LINC Asia-Pacific 2015 live case guide

CLINICAL DATA
Progressive, asymptomatic stenosis right ICA
PAOD, claudication both calfs

RISK FACTORS
Art. hypertension
Diabetes mellitus
Former smoker

DUPLEX
3.8m/sec.
Cranial CT without pathological findings

ANGIOGRAPHY
Calcified, 80% stenosis right ICA

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

2. Cannulation of the external carotid artery right
- 5F diagnostic Right Judkins catheter (CORDIS)
- 0.035" angled soft glidewire (TERUMO)

3. Exchange to a stiff guidewire and positioning of the protection device
- 0.035" SupraCore 300 cm (ABBOTT)
- 9F MOMA-system (MEDTRONIC)
- Endovascular clamping of the external and common carotid artery

4. Cannulation of the stenosis and predilatation
- 0.014" Galeo Pro ES, 175 cm (BIOTRONIK)
- 3.5/20 mm MiniTrek RX-balloon (ABBOTT)

5. Implantation of a stent and postdilatation
- Cristallo Ideale 7-10/30 mm (MEDTRONIC)
- 5.0/20 mm Submarine Rapido balloon (MEDTRONIC)

6. Aspiration of potential debris and declamping

CLINICAL DATA
Chronic ulcerations both calfs / feet
PTA left SFA Feb. 2015
CAD with PTCA 2010

RISK FACTORS
Diabets mellitus, type 2
Art. hypertension

ANGIOGRAPHY
During PTA left leg: SFA-occlusion right

ABI RIGHT
Pressure not tolerated due to ulceration

PROCEDURAL STEPS
1. Access left groin and cross-over approach
- 5F IMA diagnostic catheter (CORDIS)
- 0.035" angled soft glidewire (TERUMO)

2. Passage of the occlusion right SFA and predilatation
- 0.018" Cruiser S 300 cm guidewire (BIOTRONIK)
- 5.0/120 mm Passeo 18 balloon (BIOTRONIK)

3. PTA with drug-releasing balloon
- Passeo-18 LUX 5/120 mm (BIOTRONIK)

4. Stenting on indication
- Pulsar 18 selfexpanding stent (BIOTRONIK)

CLINICAL DATA
Severe bilateral claudication intermittens
Walking capacity 150 meters
Failed recanalization attempt right SFA Feb. 2015
CAD, PTCA 2012

RISK FACTORS
Diabetes mellitus type 2
Art. hypertension
Former smoker

ANGIOGRAPHY
bilateral long SFA-occlusions

ABI
Right 0.54; left 0.60

PROCEDURAL STEPS
1. Access left groin and cross-over access
- 5F IMA-catheter (CORDIS)
- 0.035" SupraCore guidewire 200 cm (ABBOTT)
- 6F 40 cm Balkin Up&Over sheath (COOK)

2. Passage of the occlusion
Second antegrade attempt:
- 0.035" CXI Support-Catheter 135 cm (COOK)
- 0.035" stiff angled glidewire, 300 cm (TERUMO)

In case of failure to pass from antegrade:
3. Retrograde puncture of the distal SFA
- 21 Gauge 9 cm puncture-needle (COOK)
- 0.018" V-18 Control guidewire 300 cm (BOSTON SCIENTIFIC)
- 0.018" CXI support catheter 90 cm (COOK)
- Snaring of the retrograde guidewire from above

4. PTA and stenting
- 5/100 Advance 18 balloon (COOK)
- Zilver-PTX drug-eluting stent (COOK)

CLINICAL DATA
Restpain left foot, Rutherford class 4
PTA / stent left SFA 2011,
PTA of a restenosis left SFA Feb 2015,
Failure to recanalize the ATA from antegrade Feb 2015
CAD with CABG and PTCA 1999

