long occlussion of left SFA

PROCEDURAL STEPS
1. Cross-over access with 6F sheath
- CXI Support-Catheter Straight, Angled & Angled 2 (COOK)
2. Guidewire passage to popliteal artery
- CTO-Approach guidewire 12gr (COOK)
3. Predilatation
- 18 LP Advance Balloon (COOK)
- 35 LP Advance Balloon (COOK)
4. Drug-eluting stent implantation
- Zilver-PTX (COOK-MEDICAL)
5. Postdilatation

CLINICAL DATA
- Liver only metastasis of neuroendocrine tumor, dominant left liver burden
- No risk factors, left liver first SIRT
- No extrahepatic disease

PROCEDURAL STEPS
1. Puncture site: right groin
- ST. JUDE (ABBOTT)
2. Placement of coaxial catheter in main hepatic artery
- Cobra 4F, alternative SIM-1, (CORDIS/ CARDINAL HEALTH)
3. Placement of microcatheter in left hepatic artery therapy positions according to the evaluation session
- Progreat 2.7F (TERUMO), alternative wire: Cirrus 14" (COOK)
4. Radioembolization
- SIRT with Therasphere® (BTG)

CLINICAL DATA
Singular HCC, intraoperative thermal ablation

PRESENT STATE
- First diagnosis of HCC in 9/2017,
- atypical resection, now recurrence,
- tumor board decission: DEB-TACE
- Exclusion of extrahepatic disease

PROCEDURAL STEPS
1. Puncture site: right groin
- ST. JUDE (ABBOTT)
2. Placement of coaxial catheter in the main hepatic artery
- COBRA 4F, alternative SIM-1 4F both (CORDIS/ CARDINAL HEALTH)
3. Placement of microcatheter in the feeding artery of HCC
- Progreat 2.7F (TERUMO), alternative wire: Cirrus 14" (COOK)
4. DEB-TACE
5. Control angiogram
6. If necessary additional bland embolization
- Embozene Tandem 40μm (BOSTON SCIENTIFIC)

CLINICAL DATA
IPSS: 28, QoL: 6, IIEF-5: 11, prostatic volume: 72 ml, psa: 2.86 ng/l, Qmax: 4.2 ml/s

PRESENT STATE
- Lower urinary tract symptoms due to BPH, no successful medications for more than 6 month, refusing operative therapy such as TUR
- Exclusion of prostatic cancer

PROCEDURAL STEPS
1. Puncture site: right groin
- ST. JUDE (ABBOTT)
2. Placement of coaxial catheter in distal aorta
- RIM 4F (CORDIS) or alternative (MERRIT MEDICAL); Alternative Wire: Cirrus 14" (COOK)
3. Large-FOV-dyna CT for determination of anatomy and origins of the prostatic arteries
4. Placement of microcatheter in the left prostatic artery for embolization
- Progreat 2.7F (TERUMO), alternative: Progreat 2.0F alpha (TERUMO), alternative SwiftNinja (MERRIT MEDICAL)
- Embozene 250μm (BOSTON SCIENTIFIC)
5. Placement of the microcatheter in the right prostatic artery for embolization
- Progreat 2.7F (TERUMO), alternative: Progreat 2.0F alpha (TERUMO), alternative SwiftNinja (MERRIT MEDICAL)
- Embozene 250μm (BOSTON SCIENTIFIC)

CLINICAL DATA
- Art. hypertension
- PAD
- COPD

PRESENT STATE
Growing aneurysm from 35 mm to >50 mm in 3 years

PROCEDURAL STEPS
1. Cut down left axillary artery and double puncture
2. Placement of two 7 F Shuttle sheath from above
3. Percutanous approach both groins Prostar XL 10F (ABBOTT) Placement of 14 F sheaths (COOK)
4. Cannulation of both renal arteries from above
5. Placement of Endurant bifurcated endograft just below the SMA (MEDTRONIC)
6. Placement of the Chimney stent-grafts in both renal arteries
- Atrium Advanta V 12 balloon-expandable covered stent (Maquet Gettinge-Group) or Viabahn VBX balloon expandable endoprosthesis (GORE)
7. Closure of the accesses

CLINICAL DATA
Art. hypertension, CAD, PAD

PRESENT STATE
Rapid growing of a juxtarenal abdominal aortic aneurysm from 45 mm up to 61 mm in 6 month.

