LINC Middle East 2016 live case guide

Find all live cases and live case centers listed below.

Conference day 1

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    Case 01 – Total occlusion left common iliac artery

    Center:
    University Hospital Leipzig, Division of Interventional Angiology, Leipzig, Germany
    Case 01 – LEI 01: male, 63 years, (S-F)
    Operators:
    • Andrej Schmidt,
    • Matthias Ulrich
    CLINICAL DATA
    Severe claudication left buttock, thigh and calf, walking capacity 50 meters
    Rutherford class 3
    CAD with PTCA 2008 and 2015
    Former smoker
    Art. Hypertension

    ANGIOGRAPHY
    During PTCA 2015: calcified total occlusion left common iliac artery
    ABI left 0.65

    PROCEDURAL STEPS
    1. Femoral access left side
    - 7F 25 cm sheath (TERUMO)
    Left brachial approach:
    - 7F 90 cm Check-Flo Perfomer Sheath (COOK)

    2. Guidewire passage from brachial
    - 5F 125 cm Judkins Right diagnostic catheter (CARDINAL HEALTH)
    - 0.035" stiff angled glidewire, 260 cm (TERUMO)

    3. Guidewire passage from femoral
    - 5F 80 cm Multipurpose diagnostic catheter (CARDINAL HEALTH)
    - 0.035" stiff angled glidewire, 260 cm (TERUMO)
    - Potentially double-balloon-technique with:Admiral balloon 5.0/40 mm, 135 cm (MEDTRONIC)

    4. Stentgraft implantation bilateral after predilatation
    - LifeStream covered stentgraft (BARD)
    View image
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    Case 02 – Chronic total occlusion right SFA

    Center:
    University Hospital Leipzig, Division of Interventional Angiology, Leipzig, Germany
    Case 02 – LEI 02: female, 72 years (E-R)
    Operators:
    • Sven Bräunlich,
    • Matthias Ulrich
    CLINICAL DATA
    Severe claudication right calf, walking capacity 100 meters
    Rutherford class 3
    Diabetes mellitus type 2, art. hypertension

    DUPLEX
    Partially calcified SFA-occlusion right
    ABI 0.67

    ANGIOGRAPHY
    SFA-occlusion right, moderately calcified

    PROCEDURAL STEPS
    1. Left groin access and cross-over approach
    - 5F IMA-cathter (CARDINAL HEALTH)
    - 0.035" soft angled glidewire 180 cm (TERUMO)
    - 0.035" SupraCore Guidewire 180 cm (ABBOTT)
    - 6F 40 cm Balkin Up&Over Sheath (COOK)

    2. Guidewire passage
    - 0.018" Connect guidewire, 300 cm (ABBOTT)
    - 4.0/120 mm Pacific Extreme balloon catheter, 135 cm (MEDTRONIC)
    - In case of thrombus Rotarex thrombectomy before PTA (STRAUB MEDICAL)

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

    4. Stenting on indication
    - Complete selfexpanding nitinol-stent (MEDTRONIC)
    View image
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    Case 03 – Chronic total occlusion SFA bilateral

    Center:
    University Hospital Leipzig, Division of Interventional Angiology, Leipzig, Germany
    Case 03 – LEI 03: male, 64 years (W-S)
    Operators:
    • Andrej Schmidt,
    • Yvonne Bausback
    CLINICAL DATA
    Severe claudication both calves, walking capacity 150 meters; right > left
    Rutherford classification 3
    Mitral insufficiency II, NYHA II
    Art. hypertension, former smoker
    COPD
    ABI right 0.66; left 0.67

    PROCEDURAL STEPS
    1. Left groin access and cross-over approach
    - 5F IMA-cathter (CARDINAL HEALTH)
    - 0.035" soft angled glidewire 180 cm (TERUMO)
    - 0.035" SupraCore guidewire 180 cm (ABBOTT)
    - 6F 40 cm Balkin Up&Over Sheath (COOK)

