CLINICAL DATA
Severe claudication right calf, walking capacity 60 meters
ABI right 0.65
COPD, GOLD B
Permanent atrial fibrillation

RISK FACTORS
Arterial hypertension, smoker

ANGIO
Angiography elsewhere: total occlusion right SFA, calcified

PROCEDURAL STEPS
1. Left groin retrograde and cross-over approach
- 0.035" SupraCore guidewire 190 cm (ABBOTT)
- 7F-40 cm Balkin Up&Over Sheath (COOK)

2. Guidewire passage and PTA of the occlusion right SFA
- 4.0/120 mm Armada 35 balloon (ABBOTT)
- 0.035" Radiofocus soft angled guidewire, 260 cm (TERUMO)
- 6.0/40 mm Armada 35 balloon (ABBOTT)
- Conquest high pressure balloon (C.R. BARD)

In case of failure to pass from antegrade:
3. Retrograde approach via the distal SFA right
- 21 Gauge 9 cm Micropuncture needle (COOK)
- 0.018" Connect guidewire 300 cm (ABBOTT)
- 0.018" QuickCross support catheter 90 cm (SPECTRANETICS)

4. Stenting
- 5.0 or 6.0/150 mm Supera Interwoven Selfexpanding Nitinol stent (ABBOTT)
- Stenting of the SFA-ostium: 7.0/40 mm Absolute stent (ABBOTT)

CLINICAL DATA
Very short walking capacity right since few weeks
Persistent atrial fibrillation
Diabetes mellitus, type 2
Nicotin abuse

IMPORTANT ITEMS
Angiography: Thrombotic/embolic occlusion right popliteal artery
Chronic BTK-disease

1. Right antegrade femoral access
- 6F 55 cm Check-Flo Performer, Raab Modification (COOK)

2. GW-passage and thrombectomy
- Rotarex 6F (STRAUB MEDICAL)

3. PTA and stenting on indication
- Lutonix DCB (C.R. BARD)

CLINICAL DATA
Severe claudication right calf, walking capacity 50 meters
CEA and patch-plastic 9/2014 right groin
Stenting right SFA 2009
PTA left SFA (Lithoplasty)
CAD, MI and PTCA 2009
Art. hypertension, former smoker

ANGIO
Flush-occlusion right SFA, stent within the SFA-occlusion right
ABI right 0,57

PROCEDURAL STEPS
1. Left groin retrograde and cross-over approach
- IMA-diagnostic 5F-catheter (CORDIS/CARDINAL HEALTH)
- 0.035" angled soft Radiofocus guidewire, 190 cm (TERUMO)
- 0.035" SupraCore guidewire, 190 cm (ABBOTT)
- 7F Balkin Up&Over Sheath, 40 cm (COOK)

2. Right SFA CTO-puncture (stent-puncture)
- 18 Gauge 7 cm needle
- 0.035" stiff angled Glidewire, 190 cm (TERUMO)
- 6F – 10 cm Radiofocus-Introducer (TERUMO)

3. Passage of the CTO
Retrograde passage into the right CFA:
- Pioneer-Plus Reentry-system (VOLCANO)
- 0.014" Floppy ES Guidewire, 300cm (ABBOTT)
- Snaring if the retrograde guidewire into the the cross-over-sheath

Final guidewire-passage into the popliteal artery from antegrade:
- 0.035" siff angled Glidewire 260 cm (TERUMO)

4. PTA/stenting
- Armada 35 5.0/100 mm balloon (ABBOTT)
- Supera Interwoven Nitinol stent (ABBOTT)
- SFA-ostium: Viabahn 7.0/50 mm (GORE) or Absolute stent (ABBOTT)

CLINICAL DATA
Critical limb ischemia right, ulceration dig 4, Rutherford class 5
Severe claudication right calf, walking capacity 50 meters, PTA/stenting left SFA 12/2015 for CLI left
Diabetes mellitus, type 2, art. hypertension, former smoker
ABI right: 0.2

ANGIO
Angiography (during PTA left):
long CTO right SFA, minimal calcification

PROCEDURAL STEPS
1. Left groin retrograde and cross-over approach
- IMA-diagnostic 5F catheter (CORDIS/CARDINAL HEALTH)
- 0.035" angled soft Radiofocus guidewire, 190 cm (TERUMO)
- 0.035" SupraCore guidewire, 190 cm (ABBOTT)
- 6F Balkin Up&Over Sheath, 40 cm (COOK)

2. Passage of the occlusion left SFA
- 0.035" Radiofocus angled stiff guidewire, 260 cm (TERUMO)
- 0.035" TrailBlazer supportcatheter, 135 cm (MEDTRONIC)
- Exchange to 0.018" SteelCore guidewire (ABBOTT)

3. PTA
- 5.0/120mm Pacific Plus PTA catheter, 130 cm (MEDTRONIC)
- 6.0/120 mm In.Pact Pacific DCB (MEDTRONIC)

4. Stenting on indication
- In case of dissections: provisional placement of nitinol Tacks (INTACT VASCULAR)
- In case of residual stenosis: Complete-Stent (MEDTRONIC)

CLINICAL DATA
Severe claudication right calf, walking capacity 100 meters
PTA/stent left SFA 12/2015
Diabetes mellitus, type 2, insulin-dependent
Art. hypertension, former smoker

ANGIO
Angiography right SFA during PTA/stent left SFA:
short, moderately calcified SFA-CTO right
ABI right 0.61

PROCEDURAL STEPS
1. Left groin retrograde and cross-over approach
- IMA-diagnostic 5F catheter (CORDIS/CARDINAL HEALTH)
- 0.035" angled soft Radiofocus guidewire, 190 cm (TERUMO)
- 0.035" SupraCore guidewire, 190 cm (ABBOTT)
- 6F 55 cm Flexor Check-Flo Introducer, Raabe Modifcation (COOK)

2. Guidewire passage and PTA of the occlusion right SFA
- 4.0/40 mm Pacific Plus balloon (MEDTRONIC)
- 0.018" Connect 250 T guidewire, 300 cm (ABBOTT)

3. Stenting
- NitiDES drug-eluting stent (ALVIMEDICA)

CLINICAL DATA
Restpain left foot, Rutherford class 4
Severe claudication, walking capacity 50 m
ABI left 0.42
CAD, PTCA 10/16
TAVI 03/16

RISK FACTORS
Arterial hypertension

PROCEDURAL STEPS
- Right croin retrograde and cross-over approach
- Passage and predilatation of the SFA-occlusion left
- PTA/Stenting SFA left (ELUVIA)

CLINICAL DATA
Progressive ICA-stenosis right, peak systolic velocity 5.8 m/sec.
CAD with CABG 2000
PTCA stent 12/2016
Recurrent supraventricular arrythmia, left atrial ablations 2014/2015
CEA left ICA 2010
Former smoker

ANGIOGRAPHY
Angiography during PTCA 12/2016, short, high-grade stenosis right ICA

PROCEDURAL STEPS
1. Right groin access
- 9F 25 cm Radiofocus Introducer (TERUMO)
- 5F Judkins Right diagnostic catheter (CORDIS/CARDINAL HEALTH)
- 0.035" soft angled Glidewire, 190 cm (TERUMO)
- 0.035" SupraCore 190 cm guidewire (ABBOTT)