PROCEDURAL STEPS
1. Percutanous approach both groins (Prostar XL, ABBOTT); 14F sheats (COOK) both groins
2. Change for the Lunderquist-wire (COOK) on the right side and pig-tail-cath on the left side
3. Angiography to locate CT, SMA and RAs and use of the fusion-technology
4. Placement of the 3-fenestrated Zenith-endograft (COOK) via the right groin
5. Cannulation of the renal arteries through the introducer sheath and the fenestrations by using the preloaded wire
6. Cannulation of the SMA through the left access
7. Implantation of the bridging stentgrafts (Atrium Advanta V 12 balloon-expandable covered stent (Maquet Gettinge-Group)) after deployment of the Top-Stent and removal of the preloaded wire
8. Removal of the introducer sheath
9. Implantation of the bifurcated endograft and the iliac limbs
10. Closure of the accesses

CLINICAL DATA
- Art. hypertension
- Diab. mell. II
- CAD - PTCA 1998 and 2015
- SAS

RISK FACTORS
- Hostile abdomen, obesity

PROCEDURAL STEPS
1. Percutanous approach both groins
- Prostar XL (ABBOTT)
- Placement of 14F sheath (COOK)
2. Cut down left axillary artery and cannulation of the right renal artery; Placement of a 7F sheath in the RRA
3. Placement of Endurant bifurcated endograft (MEDTRONIC) just below the left RA
4. Implantation of the Chimneygraft in the RRA from above
5. Additional fixation of the proximal sealing zone with Heli-FX Endoanchors (MEDTRONIC)
6. Closure of the groin
- Prostar XL (ABBOTT)
7. Closure of the axillary access

CLINICAL DATA
Art. hypertension, PAD

PRESENT STATE
62 mm thoracic aneuysm with a penetrating ulcer and a small AAA 41 mm in diameter

PROCEDURAL STEPS
1. Percutanous approach both groins
- 5F sheath left groin
- Prostar XL (ABBOTT) right groin
- Placement of 14F later 24F Dry-Seal-sheath (GORE) through the right groin
2. Implantation of the GORE C-TAG endograft with the active control system step by step
3. Positioning of the graft and deploiment up to 50% diameter
4. Agiography, correction of the graftposition and the C-arm angulation, if necessary angulation of the graft
5. Complete deploiment of the graft and possibly some more angulation in order to achieve ideal wall apposition
6. Final angiography, if needed post-dilation
7. Closure of the groin
- Right groin: Prostar XL (ABBOTT)
- Left groin: Angioseal (ST. JUDE)

CLINICAL DATA
- Rutherford III right leg, painfree wd 50 m
- ABI right leg 0,3
- 2012 nitinol stent right SFA

RISK FACTORS
CVRF: hypertension, hyperlipidemia

PROCEDURAL STEPS
1. Left femoral access
- 7F 45 cm Destination x-over sheath (TERUMO) to right CFA
2. Wire passage
- 0,018" V18 wire (BOSTON SCIENTIFIC) and 0,035" Quick-cross (SPECTRANETICS) support catheter
3. Filter placement
- 4 mm Spiderfilter (MEDTRONIC) to peroneal artery
4. OCT-guided atherectomy
- Pantheris 3.0 7F directional atherectomy catheter (AVINGER) of SFA ISR and popliteal artery
5. Post PTA
- 5 x 120 mm paclitaxel eluting balloons, passeo lux (BIOTRONIK)
6. Filter removal
- 0,035" Quickcross
7. Closure of access site
- Proglide VCD (ABBOTT)

CLINICAL DATA
- Art. hypertension
- CAD - PTCA Riva 2001
- Occlusion RCA
- Occlusion right ICA and CAS left ICA some years ago
- Bleeding from a gastric ulcer after NSAR 2016