    2. Gudewire passage
    - 0.035" stiff angled glidewire, 260 cm (TERUMO)
    - Seeker support catheter, 135 cm (BARD)
    - Exchange to a 0.018" SteelCore guidewire, 300 cm (ABBOTT)

    3. PTA
    - VascuTrak balloon 5.0/250 mm (BARD)
    - Lutonix DCB 5.0 or 6.0/150 mm (BARD)

    4. Stenting on indication
    - LifeStent selfexpanding nitinol-stent (BARD)
    View image
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    Case 04 – Endovascular repair of left CFA and SFA occlusion

    Center:
    Rashid Hospital, Dubai, United Arab Emirates
    Case 04 – RAH 01: male, 61 years (I-A)
    Operators:
    • Ayman Al-Sibaie,
    • A. Alfalahi
    CLINICAL DATA
    PAD with intermittent claudication, left leg pain
    Rutherford grade I Fontain IIB.
    ABI = 0.3

    IMPORTANT ITEMS
    HTN, IHD, Angioplasty and stenting done for both external iliac arteries and surgical procedure profundaplasty was done in 2012.

    PROCEDURAL STEPS
    1. Access right groin and cross-over approach
    - 7F Flexor Check-flo introducer (COOK)

    2. Recanalization of left common femoral artery
    - TERUMO 0.035" with support catheter 4 Fr. glide catheter (TERUMO)

    3. Predilation
    - 5.0 x 60 mm ballon catheter

    4. Postdilatation
    - DEB 0.035" 6.0 mm x 80 mm 130 cm In.pact Admiral (MEDTRONIC)

    5. Retrograde access to recanalize superficial femoral artery

    6. PTA with DEB depends on final angiography

    7. Spot stenting in case of dissection or residual stenosis
    - Depending on the location either SUPERA or Zilver PTX (COOK)
    View image
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    Case 05 – LEI 04: Reocclusion right SFA

    Center:
    University Hospital Leipzig, Division of Interventional Angiology, Leipzig, Germany
    Case 05 – LEI 04: female, 63 years (S-G)
    Operators:
    • Andrej Schmidt,
    • Matthias Ulrich
    CLINICAL DATA
    Severe claudication right SFA, walking capacity 100 meters
    PTA left SFA 2/2016
    PTA right SFA 2014 elsewhere
    CEA right internal carotid artery 2012
    Art. hypertension
    Diabetes mellitus type 2

    ANGIOGRAPHY
    Right SFA during PTA left SFA 2/2016
    ABI right 0.65

    PROCEDURAL STEPS
    1. Left groin access and cross-over approach
    - 5F IMA cathter (CARDINAL HEALTH)
    - 0.035" soft angled glidewire 180 cm (TERUMO)
    - 0.035" SupraCore guidewire 300 cm (ABBOTT)
    - 6F 40 cm Balkin Up&Over Sheath (COOK)

    2. Gudewire passage
    - 0.035" stiff angled glidewire, 260 cm (TERUMO)
    - CXC support catheter, 135 cm (COOK)
    - Exchange to a 0.035" SupraCore guidewire, 300 cm (ABBOTT)

    3. PTA and stenting
    - Advance 0.035" balloon 5.0/100 mm (COOK)
    - Zilver-PTX stents 6.0/120 mm (COOK)
    View image
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    Case 06 – LEI 05: Re-occlusion left, partially in-stent

    Center:
    University Hospital Leipzig, Division of Interventional Angiology, Leipzig, Germany
    Case 06 – LEI 05: male, 58 years (G-N)
    Operators:
    • Andrej Schmidt,
    • Sven Bräunlich
    CLINICAL DATA
    Severe claudication left calf, walking capacity 100 meters, restpain during night
    Rutherford class 4
    Failed antegrade recanalization attempt left SFA 2/2016
    PTA and stenting left SFA elsewhere 1/2015
    CAD, COPD, art. hypertension, former smoker
    ABI left 0.55

    PROCEDURAL STEPS
    1. Right groin access and cross-over approach
    - 5F IMA-cathter (CARDINAL HEALTH)
    - 0.035" soft angled glidewire 180 cm (TERUMO)
    - 0.035" SupraCore guidewire 180 cm (ABBOTT)
    - 7F 40 cm Balkin Up&Over Sheath (COOK)