2. Cerebral protection
- MoMa proximal protection system (MEDTRONIC)

3. Predilatation and stenting
- 3.5/20 mm MiniTrek Monorail balloon (ABBOTT)
- 8/30 mm CGuard stent (InspireMD)

4. Postdilatation
- Paladin® Carotid Post-Dilatation balloon with integrated embolic protection (CONTEGO MEDICAL)

5. Aspiration and declamping with the Paladin-filter in place

6. Retrieval of the Paladin-system

CLINICAL DATA
Severe claudication right calf, walking capacity 150 meters
Thromendartherectomy both groins 2014
Stenting/PTA left SFA 11/2016
CAD, PTCA 2000, CABG 2000
Art. hypertension, former smoker

ANGIOGRAPHY
Severely calcified distal SFA-CTO right
ABI right 0.51

PROCEDURAL STEPS
1. Left groin retrograde and cross-over approach
- IMA-diagnostic 5F catheter (CORDIS/CARDINAL HEALTH)
- 0.035" angled soft Radiofocus guidewire, 190 cm (TERUMO)
- 0.035" SupraCore guidewire, 190 cm (ABBOTT)
- 7F 55cm Flexor Check-Flo Introducer, Raabe Modifcation (COOK)

2. Passage of the distal SFA-CTO
- 0.018" Connect 250 T guidewire, 300 cm (ABBOTT)
- 0.018" QuickCross support catheter 135 cm (SPECTRANETICS)

3. Angioplasty
- 6.0/60 mm Lithoplasty balloon (SHOCKWAVE MEDICAL)

4. Stenting only on indication
- Supera Interwoven Nitinol stent (ABBOTT)

CLINICAL DATA
Critical limb ischemia left forefoot, ulceration dig I left
PTA of a tibioperoneal trunk stenosis left 12/2015, only minor healing tendency
Diabetes mellitus, type 2

ANGIOGRAPHY
Total occlusion of the anterior tibial artery

PROCEDURAL STEPS
1. Left antegrade access
- 6F 55 cm Flexor Check-Flo Introducer, Raabe Modification (COOK)

2. Guidewire passage of the ATA-CTO
- 0.014" Command ES guidewire, 300 cm (ABBOTT)
- 3.5/120 mm Armada 14 balloon (ABBOTT)

3. Arterial wall-injection of dexamethason
- BullFrog Micro-Infusion-Device (MERCATOR MEDSYSTEMS)

4. In case of dissections: placement of nitinol-Tacks (INTACT VASCULAR)

CLINICAL DATA
- Severe claudication right leg, Rutherford class 3
- Walking capacity 20 meters
- Diabetes mellitus, type 2
- ABI right 0.37

RISK FACTORS
- Arterial hypertension
- Diabetes mellitus
- Smoker

PROCEDURAL STEPS
1. Left brachial and bilateral femoral approach
2. Guidewire passage
3. Kissing stent (LIFESTREAM covered stant)

CLINICAL DATA
Critical limb ischemia left forefoot, ulceration dig I left
PTA of a tibioperoneal trunk stenosis left 12/2015, only minor healing tendency
Diabetes mellitus, type 2

ANGIOGRAPHY
Total occlusion of the anterior tibial artery

PROCEDURAL STEPS
1. Left antegrade access
- 6F 55 cm Flexor Check-Flo Introducer, Raabe Modification (COOK)

2. Guidewire passage of the ATA-CTO
- 0.014" Command ES guidewire, 300 cm (ABBOTT)
- 3.5/120 mm Armada 14 balloon (ABBOTT)

3. Arterial wall-injection of dexamethason
- BullFrog Micro-Infusion-Device (MERCATOR MEDSYSTEMS)

4. In case of dissections: placement of nitinol-Tacks (INTACT VASCULAR)

CLINICAL DATA
- Progressive aneurysm of the infrarenal aortic aneurysm, now max. diameter 58 mm
- Small caliber external iliac arteries bilateral
- Coiling of lumbar arteries and AMI 01/16
- Chronical pancreatitis with pseudocysts

RISK FACTORS
- Arterial hypertension
- Current smokera

PROCEDURAL STEPS
1. Bifemoral percutaneous approch in local anaesthesia and preclosing with 2 Proglide closure devices
2. Guidewire positioning
3. Implantation of a bifurcational stentgraft (OVATION STENTGRAFT)
4. Postdilatation

CLINICAL DATA
Severe claudication right calf, walking capacity 150 meters
ABI right 0.7

RISK FACTORS
- Arterial hypertension
- Current smoker
- Hyperlipidemia

PROCEDURAL STEPS
- Left groin retrograde and cross-over approach
- Guidewire passage
- Predilation with low profile ballon
- PTA with drug coated ballon

CLINICAL DATA
Severe claudication right leg, walking capacity 100 meters
PTA/stenting left SFA 12/2016
PTA iliac left 12/2015
Art. hypertension, current smoker

ANGIOGRAPHY
During PTA left SFA 12/2016: Long SFA-occlusion right, moderately calcified

PROCEDURAL STEPS
1. Left groin retrograde and cross-over approach
- IMA-diagnostic 5F catheter (CORDIS/CARDINAL HEALTH)
- 0.035" angled soft Radiofocus guidewire, 190 cm (TERUMO)
- 0.035" SupraCore guidewire, 190 cm (ABBOTT)
- 6F Balkin Up&Over Sheath, 40 cm (COOK)

2. Passage of the occlusion right SFA
- 0.035" Radiofocus angled stiff guidewire, 260 cm (TERUMO)
- 0.035" TrailBlazer support catheter, 135 cm (MEDTRONIC)
- Exchange to 0.018" SteelCore guidewire (ABBOTT)

3. PTA and stenting on indication
- Luminor DCB 5.0/120 mm (iVASCULAR)
- VascuFlex Multi-LOC (B. BRAUN)

CLINICAL DATA
Severe claudication right calf, walking capacity 150 meters
PTA with DCB and spotstenting right SFA 12/2014
PTA and stenting left SFA 11/2014
CAD with PTCA 2003
Art. hypertension, current smoker

ANGIOGRAPHY
SFA-reocclusion right, Nitinol stent within the occlusion

PROCEDURAL STEPS
1. Left groin retrograde and cross-over approach
- 0.035" SupraCore guidewire 190 cm (ABBOTT)
- 7F–40 cm Balkin Up&Over Sheath (COOK)

2. Guidewire passage
GW-passage from antegrade:
- 0.035" stiff angled Glidewire, 260 cm (TERUMO)
- 4.0/120 mm Admiral balloon (MEDTRONIC)
in case of failure to pass from antegrade:
- puncture of the occluded SFA-stent:
- same wire and 0.035" TrailBlazer support catheter, 90 cm (MEDTRONIC)
- snaring of the guidewire into the cross-over sheath and finalization guidewire passage of the occlusion from antegrade

3. PTA and stenting
- 6.0/80 mm Admiral balloon (MEDTRONIC)
- 6.0/250 mm Viabahn (GORE)
- 6.0/100 mm Tigris stent (GORE)

CLINICAL DATA
Severe claudication left calf, walking capacity 10 meters, rest pain
ABI left 0.31
PTA of the right EIA 11/16
Stroke 1995 with residual incomplere hemiparesis left

RISK FACTORS
- Arterial hypertension
- Hyperlipidemia

ANGIOGRAPHY
Long SFA and P1-segment occlusion left, moderately calcified

PROCEDURAL STEPS
1. Right groin retrograde and cross-over approach
2. Guidewire passage
3. Angioplasty (VASCUTAK)
4. Stenting on indication
- In case of dissections: provisional placement of nitinol Tackts (INTACT)
- In case of residual stenosis after DCB: LifeStent

CLINICAL DATA
Chronic venous disease C2EpAs2Pr (CEAP)
Symptoms: feeling of heaviness and dysesthesia in the left leg