PRESENT STATE
Progression of the aneurysm from 4.5 up to 61

PROCEDURAL STEPS
1. Cut down left axillary artery and double puncture
2. Placement of two 7F Shuttle sheaths from above
3. Percutanous approach both groins Prostar XL 10F (ABBOTT), placement of 14F sheaths (COOK)
4. Cannulation of both renal arteries from above
5. Placement of Endurant bifurcated endograft just below the SMA (MEDTRONIC)
6. Placement of the Chimney stent-grafts in both renal arteries
7. Closure of the accesses

CLINICAL DATA
- Cardiac fibrillation-anticoagulation,
- art. hypertension,
- ventilation disorders due to scoliosis of the spine-O2 therapy

PRESENT STATE
Growing TAAA, turned down for OR

PROCEDURAL STEPS
1. Percutanous approach both groins
- (Prostar XL, ABBOTT) 14 F (COOK) both groins
2. Left axillary access 5F sheath via cut down
3. Pull through wire between right femoral and axillary access. Pig tail catheter through the left groin for imaging. Registration of the Fusion technology
4. Placement of the CMD-branched-endograft (COOK) with 5 branches with help of the Fusion system
5. Placement othe the 12F Flexor sheath from above over the pull through wire
6. Closure of the groins in order to avoid SCI
7. Bridging of all the branches from the axillary access
- Advanta, VBX, Viabahn
8. Closure of the axillary access

CLINICAL DATA
- Patient presents with 2 block life-style limiting lower extremity claudication
- over last 6 months. Progressively worsening. Rutherford Category 3.
- No history of ulcer. Failed maximal medical therapy.
- ABI: right 0.71, left 0.92

RISK FACTORS
- Hypertension, ex smoker, dyslipidemia
- CAD s/p CABG
- PVD - s/p left fempop bypass

PROCEDURAL STEPS
1. Left groin access with retrograde cross over approach
- UF 4F diagnostic catheter (ANGIO DYNAMICS)
- 0.035" SupraCore guidewire, 300 cm (ABBOTT VASCULAR)
- 7F–45 cm Pinnacle sheath (TERUMO)
2. Passage through the right SFA stenosis
- 0.035" Tempo Aqua Vert support catheter, 125 cm (CORDIS)
- 0.014" Fielder guidewire, 300 cm (ABBOTT VASCULAR)
- Exchange to 0.014" Spartacore guidewire, 300 cm (ABBOTT VASCULAR)
3. Filter placement
- Exchange to a Barewire through the support catheter (ABBOTT VASCULAR)
- Emboshield Nav 6 filter placement (ABBOTT VASCULAR)
4. Plaque modification
- Chocolate balloon 5 x 120 mm (MEDTRONIC)
5. PTA with drug-coated balloon
- In.Pact Admiral 6.0 x 150 mm DCB (MEDTRONIC)

CLINICAL DATA
- Progressively worsening right leg claudication x 1 year
- No history of rest pain or ulceration
- Has failed maximal medical therapy
- Current claudication distance <1 block (Rutherford stage 3)
- ABI: right 0.82, left 0.94

RISK FACTORS
- Type 2 diabetes mellitus, hypertension, dyslipidemia, ex smoker
- History of CAD s/p CABG

PROCEDURAL STEPS
1. Left groin access with retrograde cross over approach
- UF 4F diagnostic catheter (ANGIO DYNAMICS)
- 0.035" SupraCore guidewire, 300 cm (ABBOTT VASCULAR)
- 6F–45 cm Pinnacle sheath (TERUMO)
2. Passage through the right SFA occlusion
- 0.035" Tempo Aqua Vert support catheter, 125 cm (CORDIS)
- 0.018" Connect 250 T guidewire, 300 cm (ABBOTT VASCULAR)
- If unable to cross with 0.018" guidewire, switch to an 0.035" stiff angled glidewire (TERUMO)
3. Filter placement
- Exchange to a Barewire through the support catheter (ABBOTT VASCULAR)
- Emboshield Nav 6 filter placement (ABBOTT VASCULAR)
4. Jetstream atherectomy of the right SFA calcified disease
- Jetstream 2.4/3.4 mm atherectomy (BOSTON SCIENTIFIC)
5. PTA with drug-coated balloon
- In.Pact Admiral 6.0 x 120 mm DCB (MEDTRONIC)
6. PTA with a non-compliant balloon
- Dorado 6 x 100 mm balloon (BARD)
7. Stenting and post-dilatation
- 5.5 x 150 mm Supera interwoven self-expanding Nitinol stent (ABBOTT)
- Dorado 6 x 100 mm balloon (BARD)