RISK FACTORS
Diabetes mellitus type 2
Art. hypertension

ABI
Left 0.4

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

2. Retrograde approach via the distal ATA
- Micro-puncture set (COOK)
. - 3F micropuncture sheath
. - 4 cm 21 Gauge needle
- 0.018" Connect guidewire 300 cm (ABBOTT)

3. Retrograde guidewire passage and PTA
- 0.014" Hydro-ST guidewire 300 cm (COOK)
- 2.5/120 mm Advance Micro balloon, 90 cm (COOK)

CLINICAL DATA
Restpain right foot,
Bypass fem-pop nd PTA iliac arteries right 1/2014
Failed recanalization attempt BTK right Feb 2015
Chronic venous insufficiency

RISK FACTORS
Diabetes mellitus type 2
Art. hypertension

ANGIOGRAPHY
During recanalization attempt right Feb. 2015:
Bypass patent, all 3 BTK-arteries occluded

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

2. Retrograde access via the distal peroneal artery
- 7 cm 21 Gauge needle (COOK)
- 0.018" Connect guidewire 300 cm (ABBOTT)
- 0.018" Seeker-support catheter 90 cm (BARD)

3. Snaring of the retrograde guidewire from antegrade and antegrade PTA
- 2.0 120 mm Pacific balloon (MEDRONIC)
- 3.0/150 Lutonix DCB (BARD)

CLINICAL DATA
Severe claudication left calf
Walking capacity 150 meters
COPD

CT
Long SFA-occlusion left

ABI
0.62 left

PROCEDURAL STEPS
1. Access right groin and cross-over approach
- 5F IMA-catheter (CORDIS)
- 0.035" SupraCore guidewire 200 cm (ABBOTT)
- 6F-40 cm Balkin Up&Over sheath (COOK)

2. Passage of the occlusion and PTA
- 0.035" angled stiff glidewire, 260 cm (TERUMO)
- 0.035" Seeker support catheter, 135 cm (BARD)
- 5.0/250 mm Vascutrak balloon (BARD)

3. PTA with Drug-Coated balloons and stenting on indication
- 5/150 Lutonix DCB (BARD)
- LifeStent (BARD)

CLINICAL DATA
CLI wih ulcerations both feet,
PTA right SFA and BTK-arteries Feb 2015
CAD with PTCA 2013
Renal insufficiency, GFR 64 ml/min

ANGIOGRAPHY
During PTA right leg:
severely calcified distal SFA- and Apop-occlusion left
ABI: > 1.3

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

2. Guidewire passage
- 0.035" stiff angled glidewire 260 cm (TERUMO)
- 0.035" Seeker support catheter 90 cm (BARD)

3. In case of antegrade failure retrograde approach via the severely diseased proximal ATA
- 7 cm 21 Gauge needle (COOK)
- 0.018" Connect 300 cm guidewire (ABBOTT)
- CXC 0.018" 90 cm support catheter (COOK)

4. PTA of the lesion
- 5/40 and 6/40 Armada 35 (ABBOTT)

In case of residual stenosis high-pressure balloon:
- 6/20 mm Conquest (BARD)

5. Stenting
- Supera Interwoven nitinol stent (ABBOTT)

CLINICAL DATA
Severe claudication left, walking capacity 50 meters
ABI left 0.4
CAD with PTCA 2014

RISK FACTORS
Smoker
Art. hypertension

ANGIOGRAPHY
Small external iliac artey left, high-grade stenosis left CFA, 
SFA diffusely diseased

PROCEDURAL STEPS
1. Access right groin and cross-over approach to left
- 5F IMA diagnistic catheter (CORDIS)
- 8F 40 cm Balkin Up&Over sheath (COOK)

2. Directional atherectomy of the CFA left
- Spider-Filter 6 mm distal SFA (COVIDIEN/MEDTRONIC)
- TurboHawk LX-C (COVIDIEN/MEDTRONIC)