    2. Guidewire passage
    - 0.035" stiff angled glidewire, 260 cm (TERUMO)
    - QuickCross support catheter, 135 cm (SPECTRANETICS)
    - Exchange to a 0.014" Floppy ES Extrasupport guidewire, 300 cm (ABBOTT)

    3. In case of failure to pass the guidewire from antegrade
    Stent-puncture (proximal or disal stent):
    - 18 gauge 7 cm needle proximal and 21 gauge 9 cm needle distally (COOK)
    - 0.018" V-18 Control guidewire 300 cm (BOSTON SCIENTIFIC)
    - 0.018" QuickCross support catheter 90 cm (SPECTRANETICS)

    4. Laser atherectomy and PTA
    - 7F Tandem Booster-Laser atherectomy (SPECTRANETICS)
    - Stellarex DCB 5.0/120 mm (SPECTRANTICS)
    View image
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    Case 07 – RAH 02: Right lower limb below knee triple artery segmental stenosis

    Center:
    Rashid Hospital, Dubai, United Arab Emirates
    Case 07 – RAH 02: male, 53 years (N-G)
    Operators:
    • Ayman Al-Sibaie,
    • A. Alfalahi
    CLINICAL DATA
    Right leg pain, rutherford grade III Fontain IV.
    Right SFA total occlusion balloned and stented.
    RT ABI = 0.2

    IMPORTANT ITEMS
    HTN, DM type II, IHD, CCF

    PROCEDURAL STEPS
    1. Right femoral antegrade access

    2. Antegrade recanaliztion of anterior and posterior tibial arteries, in cases not successful retrograde access will be used

    3. Retrograde pedal access
    - Micro puncture set (COOK)

    4. Recanalization
    - 0.014" wire command ABBOTT with support catheter

    5. Snaring of the wire through the femoral access

    6. Ballon angioplasty
    - Over the wire in antegrade direction ballon angioplasty 2.5 mm dilator 0.014" Armada ABBOTT
    View image
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    Case 08 – LEI 06: Severely calcified popliteal occlusion right

    Center:
    University Hospital Leipzig, Division of Interventional Angiology, Leipzig, Germany
    Case 08 – LEI 06: male, 62 years (KH-L)
    Operators:
    • Sven Bräunlich,
    • Andrej Schmidt
    CLINICAL DATA
    Critical limb ischemia with ulceration dig V
    Rutherford class 5
    CAD, ischemic cardiomyopathy, EF 45%, NYHA II
    Diabetes mellitus type 2, former smoker

    ANGIOGRAPHY
    Distal SFA / Apop P1-segment occlusion right
    Anterior and posterior tibial artery occlusion
    Severe calcification
    ABI right 0.33

    PROCEDURAL STEPS
    1. Right antegrade access
    - 6F 55 cm sheath (COOK)

    2. Guidewire passage
    - 0.035" stiff angled glidewire, 260 cm (TERUMO)
    supported by a balloon:
    - Armada 35 balloon 4.0/80 mm, 90 cm (ABBOTT)
    in case of failure to pass the CTO from antegrade retrograde approach via peroneal artery:
    - 7 cm 21 gauge needle (COOK)
    - 0.018" Connect guidewire 300 cm (ABBOTT)
    - 0.018" QuickCross support catheter (SPECTRANETICS)

    3. PTA and stenting
    - Armada 5.0 or 6.0/40 mm (ABBOTT)
    - 5.0 Supera Interwoven nitinol-stent (ABBOTT)
    View image
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    Case 09 – LEI 07: Anterior tibial artery occlusion, multiple ulcerations forefoot left

    Center:
    University Hospital Leipzig, Division of Interventional Angiology, Leipzig, Germany
    Case 09 – LEI 07: male, 65 years (H-G)
    Operators:
    • Matthias Ulrich,
    • Yvonne Bausback
    CLINICAL DATA
    Ulceration Left foot, Rutherford class 5
    Failed antegrade recanalization attempt with failure to pass the guidewire through the ATA-CTO elsewhere
    Diabetes mellitus type 2, art. hypertension, former smoker

