LINC 2019 live case guide

Conference day 2

• 8:00 - 8:25, Room 5 - Global Expert Exchange

  Case 53 – CTO, multilevel disease right

  Center:

  Leipzig, Dept. of Angiology

  Case 53 – LEI 17: male, 70 years (B-R)

  Operators:

  • Andrej Schmidt,
  • Matthias Ulrich

  CLINICAL DATA
  PAOD Rutherford class 4, claudication right calf, walking capacity 50 m, restpain during night, ABI right 0.52, EVAR and stenting right renal artery 11/2018, chronic pancreatitis
  Failed recanalization attempt right popliteal 12/18 elsewhere
  
  RISK FACTORS
  Arterial hypertension, hyperlipidemia
  
  PROCEDURAL STEPS
  1. Antegrade approach right groin
  - 7F 55 cm Flexor sheath (COOK)
  2. Antegrade guidewire passage
  in case of failure retrograde approach via the proximal anterior tibial artery
  - 2.9F sheath (pedal puncture set) (COOK)
  - 0.014“ CTO-Approach 25 gramm guidewire, 300 cm (COOK)
  - 0.018“ CXI support catheter 90 cm (COOK)
  - Advance Micro-Balloon 3.0/120 mm, 90 cm (COOK)
  3. Atherectomy of the popliteal artery
  - JetStream atherectomy device (BOSTON SCIENTIFIC)
  4. Angioplasty
  - VascuTrak 4.0/120 mm balloon (BARD)
  - Luminor DCB (iVascular)
  5. Stenting on indication
  - Spot-stenting with Multi Lock (B.BRAUN)

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• 8:08 - 8:33, Room 3 - Technical Forum

  Case 44 – Live case from Frankfurt/Main

  Center:

  Frankfurt/Main

  Case 44 – Live case from Frankfurt/Main

  Information will follow in due time. Thank you for your understanding.
• 8:18 - 8:46, Room 2 - Main Arena 2

  Case 39 – Live case from Münster

  Center:

  Münster

  Case 39 – Live case from Münster

  Information will follow in due time. Thank you for your understanding.
• 8:45 - 9:05, Room 1 - Main Arena 1

  Case 30 – CLI with CTO BTK left

  Center:

  Leipzig, Dept. of Angiology

  Case 30 – LEI 10: female, 79 years (G-H)

  Operators:

  • Sven Bräunlich,
  • Andrej Schmidt

  CLINICAL DATA
  Critical limb ischemia both lower legs with chronic ulcerations, Rutherford class 5
  ABI left 0.34, ABI right 0.45
  Recanalization right peroneal artery 01/07/2018
  PTA SFA/popliteal artery left and PTA anterior tibial right 11/2018
  Amputation forefoot left
  Amputation D1 right
  
  RISK FACTORS
  Diabetes mellitus type 2 with diabetic neuropathy, arterial hypertension, chronic renal impairment
  
  PROCEDURAL STEPS
  1. Antegrade approach left groin
  - 6F 55 cm sheath (COOK)
  2. Guidewire-passage anterior/posterior tibial
  - 0.014“ Command (ABBOTT)
  - 0.014“ PT2 Guidewire 300 cm (BOSTON SCIENTIFIC)
  - In case of failure: retrograde approach
  3. PTA
  - Vessel preparation – scoring balloon (VascuTrak, BARD)
  - Lutonix BTK DCB (BARD)
  4. In case of dissections after DCB, provisional placement of nitinol „tacks“
  - Tack Endovascular System (Intact Vascular)

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• 8:49 - 9:14, Room 3 - Technical Forum

  Case 45 – Selective internal radiation therapy in hepatocellular carcinoma

  Center:

  Jena

  Case 45 – JEN 01: male, 63 years (D-J)

  Operators:

  • René Aschenbach,
  • S. Witting,
  • R. Drescher

  CLINICAL DATA
  HCC Stage IIIa (pT3 Nx M0) 6/18
  Atypical segmentectomy segment III 6/18
  cTACE performed in referring hospital
  Multifocal HCC in both liver lobes
  Primary outside MILAN
  Universal liver tumor board waived sequential SIRT, starting right
  Evaluation showed a 2.5% shunt to the lung and estimated dose of 2.5GBq for Therasphere (BTG)
  No extrahepatic deposition of radioactivity in test-dose
  