3. PTA of the CFA and SFA
- In.Pact Pacific 6 mm and 5 mm (MEDTRONIC)

CLINICAL DATA
CLI with toe-ulceration left since 1 month
Severe claudication left calf
CAD, PTCA 1998
Chronic renal insufficiency, GFR 56 ml/ min

ANGIOGRAPHY
During PTA of an iliac stenosis left:
Long, highly calcified SFA-occlusion left

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

2. Passage of the occlusion left SFA
- 0.035" stiff angled glidewire, 260 cm
- CXC 0.035" support catheter 135 cm (COOK)

3. PTA
- Armada 5/120 mm balloon (ABBOTT)

In case of residual stenosis focal high-pressure PTA:
- Conquest 6/20 mm non-compliant balloon (BARD)

4. Stenting
- Supera interwoven nitinol stents (ABBOTT)

CLINICAL DATA
CLI with minor gangrene Dig 2 and rest-pain
Failed antegrade recanalization attempt right Feb 2015
CAD with PTC 2007
Atrial fibrillation

ANGIOGRAPHY
Occlusion right TPT and ATA

ABI
Right 0.32

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

2. Retrograde passage of the ATA
ADp-puncture with:
- 3F micropuncture set (COOK)
- 4 cm 21 Gauge needle (COOK)
- 3F sheath (COOK)
- 0.018" Connect 300 cm guidewire (ABBOTT)

3. Passage of the lesion
- 0.014" Hydro-ST Guidewire 300 cm (COOK)
- Advance Micro balloon 2.5/120 mm from retrograde (COOK)
- Potentially PTA of the TPT and ATA bifurcation in kissing-technique from above and below
- Xience Prime Everolimus-eluting stent (ABBOTT)

CLINICAL DATA
PAOD Rutherford 4
Rest pain at left foot
Smoking for 30 years
Coronary artery disease
ABI left 0.5; right 0.7

PROCEDURAL STEPS
1. Antegrade access and placement of a long sheath
- 0.035" Radiofocus Terumo angled soft guidewire, 180 cm (TERUMO)
- 6F Flexor Straight sheath, 55 cm (COOK)

2. Passage of the lesion with hydrophilic wire and predilatation
- 0.018" V-18 control wire, 300 cm (BOSTON SCIENTIFIC)
- 4/120 mm Pacific balloon dilatation catheter for POP, 130 cm (MEDTRONIC)
- 2/120 mm DEEP balloon dilatation catheter for PA and PT, 130 cm (MEDTRONIC)

3. Retrograde AT or PA puncture in case of antegrade failure
- 0.018" V-18 control wire, 300 cm (BOSTON SCIENTIFIC)
- 2/80 mm DEEP balloon dilatation catheter, 130 cm (MEDTRONIC)

CLINICAL DATA
Documented abdominal aortic aneurysm in May 2012
Coronary artery disease
Hypertension

ANGIOGRAPHY
CT angiography of abdominal aorta shows:
Maximum aneurysm diameter 60/57 mm, short and angulated neck
Right iliac: CIA 18 mm, EIA 9 mm
Left iliac: CIA 14 mm, EIA 11 mm

PROCEDURAL STEPS
1. Bilateral percutanous femoral artery access
- Perclose preloaded (ABBOTT)

2. Left brachial artery access for provisional chimney stent
- 6F 90 cm Flexor long sheath (COOK)
- Chimney stent in left renal artery: Genesis 6-18 (CORDIS)

3. Stent graft
- ENDURANT (MEDTRONIC)
- Main body from left access: 28-16-170 mm
- Right leg: 16-20-120 mm

CLINICAL DATA
PAOD Rutherford 3
Intermittent claudication of left leg
Diabetes mellitus for 20 years
ABI left 0.45, right 0.72

PROCEDURAL STEPS
1. Retrograde access of right groin
- 0.035" Radiofocus Terumo angled soft guidewire, 180 cm (TERUMO)
- 6F Flexor straight sheath, 50 cm (COOK)