    ANGIO
    ABI right 0.44
    Anterior tibial artery occlusion left, high offspring

    PROCEDURAL STEPS
    1. Antegrade access left
    - 6F 55 cm sheath (COOK)

    2. Retrograde approach via the dorsalis pedis artery left
    - Pedal puncture set (COOK)
    - 4 cm 21 gauge needle (COOK)
    - 2.9F sheath (COOK)
    - 0.018" V-18 Control guidewire 300 cm (BOSTON SCIENTIFIC)
    - 0.018" CXI support catheter 90 cm (COOK)
    - Exchange to 0.014" Hydro-ST guidewire 300 cm (COOK)
    - Advance Micro balloon 3.0/120 mm, 90 cm (COOK)

    3. PTA from antegrade with DCBs
    After predilatation from retrograde
    - Lutonix DCBs from antegrade (BARD)
    View image
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    Case 10 – LEI 08: Progressive, highgrade stenosis left internal carotid artery

    Center:
    University Hospital Leipzig, Division of Interventional Angiology, Leipzig, Germany
    Case 10 – LEI 08: male, 72 years (R-F)
    Operators:
    • Andrej Schmidt,
    • Sven Bräunlich
    CLINICAL DATA
    90% stenosis left ICA
    Minor stroke 1/2015
    Art. hypertension, diabetes mellitus type 2
    CAD with NSTEMI 11/2015, PTCA

    RISK FACTORS
    Left ICA flow-velocity progression
    1/2015: 2.5m/sec
    11/2015: 4.8m/sec
    Angiography during PTCA 11/2015: 90% stenosis left ICA

    PROCEDURAL STEPS
    1. Right groin access
    - 9F 25 cm sheath (TERUMO)

    2. Cannulation of the left external carotid artery
    - 5F Judkins right diagnostic catheter (CARDINAL HEALTH)
    - 0.035" soft angled glidewire, 190 cm (TERUMO)
    - Exchange to 0.035" SupraCore guidewire, 190 cm (ABBOTT)

    3. Cerebral protection
    - MOMA endovascular clamping device (MEDTRONIC)

    4. Predilatation, stenting and postdilatation
    - 3.5/20 mm MiniTrek RX balloon (ABBOTT)
    - Roadsaver carotid artery stent system (TERUMO)
    - 5.0/20 mm Sterling RX balloon (BOSTON SCIENTIFIC)

    5. Aspiration of potential plaque-debris before declamping of the MOMA-system

    6. Final angiography
    View image

Conference day 2

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    Case 11 – LEI 09: Severely calcified distal SFA / Apop-CTO right

    Center:
    University Hospital Leipzig, Division of Interventional Angiology, Leipzig, Germany
    Case 11 – LEI 09: male, 59 years (P-R)
    Operators:
    • Andrej Schmidt,
    • Matthias Ulrich
    CLINICAL DATA
    Restpain right foot, walking capacity 50 meters, claudication right calf
    Rutherford class 4
    PTA and stenting iliac arteries 2012 and 2/2016
    Failure to recanalize the SFA / Apop-occlusion right from antegrade
    TEA right groin 2014, PTA / Supera-stent left popliteal artery 3/2015
    End stage renal failure with chronic dialysis
    CAD, PTCA 2012, ICD

    RISK FACTORS
    ABI: > 1.4 (mediasclerosis)
    Severely calcified total occlusion of the distal SFA and Apop right

    PROCEDURAL STEPS
    1. Right groin antegrade access
    - 7F 40 cm Balkin Up&Over Sheath (COOK)

    2. Second attempt to pass the CTO from antegrade
    - 0.035" stiff angled glidewire, 260 cm (TERUMO)
    - 4.0/80 mm Armada 35 balloon, 90 cm (ABBOTT)