  RISK FACTORS
  Liver cirrhosis CHILD A, MELD 6
  Diabetis mellitus, arterial hypertonia
  
  PROCEDURAL STEPS
  1. Right groin retrograde access
  - 0.035‘‘ EMERALD guidewire 150 cm (CORDIS)
  - 5F 10 cm Radiofocus Introducer II sheath (TERUMO)
  2. Placement of diagnostic catheter in main hepatic artery
  - 0.035‘‘Radiofocus angled guidewire, 180 cm (TERUMO)
  - Diagnostic catheter SIM 1, 4F 0.035‘‘, 100 cm (CORDIS)
  3. Placement of microcatheter in right hepatic artery
  - Progreat 2.7F (TERUMO)
  - alternative wire: Cirrus 14‘ (COOK)
  4. Radioembolisation
  - SIRT with TheraSphereR yttrium-90 glass microspheres (BTG)
  5. Puncture site occlusion
  - Vascularclosure Device Exoseal (CORDIS)

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• 9:50 - 10:10, Room 2 - Main Arena 2

  Case 40 – Infrarenal AAA

  Center:

  Leipzig, Dept. of Angiology

  Case 40 – LEI 15: male, 77 years (G-G)

  Operators:

  • Andrej Schmidt,
  • Daniela Branzan

  CLINICAL DATA
  Asymptomatic infrarenal AAA, diameter max. 58 mm
  Coiling of lumbar arteries 12/2018
  
  RISK FACTORS
  Art. hypertension, chronic renal impairment, hyperlipidemia
  
  PROCEDURAL STEPS
  1. Bifemoral percutaneous approach in local anaesthesia
  - Preclosing with 2 Proglide closure devices both sides (ABBOTT)
  2. Guidewire positioning
  - Lunderquist GW 180 cm (COOK)
  3. Implantation of a bifurcational stentgraft
  - Ovation Stentgraft (ENDOLOGIX)
  Cannulation of the contralateral limb:
  - 5F Amplatz Left diagnostic catheter (CORDIS/CARDINAL HEALTH)
  - 0.035“ soft angled short Radiofocus glidewire (TERUMO)
  4. PTA
  - Proximal seal: Reliant balloon (MEDTRONIC)
  - Graft-bifurcation: 12/40 mm Admiral balloon (MEDTRONIC)

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• 10:02 - 10:27, Room 1 - Main Arena 1

  Case 31 – Live case from Leipzig

  Center:

  Leipzig, Dept. of Angiology

  Case 31 – Live case from Leipzig

  Information will follow in due time. Thank you for your understanding.
• 11:00 - 11:20, Room 5 - Global Expert Exchange

  Case 54 – Long occlusion of the left popliteal artery

  Center:

  Leipzig, Dept. of Angiology

  Case 54 – LEI 18: female, 67 years (B-U)

  Operators:

  • Sven Bräunlich,
  • Johannes Schuster

  CLINICAL DATA
  PAOD Rutherford 3, claudication left calf, walking capacity 30 m
  ABI left 0.3
  Hypotyhreosis
  
  RISK FACTORS
  Arterial hypertension, current smoker, hypelipidemia
  
  PROCEDURAL STEPS
  1. Right groin cross-over approach
  - Judkins Right 5F diagnostic catheter (CORDIS/CARDINAL HEALTH)
  - 0,035“ SupraCore guidewire 30 cm (ABBOTT)
  - 6F 55 cm Balkin Up&Over sheath (COOK)
  2. Guidewire passage of the occlusion and PTA with DCBs
  - 0.014“ Command ES guidewire, 300 cm (ABBOTT)
  - 0.018“ 90 cm Seeker support catheter (BARD)
  - 0.014“ Ultraverse balloon (BARD)
  - Lutonix-BTK DCB (BARD)
  3. In case of dissections after DCB, provisional placement of nitinol „tacks“
  - Tack Endovascular System (INTACT VASCULAR)

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• 11:08 - 11:33, Room 3 - Technical Forum

  Case 46 – Transarterial chemoembolization with drug-eluting-beads (DEB-TACE) in hepatocellular carcinom

