LINC 2018 live case guide

Conference day 1

• 8:14 - 8:45, Room 1 - Main Arena 1

  Case 01 – Severely calcified CTO of the SFA left

  Center:

  Leipzig, Dept. of Angiology

  Case 01 – LEI 01: male, 56 years (G-Q)

  Operators:

  • Andrej Schmidt,
  • Matthias Ulrich

  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)
  

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• 8:50 - 9:10, Room 2 - Main Arena 2

  Case 10 – Pelvic lymphocele causing post-thrombotic syndrom left leg

  Center:

  Zürich

  Case 10 – ZUE 01: male, 59 years (W-J)

  Operators:

  • Nils Kucher,
  • Dai-Do Do

  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
  

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• 8:59 - 9:30, Room 1 - Main Arena 1

  Case 02 – Re-occlusion left popliteal artery

  Center:

  Leipzig, Dept. of Angiology

  Case 02 – LEI 02: male, 78 years (G-A)

  Operators:

  • Sven Bräunlich,
  • Johannes Schuster

  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)
  

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• 9:10 - 9:30, Room 2 - Main Arena 2

  Case 11 – Left lower limb DVT

  Center:

  Galway

  Case 11 – GAL 01: female, 57 years (A-J)

  Operators:

  • M. Al Hajiry,
  • Gerard O'Sullivan

  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
  

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• 9:19 - 9:44, Room 3 - Technical Forum

  Case 21 – Progressive bilateral carotid artery stenosis ~80% (surveillance since 2012)

  Center:

  Berlin

  Case 21 – BLN 01: male, 79 years (R-L)

  Operators:

  • Ralf Langhoff,
  • Andrea Behne

  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)
  

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• 9:47 - 10:10, Room 2 - Main Arena 2

  Case 12 – Right common iliac occlusion in a patient with severe aortic carrefour disease

  Center:

  Cotignola

  Case 12 – COT 02: male, 70 years (P-P)

  Operators:

  • Fausto Castriota,
  • Antonio Micari

  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
  

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• 10:26 - 10:54, Room 2 - Main Arena 2

  Case 13 – TASC D iliac occlusion left

  Center:

  Leipzig, Dept. of Angiology

  Case 13 – LEI 06: male, 59 years (A-W)

  Operators:

  • Andrej Schmidt,
  • Matthias Ulrich

  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)
  
  

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• 11:00 - 11:15, Room 2 - Main Arena 2

  Case 14 – Postpartal ilio-femoral vein thrombosis left

  Center:

  Zürich

  Case 14 – ZUE 02: female, 27 years, (K-S)

  Operators:

  • Nils Kucher,
  • Dai-Do Do

  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
  

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• 11:21 - 11:41, Room 1 - Main Arena 1

  Case 03 – Chronic total occlusion right SFA

  Center:

  Leipzig, Dept. of Angiology

  Case 03 – LEI 03: male, 62 years (F-L)

  Operators:

  • Sven Bräunlich,
  • Andrej Schmidt

  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)
  

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• 11:50 - 12:16, Room 3 - Technical Forum

  Case 22 – Symptomatic left internal carotid disease in a 79-year old woman

  Center:

  Cotignola

  Case 22 – COT 03: female, 79 years (D-P)

  Operators:

  • Antonio Micari,
  • Fausto Castriota

  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)
  

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• 11:57 - 12:17, Room 1 - Main Arena 1

  Case 04 – Drug eluting stents in SFA lesions

  Center:

  Jena

  Case 04 – JEN 01: male , 46 years (F-T)

  Operators:

  • René Aschenbach,
  • Marcus Thieme

  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
  

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• 12:00 - 12:15, Room 2 - Main Arena 2

  Case 14 – Postpartal ilio-femoral vein thrombosis left

  Center:

  Zürich

  Case 14 – ZUE 02: female, 27 years, (K-S)

  Operators:

  • Nils Kucher,
  • Dai-Do Do

  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

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• 12:15 - 12:30, Room 2 - Main Arena 2

  Case 15 – Dealing with a chronic post thrombotic iliac obstruction

  Center:

  Galway

  Case 15 – GAL 02: female, 57 years (S-C)

  Operators:

  • M. Al Hajiry,
  • Gerard O'Sullivan

  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
  
  

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• 13:30 - 15:00, Room 2 - Main Arena 2

  Case 16 – Recanalization chronic iliac vein occlusion left

  Center:

  Zürich

  Case 16 – ZUE 03: female, 69 years (R-L)

  Operators:

  • Nils Kucher,
  • Ulrich Frank

  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
  

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• 13:30 - 14:15, Room 3 - Technical Forum

  Case 23 – Chronic total occlusion left

  Center:

  Leipzig, Dept. of Angiology

  Case 23 – LEI 07: male, 72 years (U-R)

  Operators:

  • Sven Bräunlich,
  • Johannes Schuster

  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)
  

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• 13:30 - 15:00, Room 2 - Main Arena 2

  Case 17 – IVC sewn graft – occluded – what to do?