DUPLEX
Complete insufficiency of the left great saphenous vein Hach 2
Side branch varicose veins below the left knee
Competent deep veins
No Thrombosis

PROCEDURAL STEPS
1. Puncture of the distal GSV with 16G Introducer
Puncture of sidebranches with 18G Introducer
Introducing of Laser Fiber (ELVeS Radial slim™ BIOLITEC)
Ultrasound control of the tip position at GSV junction

2. Application of the tumescent anesthesia around the left great saphenous vein

3. Treatment of the left GSV with 10 W/70Joul/cm

4. Foam sklerotherapy of sidebranches with Aethoxysklerol

5. Applying compression bandage left leg

6. Injection of a LMWH for thrombosis prophylaxis

CLINICAL DATA
- CLI with ulcer Dig 2 right and restpain
- PTA with DCBs 3/2016 right SFA
- PTA left SFA 2/2015
- CAD, PTCA 2012

RISK FACTORS
- Diabetes mellitus, type 2
- Arterial hypertension
- Chronic renal impairment (GFR 56 ml/min)

PROCEDURAL STEPS
1. Left femoral retrograde and cross-over approach
2. Guidewire passage of the SFA-restenosis and filter positioning (WIRION protection system)
3. Atherectomy (JETSTREAM) and PTA with DCBs

CLINICAL DATA
Severe claudication left SFA, walking capacity 100 meters
PTA with stenting right SFA 1/2016
PTA with DCBs for restenosis right SFA 12/2016
PTA/stenting iliac arteries bilateral 2009
Art. hypertension, smoker

ANGIOGRAPHY
During PTA right SFA: total occlusion left SFA
ABI left 0.67

PROCEDURAL STEPS
1. Right groin retrograde and cross-over approach
- IMA-diagnostic 5F catheter (CORDIS/CARDINAL HEALTH)
- 0.035" angled soft Radiofocus guidewire, 190 cm (TERUMO)
- 0.035" SupraCore guidewire, 190 cm (ABBOTT)
- 6F Balkin Up&Over Sheath, 40 cm (COOK)

2. Passage of the occlusion left SFA
- 0.035" Radiofocus angled stiff guidewire, 260 cm (TERUMO)
- 0.035" CXC support catheter, 135 cm (COOK)
- Exchange to 0.018" SteelCore guidewire (ABBOTT)

3. PTA and stenting on indication
- Luminor DCB 5.0/120 mm (iVASCULAR)
- VascuFlex Multi-LOC (B. BRAUN)

CLINICAL DATA
Critical limb ischemia right leg, restpain, Rutherford class 4
PTA SFA and popliteal artery right and failed antegrade recanalization
of a tibioperoneal trunk occlusion right elsewhere 12/2015
Persistent atrial fibrillation

ANGIOGRAPHY
high-grade stenosis SFA and popliteal artery right,
occlusion of the tibioperoneal trunk
ABI 0,21

PROCEDURAL STEPS
1. Left groin retrograde and cross-over approach
- 0.035" SupraCore guidewire 190 cm (ABBOTT)
- 6F-40 cm Balkin Up&Over Sheath (COOK)

2. Guidewire-passage of the SFA/popliteal stenoses and PTA
- predilatation with 0.014" NanoCross balloon (MEDTRONIC)

After failed antegrade GW-passage:
3. Retrograde passage via the peroneal artery
- 21 Gauge 7 cm needle (COOK)
- 0.018" V-18 Controll-GW 300 cm (BOSTON SCIENTIFIC)
- 0.018" QuickCross support catheter 90 cm (SPECTRANETICS)

4. PTA with a drug-coated balloon
- Chocolate Touch 6.0/120 mm (TRIREME MEDICAL)

CLINICAL DATA
Acute Type-B dissection 6 weeks ago, since then intermittend thoracic pain
CT 4 weeks later: diameter-increase of the descending aorta of 5 mm
Coiling of intercostal arteries to reduce the risk of spinal cord ischemia during TEVAR
Art. hypertension, former smoker

CT-SCAN
2 focal dissections of the descending thoracic aorta,
both have an entry without reentry,
max. diameter of the aorta 46m

PROCEDURAL STEPS
1. Bilateral femoral access
- Preloading of Proglide-Systems right (ABBOTT)

2. Positioning of guidewire
- LunderQuist 0.035" 260 cm (COOK)

3. Implantation of 2 thoracic stentgrafts
- Ankura thoracic graft (LIFETECH)
- Stengraft from left subclavian artery to the celiac trunk

CLINICAL DATA
Critical limb ischemia with gangrene dig 4/5 left, Rutherford 5
Failed recanalization of a popliteal occlusion left
CEA left femoral bifurcation 1/2017
CAD, PTCA 2004
Chronic heart failure, EF 40%
Diabetes mellitus, type 2
Chronic renal insufficiency with GFR 55 ml/min

PRESENT STATE
Angiography before CEA left groin
ABI left 1.3, mediasclerosis

PROCEDURAL STEPS
1. Left groin retrograde and cross-over approach
- IMA-diagnostic 5F catheter (CORDIS/CARDINAL HEALTH)
- 0.035" angled soft Radiofocus guidewire, 190 cm (TERUMO)
- 0.035" SupraCore guidewire, 190 cm (ABBOTT)
- 6F 55 cm Check-Flow Performer, Raabe Modification (COOK)

2. Guidewire passage
second attempt from antegarde:
- 0.018" Connect Flex guidewire, 300 cm (ABBOTT)
- 0.018" Seeker support catheter, 135 cm (C.R. BARD)

In case of failure of GW-passage from antegrade:
3. Retrograde approach via the posterior 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)

4. PTA of the distal SFA/popliteal artery occlusion
- AngioSculpt 4.0/100 mm Scoring balloon (SPECTRANETICS)
- Stellarex 4.0 or 5.0/120 mm DCB (SPECTRANETICS)

5. Stenting on indication
- Supera Interwoven Nitinol stent (ABBOTT)

CLINICAL DATA
Restpain and Severe claudication left leg, Rutherford class 4
CAD, PTCA 2012, Chronic heart failure, EF 35%
Diabetes mellitus, type 2
Art. hypertension, former smoker

DUPLEX
Left distal SFA and popliteal artery with long subtotal stenosis,
Moderately calcified, diffuse BTK-stenoses
ABI left 0.32

PROCEDURAL STEPS
1. Right groin retrograde and cross-over approach
- 6F 55 cm Check-Flo Performer, Raabe Modification (COOK)

2. Guidewire passage
- PT2 0.014” 300cm guidewire (BOSTON SCIENTIFIC)
- QuickCross support catheter (SPECTRANETICS)

3. PTA

- AngioSculpt scoring balloon 5.0/100 mm (SPECTRANETICS)
- Exchange to a 0.035" SupraCore guidewire (ABBOTT)
- Stellarex DCB (SPECTRANETICS)

CLINICAL DATA
Critical limb ischemia left, gangrene Dig 2-4,
CAD, PTCA 2012, chronic heart failure, NYHA II-III
Art. Hypertension, diabetes mellitus type 2
Previous PTA / stenting BTK for CLI 2010
Failed recanalization-attempt 1/2017

ANGIOGRAPHY
from previous unsuccessful recanalization attempt

PROCEDURAL STEPS
1. Left antegrade access
- 6Fr-55cm Check-Flo Sheath, Raabe Modification (COOK)