  Center:

  Jena

  Case 46 – JEN 02: female, 58 years (H-L)

  Operators:

  • René Aschenbach,
  • S. Witting

  CLINICAL DATA
  Differentiated hepatocellular carcinoma (G1)
  
  RISK FACTORS
  Liver cirrhosis CHILD A
  Chronische hepatitis
  
  PROCEDURAL STEPS
  1. Right groin retrograde access
  - 0.035‘‘ EMERALD guidewire 150 cm (CORDIS)
  - 5F 10 cm Radiofocus Introducer II sheath (TERUMO)
  2. Placement of diagnostic catheter in main hepatic artery
  - 0.035‘‘ Radiofocus angled guidewire, 180 cm (TERUMO)
  - Diagnostic catheter Cobra 4, 4F 0.035‘‘, 100 cm (CORDIS)
  3. Placement of microcatheter in right hepatic artery
  - Progreat 2.7F (TERUMO)
  - alternative wire: Cirrus 14‘ (COOK)
  4. Superselective placement of microcatheter in feeding artery
  5. Embolization
  - 40μm Embozene-Tandem (BOSTON SCIENTIFIC) loaded with 150 mg Doxorubicin till stasis
  6. If still perfusion after administration of the whole 3ml Embozene Tandem 40μm then additional embolization with blande microparticals Embozene 400μm till stasis is reached
  7. Control angiography
  8. Puncture site occlusion
  - Vascular closure device Exoseal (CORDIS) and pressure dressing

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• 11:13 - 11:38, Room 2 - Main Arena 2

  Case 41 – Live case from Leipzig

  Center:

  Leipzig, Dept. of Angiology

  Case 41 – Live case from Leipzig

  Information will follow in due time. Thank you for your understanding.
• 11:23 - 11:43, Room 1 - Main Arena 1

  Case 32 – BTK intervention Orbital atherectomy system (360° Stealth, CSI

  Center:

  Münster

  Case 32 – MUN 01: male, 69 years (A-S)

  Operators:

  • Arne Schwindt,
  • Konstantinos Donas

  CLINICAL DATA
  CAD, PTCA 2015, art. hypertension, PAD, COPD, calf claudication on the left side after 50 m with progress
  
  PRESENT STATE
  Subtotal occlusion with calcification of the popliteal artery
  
  PROCEDURAL STEPS
  1. Percutaneous approach from the contralateral femoral artery
  2. Use of 6F 45 cm long sheath with placement in the external iliac artery
  3. Recanalisation of the subtotal occlusion of the popliteal artery
  4. Use of the orbital atherectomy system (360°, Stealth) CSI as lithoplasty option of the severe calcified lesion to prepare the vessel
  5. Use of a DCB balloon
  6. Closure of the groin with Angioseal 6F system

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• 11:49 - 12:14, Room 3 - Technical Forum

  Case 47 - Live case from Frankfurt/Main

  Center:

  Frankfurt/Main

  Case 47 - Live case from Frankfurt/Main

  Information will follow in due time. Thank you for your understanding.
• 12:30 - 13:30, Room 1 - Main Arena 1

  Case 33 – CLI, deep vein arterialization of a "desert foot" left

  Center:

  Leipzig, Dept. of Angiology

  Case 33 – LEI 12: male, 68 years (J-K)

  Operators:

  • Andrej Schmidt,
  • Steven Kum,
  • Daniela Branzan

  CLINICAL DATA
  PAOD Rutherford 5, non-healing forefoot gangrene, mediasclerosis, ABI > 1.4
  PTA left peroneal artery 07/18 and left TPA 08/18
  Terminal kidney disease
  Paroxysmal atrial fibrilation, pacemaker 12/17
  
