CLINICAL DATA
Acute onset of severe claudication right and left calf 1-2 months ago (right > left)
Eversionatherectomy of a symptomatic internal carotid artery stenosis right 12/2014
Arterial hypertension, diabetes mellitus type 2, former smoker
ABI
Right 0.55; left 0.57
ANGIOGRAPHY
Bilateral occlusion of the SFA, non calcification
Thrombotic subtotal occlusion of the right carotid artery before surgery
PROCEDURAL STEPS 1. Right femoral retrograde and cross-over access
- 8F 40 cm Balkin Up & Over sheath (COOK)
2. Guidewire passage
- 0.018" CXI angled support-catheter 135 cm (COOK)
- 0.018" V-18 COntrol Guidewire, 300 cm (BOSTON SCIENTIFIC)
4. PTA and stenting on indication
- if residual thrombus: local thrombolysis with Actilysis
- if residual arteriosclerotic lesions: balloon-angioplasty/stenting
- Lutonix drug coated balloon 5.0/150 mm (BARD)
- Epic-Stent 6.0/150 mm (BOSTON SCIENTIFIC)
CLINICAL DATA
Severe claudicatio with worsening 3 months ago
Stenting of the SFA left 12/2013
CAD and PTCA 11/2014
Art. hypertension, diabetes mellitus type 2, former smoker
ABI
Left 0.62
ANGIOGRAPHY
During coronary angiography: In-stent reocclusion left with stent-fractures.
PROCEDURAL STEPS 1. Right femoral retrograde and cross-over access
- 8F 40 cm Balkin Up & Over sheath (COOK)
2. Guidewire passage
- 0.035" stiff angled glidewire, 260 cm (TERUMO)
- Judkins Right 5F diagnostic catheter (CORDIS)
- Exchange to 0.018" guidewire coming with the Rotarex-catheter (STRAUB MEDICAL)
CLINICAL DATA
Multifocal hepatocellular carcinoma ED: 07/14
Child A liver cirrhosis
After 1. DEB-TACE (3 ml 75 μm Tandem loaded with 150 mg doxorubicin
plus 11 μml unloaded Embozene 250 μm; CELONOVA, USA) 11.12.2014
Today: 2. DEB-TACE of the first cycle
PROCEDURAL STEPS 1. Transfemoral approach right groin
2. Short 4F sheath Radifocus (TERUMO)
3. 0.035" 180 cm J-wire
4. 4F 110 cm 4F Sidewinder Typ I (CORDIS)
5. 2,8F Microcatheter Progreat (TERUMO)
6. Embolisation
- 75μm Tandem DEB-particles (CELONOVA); loaded with 150 mg of doxorubicin
Case 37 – CLI and total occlusion of all BTK arteries right
Center:
Leipzig
Case 37 – LEI 13: male, 82 years (W-K)
Operators:
Andrej Schmidt,
Matthias Ulrich,
Sabine Steiner
CLINICAL DATA
Critical ischemia with ulcerations right forefoot (Dig 3 and 4 and lateral)
PTA of a SFA-stenosis 12/2014 with drug-eluting balloon
CAD with CABG 2008
Diabetes mellitus type 2, art. hypertension
ABI
Right 0.2
ANGIOGRAPHY
5 cm occlusion of the proximal peroneal artery and long tibial occlusions (ATA and PTA).
PROCEDURAL STEPS 1. Right antegrade access
- 5F 55 cm Ansel Sheath (COOK)
2. Guidewire passage of the occlusion(s)
- 0.014" PT2 guidewire, 300 cm (BOSTON SCIENTIFIC)
- Amphirion Deep Balloon 2.5/120 mm - 120 cm (MEDTRONIC)
In case of failure exchange to:
- 0.018" V-18 Control guidewire 300 cm (BOSTON SCIENTIFIC)
- supported by TrailBlazer 0.018" 90 cm (COVIDIEN)
3. PTA and drug administration
- Amphirion Deep 2.5/120 mm Balloon (MEDTRONIC)
- BullFrog Micro-infusion catheter for administration of Dexamethason into the arterial wall (MERCATOR MedSystems)
Case 37 – CLI and total occlusion of all BTK arteries right
Center:
Leipzig
Case 37 – LEI 13: male, 82 years (W-K)
Operators:
Andrej Schmidt,
Matthias Ulrich,
Sabine Steiner
CLINICAL DATA
Critical ischemia with ulcerations right forefoot (Dig 3 and 4 and lateral)
PTA of a SFA-stenosis 12/2014 with drug-eluting balloon
CAD with CABG 2008
Diabetes mellitus type 2, art. hypertension
ABI
Right 0.2
ANGIOGRAPHY
5 cm occlusion of the proximal peroneal artery and long tibial occlusions (ATA and PTA).
