LINC Asia-Pacific 2016 live case guide

R leg claudication, Rutherford class II, category III, Fontaine IIB
US duplex showed occlusion of RSFA

RISK FACTORS
Hypertension, diabetes mellitus II, dyslipidemia, ex smoker, PAD

PROCEDURAL STEPS
1. Left common femoral access and up and over
- 7F Pinnacle destination sheath 45 cm, up and over (TERUMO)
- If necessary, R pedal posterior tibial retrograde access (4F COOK sheath)

2. Intra-luminal approach
- 0.014" 4F Viance catheter, 150 cm (MEDTRONIC)
- 0.038" Vertip catheter, 125 cm (CARDINAL HEALTH)
- 0.014" Confianza wire, 300 cm (ABBOTT VASCULAR)
- 0.035" Glide wire, 300 cm (TERUMO)

3. Filter placement
- exchanged with 0.014" Bare wire, 315 cm (ABBOTT VASCULAR)
- Emboshield filter 4/7 mm embolic protection system (ABBOTT VASCULAR)

4. PTA and stenting as indicated
- Lutonix drug coated balloons 6.0/150 mm (C.R.BARD)
- Supera stenting 5.5/100 mm (ABBOTT VASCULAR)

CLINICAL DATA
PAOD Rutherford 3
Dm hypertension, hyperlipidemia, ex smoker
EF 60% Cr 120

PROCEDURAL STEPS
1. Cross-over access via right groin
- 6F Balkin sheath (COOK)

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 PTA 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 vessel preparation
- 5.0/100 mm Vascutrak scoring PTA catheter (C.R.BARD)

5. PTA with DEB
- 5/6mm Lutonix drug-coated balloon (C.R.BARD)

6. Spot stent on indication and postdilatation
- 5/80 mm SUPERA stent (ABBOTT)

CLINICAL DATA
Left leg pain, Rutherford class II, category III, Fontaine IIB
ABI R LE - 0.9 and L LE - 0.6
US duplex showed occlusion of calcified LSFA

RISK FACTORS
Hypertension, diabetes mellitus type II, dyslipidemia, ex-smoker,
CAD s/p multiple PCI's, PAD

PROCEDURAL STEPS
1. Right common femoral access and cross-over approach
- 7F Pinnacle destination sheath 45 cm up and over sheath (TERUMO)

2. Guide wire passage
- 0.014" Spartacore wire, 300 cm (ABBOTT VASCULAR)
- 0.038" Vertebral 135" Tempa Aqua catheter, 125 cm (CARDINAL HEALTH)
- 0.014" Confianza wire, 300 cm (ABBOTT VASCULAR)
- 0.035" Glide wire, 300 cm (TERUMO)

3. Filter placement
- exchanged with 0.014/Bare wire, 315 cm (ABBOTT VASCULAR)
- Emboshield filter 4/7 mm embolic protection system (ABBOTT VASCULAR)

4. Athrectomy and thrombectomy, if embolization occurs
- Jet stream Pathway rotational athrectomy 2.4/3.4 (BOSTON SCIENTIFIC)
- PENUMBRA aspiration thrombectomy (PENUMBRA)

5. PTA and stenting as indicated
- Lutonix drug coated balloons 6.0/150 mm (C.R.BARD)
- Supera stenting 5.5/100 mm (ABBOTT VASCULAR)

CLINICAL DATA
R leg claudication, Rutherford class II, category III, Fontaine IIB
US duplex showed occlusion of RSFA with instent occlusion in mid RSFA

RISK FACTORS
Hypertension, diabetes mellitus II, dyslipidemia, ex smoker, PAD

PROCEDURAL STEPS
1. Left common femoral access and up and over
- 7 Fr Pinnacle destination sheath 45 cm, up and over (TERUMO)
- If necessary, R pedal posterior tibial retrograde access (4F COOK sheath) and direct stent access

2. Intra-luminal approach
- 0.014" 4F Viance catheter, 150 cm (MEDTRONIC)
- 0.038" Vertip catheter, 125 cm (CARDINAL HEALTH)
- 0.014" Confianza wire, 300 cm (ABBOTT VASCULAR)
- 0.035" Glide wire, 300 cm (TERUMO)