2. Passage of the lesion
- 0.018" V-18 control wire, 300 cm (BOSTON SCIENTIFIC)
- 4/120 mm Pacific dilatation catheter, 120 cm (MEDTRONIC)

3. Dilatation and provisional stent
- 4/120 mm Pacific dilatation catheter,120 cm (MEDTRONIC)
- 6/150 mm Complete SE Nitinol vascular stent, 120 cm (MEDTRONIC)

4. Retrograde SFA puncture in case of antegrade failure
- 0.018" V-18 control wire, 300 cm (BOSTON SCIENTIFIC)
- 4/120 mm Pacific dilatation catheter, 120 cm (MEDTRONIC)

CLINICAL DATA
PAOD Rutherford 3
DM Hypertension Graves Disease
AF EF 60% Cr normal

PROCEDURAL STEPS
1. Antegrade access via right groin
- 6F sheath (TERUMO)

2. Passage of the lesion with hydrophilic wire
- 0.018" V-18 control wire, 300 cm (BOSTON SCIENTIFIC)
- 4F Ber II catheter (CORDIS)

3. Retrograde ATA access in event of antegrade failure
- 4F Micropuncture® Pedal Access Set (COOK)
- 0.018" V-18 control wire, 300 cm (BOSTON SCIENTIFIC)
- 2.6F CXI support catheter, 90 cm (COOK)

4. Predilatation and lesion preparation
- 3.5 x 120 Chocolate balloon (QT VASCULAR)

5. PTA with DEB
- In.Pact Pacific 4 or 5 x 120 mm DEB-balloon (MEDTRONIC)

6. Stenting on indication

CLINICAL DATA
PAOD Rutherford 3
DM hypertension hyperlipidemia EF 60% Cr 140

PROCEDURAL STEPS
1. Contralateral cross-over access via left groin
- 0.035" Radiofocus Terumo angled soft guidewire, 260 cm (TERUMO)
- 4F Ber II catheter (CORDIS)
- 0.035" Supra Core guidewire, 300 cm (ABBOTT)
- 6F 40 cm long Balkin sheath (COOK)

2. Passage of the lesion with hydrophilic wire and predilatation
- 0.018" V-18 Control Wire, 300 cm (BOSTON SCIENTIFIC)
- 0.035" Radiofocus Terumo angled soft guidewire, 250 cm (TERUMO)
- 4F Ber II catheter (CORDIS)
- 0.018" Trailblazer support catheter (COVIDIEN)

3. Vessel preparation
- 4 or 5 x 120 mm 3.5 x 120 Chocolate balloon (QT VASCULAR)

4. Treatment with DEB
- In.Pact Pacific 5/6 x 120 mm DEB-balloon (MEDTRONIC)

5. Stenting on indication
- Spot-stenting with a COMPLETE SE stent (MEDTRONIC)

CLINICAL DATA
Left leg swelling previous DVT right Ca Breast
CT venogram done
Diagnostic angio and IVUS done

PROCEDURAL STEPS
1. General anaesthesia

2. Left mid SFV access under ultrasound
- 5F sheath (TERUMO)
- 12F Peel-away Safe-sheath (ANGIODYNAMICS)

3. Passage of the lesion with hydrophilic wire and stiff wire
- 0.035" Radiofocus angled soft guidewire, 260 cm (TERUMO)
- 4F Ber II catheter (CORDIS)
- 0.035" Supra Core guidewire, 300 cm (ABBOTT)

4. Venogram and IVUS
- 8.5F Visions® PV.035 (VOLCANO)

5. Predilatation
- 12 x 40 Mustang balloon (BOSTON SCIENTIFIC)
- 16/18 x 40 Atlas balloon (BARD)

6. Iliac vein stenting
- Wallstent 18 x 90 (BOSTON SCIENTIFIC)

7. Postdilatation
- 16/18 x 40 Atlas balloon (BARD)

8. Postimplantation IVUS and sealing of puncture site

CLINICAL DATA
PAOD Rutherford 3
COPD hypertension hyperlipidemia IHD EF 60% CKD Cr 200