  Center:

  Galway

  Case 17 – GAL 03: male, 47 years (M-M)

  Operators:

  • M. Al Hajiry,
  • Gerard O'Sullivan

  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!!!
  
  

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• 13:45 - 14:05, Room 1 - Main Arena 1

  Case 05 – Right superficial femoral diffuse severe disease

  Center:

  New York

  Case 05 – NY 01: female, 66 years (E-M)

  Operators:

  • Prakash Krishnan,
  • Karthik Gujja,
  • S. Singla,
  • Rheoneil Lascano

  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)
  

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• 13:56 - 14:16, Room 5 - Global Expert Exchange

  Case 29 – Occlusion of tibioperoneal trunk left

  Center:

  Berlin

  Case 29 – BLN 03: female, 79 years (K-S)

  Operators:

  • Ralf Langhoff,
  • Andrea Behne

  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
  

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• 14:15 - 15:00, Room 3 - Technical Forum

  Case 24 – Critical limb ischemia with restpain right, severely calcified right SFA

  Center:

  Leipzig, Dept. of Angiology

  Case 24 – LEI 08: male, 64 years (F-B)

  Operators:

  • Andrej Schmidt,
  • Matthias Ulrich

  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)
  
  

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• 14:25 - 14:45, Room 1 - Main Arena 1

  Case 06 – Severely calcified left SFA restenosis

  Center:

  Cotignola

  Case 06 – COT 01: male, 66 years (A-V)

  Operators:

  • Antonio Micari,
  • Fausto Castriota

  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
  

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• 15:17 - 15:47, Room 1 - Main Arena 1

  Case 07 – CLI with multilevel disease right

  Center:

  Leipzig, Dept. of Angiology

  Case 07 – LEI 04: male, 65 years (J-G)

  Operators:

  • Matthias Ulrich,
  • Andrej Schmidt

  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)
  
  

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• 15:25 - 15:45, Room 3 - Technical Forum

  Case 25 – Long SFA occlusion right leg

  Center:

  Berlin

  Case 25 – BLN 02: female, 78 years (B-P)

  Operators:

  • Ralf Langhoff,
  • M. Boral

  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
  
  

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• 15:55 - 16:15, Room 3 - Technical Forum

  Case 26 – Chronic CTO left SFA, CLI

  Center:

  Leipzig, Dept. of Angiology

  Case 26 – LEI 09: female, 78 years (E-B)

  Operators:

  • Sven Bräunlich,
  • Johannes Schuster

  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)
  

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• 16:30 - 18:00, Room 2 - Main Arena 2

  Case 18 – Recanalization vena cava superior occlusion

  Center:

  Zürich

  Case 18 – ZUE 04: female, 65 years, (N-R.M.)

  Operators:

  • Nils Kucher,
  • Dai-Do Do

  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)
  

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• 16:30 - 18:00, Room 2 - Main Arena 2

  Case 19 – SVC occlusion in a dialysis patient

  Center:

  Galway

  Case 19 – GAL 04: male, 39 years (J-G)

  Operators:

  • M. Al Hajiry,
  • Gerard O'Sullivan

  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
  

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• 16:30 - 18:00, Room 2 - Main Arena 2

  Case 20 – Covera (Bard) covered stent graft to resitance venous stenosis

  Center:

  Galway

  Case 20 – GAL 05: male, 49 years (A-O-M)

  Operators:

  • M. Al Hajiry,
  • Gerard O'Sullivan

  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
  
  

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• 16:30 - 18:00, Room 3 - Technical Forum

  Case 27 – Restenosis after TEA left internal carotid artery

  Center:

  Leipzig, Dept. of Angiology

  Case 27 – LEI 10: male, 70 years (KH-J)

  Operators:

  • Andrej Schmidt,
  • Matthias Ulrich

  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
  

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• 16:30 - 18:00, Room 3 - Technical Forum

  Case 28 – Symptomatic left internal carotid artery disease in a 68-year old high-risk patient

  Center:

  Cotignola

  Case 28 – COT 04: male, 68 years (A-S)

  Operators:

  • Fausto Castriota,
  • Antonio Micari

  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)
  

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• 16:41 - 17:02, Room 1 - Main Arena 1

  Case 08 – Right superficial femoral artery occlusion – calcified

  Center:

  New York

  Case 08 – NYo2: male, 80 years, (H-P)

  Operators:

  • Prakash Krishnan,
  • Vishal Kapur,
  • Karthik Gujja,
  • S. Singla,
  • Rheoneil Lascano

  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)
  

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• 17:30 - 17:50, Room 1 - Main Arena 1

  Case 09 – Severely calcified SFA-stenosis right

  Center:

  Leipzig, Dept. of Angiology

  Case 09 – LEI 05: male, 72 years (D-W)

  Operators:

  • Andrej Schmidt,
  • Matthias Ulrich

  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)
  

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