3. Thrombectomy
- Angiojet Rheolytic aspiration thrombectomy (BOSTON SCIENTIFIC) or
- PENUMBRA aspiration thrombectomy (PENUMBRA)

4. Filter placement
- Spider filter 7 mm (MEDTRONIC)

5. Athrectomy and thrombectomy, if embolization occurs
- Silver Hawk Directional athrectomy LSM (MEDTRONIC)
- PENUMBRA aspiration thrombectomy (PENUMBRA)

6. PTA and stenting as indicated
- INPACT drug coated balloons 6.0/120 mm (MEDTRONIC)
- Supera stenting 5.5/100 mm (ABBOTT VASCULAR)

CLINICAL DATA
PAOD Rutherford 5 right ankle wound,
Left fem-pop bypass, left CIA BMS 2 weeks ago ESRF DM EF 60%

PROCEDURAL STEPS
1. Brachial access via left brachial artery
- 6F x 90 cm Shuttle sheath (COOK)

2. Stenting of right iliac lesion
- 8/9 mm Assurant Cobalt balloon mounted stent for CIA (MEDTRONIC)
- 8mm Complete SE self expanding stent for EIA (MEDTRONIC)
- Post dilatation 7/8 mm REEF HP balloon (MEDTRONIC)

3. Passage of lesion with GW
- 0.035“ Standard J-Tip guidewire, 150 cm (CARDINAL HEALTH)

4. Retrograde SFA access in event of antegrade failure, rendezvous and predil via brachial
- Pacific 4 x 120 balloon x 180 shaft length (MEDTRONIC)

5. Antegrade right CFA access and treatment of right SFA
- In.Pact Pacific 5/6 x 120 mm DEB-balloon (MEDTRONIC)
- Spot-stenting with a COMPLETE SE or Everflex stent (MEDTRONIC)

6. Consider DEB of PFA

CLINICAL DATA
CLI right 2nd toe gangrene PAOD Rutherford 5
DM hypertension hyperlipidemia IHD EF 45% Cr 102.
Recent cross-over POBA for SFA CTO, pop and peroneal stenosis

PROCEDURAL STEPS
1. Antegrade access via right groin
- 5F TERUMO sheath

2. Antegrade passage of the lesion with hydrophilic wire
- 0.014" COMMAND extra support wire 300 cm (ABBOTT)
- 2 x 40 Advance 14LP balloon (COOK)

3. Retrograde passage of lesion via ultrasound guided DP puncture
- 4F Micropuncture® Transpedal Set (COOK)
- EDGE ultrasound high frequency probe (SONOSITE)
- 0.014” COMMAND extra support wire 300 cm (ABBOTT)
- 2 x 40 Advance Micro 14 via retrograde

4. PTA of ATA
- 3.0 x 120 mm Jade high pressure balloon (ORBUS NEICH)

5. Consider DEB/stent if any SFA/pop restenosis seen

CLINICAL DATA
Progressive, asymptomatic restenosis right internal carotid artery after CEA 2005
CEA left ICA 2007
CAD, MI and PTCA 2012
art. hypertension
DUPLEX
Progression to 3.5 m/sec. right ICA

PROCEDURAL STEPS
1. Access right groin
- 9F – 20 cm sheath (TERUMO)

2. Cannulation of the right external carotid artery
- Judkins Right 5F diagnostic catheter (CARDINAL HEALTH)
- 0.035" soft angled glidewire, 180 cm (TERUMO)
- 0.035" SupraCore 300 cm stiff guidewire (ABBOTT)

3. Cerebral protection
- MOMA endovascular clamping device 9F (MEDTRONIC)

4. Cannulation, predilatation, stenting and postdilatation of the right ICA
- 0.014" Galleo Pro 175 cm guidewire (BIOTRONIK)
- MiniTreck RX-balloon 3.5/20 mm (ABBOTT)
- CGuard carotid embolic protection system (Inspire MD/PENUMBRA)
- 5.0/20 mm RX-balloon (BOSTON SCIENTIFIC)