PROCEDURAL STEPS 1. Right antegrade access
- 5F 55 cm Ansel Sheath (COOK)
2. Guidewire passage of the occlusion(s)
- 0.014" PT2 guidewire, 300 cm (BOSTON SCIENTIFIC)
- Amphirion Deep Balloon 2.5/120 mm - 120 cm (MEDTRONIC)
In case of failure exchange to:
- 0.018" V-18 Control guidewire 300 cm (BOSTON SCIENTIFIC)
- supported by TrailBlazer 0.018" 90 cm (COVIDIEN)
3. PTA and drug administration
- Amphirion Deep 2.5/120 mm Balloon (MEDTRONIC)
- BullFrog Micro-infusion catheter for administration of Dexamethason into the arterial wall (MERCATOR MedSystems)
CLINICAL DATA
Incidental finding of an abdominal aneurysm
Since 2 years recurrent abdominal pain
RISK FACTORS
Art. hypertension, smoker
CT
57 mm abdominal aneurysm, neck-kink of 60Æ
PROCEDURAL STEPS 1. Proglide closure-device preloading both groins
- 9F – 10 cm sheath both groins (TERUMO)
2. Implantation of the main body
- 0.035" Lunderquist 180 cm guidewire via right groin (COOK)
- Aorfix abdominal endovascular stentgraft (LOMBARD MEDICAL)
3. Cannulation of the contralateral limb
- Amplatz left I diagnostic catheter 5F (CORDIS)
- 0.035" soft angled TERUMO guidewire (TERUMO)
- 0.035" Lunderquist 180 cm guidewire via right groin (COOK)
4. Implanation of the contralateral limb (LOMBARD MEDICAL)
- PTA of the graft with a Reliant-balloon (MEDTRONIC) via 12F 12 cm sheaths (COOK)
Case 38 – In-stent reocclusion right SFA and high grade stenosis left CIA
Center:
Dendermonde
Case 38 – DEN 03: male, 62 years (E-V)
Operators:
Koen Deloose,
Joren Callaert
CLINICAL DATA
2008: PTA+S right CIA & EIA, left SFA
prostatic cancer, treated with radiotherapy
8/JAN/15: PTA+S left EIA & SFA
hypercholesterolemia, smoking
PRESENT STATE
Rest pain (Rutherford 4) right angiography
PROCEDURAL STEPS 1. Left CFA access, 6F
2. Crossover procedure
- RIM Catheter (COOK) + GlideWire 0.035" (TERUMO)
- Destination 7F 45 cm sheath (TERUMO)
Case 39 – Critical limb ischemia with distal SFA occlusion left /restenosis
Center:
Leipzig
Case 39 – LEI 14: female, 82 years (I-U)
Operators:
Matthias Ulrich,
Yvonne Bausback,
Tomohara Dohi
CLINICAL DATA
Criticl limb ischemia, ulceration left lower leg and Dig 2
CLI right leg with heel-ulceration
PTA right SFA 1/2015
PTA left SFA 2011 for CLI-treatment
Atrial fibrillation
CAS left ICA 4/2006
ANGIOGRAPHY
During treatment of CLI right leg: 10 cm long distal SFA-occlusion left
Below-the-knee peroneal artery patent
ABI
0.34
PROCEDURAL STEPS 1. Right groin retrograde access and cross-over sheath placement
- IMA 5F diagnostic catheter (CORDIS)
- 0.035" soft angled TERUMO glidewire (TERUMO)
- 0.035" SupraCore 190 cm (ABBOTT)
- 6F 55 cm Ansel Sheath (COOK)
2. Guidewire passage and balloon-angioplasty
- 0.018" Connect 300 cm Guidewire (ABBOTT)
- supported by CXC 0.018" Catheter, 135 cm (COOK)
In case of failure exchange to:
- 0.018" Connect 250 T Guidewire, 300 cm (ABBOTT)
3. Balloon-angioplasty and stenting
- Pacific 5.0/80 mm Balloon, 135 cm (MEDTRONIC)
- Tigris GORE Vascular Stent 6.0/100 mm stent (GORE)
CLINICAL DATA
Severe claudicatio both legs right > left, worsening 1 month ago
CAD, intermittend atrial fibrillation
Art. hypertension, diabetes mellitus type 2
CT
Occlusion right common iliac artery, partially thrombotic.