PRESENT STATE
Left hip replacement Ca prostate CO2 angiography done

PROCEDURAL STEPS
1. Antegrade access via left groin
- 5F sheath (TERUMO)
- CO2 angiography with CO2 angioset (OPTIMED)

2. Passage of the lesion with hydrophilic wire
- 0.018" V-18 control wire, 300 cm (BOSTON SCIENTIFIC)
- 4F Ber II catheter (CORDIS)

3. Retrograde distal SFA access in event of antegrade failure
- Supine frog leg position
- 0.018" V-18 control wire, 300 cm (BOSTON SCIENTIFIC)
- 2.6F CXI support catheter, 90 cm (COOK)

4. Predilatation and lesion preparation
- Paseo 18 4/5 x 120 balloon (BIOTRONIK)

5. PTA with DEB
- Lux 5 x 120 mm DEB-balloon (BIOTRONIK)

6. Postdilatation and stenting on indication
- REEF 5 x 40 high pressure balloon (MEDTRONIC)
- 4F Pulsar 18 stent (BIOTRONIK)

CLINICAL DATA
CLI left 2nd toe gangrene
PAOD Rutherford 5
DM hypertension hyperlipidemia Cr 116

PROCEDURAL STEPS
1. Antegrade access via left groin
- 5F sheath (TERUMO)

2. Antegrade passage of the lesion with hydrophilic wire
- 0.014" COMMAND Extra support wire 300 cm (ABBOTT)
- 2 x 80 Armada 14 (ABBOTT)

3. Retrograde passage of lesion via ultrasound guided DP puncture
- 4F Micropuncture® transpedal set (COOK)
- EDGE ultrasound high frequency probe (SONOSITE)
- 0.018" V-18 control wire, 300 cm (BOSTON SCIENTIFIC)
- 2.6F Angled CXI support catheter, 90 cm (COOK)

4. Predilatation and lesion preparation
- 2.5 x 100 mm Vascutrak scoring PTA catheter (BARD)

5. PTA with DEB
- 2.5 or 3 x 120 mm Lutonix drug-coated balloon (BARD)

CLINICAL DATA
Left leg claudication PAOD Rutherford 3
DM hypertension left CFA
Endarterectomy right SFA stent
EF 60%
CKD Cr 190

PROCEDURAL STEPS
1. Contralateral cross-over access via right groin
- 0.035" Radiofocus angled soft guidewire, 260 cm (TERUMO)
- 4F Ber II catheter (CORDIS)
- 0.035" Supra Core guidewire, 300 cm (ABBOTT)
- 6F 40 cm long Balkin sheath (COOK)
- CO2 angiography with CO2 Angioset (OPTIMED)

2. Passage of the lesion with CTO device and predilatation
- Truepath CTO device (BOSTON SCIENTIFIC)
- 0.018" Rubicon catheter (BOSTON SCIENTIFIC)
- 0.018" V-18 control wire, 300 cm (BOSTON SCIENTIFIC)
- Sterling balloon 4 x 120 (BOSTON SCIENTIFIC)

3. Treatment with DEB and postdilatation
- Ranger drug eluting balloon 5/6 x 120 (BOSTON SCIENTIFIC)
- Mustang balloon 6 x 40 (BOSTON SCIENTIFIC)

4. Stenting on indication
- Spot-stenting with Innova stent (BOSTON SCIENTIFIC)

CLINICAL DATA
Left leg claudication PAOD Rutherford 3
DM hypertension hyperlipidemia PCI 2011 EF 55% Cr normal
Left SFA stent in subintimal spot stent Taiwan late 2014