CLINICAL DATA
Reocclusion right SFA
Claudication right calf, walking capacity 150 meters, ABI right 0.67
PTA right SFA 2012 with plane balloon angioplasty elsewhere
PTA left SFA/stenting 2013
Re-PTA left SFA 12/2015

RISK FACTORS
15 cm long reocclusion right mid SFA
art. hypertension, former smoker, diabetes mellitus type 2

PROCEDURAL STEPS
1. Access left groin and cross-over approach
- 5F diagnostic IMA-catheter (CARDINAl HEALTH)
- 0.035" soft angled glidewire 180 cm (TERUMO)
- 0.035" stiff SupraCore guidewire 190 cm (ABBOTT)

2. Passage of the right SFA-CTO
- 0.018" Cruiser S 300 cm guidewire (BIOTRONIK)
- Passeo 4/120 mm balloon (BIOTRONIK)

3. PTA with drug-coated balloons and stenting on indication
- Passeo LUX DCB 5.0/120 mm (BIOTRONIK)
- Pulsar 18 stent (BIOTRONIK)

CLINICAL DATA
PAOD Rutherford 3
COPD hypertension hyperlipidemia IHD EF 55% Cr normal

PROCEDURAL STEPS
1. Antegrade access via left groin 6F sheath

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

3. Predilatation and lesion preparation

4. PTA with DEB
- Lux 5/6 x 120 mm DEB-balloon (BIOTRONIK)

5. Postdilatation and stent
- Conquest 5/6 x 40 balloon (C.R.BARD)
- 4F Pulsar 18 stent (BIOTRONIK)

CLINICAL DATA
Severe claudication left calf, walking capacity 150 meters,
ABI left 0.65
Abdominal aortic aneurysm 3.2 cm
Chronic renal insufficiency, GFR 35 ml/min
COPD

RISK FACTORS
CO2-angiography: long SFA-occlusion left
art. hypertension, former nicotin-abuse

PROCEDURAL STEPS
1. Access right groin and cross-over approach
- 5F diagnostic IMA-catheter (CARDINAL HEALTH)
- 0.035" soft angled glidewire 180 cm (TERUMO)
- 0.035" stiff SupraCore guidewire 190 cm (ABBOTT)

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

3. PTA and stenting
- Advance 35 balloon (COOK)
- Zilver-PTX drug-coated stent (COOK)

CLINICAL DATA
Restpain right foot, ABI right 0.44
Failed recanalization attempt 12/2015 and 1/2016 elsewhere
CAD, PTCA 2013 and 2014
Minor stroke 2012

RISK FACTORS
Angiography during previous recanalization-attempt:
Popliteal occlusion right, failure to pass into the posterior tibial artery
art. hypertension, former nicotin-abuse, diabetes mellitus type 2

PROCEDURAL STEPS
1. Access right groin anetgrade
- 6F 55 cm sheath (COOK)

2. Retrograde access via posterior tibial artery
- Transpedal access kit (COOK)
(21 Gauge 4 cm needle, 2.9F sheath)

3. Retrograde CTO-passage and PTA
- 0.014" CTO-Approach guidewire 18 gramm, 300 cm (COOK)
- CXI 0.018" angled support-catheter, 90 cm (COOK)
- Advance Micro Balloon 3.0/80 mm, 90 cm (COOK)

4. PTA and stenting from antegrade
- Advance 18 5.0 mm balloon (COOK)
- Zilver-PTX stent for the proximal popliteal artery (COOK)

CLINICAL DATA
Left leg swelling. Venous claudication and swelling x 100 metres
Hypt, hyperlipidemia, AF on Dabigatran (Pradaxa), previous DVT years ago.
CT venogram done. Duplex shows left SFJ/GSV reflux

PROCEDURAL STEPS
1. Left mid GSV access under ultrasound
- 5F TERUMO sheath
- 12F Peel-away safe-sheath (ANGIODYNAMICS)