2. Retrograde access via dorsalis pedis artery
- 2.9 Pedal Introducer Access Set (COOK)

3. Passage of the occlusion (retrograde)
- CXI support-catheter, 0.018”, 90 cm (COOK)
- Hydro-ST 0.014” Guidewire, 300cm (COOK)
- Approach CTO 25gramm Guidewire, 300cm (COOK)

4. PTA (BTK-bifurcation in kissing technique)
- retrograde: Advance Micro Balloon 3.0/120mm, 90cm (COOK)
- antegrade: Advance LP 3.0/40mm Balloon (COOK)

CLINICAL DATA
- CLI, Ulceration D5 right
- ABI right 0.4

RISK FACTORS
- Arterial hypertension
- Former smoker
- Diabetes mellitus, type 2

PROCEDURAL STEPS
1. Right groin antegrade access
3. Recanalization of the anterior tibial artery
3. Retrograde access 3F: dorsalis pedis artery

CLINICAL DATA
Severe claudication left, walking capacity 50-100 meters
Art. hypertension, nicotine-abuse
CAD, PTCA 11/2015

ANGIOGRAPHY ELSEWHERE
Common iliac artery occlusion left moderately calcified

PROCEDURAL STEPS
1. Left femoral access
- 7F 25 cm Radiofocus Introducer (TERUMO)
- 0.035" SupraCore guidewire 300 cm (ABBOTT)
Left brachial approach:
- 7F 90 cm Check-Flo Performer (COOK)

2. Antegrade and retrograde guidewire passage
brachial:
- 5F Judkins Right diagnostic catheter 125 cm (CORDIS/CARDINAL HEALTH)
from femoral:
- 5F Multipurpose diagnostic catheter 80 cm (CORDIS/CARDINAL HEALTH)
- 0.035" stiff angled glidewire, 260 cm (TERUMO)

3. Predilatation and stenting of the aorto-iliac bifurcation
- Armada 35 6/40 mm ballon (ABBOTT)
- LifeStream covered stent 7/58 bilateral in kissing-technique (C.R. BARD)

CLINICAL DATA
Restpain during night and severe calcification left, Rutherford 4
Failed recanalization attempt left leg 11/2015
PTA/stenting right SFA-CTO 12/2016
Art. hypertension, diabetes mellitus, type 2
Former smoker

PROCEDURAL STEPS
1. Right groin retrograde and cross-over approach
- IMA 5F diagnostic catheter (CORDIS/CARDINAL HEALTH)
- 0.035" soft angled Radiofocus guidewire, 190 cm (TERUMO)
- 0.035" SupraCore guidewire 190 cm (ABBOTT)
- 7F 55 Check-Flo Performer Sheath, Raabe Modification (COOK)

2. Antegrade guidewire passage
- 0.035" Stiff angled Glidewire, 260 cm (TERUMO)
- CXC 0.035" support catheter, 135 cm (COOK)

3. Retrograde guidewire passage:
Access via the proximal anterior tibial artery:
- 7 cm 21 Gauge needle (COOK)
- 0.018" V-18 Control guidewire, 300 cm (BOSTON SCIENTIFIC)
- 4Fr-10cm Radiofocus Introducer (TERUMO)
- Pacific Plus 4.0/40 mm balloon, 90 cm (MEDTRONIC)

4. PTA and stenting
- 6.0/20mm Admiral Xtreme Balloon (MEDTRONIC)
- 7.0/20 Conquest non-compliant high-pressure balloon (C.R. BARD)
- In case of inability to open the balloons fully implantation of a Viabahn 7.0/100 mm (GORE)
- Relining with Supera Interwoven Nitinol stent (ABBOTT)

CLINICAL DATA
Restpain left foot, Rutherford class 4
PTA/stenting aortic bifurcation 11/2016
D iabetes mellitus, type 2
Art. Hypertension

ANGIOGRAPHY
During PTA of the aortic bifurcation:
moderately calcified distal SFA/P1-occlusion left

PROCEDURAL STEPS
1. Antegrade approach left
- 7F 55 cm Check-Flo Sheath, Raabe Modification (COOK)

2. Guidewire passage
- 5.0/40 mm Pacific Plus balloon, 90 cm (MEDTRONIC)
- 0.018" Victory guidewire, 18 gramm, 30 cm (BOSTON SCIENTIFIC)

3. PTA and stenting
- 6.0/40mm Pacific Plus balloon, 90 cm (MEDTRONIC)
- Supera Interwoven Nitinol stent (ABBOTT)

CLINICAL DATA
Critical limb ischemia right, ulcerations dig 2 / 3, Rutherford 5
Endstage renal failure, chronic hemodialysis until 1997
Renal transplantation 1997
Art. Hypertension

PRESENT STATE
CO2-angiography
ABI right: mediasclerosis

PROCEDURAL STEPS
1. Left groin retrograde and cross-over approach
- IMA 5F diagnostic catheter (CORDIS/CARDINAL HEALTH)
- 0.035" soft angled Radiofocus guidewire, 190 cm (TERUMO)
- 0.035" SupraCore Guidewire 190 cm (ABBOTT)
- 6F-55 cm Check-Flo Sheath, Raabe Configuration (COOK)

2. Antegrade guidewire passage
- 0.035" Stiff angled Glidewire, 260 cm (TERUMO)
- CXC 0.035" support catheter, 135 cm (COOK)

In case of guidewire passage failure:
3. Retrograde approach via the distal SFA
- 9 cm 21 Gauge needle (COOK)
- 0.018" V-18 Control guidewire, 300 cm (BOSTIN SCIENTIFIC)

4. PTA and stenting
- 6.0/20 mm Admiral Xtreme balloon (MEDTRONIC)
- 7.0/20 Conquest non-compliant high-pressure balloon (C.R. BARD)
- In case of inability to open the balloons fully implantation of a Viabahn 7.0/100 mm (GORE)
- Relining with Supera Interwoven Nitinol stent (ABBOTT)

CLINICAL DATA
Incidental finding of a juxtarenal aortic aneurysm
with progression to 61 mm max. diameter
Accessory renal arteris on both sides
Coiling of intercostal and lumbar arteries before FEVAR
to reduce the risk of spinal ischemia
Coiling of the accessory right renal artery
CAD, PTCA 2012 heart failure, EF 40%
Thyreoidectomy 1/2017

IMPORTANT ITEMS
CT-scans and Stentgraft-plan

PROCEDURAL STEPS
1. Bilateral femoral access and left axillar percutaneous access
- Preloading of Proglide-Systems (ABBOTT) for all 3 access-sites

2. Implantation of the CMD thoracoabdominal stentgraft (JOTEC)

3. Implantation of E-ventus covered stents into the visveral arteries (JOTEC)

4. Implantation of the bifurcated component with extension into the common iliac arteries

CLINICAL DATA
- Asymptomatic highgrade stenosis of the ostium of the common carotid artery left
- Duplex-sonography because of recurrent dizziness: severe flow-disturbance of the proximal common carotid artery and slow flow

RISK FACTORS
- Arterial hypertension
- Diabetes mellitus, type 2
- Former smoker

Information will follow in due time.

Information will follow in due time.

Information will follow in due time.

Information will follow in due time.