2. Passage of the occlusion from antegrade and retrograde
Left:
- SOS-catheter 5F (COOK)
- 0.035" stiff straight TERUMO 260 cm (TERUMO)
Right:
- 0.018" Connect Flex 300 cm (ABBOTT)
3. Guidewire exchange to
- 0.035" SupraCore Guidewire (ABBOTT)
4. Predilatation right
- 5.0/40 mmm Armada 35 balloon (ABBOTT)
5. Implantation of covered stents in kissing-technique
- Advanta V-12 (MAQUET GETINGE GROUP)
CLINICAL DATA
46-year-old gentleman with a history of chronic DVT for several years, first seen in June 2013. He has persistent progressive symptoms with left leg swelling and ankle pain, despite reliable use of graded compression stockings and other conservative measures. This is interfering with his work as an electrician. His medications are aspirin 81 mg only.
PROCEDURAL STEPS 1. US guided popliteal puncture
- Sono-site ultrasound, Micropuncture set (COOK)
- Upsize to 7F sheath (TERUMO)
CLINICAL DATA
Severe claudication right calf
PTA and stenting left SFA 12/2014
Art. hypertension, diabetes mellitus type 2
Renal insufficiency (GFR 65ml/min), former smoker
CAD with PTCA 11/2013
ANGIOGRAPHY
During PTA left SFA: long SFA-occlusion right.
ABI
Right 0.56
PROCEDURAL STEPS 1. Left femoral retrograde and cross-over access
- 6F 40 cm Balkin Up & Over sheath (COOK)
2. Guidewire passage of the SFA-occlusion
- 0.035" stiff angled glidewire, 260 cm (TERUMO)
- 0.015" Seeker Support-Catheter, 135 cm (BARD)
- Exchange to a 0.018" guidewire SteelCore 300 cm (ABBOTT)
3. PTA
- Vascutrak Balloon 5.0/250 cm (BARD)
- Lutonix 5.0/150 mm drug-coated balloon (BARD)
4. Stenting on indication
- LifeStent selfexpanding Nitinol-stent (BARD)
Case 42 – Reocclusion of the right tibioperoneal trunk
Center:
Leipzig
Case 42 – LEI 17: male, 50 years (G-S)
Operators:
Andrej Schmidt,
Matthias Ulrich
CLINICAL DATA
Critical limb ischemia with ulceration dig 5 right
PAOD with stenting right SFA 11/2010 and restenosis 12/2014
PTA with drug-eluting balloons 12/2014
Failure to pass the TTF-occlusion from antegrade 12/2014
ANGIOGRAPHY
12/2014: calcified TTF-occlusion, stenosis of the proximal peroneal artery
PROCEDURAL STEPS 1. Antegrade access right groin
- 5F 55 cm Ansel Sheath (COOK)
2. Guidewire passage
retrograde access via the peroneal artery:
- 7 cm 21 Gauge puncture needle (COOK)
- 0.018" V-18 Control Guidewire 300 cm (BOSTON SCIENTIFIC)
- Seeker 0.018" 90 cm support-catheter (BARD)
3. Guidewire exchange
After snaring of the guidewire from antegrade PTA of the lesion:
- Exchange to a 0.014" guidewire (Floppy ES ABBOTT)
- Vascutrak 3.5/40 mm Balloon (BARD)
- Lutonix Drug-Coated Balloon 3.5/120 mm (BARD)
Case 62 – Symptomatic severe stenosis of ostial right CCA, left ICA & SCA
Center:
São Paulo
Case 62 – SAO 02: female, 69 years (E-C)
Operators:
Armando Lobato,
Dino Felli Colli,
Robert Guimaraes,
Salomao Goldman
CLINICAL DATA
04/12 TIA (Dysarthria and right arm paresis)
RISK FACTORS
Hypertension, former smoker, hyperlipidaemia, diabetes mellitus
PROCEDURAL STEPS 1. Femoral access: Navigation of a diagnostic catheter into the left ECA
- 5F JB1 diagnostic catheter, 100 cm (CORDIS)
- 0.035" TERUMO angled guide-wire, 260 cm (TERUMO)
2. Introduction of the cerebral protection device and endovascular clamping
- 8F - 11 cm introducer (CORDIS)
- 0.035" E-Wire guide-wire, 260 cm (JOTEC)
- Endovascular Clamping Device – MoMa 8F (MEDTRONIC)
3. Passing of the left ICA lesion and stenting
- 0.014" Choice Pt Extra stiff guide-wire, 190 cm (BOSTON SCIENTIFIC)
- 3.5/20 mm Falcon Bravo RX PTA Balloon Catheter (MEDTRONIC)
- 40 mm Adapt RX Carotid Stent (BOSTON SCIENTIFIC)
5. Left brachial access: Navigation of a diagnostic catheter into the left ECA
- 7F – 45 cm introducer (CORDIS)
- 7F VERT diagnostic catheter, 100 cm (TERUMO)
- 0.035" Teruma angled guide-wire, 260 cm (TERUMO)
6. Passing of the left subclavian artery lesion and stenting
- 70/20 mm Powerflex Pro OTW PTA ballon catheter (CORDIS)
- Stent Genesis 90 x 29 7F OTW (CORDIS)
CLINICAL DATA
73-year-old woman with known bilateral severe renal artery stenosis
from a CTA on 10/16/2013 with atrophy in the left kidney.