  RISK FACTORS
  Arterial hypertension, hyperlipdemia, dialysis
  
  PROCEDURAL STEPS
  1. Left groin antegrade access
  - 7F 55 cm Flexor Check-Flo sheath, Raabe Modification (COOK)
  Left distal venous tibial retrograde access
  - 5F sheath Introducer 2R (TERUMO)
  Arteriography and phlebography to define the optimal level for arterio-venous crossing
  2. Crossing from artery to vein
  - LimFlow Arterial Catheter 7F (LIMFLOW)
  - LimFlow Venous Catheter 5F (LIMFLOW)
  - LimFLow Ultrasound System (LIMFLOW)
  - PT2 0.014“ Guidewire to pass from artery into vein (BOSTON SCIENTIFIC)
  - Predilatation with MiniTrek 3.5/20 mm OTW Coronary Balloon (ABBOTT)
  3. Guidewire passage through vein and vein preparation
  - PT2 0.014“ guidewire (BOSTON SCIENTIFIC) or
  - Command 18 guidewire (ABBOTT)
  - Push Valvulotome 4F (LIMFLOW)
  - 4.0/120 mm Pacific ballon (MEDTRONIC)
  4. Implantation of covered stentgrafts
  - LimFlow Extension stentgrafts 7F 5.5 mm x 150 mm (LIMFLOW) for vein coverage
  - LimFLow Crossing Stentgraft 7F 3.5 x 60 mm (LIMFLOW) for connection artery to vein

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• 13:30 - 15:00, Room 3 - Technical Forum

  Case 48 – Live case from Columbus

  Center:

  Columbus

  Case 48 – Live case from Columbus

  Information will follow in due time. Thank you for your understanding.
• 14:30 - 14:55, Room 1 - Main Arena 1

  Case 34 – Occlusion of the left SFA

  Center:

  Leipzig, Dept. of Angiology

  Case 34 – LEI 13: male, 65 years (G-Z)

  Operators:

  • Matthias Ulrich,
  • Axel Fischer

  CLINICAL DATA
  PAOD Rutherford 3, walking capacity of 40 m, claucation left calf
  ABI left 0.6
  
  RISK FACTORS
  Arterial hypertension, hyperlipidemia, strong smoker (50PY)
  
  PROCEDURAL STEPS
  1. Right groin cross-over approach
  - Judkins Right 5F diagnostic catheter (CORDIS/CARDINAL HEALTH)
  - 0,035“ SupraCore guidewire 30 cm (ABBOTT)
  - 6F-55 cm Balkin Up&Over sheath (COOK)
  2. Guidewire passage
  - 0.035“ stiff, angled glidewire, 260 cm (TERUMO)
  - 0.035“ Seeker support catheter, 135 cm (BARD)
  In-case of inability to reenter distal:
  - either retrograde approach via distal SFA or GoBack Crossing Catheter (UPSTREAM PERIPHERAL)
  3. Angioplasty
  - ULTRASCORE Balloon 5.0/100 mm (BARD)
  - Lutonix GEOALIGN marking system DCB 6.0/120 mm (BARD)

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• 14:35 - 14:50, Room 2 - Main Arena 2

  Case 42 – 4-CMD-BEVAR for a thoracoabdominal aneurysm type 4 – Bridging stentgrafts: VBX

  Center:

  Münster

  Case 42 – MUN 03: male, 81 years (F-E)

  Operators:

  • Martin Austermann,
  • Michel Bosiers,
  • S. Mühlenhöfer

  CLINICAL DATA
  Art. hypertension, CAD, deep vein thrombosis and LE 10/2018, prostate carcinoma 2014 healed
  
  IMPORTANT ITEMS
  Incidental finding of the aneurysm during therapy of the LE
  
  PROCEDURAL STEPS
  1. Left axillary access 5F sheath via cut down
  2. Percutanous approach both groins (Prostar XL, ABBOTT)
  14F (COOK) both groins
  3. Lunderquist wire through the right groin
  Pig tail catheter through the left groin for imaging
  Registration of the Fusion technology
  4. Placement of the CMD-branched-endograft (COOK) with 4 branches by using the Fusion system
  5. Placement of the bifurcated graft: Unibody (COOK) and the iliac extensions
  Then closure of the groins to avoid paraplegia
  6. Connection of all targetvessels through the corresponding branches using Viabahn BX (GORE) from above
  7. Closure of the axillary access

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• 15:05 - 15:30, Room 1 - Main Arena 1

  Case 35 – Severe, asymptomatic left internal carotid artery stenosis

  Center:

  Columbus

  Case 35 – COL 01: 71 years (W-M)

