LINC Middle East 2016 live case guide

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)

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)

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)

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)

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)

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)

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)

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

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)

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)

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)

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)

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)

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)

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)

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)

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

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