    3. In case of failure retrograde approach via the proximal anterior tibial artery
    - 7 cm 21 gauge needle (COOK)
    - 0.018" Connect guidewire, 300 cm (ABBOTT)
    - 0.018" CXC support catheter, 90 cm (SPECTRANETICS)
    potentially sheath-insertion:
    - 4F 10 cm Radiofocus Sheath, 0.025" GW-compatible (TERUMO)

    4. PTA and stenting
    - 5.0/40 mm and 6.0/40 mm Armada 35 balloon (ABBOTT)
    - 5.0 or 6.0 mm Supera interwoven nitinol-stent (ABBOTT)
    View image
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    Case 12 – RAH 03: AAA with extension to common iliac arteries modified implantation technique of IBD

    Center:
    Rashid Hospital, Dubai, United Arab Emirates
    Case 12 – RAH 03: male, 55 years (M-A)
    Operators:
    • Ayman Al-Sibaie,
    • A. Alfalahi
    CLINICAL DATA
    Infrarenal AAA measuring 5.7 cm extending over the aortic bifurcation to common iliac arteries

    RISK FACTORS
    -Short common iliac arteries, the internal iliac artery bilaterally are seen originating approx. 1 cm distal to the orgin of common iliac arteries.
    -Standard devices can't provide long term distal sealing.
    -Modified implantation technique of IBD is required as the right common iliac artery is too short to do it according to IFU.

    PROCEDURAL STEPS
    MAIN BODY (ZENITH COOK) insertion through left femoral access

    2. Through and through wire from left brachial access through the main body to right femoral access

    3. Insertion IBD (ZENITH COOK) through the right femoral access using the through and through wire as an access to the Internal iliac artery branch

    4. Periphral stent graft 7F BENTLEY InnoMED will be inserted through the left brachial access through the IBD into right internal iliac artery

    5. Connecting IBD with main body

    6. Extending left iliac limb into the external iliac artery covering the left internal iliac artery
    View image
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    Case 13 – LEI 10: Percutaneous EVAR

    Center:
    University Hospital Leipzig, Division of Interventional Angiology, Leipzig, Germany
    Case 13 – LEI 10: male, 72 years (M-W)
    Operators:
    • Andrej Schmidt,
    • Daniela Branzan
    CLINICAL DATA
    Progressive infrarenal abdominal aortic aneurysm
    Art. hypertension, former smoker
    Prostatic cancer surgery 2015

    DUPLEX
    Duplex-sonographic measurement
    12/2012: 32 mm max. diameter
    12/2015: 51 mm max. diameter, excentric infrarenal aneurysm


    PROCEDURAL STEPS
    1. Percutaneous access in local anaesthesia both groins
    - Preloading of 2 Proglide-systems per groin (ABBOTT)
    - 9F 10 cm Radiofocus sheath (TERUMO)
    - Lunderquist guidewire 180 cm (COOK)

    2. Implantation of the stentgraft
    - Ovation stentgraft (ENDOLOGIX / TRIVASCULAR)
    - Polymere filling of the graft
    - Cannulation of the contralateral limb
    - 5F Amplatz left diagnostic catheter (CARDINAL HEALTH)
    - 0.035" soft angled guidewire, 190 cm (TERUMO)
    - Implantation of both limb-extensions (ENDOLOGIX / TRIVASCULAR)

    3. PTA
    - Proximal seal: Reliant balloon (MEDTRONIC)
    - Graft-bifurcation: 12/40 mm Admiral balloon in kissing-technique (MEDTRONIC)

    4. Closure of the groins
    - Preloaded Proglide-systems (ABBOTT)
    View image
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    Case 14 – LEI 11: Iliofemoral venous intervention

    Center:
    University Hospital Leipzig, Division of Interventional Angiology, Leipzig, Germany
    Case 14 – LEI 11: female, 28 years (L-M)
    Operators:
    • Andrej Schmidt,
    • Yvonne Bausback,
    • Daniela Branzan
    CLINICAL DATA
    Iliac vein left side and distal inferior vena cava thrombosis 6/2013
    Venous claudication left (painfree walking capacity 500 meters)
    Swelling left leg despite compression therapy
    No skin changes, groin varicosis left

    PRESENT STATE
    Phlebography via popliteal vein:
    postthrombotic residuum left common femoral vein,
    total occlusion iliac vein left, varicous groin-veins.