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

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

4. Predilatation
- 16/18 x 40 Atlas balloon (C.R.BARD)

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

6. Postdilatation and IVUS control
- 16/18 x 40 Atlas balloon (C.R.BARD)

7. RFA of GSV
- Venefit with ClosureFast catheter to GSV

CLINICAL DATA
Bilateral feet resting pain (left > right) with ulceration at left great toe for 1 month
PTA for left TP trunk and post. tibial A 02/2013
PTA and stenting for right SFA 01/2016, PTA for right peroneal artery 01/2016
ESRD under regular H/D, 3-V CAD s/p PCI, Type 2 DM, HTN
ABI: right:0.73; left:0.58

ANGIOGRAPHY
Stenosis at left popliteal artery, restenosis at left TP trunk to single remaining post. tibial A, reocclusion at left distal post. tibial A

PROCEDURAL STEPS
1. Left CFA antegrade access
- 6F 10 cm sheath (TERUMO)
- 6F 55 cm Multipurpose guiding catheter (BOSTON SCIENTIFIC)

2. Passage of the lesion(s)
- 0.014" PT2 guidewire, 300 cm (BOSTON SCIENTIFIC)
- 0.018" CXI support-catheter, 150 cm (COOK)
- In case of failure, exchange to V-18 control guidewire, 300 cm (BOSTON SCIENTIFIC)

3. Lesion preparation
- Amphirion Deep, 2.0–2.5/210 mm (MEDTRONIC)

4. Drug-coated balloon angioplasty
- Lutonix 014 Drug-coated balloon, 2.5/120 mm for distal post. tibial A (COOK)
- Lutonix 014 Drug-coated balloon, 3.0/120 mm for proximal post. tibial artery (COOK)

5. Stenting for TP trunk on indication
- Bioabsorbable vascular scaffold 3.5/28 mm (ABBOTT)
- With/without OCT study (ST. JUDE MEDICAL)

6. Drug-coated balloon angioplasty
- In.PACT Admiral drug-coated balloon 4.0/80 mm for pop. A (MEDTRONIC)

CLINICAL DATA
Left leg shallow wounds and rest pain PAOD Rutherford 5
DM hypertension right SFA in-stent occlusion Rotarex and DEB
Left 4th /5th toe dermal gangrenet, EF 60%, Cr normal

PROCEDURAL STEPS
1. Contralateral cross-over access via right groin
- 6F 40 cm long Balkin sheath (COOK)

2. Passage of the lesion
- 0.018" V-18 control wire, 300 cm (BOSTON SCIENTIFIC)
- 0.035" TERUMO angled Soft/Stiff guide-wire, 260 cm (TERUMO)
- 4F Ber II catheter (CORDIS)

3. Treatment with stent /DEB
- SUPERA 5 X 150 (ABBOTT) after predil with DORADO 6 x 40 (C.R.BARD)

4. ATA recanalization via antegrade (retrograde DP access in event of failure)
- 0.014" Command ES Wire (ABBOTT)
- Armada 14 2.5/3 x 120 (ABBOTT)

5. Treatment of TPT
- 3.5 x 15 NC TREK balloon for TPT lesion (ABBOTT)
- 3.5 x 28 ABSORB Bioabsorbable Vascular Scaffold/BVS (ABBOTT) for TPT lesion
- Post Dil 3.5 x 15 NC TREK balloon (ABBOTT)

CLINICAL DATA
Claudication of left leg for 6 months; Rutherford 3

RISK FACTORS
Diabetes, hypertension

PROCEDURAL STEPS
1. Right femoral retrograde access and cross-over
- 6F 40 cm long sheath (COOK)

2. Crossing the occlusion
- 0.018" V-18 Control guidewire, 300 cm (BOSTON SCIENTIFIC)

3. Retrograde distal SFA bailout access for unsuccessful passage

4. Predilatation
- 4/220 mm SAVVY Long OTW balloon, 130 cm (CORDIS)

5. DCB and proventional stent
- 5/200 mm Orchid DCB Balloon, 130 cm (ACOTEC)
- 6.0/200 mm, EVERFLEX, Nitinol stent system 120 cm (EV3)