CLINICAL DATA
Bilateral buttock and leg claudication after 50 to 100 meters (PAOD Rutherford 2 / Fontaine IIb) since a couple of months

PRESENT STATE
CVRF: arterial hypertension, ex nicotine
ABI at rest: right leg: 0.8; left leg: 0.8; post exercise 0.6 / 0.6
Duplex: distal occlusion of infrarenal abdominal aorta and the origins of both CIAs
Patent inferior mesenteric artery, bilateral internal and external iliac arteries

PROCEDURAL STEPS
1. Retrograde access
- Insertion of 6F 90 cm shuttle sheath via left brachial artery and insertion of a 23 cm long 7F sheath into each CFA

2. Antegrade crossing attempt of the aortic occlusion
- 5F vertebral catheter, 0.035'' Gluidewire (TERUMO) into one of the CIAs

3. Predilatation
- 5 mm Admiral balloon (MEDTRONIC)

4. Retrograde crossing attempt of the contralateral CIA

5. Predilatation
- 5 mm Powerflex balloon (CORDIS)

6. Stenting of distal abdominal aorta
- Smart 14/40 mm stent (CORDIS)

7. Stenting of both CIAs
- Restorer balloon expandable stents (iVASCULAR)

CLINICAL DATA
Calf claudication left leg after 100m since 3 months (PAOD Fontaine IIb/Rutherford 3)
Stent recanalisation left popliteal artery 2012
DCB angioplasty and stent-in-stent angioplasty of left popliteal ISR 01/2016

PRESENT STATE
CVRF: arterial hypertension, ex nicotine, hypercholesterinemia
ABI at rest: right leg: 1.1; left leg: 0.3
Duplex: instent reocclusion of left popliteal artery

PROCEDURAL STEPS
1. Antegrade access, 6F, left CFA

2. Crossing attempt of the popliteal artery occlusion
- 0.014'' Advantage 14 GW (TERUMO)

3. Laser debulking of the occlusion

- Turbo elite, 2.3 mm (SPECTRANETICS)

4. Postdilatation
- 5/100 mm Stellarex DCB (SPECTRANETICS)

Information will follow in due time.

CLINICAL DATA
Calf claudication left leg after 200m (PAOD Fontaine IIb / Rutherford 3
Stentangioplastie left renal artery 11/2016
Rekanalisation (stent & DCB) right SFA 7/2015
Stent angioplasty CIA&EIA both sides and PTA IIA right 09/201

PRESENT STATE
Ex-Nicotine
Hypertension
Hypercholesterinemia
Diabetes mellitus type II
ABI at rest: 0.5 / 0.6
Oscillometry: Reduced amplitudes right tigh, calf & ankle
Reduced amplitudes left calf & ankle
Duplex:Calcified high grade stenosis of left distal SFA

PROCEDURAL STEPS
1. Antegrade access, 6F, left CFA

2. Crossing of the SFA lesion with a 0.035’’ Glidewire (TERUMO)

3. Predilatation of distal SFA (Powerflex 5mm, CORDIS)

4. Implantation of a BioMimics stent 6 or 7 mm (VERYAN)

5. Postdilatation (6/20mm Powerflex, CORDIS)

CLINICAL DATA
Non-healing crural ulcer right calf (PAOD Fontaine IV / Rutherford 5)
11/2016 recanalisation of right SFA, popliteal artery & TPT
11/2014 recanilsation of right SFA, popliteal artery & TPT (DCB and spot stenting)
DVT right leg 10/2014

RISK FACTORS
CVRF: hyperlipidemia, obesity
ABI at rest: right leg: 0.6; left leg: 1.0
Duplex: persistent occlusion of right ATA /& PTA

PROCEDURAL STEPS
1. Antegrade sheath insertion 6F, right CFA
Insertion of a 5F Envoy guiding catheter (CORDIS)

2. Attempt to antegradely recanalise the PTA (predilatation followed by DCB, Chocolate touch, TRIREME)

3. Retrograde recanalisation of ATA (predilatation followed by DCB)

4. Sheath removal in the groin with Femoseal (TERUMO)

CLINICAL DATA
Bilateral PAOD Rutherford 2 / Fontaine IIa
Bilateral CIA stent-angioplasty 10/2014
Bilateral chronic venous insufficiency

PRESENT STATE
CVRF: ex-smoker, hyperlipidemia, obesity
ABI at rest: right leg: 0.8; left leg: 0.6
Duplex: Bilateral high grade ISR at the origin of the CIA

PROCEDURAL STEPS
1. Bilateral retrograde access
- 23 cm long 7F sheath into the CFA (CORDIS)

2. Crossing of ISR
- 0.035'' guidewire (TERUMO)

3. Bilateral stentgraft implantation in a modified kissing stent fashion
- BeGraft 8 mm (BENTLEY)

4. Sheath removal
- Femoseal (TERUMO)

CLINICAL DATA
PAOD Rutherford 2 / Fontaine IIb right leg
Recanalisation left CIA 12/2016
Stent reconsruction of aortic bifurcation 2014

PRESENT STATE
CVRF: ex-smoker, hyperlididemia
ABI right leg: 0.6; left leg: 1.0
Duplex: high grade stenosis of right CFA

PROCEDURAL STEPS
1. Left transbrachial retrograde access
- 6F 90 cm shuttle sheath (COOK)

2. Filter placement
- 6 mm Spider filter (MEDTRONIC) distal right SFA

3. Directional atherectomy
- Turbohawk SX-C (MEDTRONIC)

4. Drug coated balloon angioplasty
- 7/40 mm Inpact Pacific (MEDTRONIC)

5. Stenting on indication

CLINICAL DATA
Coronary heart disease, aortocoronary bypass
PAD, PTA left SFA 2011, right SFA 2015

RISK FACTORS
Hypertension, hyperlipidemia

PROCEDURAL STEPS
1. Transfemoral retrograde approach
- 8F short sheath (TERUMO)
- Diagnostic 5F catheter Weinberg shape (COOK)
- TERUMO stiff angled 0.035" wire into left ECA

2. Exchange to
- Vista Brite Tip IG guiding catheter MPA1 shape into left CCA (CORDIS)

3. Distal protection
- Filter Wire EZ (BOSTON SCIENTIFIC) into distal ICA left

4. Stenting
- Roadsaver Carotid Micromesh stent (TERUMO) 8 x 25 mm

5. Carotid postdilatation
- 5 x 20 mm Paladin balloon with integrated embolic protection (40 micron pore size) (CONTEGO-MEDICAL)

6. Paladin filter closure and combined filter/balloon-system removal
- removal of the distal EPD-Filter Wire EZ
- removal of guiding catheter (wire controlled)

7. Closure of puncture site
- Angioseal 8F
- transfer patient to ICU

CLINICAL DATA
PAOD, Rutherford 3–4, ABI 0.63 right, 0.93 left, stenting of the distal SFA and P3-segment 2015, peripheral bBypass surgery left leg

RISK FACTORS
Art. hypertension, severe atherosclerosis of the aorta, severly impaired walking distance

PROCEDURAL STEPS
1. Antegrade access right common femoral
- 5F Terumo Destination 45 cm

2. Recanalisation of the occluded stent in the P3 segment

3. PTA and stenting
- Cr8 BTK 4 x 38 mm DES (ALVIMEDICA)

4. Recanalisation of the ATA and peroneal, PTA with 2.5 and 3 mm balloon


5. Back-up: retrograde access via peroneal artery

6. Closure of puncture site by manual compression

CLINICAL DATA
PAOD Rutherford 3, claudication right calf at 50 meters
Recanalization SFA stent and PTA with DCB for claudication 11/2016

RISK FACTORS
Coronary heart disease, aortocoronary bypass
Hypertension, hyperlipidimia, diabetes type II
ABI 0,6 right, 1,0 left after intervention

ANGIOGRAPHY
Distal SFA occlusion right side

PROCEDURAL STEPS
1. Left femoral access and cross-over approach
- 6F 45 cm cross-over sheath Fortress (BIOTRONIK)