  Operators:

  • Michael Jolly,
  • Gary Ansel

  CLINICAL DATA
  Yearly carotid artery surveillance given diffuse vascular disease.
  Asymptomatic patient with progressive LICA disease over past year.
  On optimal medical therapy (ASA, clopidogrel, atorvastatin 80 mg, losartan 100 mg).
  Pt unwilling to undergo carotid surgery
  
  RISK FACTORS
  CAD s/p 4vCABG 2000, prior subsequent PCI, HTN, HLD,
  ischemic cardiomyopathy (EF 40%), stable angina
  
  PRESENT STATE
  Asymptomatic, denies TIA/CVA/amarosis fugax
  
  DUPLEX
  Carotid duplex Nov 2018 – RICA 157/21 cm/s ratio 2.0, LICA 290/104, ratio 5.2;
  CT neck: 70-80% LICA stenosis, no significant LCCA stenosis
  
  ANGIOGRAM
  Carotid angiogram: 80% LICA bifurcation stenosis by NASCET
  
  PROCEDURAL STEPS
  1. Micropuncture femoral artery access
  2. Sheath placement
  - 6F 90 cm braided sheath delivery into LCCA
  3. Distal embolic protection
  - Nav6 Emboshield wire (ABBOTT)
  4. Stenting
  - Xact 10-8 x 40 mm (ABBOTT)
  5. Predilatation
  - 4x20 mm NC balloon (ABBOTT)
  4. Postdilatation
  - 5 x 30 mm NC balloon (ABBOTT)(if necessary)

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• 15:08 - 15:29, Room 3 - Technical Forum

  Case 49 – Prostatic artery embolization for symptomatic benign prostatic hyperplasia

  Center:

  Jena

  Case 49 – JEN 03: male, 58 years (M-K)

  Operators:

  • Tobias Franiel,
  • F. Bürckenmeyer

  CLINICAL DATA
  Prostatic volume 80 ml
  Negative TRUST-guided systematic biopsy due to increased PSA 6.0
  IPSS: 19 (0-35), QoL: 3 (0-6), Qmax: 13.0 ml/s with voided volume of 160 ml
  IIEF-5: 15 (1-25)
  
  RISK FACTORS
  Arterial hypertension
  
  DUPLEX
  Post void residual urine of 100ml
  
  PRESENT STATE
  Lower urinary tract symptoms due to BPH (confirmed by urology department)
  No successful medication therapy for more than 6 month, refusing operative therapy
  
  PROCEDURAL STEPS
  1. Right groin access
  - ST. JUDE (ABBOTT)
  2. Placement of coaxial catheter in distal aorta
  - RIM 4F (CORDIS) or alternative (MERRIT Medical)
  - Alternative wire: Cirrus 14“ (COOK)
  3. Large-FOV-dyna CT for determination of anatomy and origins of the prostatic arteries
  4. Placement of microcatheter in the left prostatic artery for embolization
  - Progreat 2.7F (TERUMO), alternative: Progreat 2.0F alpha (TERUMO), alternative SwiftNinja (MERRIT Medical)
  - Embozene 250 μm (BOSTON SCIENTIFIC), alternative: 400 μm (BOSTON SCIENTIFIC)
  5. Placement of the microcatheter in the right prostatic artery for embolization
  - Progreat 2.7F (TERUMO), alternative: Progreat 2.0F alpha (TERUMO), alternative SwiftNinja (MERRIT Medical)
  - Embozene 250 μm (BOSTON SCIENTIFIC)
• 15:53 - 16:14, Room 3 - Technical Forum

  Case 50 – Live case from Frankfurt/Main

  Center:

  Frankfurt/Main

  Case 50 – Live case from Frankfurt/Main

  Information will follow in due time. Thank you for your understanding.
• 15:54 - 16:22, Room 1 - Main Arena 1

  Case 36 – Live case from Columbus

  Center:

  Columbus

  Case 36 – Live case from Columbus

  Information will follow in due time. Thank you for your understanding.
• 16:48 - 17:13, Room 1 - Main Arena 1

  Case 37 – Live case from Leipzig

  Center:

  Leipzig, Dept. of Angiology

  Case 37 – Live case from Leipzig

  Information will follow in due time. Thank you for your understanding.
• 16:48 - 17:13, Room 2 - Main Arena 2

  Case 43 – Double Chimney EVAR in order to extent a existing bifurcated endograft with insufficiant proximal sealing and growing aneurysm

  Center:

  Münster

  Case 43 – MUN 04: male, 82 years (W-K)

  Operators:

  • Martin Austermann,
  • E. Beropoulis,
  • S. Mühlenhöfer

  CLINICAL DATA
  CAD, MI and PTCA 2007, art. hypertension
  
  PRESENT STATE
  Previous Onyx Embolization of type2 EL‘s
  Still growing aneurysm
  Degeneration of the aneurysm neck with loss of sealing
  
  PROCEDURAL STEPS
  1. Cut down left axillary artery and double puncture
  2. Placement of two 7F Shuttle sheaths from above
  3. Percutanous approach right groin Prostar XL 10F (ABBOTT)
  Placement of 14F sheaths (COOK)
  Puncture of the left groin for imaging through a 5F sheath
  4. Cannulation of both renal arteries from above
  5. Placement of the Endurant aortic extension ETCF 36 36 C 49 (MEDTRONIC)
  6. Placement of the Chimney stent-grafts in both renal arteries: Advanta V12 (Getinge)
  7. Closure of the accesses

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• 16:51 - 17:15, Room 3 - Technical Forum

  Case 51 – Aneurysma embolization (coiling) of the splenic artery

  Center:

  Jena

  Case 51 – JEN 04: female, 74 years (V-S)

  Operators:

  • F. Bürckenmeyer,
  • I. Diamantis

  CLINICAL DATA
  16 mm neurysm of the lienal artery with growth tendency
  
  RISK FACTORS
  Arterial hypertension, rheumatoid arthritis
  
  PROCEDURAL STEPS
  1. Right groin retrograde access
  - 0.035‘‘ EMERALD guidewire 150 cm (CORDIS)
  - 5F 10 cm Radiofocus Introducer II sheath (TERUMO)
  2. Placement of diagnostic catheter in main hepatic artery
  - 0.035‘‘ Radiofocus angled guidewire, 180 cm (TERUMO)
  - Diagnostic catheter Cobra 4, 4F 0.035‘‘, 100 cm (CORDIS)
  3. Placement of microcatheter in splenic artery
  - Progreat 2.7F (TERUMO)
  - alternative wire: Cirrus 14‘ (COOK)
  4. Embolization
  - PENUMBRA Coils system
  5. Control angiography
  6. Puncture site occlusion
  - Vascular Closure System Exoseal (CORDIS) and pressure dressing

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• 17:29 - 17:53, Room 3 - Technical Forum

  Case 52 – Live case from Frankfurt/Main

  Center:

  Frankfurt/Main

  Case 52 – Live case from Frankfurt/Main

  Information will follow in due time. Thank you for your understanding.
• 17:31 - 17:56, Room 1 - Main Arena 1

  Case 38 – Instent restenosis case

  Center:

  Columbus

  Case 38 – COL 03: male, 58 years

  Operators:

  • Mitchell Silver,
  • Michael Jolly,
  • Christopher Huff,
  • Gary Ansel

  CLINICAL DATA
  Pt with 4 year history of PAD, s/p multiple interventions of the iliac, femoropopliteal and tibial vessels for claudication and previous critical limb Ischemia. Originally treated multilevel for left foot ulceration in 2015, restenosis of iliacs treated wtih stent grafts, SFA occlusion attempted to be treated with cilostazol but no effect at 3 months. Now s/p Super stent in 2015 that occluded, treated with DCB and proximal DES extension in 2017. Now with recurrent RC II claudication and duplex scan with restenosis
  ABI R: .96 and L: .88
  
  RISK FACTORS
  DM II, CAD, HTN, hyperlipidemia, past smoker
  
  DUPLEX
  Peak velocity of 343 within the stent
  
  PROCEDURAL STEPS
  1. Contralateral femoral access
  2. Placement of 7F or 8F braided sheath
  3. Excimer Laser debulking
  4. Hig pressure PTA
  5. If good result DCB, if poor result consider DES
  6. Suture based sheath removal

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