CLINICAL DATA
Left leg claudication PAOD Rutherford 4
DM hypertension hyperlipidemia PPM previous left SFA stenting

PROCEDURAL STEPS
1. Contralateral cross-over access via Right groin
- 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 TERUMO angled soft guidewire, 250 cm (TERUMO)

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

4. Mechanical thrombectomy and debulking
- Predilatation with Powercross 2/3 x 120 balloon (MEDTRONIC)
- 8F Rotarex (STRAUB MEDICAL)

5. Post debulking IVUS
- o.014" Eagle Eye® Platinum IVUS catheter with virtual histology

6. Treatment with DEB and stent on indication

CLINICAL DATA
Intermittent claudication of left leg for months
Diabetes mellitus, arterial hypertension, hyperlipidemia
Duplex US showed the dampened waveform distal to CFA
The ABI levels: left 0.77, right 0.89
CTA: heavily calcified stenosis involving Lt CFA, mild stenosis at left middle SFA

PROCEDURAL STEPS
1. Right femoral cross-over access
- 8F Balkin 40 cm cross-over sheath (COOK)

2. Guidewire passage and distal protection
- 0.014" PT2 guidewire 300 cm (BOSTON SCIENTIFIC)
- Spider FX embolic protection device (MEDTRONIC-COVIDIEN)

3. IVUS assessment
- Visions® PV 0.018 catheter (VOLCANO)

4. Directional atherectomy
- Turbohawk LS-C or LX-C (MEDTRONIC-COVIDIEN)

5. Drug coated balloon angioplasty
- In.PACT Admiral 0.035" 7.0/60 mm (MEDTRONIC)

CLINICAL DATA
Severe claudication left calf, walking capacity 200 meters, ABI left 0.67
CAD, PTCA 2013

DUPLEX
Long SFA-occlusion left

RISK FACTORS
Art. hypertension, nicotin abuse

PROCEDURAL STEPS
1. Access right groin and cross-over approach
- 5F diagnostic IMA-catheter (CARDINAl HEALTH)
- 0.035" soft angled glidewire 180 cm (TERUMO)
- 0.035" stiff SupraCore guidewire 190 cm (ABBOTT)

2. Guidewire passage
- Mustang balloon 5.0/120 mm (BOSTON SCIENTIFIC)
- 0.035" stiff angled glidewire, 260 cm (TERUMO)
in case of failure to reenter distal:
- attempt with Victory 18 30 gramm 300 cm (BOSTON SCIENTIFIC)

3. PTA with drug-coated balloons and stenting on indication
- Ranger DCB (BOSTON SCIENTIFIC)
- EPIC selfexpanding nitinol-stent (BOSTON SCIENTIFIC)

CLINICAL DATA
Left leg swelling. Recent cellulitis
Hypothyroidism, recent left calf DVT on Warfarin.
CT venogram done.

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

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

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

4. Predilatation
- 16/18 x 40 Atlas balloon (C.R.BARD)

5. Iliac Vein Stenting
- Wallstent 18 x 90 (BOSTON SCIENTIFIC)

6. Postdilatation and IVUS control
- 16/18 x 40 Atlas balloon (C.R.BARD)

CLINICAL DATA
Severe claudication right calf, walking capacity 100 meters,
ABI right 0.54
CAD, MI and PTCA 2012
Renal artery stenosis PTA 2013
COPD
failed antegrade recanalization attempt right SFA 2/2016

PROCEDURAL STEPS
1. Access left groin and cross-over approach
- 5F diagnostic IMA-catheter (CARDINAl HEALTH)
- 0.035" soft angled glidewire 180 cm (TERUMO)
- 0.035" stiff SupraCore guidewire 190 cm (ABBOTT)

2. Guidewire passage of the right SFA-flush-occlusion
- 0.035" stiff angled glidewire, 260 cm (TERUMO)
- 5F diagnostic IMA-catheter (CARDINAl HEALTH)
In case of failure to enter the CTO retrograde approach via distal SFA:
- 9 cm 21 Gauge needle (COOK)
- 0.018" V-18 Control guidewire 300 cm (BOSTON SCIENTIFIC)
- 0.018" Seeker support catheter 90 cm (C.R.BARD)