2. Recanalisation right SFA
- 0.018" Advantage glidewire (TERUMO)
- 0.018" CXI support catheter (COOK)

Back-up material:
- Connect 250T CTO-wire (ABBOTT)
- Outback reentry system (CORDIS)

3. PTA
- Passeo18 ballon 3 x 150 mm (BIOTRONIK)
- 5 mm Passeo18 Lux DEB (BIOTRONIK)

4. Stenting
- Pulsar18 stent 5 x 200 mm (BIOTRONIK)

5. Postdilatation
- 5 x 200 mm Passeo1 8 balloon (BIOTRONIK)

6. Puncture site closure
- Angioseal 6F (TERUMO)

CLINICAL DATA
Iliofemoral DVT right side in 2014
Currently no anticoagulation therapy
Moderate renal insufficiency (atrophic left kidney)

RISK FACTORS
Venous claudication while standing and walking (works as a chef de cuisine)
Leg swelling right > left
Hyperpigmentation right lower leg

PROCEDURAL STEPS
1. Venous access with ultrasound guidance in both femoral and right IJ veins
- 10F sheath

2. Wire crossage
- TERUMO 0.035" stiff angled

3. Phlebography, IVUS

4. Predilation
- Atlas Balloon 14–20 mm (C.R. BARD)

5. Implantation of dedicated Iliac vein stents
- IVC: Sinus XL 22–24 mm (OPTIMED)
- Sinus-XL Flex 14 mm (OPTIMED)

6. High-pressure postdilatation of stents
- Atlas balloon 14–20 mm (C.R. BARD)

CLINICAL DATA
Acute left-sided iliofemoral deep vein thrombosis in 04/2008

RISK FACTORS
Long distance flight, estrogen-containing contraceptives, no known thrombophilia (negative testing)
Chronic venous insufficiency leg with Villalta Score: 9 points

PROCEDURAL STEPS
1. Venous access with ultrasound guidance in left popliteal vein
- 10F sheath

2. Reconstruction of iliac veins

3. Predilation
- Atlas balloon 12–14 mm (C.R. BARD)

4. Implantation of dedicated iliac vein stents
- MT stent: Sinus obliquus 14 mm (OPTIMED)
- Iliac veins: Sinus-XL Flex 14 mm (OPTIMED)

5. High-pressure post-dilation of stents
- Atlas balloon 14 mm (C.R. BARD)

CLINICAL DATA
Acute left-sided iliofemoral deep vein thrombosis in 04/2008

RISK FACTORS
Long distance flight, estrogen-containing contraceptives, no known thrombophilia (negative testing)
Chronic venous insufficiency leg with Villalta Score: 9 points

1. Venous access with ultrasound guidance in left popliteal vein
- 10F sheath

2. Reconstruction of iliac veins

3. Predilation
- Atlas balloon 12–14 mm (C.R. BARD)

4. Implantation of dedicated iliac vein stents
- MT stent: Sinus obliquus 14 mm (OPTIMED)
- Iliac veins: Sinus-XL Flex 14 mm (OPTIMED)

5. High-pressure post-dilation of stents
- Atlas balloon 14 mm (C.R. BARD)

CLINICAL DATA
Protein S deficiency and factor V Leiden mutation
Ongoing anticoagulation therapy
Recurrent ilio-femoral thrombosis despite medical therapy
Implantation of permanent Simon™ filter (2004/USA)

RISK FACTORS
Chronic venous insufficiency both legs with:
venous claudication, varicose veins, hyperpigmentation, leg swelling
Villalta-score: 6 points

PROCEDURAL STEPS
1. Venous access
- Venous access with ultrasound guidance in both femoral veins (10F sheath)
- Venous access IJ (18F sheath)

2. Filter extraction with endobronchial forceps from IJ access
- Forceps Alligator 2.5 mm x 55 cm hard foreign body double action (KARL STORZ)

3. Reconstruction of IVC and iliac veins

4. Predilatation
- Atlas balloon 14–20 mm (C.R. BARD)

5. Implantation of dedicated IVC and Iliac vein stents
- IVC: Sinus XL 22 mm (OPTIMED)
- Iliac veins: Sinus-XL Flex 14 mm (OPTIMED)

6. High-pressure postdilatation of stents
- Atlas balloon 14–20 mm (C.R. BARD)

CLINICAL DATA
Primary (spontaneous) upper extremity deep vein thrombosis 06/15
(Paget-Schroetter syndrome) --> lysis and anticoagulant therapy
Known bony exostosis of the first rib and the clavicula --> resection the the first rib and stenting of the subclavian vein in 12/15
Recurrent swelling of the right arm --> thrombus aspiration in a tertiary care hospital (11/16)

PRESENT STATE
Swelling of the right arm since several weeks

PROCEDURAL STEPS
1. Venous access with ultrasound guidance in right femoral vein
- 10F sheath

2. Wire crossage
- Terumo 0.035" stiff angled

3. Phlebography

4. Predilatation
- Dorado balloon 10 mm (C.R. BARD)

5. Implantation of dedicated vein stent (stent-in-stent)

6. High pressure postdilatation of stent
- Atlas balloon 12 mm (C.R. BARD)

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CLINICAL DATA
80 years old male with weight loss
CT and MRI proofed HCC in central right liver lobe

HISTORY
Child B cirrhosis

PROCEDURAL STEPS
1. Canulation celiac trunk with guiding catheter

2. Large FOV – Dyna-CT for feeder evaluation

3. Chemoembolisation with doxorubicin
- Embozene Tandem 40μm

CLINICAL DATA
Abdominal pain and abnormal intermenstrual bleeding

IMAGING
MRI proofed a 4 cm right-sided uterine fibroid

PROCEDURAL STEPS
1. Canulation of both uterine arteries
- RIM-catheter
- 2.7F Progeat Microcatheter (TERUMO)

2. Embolisation
- Gelatine Sponge/Gelbeads 500-700 μm (VASCULAR SOLUTIONS)

Information will follow in due time.

CLINICAL DATA
Incidental finding of AAA during work-up for intermittent claudication
CTA: AAA 51 mm, aneurysm proximal right CIA, dilatation distal left CIA
Plan: EVAR + left iliac branched device + embolisation right IIA

RISK FACTORS
Former smoker, hypertension

HISTORY
Aortic valve stenosis, CVA, bilateral inguinal hernia repair, lumbar herniated disc repair

PRESENT STATE
Duplex supra-aortic vessels: normal
Cardiac ultrasound: EF 74%, AS (3.13 cm2), Ao asc 45 mm

PROCEDURAL STEPS
1. L: 10F sheath, Lunderquist, dilators (up to 20F) 50 U/kg Heparin

2. R: 5F55 sheath, TERUMO, SIM, AMI embolized (Amplatzer 6 mm)

3. R: 10F Right IIA embolized (Coils 10 mm)

4. R: 10F sheath, wire exchange: starter, TERUMO, Rosen-GW stiff wire (COOK), 12F sheath, 45cm; tip positioned above aortic bifurcation

5. L: ZBIS advanced into distal aorta, unsheath until preloaded catheter of ZBIS appears; exchange wire of preloaded catheter for 260 cm TERUMO