PROCEDURAL STEPS
1. Contralateral cross-over access via right groin
- 0.035" Radiofocus angled soft guidewire, 260 cm (TERUMO)
- 4F Ber II catheter (CORDIS)
- 0.035" Supra Core guidewire, 300 cm (ABBOTT)
- 6/8F 40 cm long Balkin sheath (COOK)

2. Antegrade passage of the lesion with hydrophilic wire
- 0.018" V-18 control wire, 300 cm (BOSTON SCIENTIFIC)
- 0.035" Radiofocus angled soft guidewire, 250 cm (TERUMO)
- 4F Ber II catheter (CORDIS)

3. Retrograde puncture of occluded stent in event of antegrade failure
- 0.035" Radiofocus angled soft guidewire, 250 cm (TERUMO)
- 4F CXI support catheter, 90 cm

4. Mechanical thrombectomy and debulking
- Predilatation with Powercross 3 x 120 balloon (COVIDIEN)
- 6/8F Rotarex (STRAUB MEDICAL)

5. Postdebulking IVUS
- 0.014" Eagle Eye® Platinum IVUS catheter with virtual histology

6. Treatment with DEB and stenting on indication
- In.Pact Pacific 5/6 x 120 mm DEB-balloon (MEDTRONIC)
- SUPERA stent (ABBOTT)

CLINICAL DATA
Right leg claudication PAOD Rutherford 3
DM hypertension hyperlipidemia EF 69% Cr normal
Right CFA endarterectomy and patch Oct 2014 failed antegrade attempt

PROCEDURAL STEPS
1. Antegrade access via right groin
- 6F sheath (TERUMO)

2. Passage of the lesion with hydrophilic wire
- 0.018" V-18 control wire, 300 cm (BOSTON SCIENTIFIC)
- 4F Ber II catheter (CORDIS)

3. Retrograde PT access in event of antegrade failure
- 4F Micropuncture® pedal access set (COOK)
- 0.018" V-18 control wire, 300 cm (BOSTON SCIENTIFIC)
- 2.6F CXI support catheter, 90 cm (COOK)

4. Predilatation and lesion preparation
- 5/6 x 120 mm Fox SV (ABBOTT)
- 5/6 x 40 mm Armada 35 (ABBOTT)

5. Stent implantation and postdilatation
- SUPERA 5 mm x 150 stent (ABBOTT)

6. Consider treatment of runoff
- 0.014" COMMAND extra support wire, 300 cm (ABBOTT)
- 2.5 x 15 NC TREK balloon for PT lesion (ABBOTT)

7. Implantation of bioabsorbable scaffold
- 2.5 x 28 ABSORB bioabsorbable vascular scaffold/BVS (ABBOTT) for TPT and PT lesion

CLINICAL DATA
PAOD Rutherford 3
DM hypertension hyperlipidemia EF 60% Cr 140

PROCEDURAL STEPS
1. Contralateral cross-over access via right groin
- 0.035" Radiofocus angled soft guidewire, 260 cm (TERUMO)
- 4F Ber II catheter (CORDIS)
- 0.035" Supra Core guidewire, 300 cm (ABBOTT)
- 7F 40 cm long Balkin sheath (COOK)

2. Passage of the lesion with hydrophilic wire and filter placement
- 0.014" PT2 MS 300 cm guidewire (BOSTON SCIENTIFIC)
- 4F Ber II catheter (CORDIS)
- 0.018" Trailblazer support catheter (COVIDIEN)
- Spider FX 3 mm into ATA (COVIDIEN)

3. Directional arterectomy
- Turbohawk (COVIDIEN)

4. Treatment with DEB
- In.Pact Pacific 5/6 x 120 mm DEB-balloon (MEDTRONIC)

5. Filter retrieval

CLINICAL DATA
Incidentally detected infra-renal abdominal aortic anuerysm (6.5 x 6.5 cm)
extending into the right common iliac artery
Clinical examination: Expansile pulsatile mass in abdomen

RISK FACTORS
Hypertension, hyperlipiedemia
Mild Alzheimer dementia

CT AORTOGRAM
6.5 cm infra-renal AAA with anyersmal right CIA (2.7 cm)

PLAN
pEVAR with right iliac branch device

PROCEDURAL STEPS
1. US guided percutaneous access of both CFAs followed by preclosing with 2 Proglide closure devices.