    PROCEDURAL STEPS
    1. Prone position of the patient in general anaesthesia

    2. Duplex-guided access left popliteal vein
    - 11F 10 cm Radiofocus sheath (TERUMO)

    3. Guidewire passage of the left iliac veins
    - 0.035" stiff straight glidewire, 260 cm (TERUMO)
    - 4F 100 cm Judkins Right diagnostic catheter (CARDINAL HEALTH) or
    - 0.018" V-18 Control guidewire, 300 cm (BOSTON SCIENTIFIC)
    - 3.0/120 mm Pacific Extreme balloon (MEDTRONIC)

    4. PTA
    - Atlas high pressure balloon 14/60 mm (BARD)

    5. Implantation of dedicated iliac vein stents
    - Sinus-Obliquus 14-16 mm (OPTIMED)
    - Sinus-XL Flex 14-16 mm (OPTIMED) or
    - Zilver Vena venous self-expanding stent (COOK)

    6. Postdilatation
    - Atlas high pressure balloon 14/60 mm (BARD)
    View image
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    Case 15 – LEI 12: Acute reocclusion left SFA after PTA / stent

    Center:
    University Hospital Leipzig, Division of Interventional Angiology, Leipzig, Germany
    Case 15 – LEI 12: male, 62 years (S-D)
    Operators:
    • Sven Bräunlich,
    • Matthias Ulrich
    CLINICAL DATA
    Severe claudication left calf, walking capacity 150 meters
    Rutherford class 3
    PTA left SFA 1/2016 elsewhere with an acute reocclusion 2 days post PTA
    CAD, MI 2012
    Diabetes mellitus type 2, art. hypertension, current smoker

    CURRENT STATE
    ABI left 0.70
    Angiography of the left SFA-stenosis before PTA and after stenting
    Angiography of the acute reocclusion of the SFA 2 days later

    PROCEDURAL STEPS
    1. Right groin retrograde and cross-over approach
    - IMA diagnostic 5F catheter (CORDIS / CARDINAL HEALTH)
    - 0.035" angled soft Radiofocus glidewire, 190 cm (TERUMO)
    - 0.035" SupraCore guidewire, 190 cm (ABBOOTT)
    - 8Fr Balkin Up&Over Sheath, 40 cm (COOK)

    2. Passage of the occlusion and percutaneous thrombectomy
    - 0.018" Connect guidewire 300 cm (ABBOTT)
    - 0.018" QuickCross support catheter 135 cm (SPECTRANETICS)
    - Exchange to Rotarex guidewire (STRAUB MEDICAL)
    - 8F Rotarex thrombectomy catheter (STRAUB MEDICAL)

    3. PTA with DCBs
    - In.Pact Pacific 5.0/120 mm (MEDTRONIC)

    4. Stenting on indication
    - Complete selfexpanding nitinol-stent (MEDTRONIC)
    View image
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    Case 16 – LEI 13: Restpain left leg, unsuccessful recanalization attempt

    Center:
    University Hospital Leipzig, Division of Interventional Angiology, Leipzig, Germany
    Case 16 – LEI 13: male, 76 years (M-P)
    Operators:
    • Matthias Ulrich,
    • Andrej Schmidt
    CLINICAL DATA
    Restpain left foot, claudication left calf, walking capacity 20 meters
    Rutherford class 4
    Fem-pop bypass surgery left 2012 with early failure
    PTA and stent left distal SFA 1/2013
    Reocclusion 12/2015 and failure to recanalize from antegrade and retrograde elsewhere
    Art. hypertension
    Surgery of a colon-carcinoma 2012

    ANGIOGRAPHY
    Left: total occlusion of the SFA to the popliteal segment
    ABI left 0.2