3. PTA and stenting on indication
- VascuTrak scoring balloon 5.0/300 mm (C.R.BARD)
- Lutonix 5.0 or 6.0 150 mm DCB (C.R.BARD)
- Lifestent (C.R.BARD)

CLINICAL DATA
PAOD Rutherford 5, forefoot right
SFA-Angioplasty right 02/2016
CAD, PTCA 8/2013
Diabetes mellitus type 2
former smoker

ANGIOGRAPHY
Occlusion of all 3 BTK vessels,
collateral filling of the distal peroneal artery and dorsalis pedis artery

PROCEDURAL STEPS
1. Antegrade access right groin
- 5F 55 cm Flexor Check-Flo introducer (COOK)

2. Antegrade passage and PTA
- Command ES guidewire 300 cm (ABBOTT)
- Ultraverse 0.014" balloon 2.0/120 mm (C.R.BARD)
- VascuTrak 2.5/250 mm Balloon (C.R.BARD)

3. In case of antegrade failure:
retrograde puncture of the dorsalis pedis/peroneal artery
- 21 Gauge / 7 cm needle (COOK)
- Connect 300 cm guidewire (ABBOTT)
- Seeker support catheter 0.018" 90 cm (C.R.BARD)

4. PTA with DCBs
- Lutonix 2.5/150 mm DCB (C.R.BARD)

CLINICAL DATA
Claudication of left leg for 8 months; Rutherford 3

RISK FACTORS
Smoking; hypertension; CAD

PROCEDURAL STEPS
1. Right brachial access
- 6F 90 cm long sheath (COOK)

2. Crossing the occlusion
- 0.018" V-18 Control guidewire, 300 cm (BOSTON SCIENTIFIC)

3. Left femoral retrograde bailout access

4. PTA and proventional stent
- 6/80 mm ADMIRAL OTW balloon, 130 cm (MEDTRONIC)
- 8/120 mm, COMPLETE SE, nitinol stent system 120 cm (MEDTRONIC)

CLINICAL DATA
PAOD Rutherford 4, restpain right, severe claudication, walking capacity 100 meters
ABI right 0.44
Aortic valve replacement 2009
Diabetes mellitus type 2
former smoker
PTA of a proximal SFA-stenosis right 1/2016,
failed antegrade passage of the popliteal occlusion right

PROCEDURAL STEPS
1. Antegrade access right groin
- 7F 55 cm Flexor Check-Flo Introducer (COOK)

2. Retrograde passage via the anterior tibial artery
- 7 cm 21 gauge needle (COOK)
- 0.018" QuickCross support catheter 90 cm (SPECTRANETICS)
- 0.018" Connect guidewire 300 cm (ABBOTT)
- Snaring of the retrograde guidewire from retrograde

3. Atherectomy
- 4 mm Spider filter (MEDTRONIC)
- HawkOne 6 cm tip (MEDTRONIC)

4. PTA with DCBs
- In.Pact Pacific DCB (MEDTRONIC)

CLINICAL DATA
PAOD Rutherford 5, forefoot-ulcerartion right, restpain toes
ABI right 0.22
PTA of a popliteal stenosis right,
failure to recanalize a posterior tibial occlusion from antegrade
CAD, PTCA 2004
Diabetes mellitus type 2 with diabetic nephropathy, GFR 53 ml/min
paroxysmal atrial fibrillation
BTK: patent peroneal artery, flush-occlusion of the posterior tibial artery

PROCEDURAL STEPS
1. Antegrade access right groin
- 6F 55 cm Flexor Check-Flo introducer (COOK)

2. Retrograde passage via the posterior tibial artery
- transpedal puncture-kit (COOK)
(4 cm 21 gauge needle, 2.9F sheath)
- CXI 0.018" 90 cm support catheter (COOK)
- CTO-Approach 0.014" guidewire, 18 gramm, 300 cm (COOK)
- Advance Micro-balloon 2.5/120 mm (COOK)