6. R: Snare through-and-through (tat)-wire (TERUMO, 0.035") – advance dilator of 12F sheath

7. R: 12F dilator connects to tip of preloaded catheter – secure both ends with clamps

8. Position C-arm and open branch of ZBIS (COOK)

9. Advance 12F dilator into ZBIS (pull & push, 'nobody holds the wire')

10. Puncture valve of 12F TERUMO/catheter to catheterize IIA, angio

11. Wire exchange/Rosen

12. Over Rosen, advance 55 cm 7F sheath into 12F to IIA, tat-wire under tension

13. Advance bridging stentgraft in 7F sheath

14. Remove tat-wire

15. Pull down ZBIS, depending on angle of IIA

16. Pull back 7F sheath and inflate bridging stent

17. Advance 7F sheath again into stentgraft – dilate distal seal if required – Angio

18. Finish deployment of Zbis – release trigger wires

19. Secure branch/stentgraft with balloon while removing nose cone

20. Continue with EVAR

21. R: release proximal stent

22. L: iliac angiogram

23. L: contralateral limb insertion holding the main body, deployment

24. R: finish bifurcated endograft deployment + distal attachment release

27. R: ipsilateral limb insertion & deployment + IIE stenting (Nitinol stent LUMINEX 10*60 mm)

28. R+L: CODA balloon (COOK)

29. L: Long angio catheter/Angiogram +/- non-contrast CBCT

30. R+L: sheaths retrieval + close groins

CLINICAL DATA
2013: type B aortic dissection, conservative treatment
Acute tubular necrosis and occlusion right renal artery with atrophic right kidney
2014 aneurysmatic evolution infrarenal aorta: Open AAA tubular repair
Aneurysmatic evolution descending thoracic and thoraco-abdominal aorta,
with a maximum diameter 61 mm
November 2016: TEVAR
January 2017: FEVAR

RISK FACTORS
Smoker, hypertension

HISTORY
Gastric ulcers, pancreatitis, OSA, GORD

PRESENT STATE
At present asymptomatic
Renal function: creatinine 12 mg/l, GFR 64
Cardiac ultrasound: normal EF, mild AI, otherwise normal
Duplex carotid arteries: normal
Spirometry: mild obstructive pattern

PROCEDURAL STEPS
1. L: 7F sheath/Lunderquist/dilators (up to 20F) + 100 U/kg Heparin (Target ACT≥250)
2. L: 20F sheath above the aortic bifurcation
3. L (through 20F): Two 7F sheaths, one 6F sheath
4. L (through 20F): Advance marked angio catheter through 7F sheath
5. R: 10F sheath/Lunderquist/dilators up to 20F
6. Fluoroscopy to locate fenestrated endograft markers
7. R: Advanced fenestrated endograft (COOK)
8. Aortic angiogram/fenestrated endograft deployment
9. L: Catheterization of the fenestrated endograft lumen through 6F sheath with C2/KMP catheter and TERUMO wire
10. Advance 6F sheath to the endograft lumen
11. C2/RIM/DAV + TERUMO/Roadrunner through 6F for renal artery catheterisation
12. Renal angiogram +/- nitro injection
13. Exchange TERUMO for a Rosen
14. Advance 6F to the renal artery
15. Advance stent into the parking position
16. L: Through last 7F sheath advance C2+ TERUMO to catheterize fenestrated endograft lumen
17. Advance 7F below the fenestration of SMA
18. C2/VS1 + TERUMO/Roadrunner through 7F sheath to catheterize SMA
19. Vessel angiogram to check position in main trunk
20. Exchange TERUMO for Amplatz (BOSTON SCIENTIFIC) wire
21. Advance 7F in the target vessel
22. Advance stent into parking position
23. 16-19 for the coeliac trunk
24. R: Release reducing ties / proximal attachment and distal attachment
25. R: Nose capture & retrieval under fluoroscopy/Molding with CODA balloon (COOK)
26. L: Renal artery stent deployment (1/3 aortic lumen) after 6F retrieval
27. L: Flare the stent inside the aortic portion with 10–20 mm balloon
28. L: Advance 6F in the renal stent/selective angiogram
29. L: SMA stent deployment (1/3 aortic lumen) after 7F retrieval
30. L: CT stent deployment (1/3 aortic lumen) after 7F retrieval
31. L: Flare the stent inside the aortic portion with 10-20 mm balloon
33. R: Remove fenestrated device delivery system
34. L: Pull back 20F sheath in common iliac
35. Continue with EVAR procedure
36. CODA balloon at the level of overlaps (COOK)
37. L: Long angio catheter/Angiogram +/- non-contrast CBCT

Information will follow in due time.

CLINICAL DATA
PAOD Rutherford IV left leg, rest pain at night, walking distance limited to 50 m
ABI: right leg 0,9; left leg 0,6

RISK FACTORS
CVRF: hyperlipidemia, hypertension, nicotin
Carotid surgery 2013
MR-Angiogram: bilateral iliac stenosis, CTO of left SFA 9 cm long

PROCEDURAL STEPS
1. Right femoral access and crossover
- Insertion of 6F 45 cm Destination sheath (TERUMO)

2. Stent PTA
- Stent PTA common iliac artery bilateral (Dynamic/BIOTRONIK)

3. Recanalization left SFA
- v18 wire (BOSTON SCIENTIFIC) and Quick-cross catheter (SPECTRANETICS)

4. Predilation
- 5 x 120 balloon (Advance 18/COOK)

5. Stent implantation
- Zilver-PTX drug eluting stent (COOK)

6. Puncture site closure with CELT 6F VCD

CLINICAL DATA
CVRF: hypertension
CHD, RCA-PTCA 2016 with DES
Aortic valve stenosis

RISK FACTORS
In CC-Duplex high grade right ICA stenosis with vmax of 290 cm/sec.
MR-Angiogram: Type II aortic arch, 90% right ICA stenosis

PROCEDURAL STEPS
- Right femoral access, aortic arch angiogram, canulation of right common carotid artery with 0,035 Advantage wire (TERUMO) and insertion of 6F 90cm shuttle-sheath (COOK)

- Angiogram of lesion, placement of 0,014 Choice PT wire (BOSTON SCIENTIFIC) distal to lesion

- Delivery of Nanoparasol filter (TERUMO) distal to lesion

- Implantation of Roadsaver micromesh stent (TERUMO)

- Postdilation of stent (Sterling RX, BOSTON SCIENTIFIC)

- Filter capture and final angiogram

Information will follow in due time.

CLINICAL DATA
EVAR with INCRAFT-Endograft 12/2015 – in follow up aneurysm expansion from initially 53 mm to up to date 58 mm

IMPORTANT ITEMS
Mitral and aortic valve insufficency grade 1
CVRF: arterial hypertension
Angio-CT 12/2016: persisting flow in the aneurysm sac via IMA and lumbars L4

PROCEDURAL STEPS
1. Left transbrachial access, aortic angiogram in oblique projection, canulation of superior mesenteric artery

2. Insertion of 6F 90 cm shuttle sheath (COOK) into SMA, canulation of middle colic artery with 4F 120 cm glidecath (TERUMO) and choice PT wire (BOSTON SCIENTIFIC)

3. Insertion of Echelon microcatheter (MEDTRONIC) into endoleak, preparation of catheter with DMSO, embolization of endoleak with Onyx L 34 (MEDTRONIC)

4. Retrival of microcatheter, selective angiogram of right hypogastric artery; if neccessary selective embolization of lumbar arteries L4 with Onyx L34 in case of remaining endoleak

Information will follow in due time.

CLINICAL DATA
Rapidly growing abdominal aneurysm up to 9 cm in diameter after EVAR 2008

RISK FACTORS
PAD, renal impairment, obesity, art. Hypertension

PROCEDURAL STEPS
1. Percutanous approach both groins (Prostar XL, ABBOTT)
14F sheath (COOK) both groins.