CLINICAL DATA
Right nephrectomy, pneumothorax, chronic renal insuffisency MDRD 46 ml/min

RISK FACTORS
Smoking

PARACLINICS
- Echocardiography: normal
- Supra aortic trunks US: normal

PROCEDURAL STEPS
1. R: ZBIS (COOK) advanced into distal aorta, unsheath until tip of prelaoded catheter is released; advance 260 cm Terumo
2. L: advance 12F sheath + snare
3. L: snare 260 Terumo, through-and-through wire, advance 12F dilatator tip to tip of preloaded catheter – secure both ends of Terumo wire with clamps
4. L: unsheath ZBIS to release internal branch – advance 12F sheath into ZBIS (pull and push), access hypogastric with parallel wire, advance 7F sheath-55 cm and bridging stent
5. Release through and through wire, pull down ZBIS to position the branch at the IIA origin + bridging stent deployment
6. Selective angiogram + ZBIS final deployment
7. L: insert and deploy bifurcated component
8. R: catheterize contro limb and deploy bridging ZSLE 16 limb
9. Coda balloon, completion angiogram, CBCT

CLINICAL DATA
- Acute type A aortic dissection open repair in 2014
- Aortic arch aneurysm 09/2015: left common carotid subclavian by pass + 2 branches arch endograft

RISK FACTORS
- Smoking, hypertension, dyslipidemia, BMI >30
- Obstructive sleep apnea syndrome, transient stroke

PARACLINICS
- PFT: restrictive syndrome
- CTscan: thoraco abdominal aneurysm, 70 mm maximal diameter
- Cardiac stress test: negative
- Supra aortic trunks US: no significative lesion

PROCEDURAL STEPS
1. Percutaneous access R and L CFA with Proglide systems; 100ULkg Heparin (Target ACT>250)
2. R: Dilatators up to 20F, insertion of TEVAR
3. L: 16F introducer + Pigtail angiocatheter
4. Aortic angiogram / TEVAR deployment
5. Insertion of FEVAR delivery system (COOK)
6. Aortic angiogram / fusion regsitration + FEVAR deployment + access target vessels through fenestrations / bridging stents
7. ZBIS deployment (COOK)
6. Bifurcated component deployment
7. Completion angiogram + non injected CBCT

CLINICAL DATA
- Appendicectomy/ pulmonary lobectomy
- Present state: asymptomatic

RISK FACTORS
Hypertension, smoking, dyslipidemia

PARACLINICS
- Echocardiography: LVEF 65% stress test negative
- PTF: COPD

PROCEDURAL STEPS
1. Bilateral cervicotomy
2. Percutaneous access R and L CFA with Proglide systems; 100UI/kg Heparin (Target ACT>300)
3. L: Dilatators up to 22F + advance branched endograft to the arch
4. Aortography + fusion fine tuning
5. Branched endograft deployment under rapid pacing (COOK)
6. From RCCA, access to the Inominate branch + deployment of the bridging stent
7. From LCCA, access to the carotid branch + deployment of the bridging stent
8. From the groin, access to the LSCA branch + artery + deployment of the bridging stent
9. Completion angiography + non injected CBCT
10. Close access sites

CLINICAL DATA
No medical history

RISK FACTORS
Smoking, hypertension

CT-SCAN
Type IV abdominal aneurysm/ 2 right renal arteries/ inferior mesenteric artery > 4 mm