2. Aortogram and placement of Lunderquist wire from right side.

3. Insertion of Zenith iliac branch device (COOK MEDICAL) from right side.
Snaring of the through and through wire using Indi snare (COOK MEDICAL) from the left side. Insertion of 7F long sheath into the branch from left side. Selective cannulation of the right internal iliac artery and placement of stiff wire (ROSEN).
Insertion of Atrium covered stent into the right IIA.

4. Placement of stiff wire (Lunderquist) from left side.
Insertion of the COOK Zenith stent graft main body from the left side.

5. Cannulation of the contra-lateral limb from the right side and placement of bridging piece.

6. Completion of deployment of main body and extension of left ipsilateral limb.

7. Closure with preclose Proglide.

CLINICAL DATA
Right lateral foot wound, started as an abrasion and gotten progressively worse
Left BKA

RISK FACTORS
Poorly controlled diabetes mellitus
Chronic hyponatreamia

DOPPLER STUDY
Long segment SFA occlusion with stenosis in the popliteal artery and ATA occlusion

ANGIOGRAM
Long segment calcified SFA occlusion

PROCEDURAL STEPS
1. Antegrade right CFA access with US guidance and insertion of 6F Brite tip sheath (CORDIS)

2. Antegrade recannalisation of SFA
- 4F Bernstein and 0.035" stiff terumo/ 0.018" V18
- 2.7F COOK CXI with 0.014" Winn 200T wire (ABBOTT)

3. If antegrade approach fails for retrograde access via popliteal artery and SAFARI
- 0.018" V18 and 2.7F Cook CXI catheter

4. Following crossing angioplasty with DEB +/- stent

5. Internal balloon tamponade of popliteal access site

6. Attempts at recannalisation of the ATA

7. Closure
- 6F StarClose closure device (ABBOTT)

CLINICAL DATA
PAOD with non healing ulcer on lateral aspect of left first toe with sloughy base
Non palpable left DP/PT /Popliteal

RISK FACTORS
Smoker
Hypertension
Hyperlipidemia

DOPPLER STUDY
Left leg: Chronic total occlusion of left SFA with stenosis
in the popliteal artery and with long segment ATA occlusion
Left Toe pressure 60

PROCEDURAL STEPS
1. US guided antegrade approach
- 6F 11 cm Brite tip sheath (CORDIS)

2. Antegrade crossing of SFA CTO
- 4F Bernstein catheter and 0.035" stiff terumo (TERUMO)
- 0.018" V18 wire (BOSTON SCIENTIFIC)
- If fails then, retrograde approach via proximal ATA puncture using micropuncture set (COOK) and SAFARI technique 2.7F CXI catheter (COOK) and 0.018" V18 wire (BOSTON SCIENTIFIC)

3. Angioplasty
- MUSTANG balloon (BOSTON SCIENTIFIC)

4. Stenting
- SUPERA stent (ABBOTT)

5. Proximal ATA access site controlled using internal balloon tamponade
- 3 mm STERLING balloon (BOSTON SCIENTIFIC)

6. ATA occlusion recannalisation
0.018" V18 wire (BOSTON SCIENTIFIC) followed by plasty with 3 mm Sterling balloon

7. Closure
- 6F StarClose closure device (ABBOTT) using fluoroscopic and US guidance

CLINICAL DATA
Rutherford 5, chronic minor wound at left big toe
DM type 2, HTN, hepatitis C
Bilateral PAD s/p right femoral-popliteal graft bypass
s/p left knee replacement
EF: 76%, Cr 0.79