    PROCEDURAL STEPS
    1. Right groin retrograde and cross-over approach
    - IMA diagnostic 5F catheter (CORDIS / CARDINAL HEALTH)
    - 0.035" angled soft Radiofocus glidewire, 190 cm (TERUMO)
    - 0.035" SupraCore guidewire, 190 cm (ABBOOTT)
    - 6F Balkin Up&Over Sheath, 40 cm (COOK)

    2. Retrograde approach via the occluded SFA
    - 18 gauge 7 cm needle (COOK)
    - 0.035" stiff angled glidewire 190 cm (TERUMO)
    - 4F 12 cm Sheath (St. JUDE)
    - 0.018" Connect 250 T guidewire, 300 cm (ABBOTT)
    - 4F Judkins right diagnostic catheter (CARDINAL HEALTH)

    3. In case of failure to reenter from retrograde into the common femoral artery
    - Exchange to a 6F 10 cm sheath (TERUMO)
    - Outback reentry device from retrograde (CARDINAL HEALTH)
    - 0.014 Stabilizer 300 cm guidewire (CARDINAL HEALTH)

    4. PTA and stenting
    - Advance 18 balloon 5.0/100 mm (COOK)
    - Zilver-PTX stent (COOK)
    View image
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    Case 18 – LEI 14: Restpain with popliteal occlusion left

    Center:
    University Hospital Leipzig, Division of Interventional Angiology, Leipzig, Germany
    Case 18 – LEI 14: male, 56 years (J-H)
    Operators:
    • Sven Bräunlich,
    • Matthias Ulrich
    CLINICAL DATA
    Restpain left foot, claudication left calf, walking capacity 20 meters
    Rutherford class 4
    Failure to recanalize from antegrade elsewhere Art. Hypertension

    ANGIOGRAPHY
    Chronic occlusion of the left popliteal artery (P1-P3)
    ABI left: 0.4

    PROCEDURAL STEPS
    1. Left antegrade approach
    - 6F 55 cm sheath (COOK)

    2. Second attempt to pass the occlusion from antegrade
    - Connect 250 T guidewire, 300 cm (ABBOTT)
    - 4.0/80 mm Pacific Extreme balloon, 90 cm (MEDTRONIC)

    3. In case of failure: retrograde approach via the proximal anterior tibial artery
    - 7 cm 21 gauge needle (COOK)
    - Connect guidewire, 300 cm (ABBOTT)
    - QuickCross support catheter (SPECTRANETICS)

    4. PTA and stenting
    - 5.0 and 6.0/40 mm Pacific Extreme balloon (MEDTRONIC)
    - 5.0 and 6.0 Supera interwoven nitinol stent (ABBOTT)
    View image
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    Case 19 – LEI 15: Restpain with multilevel disease right

    Center:
    University Hospital Leipzig, Division of Interventional Angiology, Leipzig, Germany
    Case 19 – LEI 15: female, 82 years (H-L)
    Operators:
    • Andrej Schmidt,
    • Yvonne Bausback
    CLINICAL DATA
    Restpain right foot, claudication left calf, walking capacity 50 meters
    Rutherford class 4
    Art. Hypertension

    ANGIOGRAPHY
    Right: Proximal SFA-stenosis, occlusion of the P1-segment and tibioperoneal trunk
    ABI left: 0.44

    PROCEDURAL STEPS
    1. Left groin retrograde and cross-over approach
    - IMA diagnostic 5F catheter (CARDINAL HEALTH)
    - 0.035" angled soft Radiofocus glidewire, 190 cm (TERUMO)
    - 0.035" SupraCore guidewire, 190 cm (ABBOOTT)
    - 7F Balkin Up&Over Sheath, 40 cm (COOK)

    2. Guidewire passage
    - Connect 250 T guidewire, 300 cm (ABBOTT)
    - CXC support catheter, 135 cm (COOK)

    3. Filter protection and atherectomy
    - Spider-filter 4 mm into the posterior tibial artery (MEDTRONIC)
    - HawkOne 6.6 cm tip (MEDTRONIC)

    4. PTA with drug-coated balloons
    - In.Pact Pacific 5.0 and 4.0 mm (MEDTRONIC)
    View image