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)
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
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)
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)
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)
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)
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)
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