CTA
Skipped focal mild-severe stenosis in the LSFA
Focal skipped mild stenosis in the P3 portion of LPopA
Short CTO in the proximal LATA
and skipped focal high grade stenosis

DUPLEX
ABI: right 0.57, left 0.55
Lt. distal CFA bifurcation mod stenosis; 
and lt. femoropopliteal difuse stenosis 
and multiple significant lesions; 
bil severe infrapopliteal diseased 
with multiple severe stenosis 
and segemental occcluded lesions at bil ATA amd PTA

PROCEDURAL STEPS
1. Retrograde access (ultrasound guided puncture) via RCFA
- 5F Tempo Flush pigtail catheter (CORDIS)
- 0.035" Radiofocus Terumo Angled Stiff guidewire (TERUMO)
- 6F Balkin cross over sheath (COOK)

2. Passage of the lesion with hydrophilic wire to TP
- 0.018" V18 control wire, 300 cm (BOSTON SCIENTIFIC)

3. Predilatation and PTA with DEB for SFA/PopA
- Pacific Xtreme 4/40 (MEDTRONIC)
- In-Pact Pacific DEB balloon 5/6 mm (MEDTRONIC)

4. PTA for BTK
- 0.018" V18 control wire, 300 cm (BOSTON SCIENTIFIC)
- Amphirion 2/2.5/3 (MEDTRONIC)

CLINICAL DATA
ESRD under regular hemodialysis, hearing impairment, EF 71%
Left radio-graft-basilic fistula s/p Viabahn (6/150 mm)
for venous anastomosis junction

RISK FACTORS
Increased venous pressure during hemodialysis

VENOGRAPHY
Two skipped focal instent stenosis (about 30-50% stenosis)
and short segmental 70% stenosis in the distal edge of Viabahn

PROCEDURAL STEPS
1. Antegrade puncture via proximal graft
- 6F sheath (TERUMO)

2. Angiography to estimate lesions

3. PTA with DEB for instent restenosis
- InPact Admiral DEB balloon 6/120 mm (MEDTRONIC)

CLINICAL DATA
Herniated interveterbral disc with right leg numbness
Infra-renal AAA was incidentally found by CT
Hypertension, previous smoker, gout
Cr 1.32, EF: 70%

CTA
Infrarenal AAA (5.8 x 5.6 cm, od) and RCIA aneurysm (3.9 cm/id) with much mural thrombus

PROCEDURAL STEPS
1. Retrograde access (ultrasound guided puncture) via RCFA and LCFA
- Preclose techniques: Proglide (ABBOTT)
- 8F and 10F sheaths for RCFA and LCFA (TERUMO)

2. Angiography of AAA
- 5F Tempo Flush pigtail catheter (CORDIS)
- 0.035" Radiofocus Terumo Angled soft guidewire (TERUMO)
- 0.038" Amplatz Stiff wire, 260 cm (BOSTON SCIENTIFIC)
- 5F sizing catheter (MERIT)

3. Deployment of AAA stent graft
- Endurant: mainbody left side up, contralateral limb: right side (METRONICS)
- 5F VanSchie catheter (COOK)
- 0.035" Radiofocus Terumo Angled soft guidewire (TERUMO)
- 0.038" Amplatz Stiff wire, 260 cm (BOSTON SCIENTIFIC)

4. Post dilatation

5. Retrograde access (ultrasound guided puncture) via left brachial artery
- 5F Tempo Flush pigtail catheter (CORDIS)
- 0.035" Radiofocus Terumo Angled soft guidewire (TERUMO)

6. Cannulation of RIIA
- 5F Tempo Aqua Hydrophilic coating catheter (CORDIS)
- 0.035" Radiofocus Terumo Angled soft guidewire (TERUMO)

7. Distal sandwich technique: Deployment of stent graft for REIA and RIIA
- Viabahn stent graft 10/100-150 mm (GORE)

8. Postdilatation