PROCEDURAL STEPS
1. Percutaneous access R and L CFA with Proglide systems
2. Inferior mesenteric artery embolization with 6 mm Amplatzer; 100UI/kg Heparin (Target ACT>250)
3. L: 20F 25cm sheath in the LCFA over Lunderquist –Valve puncture with 6F and 7F 55cm + Pigtail angio catheter
4. R: Dilatators up to 20F + insertion of fenestrated endograft
5. Aortic angiogram/ Fusion registration/ FEVAR deployment (COOK)
6. Access target vessels through fenestrations
7. Bridging stents deployment
8. Bifurcated component deployment
9. Coda inflation at overlap
10. Completion aortography + non injected CBCT

CLINICAL DATA
- Status post kissing iliac stent placement in 2012
- now presents with recurrent lifestyle – limiting claudication in the right thigh and calf, failed medical and exercise Rx

RISK FACTORS
HTN, Dyslipidemia, former 2pk/day smoker stopped 2012

DUPLEX
1/3/18 Mild right iliac in-stent restenosis and high grade distal right superficial femoral above knee popliteal artery stenosis

PROCEDURAL STEPS
1. Antegrade right SFA access
- 6F SlenderTM sheath
2. Distal filter placement (Medtronic Spider)
3. Atherectomy, TBD, with filter placement
4. POBA for additional vessel prep (Medtronic Charger)
5. DCB (Medtronic In.Pact)
6. Any necessary additional procedures

CLINICAL DATA
Left heel and left great toe ulceration and pain at rest now with difficulty ambulating

RISK FACTORS
DM, HTN, hyperlipidemia, emphysema

HISTORY
- Revasc of SFA/pop on 1/3/18, Flex peripheral scoring catheter, DCB In.Pact Admiral
- Failed revascularization of AT from antegrade approach.

PROCEDURAL STEPS
1. Left groin access
- 4F Terumo sheath
2. Angiogram and methylene blue injection into peroneal artery
3. DP access using US for guidance
- 4F Pinnacle/Precision or 4F Pedal Access kit
4. Attempt to cross from retrograde access
5. Atherectomy
- Laser (SPECTRANETICS-PHILIPS) vs. Orbital (CSI CARDIOVASCULAR SYSTEMS), either from antegrade or retrograde access
6. PTA
- 2 or 2.5 mm x 300 mm catheter
7. Possible attempt to revascularize the pedal loop

CLINICAL DATA
57 yo male with claudication x 1 yr, not improved with Cilostazol, he works in food delivery business and the symptoms have made his work difficult.

RISK FACTORS
HTN, long time smoker (trying to quit-currently with nicotine patch)

PROCEDURAL STEPS
1. Bilateral groin access
2. Will plan for treatment using Endologix AFX Unibody Endograft
3. Pre-close technique utilizing
2 Per-Close devices (ABBOTT)
4. Aortogram to size device
5. Deploy device, possible extension to cover iliac disease using Ovation limb (ENDOLOGIX)
6. Alternate plan: b/l groin access and kissing balloon stent graft, VBX (GORE)

CLINICAL DATA
Non-healing right hallux tip gangrene

RISK FACTORS
HTN, dyslipidemia, CAD, prior RLE revasc

PROCEDURAL STEPS
1. Antegrade RLE angio
- 6F slender sheath (TERUMO)
2. Retrograde pedal venous access (COOK)
3. Retrograde snare placement in posterior tibial vein
- EN Snare (MERIT)
4. Outback (CORDIS) entry from posterior tibial artery to vein
5. Placement of stent graft
- Viabahn (GORE) or Graftmaster (ABBOTT)
6. Flex angiotome or cutting balloon valvulotomy
7. Selective embolization if needed

RISK FACTORS
- HTN, dyslipidemia, hypertension, former 2pk/day smoker stopped 2012
- Type 1 diabetes mellitus
- End stage renal disease on maintance hemodialysis via left radiocephalic AV fistula
- Atrial fibrillation, prior forced maturation, recurrent juxta-anastamotic stenosis

DUPLEX
- 1/3/18 mild right iliac in-stent restenosis and high grade distal right
- Superficial femoral above knee popliteal artery stenosis

PROCEDURAL STEPS
1. US guided radial artery access (COOK)
2. 5F Slender sheath insertion (TERUMO)
3. POBA
4. POBA for additional vessel prep
- Conquest high pressure balloon (BARD)
5. Bard Lutonix DCB
6. Any necessary additional procedures