2. First angiography through the right groin and use of the fusion technique.
Changing of the left 14F sheath for a 20F sheath in order to test the access

3. Placement of the 3-fenestrated Zenith-tube-endograft with a double wide scallop (COOK) via the left groin

4. Cannulation of the renal arteries through the delivery-system by means of the preloaded wire
Cannulation of the SMA through the fenestration from the right groin

5. Advancement of 7F sheath into the SMA
Removal of the preloaded wire and advancement of the 6F sheath into the RA`s

6. Complete release of the endograft and stenting of the fenestrations with covered stents (Advanta V12, MAQUET) and flairing

7. Closure of the accesses. (Prostar XL, ABBOTT)

CLINICAL DATA
Rutherford 3 right limb, ABI:0.4, no peripheral pulses

RISK FACTORS
Arterial hypertension, hyperlipidemia, current smoker (30 p/y)

PROCEDURAL STEPS
1. Cut down right groin, Puncture of the CFA and recanalization of the EIA occlusion with a 0.035" wire (Advantage, TERUMO) or an 0.018" wire (V18, BOSTON SCIENTIFIC)
Use of a Quick Cross catheter (SPECTRANETICS)

2. Arteriotomy and endarterectomy of CFA and proximal SFA
Use of a ring stripper and a Forgarty catheter for endarterectomy of the EIA

3. Stenting of the EIA with a 7 x 80 mm Complete stent (MEDTRONIC)

4. Patchplasty of the CFA with a Dacron Patch (MAQUET) and control angiography

5. Wound closure

Information will follow in due time.

CLINICAL DATA
Growing abdominal aortic aneurysm with conical neck from 4,5 cm to 5,5 cm
PAD with severe calcified and stenosed iliac arteries

RISK FACTORS
CAD – PTCA and PM-Implantation 5/16, chronic heart failure,
carotid stenosis both sides, PAD – venous bypass 11/06

PROCEDURAL STEPS
1. Percutanous approach both groins
- Prostar XL (ABBOTT)
- Placement of 14F sheath (COOK)

2. Placement of Endurant bifurcated endograft (MEDTRONIC) just below the RA`s

3. Additional fixation of the proximal sealing zone
- Heli-FX Endoanchors (MEDTRONIC)

4. Closure of the groin
- Prostar XL (ABBOTT)

Information will follow in due time.

Information will follow in due time.

Information will follow in due time.

CLINICAL DATA
Post-dissection thorakoabdominal aneurysm with a diameter of 7 cm
Aszendens and aortic arch repair by frozen elefant trunk in the acute phase and endovascular extension to open the true lumen but still increase of the still perfused false lumen.

RISK FACTORS
Art. hypertension, CAD

PROCEDURAL STEPS
1. Percutanous approach both groins (Prostar XL, ABBOTT) 14F (COOK) both groins
Careful cannulation of the true lumen

2. Angiogaphy to locate CT, SMA and RRA coming out of the true lumen and use of fusion technology

3. Changing the left 14F sheath for a 22F sheath
Placement of three 5F sheaths into the 22F sheath and pre-cannulation of the right renal artery and SMA by using fusion technology.

4. Placement of the 4-fenestrated Zenith-endograft (tube) (COOK) via the right groin
Cannulation of the SMA and RRA through the fenestrations

5. Advancement of 7 and 8F sheaths into the target vessels
Complete release of the endograft and stenting of the fenestrations for the SMA and RRA with covered stents (Advanta V12-MAQUET) and flairing
Cannulation of the CT and stenting

6. Cannulation of the fenestration for the LRA, perforation of dissectionmembrane and cannulation of the LRA coming out of the false lumen and implantation of another bridging stentgraft (Advanta V12)

7. Placement of the distal bifurcated graft and the iliac extensions
Closure of the accesses

Information will follow in due time.

CLINICAL DATA
Patient presents with right lower extremity ischemic rest pain
Rutherford grade 2, category 4
Fontaine stage III
Symptoms have been getting progressively worse over the last few weeks
No ischemic ulcers noted.
ABI: Right ABI 0.38.

RISK FACTORS
Hypertension, hyperlipidemia, diabetes mellitus, previous history of tobacco use

PROCEDURAL STEPS
1. Left groin access with retrograde cross over approach
- UF 4F diagnostic catheter (ANGIODYNAMICS)
- 0.035" SupraCore guidewire, 300 cm (ABBOTT)
- 7 F – 45 cm Pinnacle Sheath (TERUMO)

2. Passage through the right SFA calcified stenosis
- 0.018" Trailblazer Vert support catheter, 135 cm (MEDTRONIC)
- 0.014" Fielder guidewire, 300 cm (ASAHI)

3. Filter placement
- Exchange to a Barewire through the support catheter (ABBOTT)
- Emboshield Nav 6 filter placement (ABBOTT)

4. Jetstream atherectomy of the right SFA calcified disease
- Jetstream 2.4/3.4 mm atherectomy (BOSTON SCIENTIFIC)

5. PTA with a non-compliant balloon
- Dorado 6 x 200 mm balloon (C.R. BARD)

6. Stenting and postdilatation
- 5.5 x 150 mm Supera interwoven self-expanding Nitinol stent (ABBOTT)
- Dorado 6 x 150 mm balloon (C.R. BARD)

CLINICAL DATA
Uveal melanoma 07/2013, enucleation of the right eye 08/2013,
unresectable liver metastases 03/2016,
chemosaturation 04/2016, 06/2016, 11/2016, 12/2016

RISK FACTORS
Type 2 diabetes mellitus, hypertension

PROCEDURAL STEPS
1. Evaluation procedure (some days) prior to treatment:
- Anatomical mapping
- Embolization (to avoid reflux or infusion into GI or visceral arteries)

2. US-guided venous and arterial access to avoid multiple punctures
Establishment of 10F jugular venous return sheath, 18F femoral venous sheath for the venous isolation catheter and 4F femoral arterial sheath

3. Full Heparinization (about 30.000 IE) with ACT control (> 450 sec!)
Arterial catheter placement for Infusion into hepatic artery
Connection and start of extracorporeal circuit

4. Isolation of the hepatic veins by inflation of the double balloon catheter
Check for proper isolation with DSA (no leakage!) and fixation the catheter

5. Closing the Bypass-line to bring the filters of the extracorporeal circuit online
CAVE: Watch out for blood pressure drop

6. Start of arterial infusion of Melphalan (3 mg/kg) with injector (25 ml/min)
Check intermittently for arterial spasms (if any consider nitroglycerin)
After Melphalan is fully injected, 30 min wash-out period is applied

7. Deflation of the balloons and disconnection of the filters
Removal of arterial and venous catheters
Removal of the sheaths after coagulation status has been normalized

CLINICAL DATA
Incidental finding of an eccentric infrarenal AAA with 5.1 cm diameter
4.5 mm IMA
3 mm lumbal artery 3 (already embolised)
4 mm lumbal artery 5 with common trunc
Art. hypertension, hyperlipidemia, former smorker

CT-SCAN
AAA with max. 51 mm diameter, eccentric, potentially old containt rupture

PROCEDURAL STEPS
1. Right groin access
- 4F sheath CFA
- 4F sidewinder cath.

2. Embolisation of IMA
- 4F sidewinder cath.
- 5 mm Amplatzer Vascular Plug4 (ST. JUDE/ABBOTT)

3. Embolisation of lumbal arteries 5
- VortX Diamond Coils (BOSTON SCIENTIFIC)
- POD Anchor Coil (PENUMBRA)