She has not had congestive heart failure.
She was a former smoker; stopped approximately two years ago.
She has a history of coronary artery disease with myocardial infarction
and coronary stents in 2012. She does not have dyslipidemia or diabetes.
Current blood pressure medications are clonidine 0.1 b.i.d., Toprol 12.5 daily,
and losartan/hydrochlorothiazide 50/12.5 daily. She also takes Zocor 40,
Plavix 75, and aspirin 81.
VITAL SIGNS
Blood pressure, was 178/67 mmHg in the right arm and 161/70 mm Hg in the left arm.
LABS
GFR 66 ml/min.1.73m2
PROCEDURAL STEPS 1. Right femoral puncture and insertion of 7F RDC guide sheath (CORDIS)
2. Selective catheterization of left renal artery
- Spartacore wire (ABBOTT)
3. Possible Buddy Wire and pressures
- Radi wire (VOLCANO)
4. Renal artery stenting
- Formula 414 stents (COOK)
Case 51 – Abdominal aneurysm 5.5 cm with irregular neck
Center:
Leipzig
Case 51 – LEI 20: male, 76 years (H-D)
Operators:
Andrej Schmidt,
Daniela Branzan,
Tomohara Dohi
CLINICAL DATA
Progression of an abdominal aneurysm to 55mm
CAD with PTCA 2008
Mitral valve moderate insufficiency
Art. hypertension, diabetes mellitus type 2
CT
55 mm abdominal aneurysm with irregaular neck, thrombus
PROCEDURAL STEPS 1. Proglide closure-device preloading both groins
- 9F – 10 cm sheath both groins (TERUMO)
2. Implantation of the main body
- 0.035" Lunderquist 180cm guidewire via right groin (COOK)
- Ovation abdominal endovascular stentgraft (TRIVASCULAR)
3. Cannulation of the contralateral limb
- Amplatz left I diagnostic catheter 5F (CORDIS)
- 0.035" soft angled TERUMO guidewire (TERUMO)
- 0.035" Lunderquist 180 cm guidewire via right groin (COOK)
4. Implanation of the contralateral limb (TRIVASCULAR)
- PTA of the graft with a Reliant-balloon (MEDTRONIC) via 12F 12 cm Sheaths (COOK)
CLINICAL DATA
Patient is a 57-year-old gentleman with history of hypertension sleep apnea and obesity who presented to emergency room for 3 days history of sudden onset severe left abdominal pain and worse during inspiration and sometimes radiating to his left shoulder. An abdominal CT scan showed a splenic infarct 2.5 cm celiac artery aneurysm.
RISK FACTORS
History of a cardiomyopathy with negative cardiac catheterization, nonischemic left bundle branch block, renal insufficiency Echocardiogram showed LVEF 40% without atrial or ventricular thrombus.
PROCEDURAL STEPS 1. US guided radial puncture
- Sono-site ultrasound, Micropuncture set (COOK)
- Adminstration of NTG and Verapamil
- Insertion of 6F Slender Sheath (TERUMO)
- Traverse arch, wire descending thoracic aorta and exchange for 5F Shuttle Sheath (COOK)
Case 52 – Sac hygroma after EVAR: endograft relining
Center:
São Paulo
Case 52 – SAO 01: male, 81 years (N-T)
Operators:
Armando Lobato,
Dino Felli Colli,
Robert Guimaraes,
Marcelo Cury
CLINICAL DATA
Asymptomatic expanding aneurysm sac after EVAR without apparent endoleak secondary to sac hygroma
RISK FACTORS
Hypertension, COPD, hyperlipidaemia, former smoker
PROCEDURAL STEPS 1. Cut down bilateral common femoral arteries
- DrySeal Introducer 18F (WL GORE)
- DrySeal Introducer 20F (WL GORE)
- 0.035" E-Wire guide-wire, 260 cm (JOTEC)
2. Endograft relining
- Endurant proximal cuff 28 x 45 mm (MEDTRONIC)
- Endurant iliac limb externsion 16 x 16 x 120 mm 14F (MEDTRONIC)
- Endurant iliac limb externsion 16 x 20 x 120 mm 16F (MEDTRONIC)
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