3. PTA and arterial wall-injection of dexamethason
- BullFrog Micro-Infusion-Device (MERCATOR MEDSYSTEMS)

CLINICAL DATA
Right common iliac artery aneurysm 4 cm
Hypertension, hyperlipidemia

PROCEDURAL STEPS
1. Main body of AAA stent graft (ENDURANT II, MEDTRONIC)
- 32-16-124 mm from left

2. Home-made fenestration graft for RIIA
- 13-13-82 mm iliac limb (MEDTRONIC)

3. RIIA covered stent
- 7F 90 cm Flexor Check-Flo Performer from left brachial artery (COOK)
- 10-59 mm Advanta V12 covered stent (ATRIUM)

4. Left iliac limb
- 16-24-82 mm (MEDTRONIC)

5. Right iliac bridging limb
- 16-16-82 mm (MEDTRONIC)

6. Postdilatation
- Reliant balloon (MEDTRONIC)

CLINICAL DATA
Asymptomatic 6.9cm AAA
Ex-smoker, hypertensive, hyperlipidaemia, chronic obstructive airway disease,
ischemic heart disease, mulitnodular goitre, chronic kidney disease (baseline sCr 300+),
anaemia of chronic illness (Hb 7 to 8 g/dl), Ca prostate (conservative treatment)
Ischemic bowel s/p subtotal colectomy and ileostomy in 2009

PROCEDURAL STEPS
1. Bilateral femoral arterial punctures, US guided,
pre close with Proglide x 2 each side.
Bilateral brachial arterial punctures, US guided, 6F sheaths

2. Both renal arteries cannulated from brachial approach with TERUMO glidewire
and MPA catheter. Exchanged for Rosen wire and 7F x 90cm Destination sheaths
(TERUMO) to introduce 5x38 mm BeGraft (INNOMED) for renal chimneys

3. Nellix device introduced from below over Lunderquist wires.
Test fill endobags with saline followed by angio run
to confirm good aneurysm seal/exclusion.

4.Fill endobags with polymer and allow to cure.
Check for endoleaks. Secondary fill if needed.

CLINICAL DATA
Acute back pain 20 days ago
Maximal thoracic aortic diameter 5.0 cm

RISK FACTORS
Hypertension, smoking

PROCEDURAL STEPS
1. Left brachial access for angiogram

2. Right femoral access – preclose technique
- Proglide preloaded (ABBOTT)

3. Stentgraft implantation
- 32-26-200 Castor branched stentgraft (MICORPORT)

CLINICAL DATA
Recurrent left arm swelling
Diabetic, hypertensive, hyperlipidaemia, ischaemic heart disease.
End stage kidney disease on hemodialysis via left arm brachiocephalic AVF x 6 years.

CURRENT STATE
Had left arm swelling 3 months ago due to left brachiocephalic vein occlusion treated successfully with balloon angioplasty. Now symptoms recurred.

PROCEDURAL STEPS
1. Antegrade puncture of left BCAVF, 7F sheath

2. Lesion crossing
- 0.035 TERUMO glidewire and 4F Ber catheter
- Right femoral approach if lesion crossing failed via arm approach.

3. Angioplasty
- 14.0/40 mm Conquest balloon (C.R.BARD)

4. Stenting if poor result
- Sinus XL stent (OPTIMED)

CLINICAL DATA
ESRD s/p PD for 2 years, shifted to HD since 2013/07 due to peritonitis
Right forearm loop AVG was created on 2013/08. High pressure since 2014/12
Type 1 DM, hypertension
Left renal cell carcinoma s/p laparoscopic radial nephrectomy in 2014

PROCEDURAL STEPS
1. Antegrade puncture of AV graft
- 7F 5 cm sheath (TERUMO)

2. PTA to venous anastomosis and basilic vein with DEB
- 6/80 mm Admiral (MEDTRONIC)
- 7/80 mm InPact Admiral DEB (MEDTRONIC)