CLINICAL DATA
Chronic LLE swelling, prior LLE fem-pop bypass

PROCEDURAL STEPS
1. US guided access into L GSV
- 10F sheath (BOSTON SCIENTIFIC)
2. Pelvic venogram
3. IVUS
- VOLCANO (PHILIPS)
4. Iliac vein stent
- Wallstent (BOSTON SCIENTIFIC)
5. Post stent venogram and IVUS
6. GSV Ablation via one access site
- Venoseal (MEDTRONIC)

CLINICAL DATA
- Swelling left leg
- Residual small pelvine lymphocele post sclerotherapy

RISK FACTORS
Compression left external iliac vein, inactive prostate carcinoma

CT-SCAN
Lymphocele (post sclerotherapy)

PROCEDURAL STEPS
1. Retrograde left common femoral vein access
- 10F sheath
2. Retrograde recanalization left iliac vein obstruction
3. IVUS
4. Vessel preparation
5. Stenting
- New generation woven nitinol stent (Blue Flex stent) 10F (14/100 and 14/150)
6. Post dilatation

CLINICAL DATA
Post-thrombotic syndrome with leg swelling and claudicatio venosa

RISK FACTORS
Delivery, postpartum status, May-Thurner anatomy

DUPLEX
Occlusion left external iliac and common femoral veins; maintained venous inflow by V. femoralis & V. profunda femoris

PROCEDURAL STEPS
1. Ultrasound-assisted retrograde left common femoral vein access
- 10F sheath
2. Passage left iliac vein occlusion
3. IVUS
4. Vessel preparation
5. Stenting
- VIC: Sinus Obliquus (14/150) (OPTI MED)
- VIC: Sinus XL Flex (14/100) (OPTI MED)
- VFC: Sinus XL Flex (14/80) (OPTI MED)
6. Post-dilatation

CLINICAL DATA CLINICAL DATA
Post-thrombotic syndrome with leg swelling and claudicatio venosa

RISK FACTORS
Delivery, postpartum status, May-Thurner anatomy

DUPLEX
Occlusion left external iliac and common femoral veins; maintained venous inflow by V. femoralis & V. profunda femoris

PROCEDURAL STEPS
1. Ultrasound-assisted retrograde left common femoral vein access
- 10F sheath
2. Passage left iliac vein occlusion
3. IVUS
4. Vessel preparation
5. Stenting
- VIC: Sinus Obliquus (14/150) (OPTI MED)
- VIC: Sinus XL Flex (14/100) (OPTI MED)
- VFC: Sinus XL Flex (14/80) (OPTI MED)
6. Post-dilatation

CLINICAL DATA
Post-partal iliac vein thrombosis (1969) with post-thrombotic syndrome

RISK FACTORS
APC-resistance, atypical left iliac vein compression

CT-SCAN
Spontaneous palma, no May-Thurner anatomy but atypical iliac vein compression

PROCEDURAL STEPS
1. Ultrasound-assisted retrograde left femoral vein access
- 10F sheath
2. Passage left iliac vein occlusion
3. IVUS
4. Vessel preparation
5. Stenting
- VIC: Sinus Obliquus (14/150) (OPTI MED)
- VIE: Sinus XL Flex (14/100) (OPTI MED)
- VFC: Sinus XL Flex (14/80) (OPTI MED)
6. Postdilatation

CLINICAL DATA
- PM-associated occlusion of vena cava superior
- Bi-parietotemporal headache
- Sick-sinus syndrome with dual-champer PM implantation 2012
- Persisting pericardial effusion

CLINICAL IMAGE
Epigastric collateral veins

CT
Occlusion V. cava superior and innominate vein, insufficient hemiacygos collateral vein,
atypical mamarian and epigastric veins, PM-electrodes in situ

PROCEDURAL STEPS
1. Ultrasound-assisted access
- Left common femoral vein 10F sheath
- Right internal jugular vein 6F sheath
2. Passage V. cava superior occlusion
3. IVUS
4. Balloon angioplasty
- Atlas Gold Balloon (up to 16 mm) (BARD)