CLINICAL DATA
Non healing right big toe ulcer x 3 months
Diabetic, hypertensive, hyperlipidaemia, ischaemic heart disease with CABG 10 yrs ago
(EF 50%), end stage kidney disease on hemodialysis
Toe pressures: right 40mmHg, left 129mmHg
Duplex scan of right leg showed long segment CTO of upper/mid SFA and anterior tibial

PROCEDURAL STEPS
1. Ultrasound guided downhill puncture
- 6F Britetip sheath

2. Subintimal crossing of SFA CTO
- 0.035 TERUMO glidewire and 4F Ber catheter
- Retrograde popliteal access if antegrade crossing failed.

3. Angioplasty
- 6.0/200mm Mustang balloon (BOSTON SCIENTIFIC)
- Ranger drug eluting balloon (BOSTON SCIENTIFIC)

4. Subintimal crossing of ATA/DP CTO
- V18 Control wire and 4F Ber catheter.
- Pedal plantar loop technique if antegrade crossing failed.

5. Angioplasty
- 3.0/150 mm Sterling balloon (BOSTON SCIENTIFIC)
- Ranger drug eluting balloon (BOSTON SCIENTIFIC)

CLINICAL DATA
PAOD Rutherford 3, severe claudication left leg
ABI left 0.71
Stenting right common iliac artery 2012,
Unsuccessful recanalizaiton attempt left CIA 1/2016 elsewhere
CAD, PTCA 6/2015
Diabetes mellitus type 2, current smoker

ANGIOGRAPHY
Common iliac occlusion left, plaque distal abdominal aorta, stent CIA right patent

PROCEDURAL STEPS
1. Left brachial access
- 7F 90 cm Check-Flow-Performer sheath (COOK)
Left femoral approach
- 11F 25 cm Radiofocus II sheath (TERUMO)

2. Guidewire passage of the occlusion left CIA
transbrachial:
- 5F 125 cm Judkins Right Diagnostic catheter (CARDINAL HEALTH)
- 0.035" stiff angled glidewire, 260 cm (TERUMO)
left femoral:
- 5F 80 cm Multipurpose Diagnostic catheter (CARDINAL HEALTH)
- 0.035" stiff angled glidewire, 260 cm (TERUMO)
- potentially double-balloon technique

3. Stenting
- Sinus aortic stent for the abdominal aorta (OPTIMED)
- Lifestream 8/57 mm covered stent left CIA (C.R.BARD)
- Lifestream 8/37 mm covered stent right CIA (C.R.BARD)

CLINICAL DATA
PAOD Rutherford 4, Restpein right foot
ABI left 0.44
PTA left SFA and popliteal artery 1/2016
CEA right groin 2012

RISK FACTORS
Diabetes mellitus type 2, current smoker

ANGIOGRAPHY
Occlusion distal SFA / Apop artery right

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

2. Guidewire passage:
- 0.018" Connect guidewire, 300 cm (ABBOTT)
- CXC 0,018" 90 cm support catheter (COOK)
In case of failure:
- 0.035" stiff angled glidewire (TERUMO)
- CXC 0,035" 90 cm support catheter (COOK)
If failure:
retrograde access via posterior tibial artery

3. PTA and stenting
- Armada 35 balloon (ABBOTT)
- Supera Interwoven nitinol stent (ABBOTT)

CLINICAL DATA
PAOD Rutherford 5, gangrene at 4 and 5 toes

RISK FACTORS
Diabetes, smoking

PROCEDURAL STEPS
1. Left femoral retrograde access
- 6F 40 cm cross-over sheath (COOK)

2. Crossing the occlusion
- 0.018" V-18 Control guidewire, 300 cm (BOSTON SCIENTIFIC)
- 0.014" PT2 wire (BOSTON SCIENTIFIC)

3. Retrograde peroneal artery puncture (bailout access)

4. PTA and proventional stent
- 4/220 mm SAVVY long OTW Balloon, 130 cm (CORDIS)
- 6.0/200 mm, EVERFLEX, Nitinol Stent System 120 cm (EV3)